Combined Social Worker and Pharmacist Transitional Care Program

Multidisciplinary Care Transition Intervention - Cardinal Health Grant

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.

Study Overview

• Status: Completed
• Conditions: Patient Discharge; Patient Admission
• Intervention / Treatment: Behavioral: Combined Social Worker and Pharmacist Program; Behavioral: No Intervention: Usual 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.

• Study Type: Interventional
• Enrollment (Actual): 100
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Illinois
    • Chicago, Illinois, United States, 60612
      • Rush University Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

Description

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

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Non-Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Social Worker + Pharmacist Intervention; Intervention arm offering enhanced services from a social worker and a pharmacist post-discharge	Behavioral: Combined Social Worker and Pharmacist Program; Physician or nurse performs a med rec during hospital stay Clinical pharmacist completes an additional med rec of home meds, assesses med-related risks, and provides education After discharge, a Master's prepared social worker contacts the patient and conducts an assessment from a psychosocial perspective to identify any unmet needs. Pharmacist will be available to patients should they have any medication-related questions post-discharge; Other Names: EDPP Plus Pharmacist
Experimental: Usual Care; Patients receiving usual care will have a medication reconciliation performed by a physician or nurse during their hospital stay. No further support or interventions are provided post discharge.	Behavioral: No Intervention: Usual Care; Patient receives usual care upon discharge from the hospital.; Other Names: Control Group

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
30-day Same Hospital Readmission Rate	30 days following hospital discharge

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Total Cost of Care	Outcome measure seeks to capture the total cost of care within 30 days of discharge (i.e., costs associated with hospital readmissions, ED visits, outpatient visits, and program costs, if applicable).	30 days following hospital discharge

Collaborators and Investigators

• Sponsor: Rush University Medical Center
• Investigators: Principal Investigator: Shannon Sims, MD, PhD, Rush University Medical Center

Study record dates

Study Major Dates

• Study Start: April 1, 2011
• Primary Completion (Actual): December 1, 2011
• Study Completion (Actual): December 1, 2011

Study Registration Dates

• First Submitted: December 30, 2011
• First Submitted That Met QC Criteria: December 30, 2011
• First Posted (Estimate): January 4, 2012

Study Record Updates

• Last Update Posted (Estimate): May 31, 2013
• Last Update Submitted That Met QC Criteria: May 30, 2013
• Last Verified: May 1, 2013

More Information

Terms related to this study

• Other Study ID Numbers: 11010702-IRB01; Care Trans-IT (Other Grant/Funding Number: Cardinal Health)