The road to recovery begins at home

Charlotte Gordon expected a long recovery after her knee replacement surgery. But before she could even get started down that road, she faced a more immediate problem: How would she climb the 11 steps to her front door, only hours after surgery? 

That was just the first of many challenges Gordon expected to encounter during her recovery.  

“Once I got in the house, I didn’t know how I would get up 13 more stairs to my bedroom on the second floor,” she said. “My daughter had taken a week off from work, but I knew I would need more help and support as I recovered.”  

While she preferred to go home as soon as possible, Gordon instead prepared to spend the first several days recuperating in a skilled nursing facility (SNF), which is a common approach after major surgery. Then she heard about Penn Medicine At Home’s SNF at Home pilot program, which offers a seamless transition from the hospital to home, and the extra support patients may need to recover in familiar surroundings. 

Ujwala Tambe, MSN, RN, Clinical Director, Penn Medicine At Home, said the COVID-19 pandemic appeared to prompt even more patients to consider the possibility of a home recovery after surgery or another medical event. SNF at Home enables that to happen safely for the right subset of patients by providing intensive, short-term home services to those who have the ability, support, and desire to recover at home.  

“We recognize that a skilled nursing or rehab facility is the absolute right choice for some patients,” she said. “The SNF at Home program is a great alternative for those patients who fall on the cusp of needing to go to a facility but would prefer to recover at home. These patients have the necessary home supports in place, but they require more than what traditional home care services alone can offer.” 

SNF at Home began as a pilot for patients discharged from Penn Presbyterian Medical Center in early 2023, with patients who had elective surgery on a major lower joint. The program is currently available to a limited, but growing, number of Penn Medicine patients, based on their diagnosis and hospital location. 

To date, SNF at Home has served 90 patients who have had hip or knee replacement at Penn Presbyterian or Pennsylvania Hospital, or geriatric hip fracture treatment at Penn Presbyterian. In addition, 48 patients discharged from Hospital of the University of Pennsylvania, recovering from a stroke, have also received treatment through the program. 

An ‘amazing process for a difficult situation’ 

The program—which recently opened to stroke patients at the Hospital of the University of Pennsylvania—counts Charlotte Gordon as one of its many success stories.  

Gordon, who lives in Delaware County, also has primary bilateral lymphedema, which causes severe swelling. While her condition is typically controlled, she was concerned about how her body would respond to major surgery.  

She was relieved to have the option to recover at home following her knee replacement surgery. Her experience with SNF at Home began with an ambulance transport from the hospital, complete with extra support for her initial climb up the stairs.  

“They took care of everything,” she said. “The ambulance brought my luggage, medical equipment, prescriptions, and me. Within an hour, a nurse arrived at my home to check on me.”  

Gordon experienced significant swelling after her surgery, which she managed with the assistance of her in-home care team, including a wound care nurse and physical, occupational, and lymphedema therapists. A home health aide helped her with personal care as needed. 

One day, her blood sugar dropped to the point that she felt dizzy and nauseous. Alerted by her remote monitoring equipment, her care team directed her to sit up and drink some apple juice until her blood sugar returned to a more normal level.  

From hospital to home 

Scott G. Rushanan, OTD, MBA, OTR/L, Penn Medicine At Home’s system director for Patient Access, Informatics, and Rehabilitation, said SNF at Home aligns with Penn Medicine’s strategic goals and priorities in ways that streamline processes for the health system while also making care easier for patients. 

“SNF at Home offers a number of potential benefits, including increased patient satisfaction due to smoother transitions and more time at home,” he said. “This program offers high-quality care, with really great patient outcomes, at a lower overall cost to insurance companies.”   

Patients in the program generally experience shorter hospital stays. When patients can go home instead of being admitted to another facility, it also eliminates the potential delays if a bed is not immediately available.  

To be eligible for SNF at Home, patients must meet clinical risk criteria to indicate that they can safely and successfully recover at home, with the goal of scaling back on intensive in-home services within seven to 10 days.  

Practically speaking, patients must have regular support from family or friends, including nighttime supervision. They must be able to manage activities such as getting out of bed and walking to the bathroom with help from no more than one caregiver.  

Patients who require more assistance or have certain medical conditions are better suited to recover in a skilled nursing or rehab facility, Tambe said. This can include significant cognitive challenges or newly diagnosed conditions, such as congestive heart failure, which require frequent monitoring or oversight.  

Extra sets of hands–and eyes 

Planning for the transition to home most often begins before a procedure, when the SNF at Home team evaluates the patient’s overall health, home setup, and caregiver support. Patients also can be identified and enrolled if they are already in the hospital for a more emergent procedure.  

To ensure a smooth transition, the team proactively schedules the patient’s first week of home visits. On the day of hospital discharge, a nurse visits the home to check on the patient, ensuring that any durable medical equipment has arrived, and reviewing medication instructions.  

Patients then begin daily physical and occupational therapy to optimize function, safety, and independence. A home health aide and social worker are available to assist with personal-care needs, caregiver support, and connections to community services. Virtual case management services provide additional oversight through remote monitoring of vital signs, including blood pressure, temperature, and pain.  

“Remote monitoring helps us to keep a closer eye on our patients when the care team is not physically in the home,” Tambe said. “If we see something of concern, we can visit the home to check on them, or schedule an urgent visit through the Penn Cavalry program.” 

SNF at Home patients may receive additional services based on their individual circumstances, such as a community health worker to assist with ongoing social needs, personal care assistance from a home health aide, meal services or medication delivery.  

With these early and intensive supports, most patients are able to reduce the frequency of in-home therapy and other services within about a week, scaling back nurse and therapy visits and virtual case management to a cadence similar to that of a traditional home health patient. 

Other services, such as support from a home health aide or community health worker, might continue even after patients are discharged from the program. 

For patients like Charlotte Gordon, the program is bringing new ease to what could be a difficult transition after leaving the hospital. From the pre-hospital evaluation to coordination of her follow-up appointments, Gordon credits the extra support from SNF at Home for her successful start down the road to recovery.  

“They did an awesome job of assisting me and my family,” she said. “It’s an amazing process for a difficult situation.”