Collaborative Home Visits to Reduce Hospital Readmissions and Improve Medication Use During Transitions of Care

Study Overview
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Brief Summary
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The primary objective is to develop a sustainable practice model emphasizing home visits by a collaborative physician and pharmacist team to decrease unplanned emergency department visits and hospital readmissions at 30 and 90 days for high-risk home bound patients. Secondary objectives include (1) tracking the number, type, and severity of adverse drug events (ADE) and potential adverse drug events (pADE) that occur following hospital discharge and (2) resolving any identified ADE and pADE within 7 days of hospital discharge. Adult patients will be scheduled for a home visit by the Healthy at Home Columbus program at the time of hospital discharge. The home visit will occur within 7 days of hospital discharge and will consist of a complete hospital and medication review by a physician or nurse practitioner and a pharmacist (including all lab tests, imaging studies, medication changes, and proposed plan of care at the time of discharge). The investigators hypothesize these home visits will reduce 30 and 90 days hospital readmission rates and ED visits. The number of emergency department visits and unplanned hospital readmissions will be tracked at 30 and 90 days following discharge from the hospitalization that led to study enrollment. A comparison cohort of patients discharged in the 12 months prior to study initiation will be used to compare the effectiveness of the home visit program. The number and type of adverse drug events (ADE) and potential adverse drug events (pADE) that occur during transitions of care will also be characterized. All ADE and pADE will be resolved during the initial home visit and will be classified based on severity. All ADE and pADE will be evaluated independently by two pharmacist reviewers; each reviewer will independently assign a severity rating to each ADE and pADE.

Official Title
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COLLABORATIVE HOME VISITS TO REDUCE HOSPITAL READMISSIONS AND IMPROVE MEDICATION USE DURING TRANSITIONS OF CARE

Conditions
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Transitional Care Coordination, Home Visits

Intervention / Treatment
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* Other: Collaborative visit with provider and pharmacist


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Adult patients discharged from the hospital in the last 7 days and with more than two chronic conditions and significant obstacles to accessing care in an office setting are eligible for study participation Exclusion Criteria: Adult patients able to access care in an office setting. Adult patients discharged from the hospital greater than 7 days prior to the office visit.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Recently discharged homebound patients<br> | Other: Collaborative visit with provider and pharmacist<br> <br> |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hospital Readmission |  | 30 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Emergency Department Visit |  | 30 days | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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home visits, transitions of care, pharmacist