Clinical trial NCT01503554: Combined Social Worker and Pharmacist Transitional Care Program
Official title: Multidisciplinary Care Transition Intervention - Cardinal Health Grant
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Patient Admission
Patient Discharge
Lead sponsor: Rush University Medical Center
Sponsor class: OTHER
First posted: 2012-01-04
Enrollment: 100
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: yes
Allocation: NON_RANDOMIZED
Intervention model: PARALLEL
Primary purpose: HEALTH_SERVICES_RESEARCH

Brief summary: In an effort to improve care coordination and reduce hospital readmissions, Rush University Medical Center developed the Combined Social Worker and Pharmacist Program, which targets both the psychosocial and clinical risk factors that can lead to rehospitalization. This study will evaluate the impact of this program on 30-day same hospital readmission rates and total cost of care.

Detailed description: If a patient is enrolled in the Combined Social Worker and Pharmacist Program their care will differ from usual care in a number of different ways. First, while the patient is in the hospital, an interdisciplinary group of providers will round on the patient on a regular basis. This interdisciplinary team will be composed of an attending physician, clinical pharmacist, nurse, case manager, and social worker, who will all evaluate the patient's needs from a variety of perspectives to ensure that the patient is prepared for discharge and self-manage post-discharge. During the patient's hospital stay, a clinical pharmacist will also conduct a detailed medication reconciliation of home medications, assess medication-related risks, and provide relevant education to patients participating in the program. After the patient is discharged from Rush University Medical Center, a Master's prepared social worker will then contact the patient and conduct an assessment from a psychosocial perspective to identify any unmet needs. Lastly, a clinical pharmacist will be available to patients enrolled in the Combined Social Worker and Pharmacist Program, should they have any medication-related questions post-discharge.

Eligibility criteria: Inclusion Criteria:

* Age \> 18
* Planned discharge to home or home health
* English-speaking
* At least one of the following risk factors:
* Use of high risk medication(s): Anti-coagulant therapy, dual ASA/plavix therapy, anticholinergic agent, digoxin, opioids, psychotropic medications, or erythrocyte stimulating factor
* Clinical risk factor: Depression, fall risk, limited functional capacity, substance abuse, dementia
* Psycho-social risk factor: high care giver burden, family conflict, limited health literacy, lives alone, significant patient stress, transportation concerns, health care scheduling concerns, inadequate emotional support.

Exclusion Criteria:

* Hospice
* Solid organ transplant
* End-stage renal disease
* Current chemotherapy or radiation therapy

Primary outcomes:
measure: 30-day Same Hospital Readmission Rate
timeFrame: 30 days following hospital discharge
Secondary outcomes:
measure: Total Cost of Care
timeFrame: 30 days following hospital discharge
Other outcomes:
Locations:
city: Chicago
country: United States
facility: Rush University Medical Center
state: Illinois
Study officials:
affiliation: Rush University Medical Center
name: Shannon Sims, MD, PhD
role: PRINCIPAL_INVESTIGATOR
References: