Clinical trial NCT01004328: Using Health Information Technology (HIT) to Improve Transitions of Complex Elderly Patients From Skilled Nursing Facility (SNF) to Home
Official title: Using HIT to Improve Transitions of Complex Elderly Patients From SNF to Home
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Adverse Outcomes
Keywords: patient safety
care transitions
therapeutic monitoring
skilled nursing facilities
Adverse outcomes after discharge from a SNF to home
Lead sponsor: University of Massachusetts, Worcester
Sponsor class: OTHER
First posted: 2009-10-29
Enrollment: 626
Sex: ALL
Minimum age (years): 65
Standard ages: OLDER_ADULT
Accepts healthy volunteers: yes
Allocation: NA
Intervention model: SINGLE_GROUP
Primary purpose: HEALTH_SERVICES_RESEARCH

Brief summary: 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.


Eligibility criteria: 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.

Primary outcomes:
measure: Rate of follow-up to an outpatient provider within 21 days of SNF discharge.
timeFrame: 1 year 3 months
measure: Prevalence of appropriate monitoring for selected high risk medications at 30 days from the time of SNF discharge.
timeFrame: 1 year 3 months
measure: Incidence of adverse drug events (ADEs) 45 days after discharge.
timeFrame: 1 year 3 months
measure: Rate of SNF readmission and emergency department (ED) within 30 days of discharge.
timeFrame: 1 year 3 months
Secondary outcomes:
measure: Determine costs directly related to the development and installation of the HIT-based transitional care intervention
timeFrame: 3 years
Other outcomes:
Locations:
city: Worcester
country: United States
facility: Fallon Clinic
state: Massachusetts
Study officials:
affiliation: University of Massachusetts Medical School/Meyers Primary Care Institute
name: Terry S Field, DSc
role: PRINCIPAL_INVESTIGATOR
References: