Using Health Information Technology (HIT) to Improve Transitions of Complex Elderly Patients From Skilled Nursing Facility (SNF) to Home

Study Overview
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Brief Summary
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The incidence of drug-induced injury is high in the ambulatory geriatric population, especially for elders with complex healthcare needs during high risk transitions to the ambulatory setting. In a previous study funded by the National Institute on Aging and the Agency for Healthcare Research and Quality [AHRQ] (AG 15979), the investigators determined that drug-related injuries occur at a rate of more than 50 per 1000-patient years in older adults in the ambulatory setting and that 28% are preventable. Independent risk factors for adverse drug events among older adults in the ambulatory setting included advanced age, multiple comorbid conditions, and the use of medications requiring close monitoring. In this project, Using HIT to Improve Transitions of Complex Elderly Patients from SNF to Home (1 R18 HS017817), the investigators are testing the use of an electronic medical record (EMR)-based transitional care intervention for complex elderly patients transitioning from subacute care in a skilled nursing facility (SNF) to the ambulatory setting. The growing trend for physicians and other healthcare providers to restrict their practices to single settings and not follow complex patients as they move between settings leaves older patients discharged from subacute care particularly vulnerable. This transition is uniquely challenging because of the complex healthcare needs of this population, who often require outpatient primary care physicians to coordinate with visiting nurses in order to manage complex medication regimens and fluctuating clinical status. To facilitate high-quality transitions from the subacute to the ambulatory setting and support interdisciplinary communication, the investigators will use the EMR to assure that physicians in the ambulatory setting receive key health information and alerts.

Official Title
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Using HIT to Improve Transitions of Complex Elderly Patients From SNF to Home

Conditions
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Adverse Outcomes

Intervention / Treatment
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* Other: Intervention 1: Electronic medical record (EMR)-based transitional care intervention


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: 65 years and older, Member of the study site health plan, Received care from one of the study site's geriatricians during a SNF stay, Discharged from SNF to home. Exclusion Criteria: Does not meet inclusion criteria.

Ages Eligible for Study
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Minimum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intervention Group 1<br>All participants | Other: Intervention 1: Electronic medical record (EMR)-based transitional care intervention<br>* Electronic delivery of enhanced discharge information to the ambulatory physician with plans for follow-up appointment, notice of any new medications, and recommendations for laboratory monitoring<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of follow-up to an outpatient provider within 21 days of SNF discharge. |  | 1 year 3 months | 
| Prevalence of appropriate monitoring for selected high risk medications at 30 days from the time of SNF discharge. |  | 1 year 3 months | 
| Incidence of adverse drug events (ADEs) 45 days after discharge. |  | 1 year 3 months | 
| Rate of SNF readmission and emergency department (ED) within 30 days of discharge. |  | 1 year 3 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Determine costs directly related to the development and installation of the HIT-based transitional care intervention |  | 3 years | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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patient safety, care transitions, therapeutic monitoring, skilled nursing facilities, Adverse outcomes after discharge from a SNF to home