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

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

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.

Study Overview

• Status: Withdrawn
• Conditions: Home Visits; Transitional Care Coordination
• Intervention / Treatment: Other: Collaborative visit with provider and pharmacist

• Study Type: Observational

Contacts and Locations

Study Locations

• United States
  • Ohio
    • Columbus, Ohio, United States, 43221
      • The Ohio State University Division of General Internal Medicine Martha Morehouse

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Patients will be selected from the OSU Healthy at Home program that have been recently discharged from the hospital.

Description

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.

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Recently discharged homebound patients	Other: Collaborative visit with provider and pharmacist

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Hospital Readmission	30 days

Secondary Outcome Measures

Outcome Measure	Time Frame
Emergency Department Visit	30 days

Other Outcome Measures

Outcome Measure	Time Frame
Number of drug related problems identified	30 days
Type of drug related problems identified	30 days

Collaborators and Investigators

• Sponsor: Ohio State University
• Collaborators: American Society of Health-System Pharmacy Foundation

Study record dates

Study Major Dates

• Study Start: October 1, 2013
• Primary Completion (Anticipated): December 1, 2014
• Study Completion (Anticipated): December 1, 2014

Study Registration Dates

• First Submitted: March 12, 2014
• First Submitted That Met QC Criteria: March 13, 2014
• First Posted (Estimate): March 14, 2014

Study Record Updates

• Last Update Posted (Actual): September 30, 2022
• Last Update Submitted That Met QC Criteria: September 28, 2022
• Last Verified: September 1, 2022

More Information

Terms related to this study

• Keywords: transitions of care; pharmacist; home visits
• Other Study ID Numbers: 2013H0185