Skilled Nursing Facility Care at Home

Inclusion Criteria: * \>=18 years old * Requires SNF PAC care following hospitalization, as determined by the inpatient team (requires documented rehabilitative therapy recommendation) * Community-dwelling before hospitalization * Likely to return to community-dwelling status following short-term rehabilitation as determined by RAH liaison * Lives within 10 miles of any study site hospital (or per specified catchment) * Surgical trauma and elective patients (weight bearing as tolerated and transfer with no more than one-person assist) * Neurology patients - Stroke (needs acute rehabilitation, but insurance will not cover, so bound for SNF. Does not meet acute rehabilitation criteria and does not need long-term placement) Exclusion Criteria: * Environmental * Undomiciled * No working heat (October-April), no working air conditioning if forecast \> 80°F, or no running water * In police custody * Resides in a facility that does not allow advanced on-site care * Domestic violence screen positive * Weapons that cannot be appropriately secured * Difficulty accessing the bathroom (unless there is space for a bedside commode where the patient sleeps or if the patient is entirely dependent on toileting) * Home has insufficient accessible space to sleep, eat, and perform rehabilitative therapy * Home lacks sufficient kitchen facilities to either cook or heat meals * Patient, or patient's family caregiver, unable to communicate via telephone * Patient, or patie…