Major German Trial Puts Rehabilitation at the Heart of Nursing Home Care

Nursing homes have long been treated as places where older adults go to be cared for, not to recover. A large German study now challenges that assumption head-on. The SGB Reha trial, a stepped-wedge cluster randomized study conducted across twelve nursing homes in North Rhine-Westphalia and Hamburg, is testing whether a cross-sectoral, multidisciplinary rehabilitation and gerontopsychiatric treatment model can restore independence, sharpen cognition, and improve quality of life for residents—while simultaneously cutting hospitalizations, reducing reliance on psychotropic drugs, and lowering treatment costs. With recruitment and data collection now complete and analyses underway, the trial represents one of the most ambitious attempts to re-engineer long-term care from the inside out.

The scale of the problem the trial addresses is enormous. Demographic change in Germany has pushed the number of people needing care to 5.7 million, of whom roughly 800,000 live in residential facilities. These residents are among the most medically vulnerable people in the health system, characterized by multimorbidity, frailty, cognitive impairment, polypharmacy, and behavioral or psychological symptoms. Psychotropic medication use is particularly prevalent in German nursing homes, and it is linked to sedation, falls, hospitalizations, and further cognitive decline. Yet structured rehabilitative and gerontopsychiatric treatment approaches remain poorly integrated into routine long-term care, leaving a gap between what the evidence suggests is possible and what residents actually receive.

The stakes are especially high for people arriving in nursing homes after a hospital stay. Extended hospitalization significantly increases the risk of permanent full-time residential care, and about 40 percent of patients who receive short-term care after a hospital stay end up remaining in a long-term facility. Previous research offers a tantalizing hint of what could be achieved instead: a specialized nursing home rehabilitation program involving 481 residents showed that an intensive cross-sectoral, multidisciplinary concept—including activating nursing care and additional therapeutic support—improved activities of daily living in more than half of residents and enabled 68 percent of participants to return home after discharge, with most remaining in their home environment for at least six months. Preliminary analyses of a local best-practice model at Haus Ruhrgarten in Mülheim an der Ruhr also showed statistically significantly lower treatment costs and fewer, shorter hospital stays compared with similar facilities.

SGB Reha takes that best-practice model and subjects it to rigorous testing. The study enrolled 720 nursing home residents aged 65 or older who had been admitted within the previous twelve months, either routinely or following a hospital stay, and who had a care level of at least 2 on Germany’s five-point statutory scale of care dependency. Alongside the residents, the trial recruited 720 relatives and 180 nursing home staff, allowing the researchers to assess intervention effects across multiple stakeholder groups rather than focusing narrowly on individual clinical outcomes.

The design is a methodological point of interest in its own right. The trial uses a stepped-wedge cluster randomized design, in which all twelve facilities—six urban and six rural—begin in the control condition of treatment as usual, and four homes transition to the intervention at each of three crossover steps across four six-month study periods. Randomization was stratified by facility location, with two urban and two rural homes switching per step. This approach was chosen because it permits sequential implementation under real-world care conditions while preserving randomized allocation, accommodates the organizational realities of staff training, and ensures that every participating home ultimately receives the intervention—an ethical advantage that parallel-group designs cannot offer. Data collection for residents and relatives occurred at baseline and at three and six months within each period.

The intervention itself is deliberately comprehensive. At its structural core are structured multidisciplinary case conferences held every two weeks, alternating between small and large formats, that bring together nursing staff, social care professionals, therapists, neurologists and psychiatrists, and a consulting pharmacist. These conferences establish individual objectives, assess progress, adapt personalized care and therapeutic strategies, and systematically review medications—with a particular emphasis on reducing psychotropic drugs and preventing polypharmacy. Where the prescribing physician attends, medication changes can be initiated directly; otherwise recommendations are forwarded to the treating general practitioner, with final prescribing authority always resting with physicians in accordance with German law. Each resident also receives therapeutic services drawn from at least two of three clusters: physiotherapy or motor therapy, occupational therapy, or music and art therapy, all integrated into daily routines to preserve continuity and ecological validity.

Measurement is correspondingly thorough. The primary outcome is independence in activities of daily living, captured by the SINGER instrument—Scores of Independence for Neurologic and Geriatric Rehabilitation—which assesses twenty aspects of daily independence and showed excellent internal consistency and interrater reliability in its development studies, along with markedly reduced ceiling effects compared with the Barthel Index. Secondary outcomes span frailty measured with the Tilburg Frailty Indicator, cognition via the Montreal Cognitive Assessment, health-related quality of life with the SF-12, fine motor skills using the 20-Cents Test, handgrip strength, nutritional state, hospital stays, psychotropic medication in defined daily doses, polypharmacy, and the proportion of residents discharged back to their own homes. Relatives’ quality of life is tracked with the WHOQOL-BREF, while staff job satisfaction is assessed with the Copenhagen Psychosocial Questionnaire.

The study also embeds a sophisticated evaluation architecture beyond the clinical endpoints. Health-economic analyses, conducted from the perspective of the statutory health insurer using routine claims data for residents insured with AOK Rheinland/Hamburg, will compare healthcare expenditures between intervention and control conditions and weigh them against the per-person costs of the intervention itself. A process evaluation employing the Organizational Readiness for Implementing Change questionnaire and the Consolidated Framework for Implementation Research will identify barriers and facilitators across contextual, organizational, and individual levels, while semi-structured interviews and participant observation capture the subjective experiences of residents, relatives, and staff. An independent external Safety Board of two gerontopsychiatry experts reviews safety every six months and holds authoritative power to modify or terminate the trial.

The researchers are candid about the trial’s limitations. The intervention is highly complex, with multiple interacting components, making it difficult to isolate which specific elements drive any observed effects. Facilities were granted flexibility in implementation, so fidelity may vary. Blinding of staff and participants is infeasible in a facility-level intervention, and although outcome assessors were kept blind—told only that the study concerned psychometric validation, with study nurses concealing each facility’s status—complete blinding cannot be guaranteed. Residents with severe dementia who cannot consent, including those under legal guardianship, were excluded on ethical grounds, which limits generalizability to the most vulnerable populations. One rural facility also withdrew and was replaced by an urban one, disrupting the planned urban-rural balance. With only twelve clusters, the statistical models rely on restricted maximum likelihood estimation with Kenward-Roger correction for degrees of freedom.

Nevertheless, the trial’s potential implications are far-reaching. If the intervention proves effective, it could provide the evidence base for sustainable cross-sectoral models that integrate therapeutic-rehabilitative approaches into standard residential long-term care—shifting nursing homes from custodial maintenance toward recovery-oriented, person-centered care. The researchers hypothesize improvements in daily functioning, staff job satisfaction, and quality of life for residents and relatives, alongside fewer hospitalizations, reduced medication use, lower treatment costs, and more residents returning to their own homes. Given the close links between functional decline, hospitalization, polypharmacy, and gerontopsychiatric symptoms, strengthening multidisciplinary rehabilitative care may prove one of the most consequential strategies available for improving outcomes in aging societies—while demonstrating that even in the final chapters of life, recovery remains possible.

Subject of Research: Cross-sectoral gerontopsychiatric rehabilitation in nursing homes evaluated with a stepped-wedge cluster randomized trial

Article Title: Cross-sectoral gerontopsychiatric treatment and rehabilitation in nursing homes (SGB Reha)—study protocol for a stepped-wedge cluster randomized trial

Article References: Mierzwa, N., Gradel, B., Förstner, B. R., Deeken, F., Desch, A., Schroth, J. M., Du, M., Dierbach, O., Holmberg, C., Hauptmann, M., Rapp, M., & Häusler, A. (2026). Cross-sectoral gerontopsychiatric treatment and rehabilitation in nursing homes (SGB Reha)—study protocol for a stepped-wedge cluster randomized trial. Frontiers in Health Services, 6, Article 1895079. https://doi.org/10.3389/frhs.2026.1895079

Image Credits: AI Generated

DOI: 10.3389/frhs.2026.1895079

Keywords: nursing homes, rehabilitation, gerontopsychiatry, stepped-wedge design, polypharmacy, psychotropic medication, activities of daily living, long-term care, health services research, quality of life, cluster randomized trial, Germany