Choose Home: Initial Evaluation of a Novel Home-Based Care Program After Subacute Rehabilitation

Many older adults prefer aging in place, but complex medical and social care needs and fragmented care systems are barriers to maintaining independence at home. Choose Home was implemented at the Veteran Affairs Boston Health Care System in September 2023 to address a critical care gap for patients who seek to remain independent at home but are at high risk for acute care hospitalizations and institutionalization in long-term care facilities. This report describes a subpopulation (n = 16) of patients enrolled after subacute rehabilitation discharge who were at very high risk of readmission and long-term care entry. Among 16 patients (mean age, 76.8 years; 81% with severe frailty), the program provided an average of 14.8 (SD, 11.2; range, 3-50) care encounters over 96.3 days (range, 19-224). Qualitative analysis of veterans' medical records revealed key program interventions categorized into 4 themes: (1) Clinical care, (2) Case management, (3) Psychosocial safety, and (4) Home safety. At program discharge, 81.3% (n = 13) of patients remained independent in the community and transitioned to longitudinal care teams: primary care (n = 7; 43.8%), home-based primary care (n = 3; 18.8%), and hospice (n = 3; 18.8%). This innovation demonstrates the early feasibility of episodic, home-based care for medically and socially complex patients transitioning home after subacute rehabilitation.