Combined Social Worker and Pharmacist Transitional Care Program
2013年5月30日 更新者：Shannon Sims, MD、Rush University Medical Center
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.
研究概览
地位
完全的
详细说明
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.
研究类型
介入性
注册 (实际的)
100
阶段
- 不适用
联系人和位置
本节提供了进行研究的人员的详细联系信息，以及有关进行该研究的地点的信息。
学习地点
-
-
Illinois
-
Chicago、Illinois、美国、60612
- Rush University Medical Center
-
-
参与标准
研究人员寻找符合特定描述的人，称为资格标准。这些标准的一些例子是一个人的一般健康状况或先前的治疗。
资格标准
适合学习的年龄
18年 及以上 (成人、年长者)
接受健康志愿者
是的
有资格学习的性别
全部
描述
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
学习计划
本节提供研究计划的详细信息，包括研究的设计方式和研究的衡量标准。
研究是如何设计的？
设计细节
- 主要用途：卫生服务研究
- 分配：非随机化
- 介入模型：并行分配
- 屏蔽：无（打开标签）
武器和干预
参与者组/臂 |
干预/治疗 |
|---|---|
|
实验性的：Social Worker + Pharmacist Intervention
Intervention arm offering enhanced services from a social worker and a pharmacist post-discharge
|
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
其他名称：
|
|
实验性的：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.
|
Patient receives usual care upon discharge from the hospital.
其他名称：
|
研究衡量的是什么？
主要结果指标
结果测量 |
大体时间 |
|---|---|
|
30-day Same Hospital Readmission Rate
大体时间：30 days following hospital discharge
|
30 days following hospital discharge
|
次要结果测量
结果测量 |
措施说明 |
大体时间 |
|---|---|---|
|
Total Cost of Care
大体时间：30 days following hospital discharge
|
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
|
合作者和调查者
在这里您可以找到参与这项研究的人员和组织。
调查人员
- 首席研究员：Shannon Sims, MD, PhD、Rush University Medical Center
研究记录日期
这些日期跟踪向 ClinicalTrials.gov 提交研究记录和摘要结果的进度。研究记录和报告的结果由国家医学图书馆 (NLM) 审查，以确保它们在发布到公共网站之前符合特定的质量控制标准。
研究主要日期
学习开始
2011年4月1日
初级完成 (实际的)
2011年12月1日
研究完成 (实际的)
2011年12月1日
研究注册日期
首次提交
2011年12月30日
首先提交符合 QC 标准的
2011年12月30日
首次发布 (估计)
2012年1月4日
研究记录更新
最后更新发布 (估计)
2013年5月31日
上次提交的符合 QC 标准的更新
2013年5月30日
最后验证
2013年5月1日
更多信息
与本研究相关的术语
其他研究编号
- 11010702-IRB01
- Care Trans-IT (其他赠款/资助编号：Cardinal Health)
此信息直接从 clinicaltrials.gov 网站检索，没有任何更改。如果您有任何更改、删除或更新研究详细信息的请求，请联系 register@clinicaltrials.gov. clinicaltrials.gov 上实施更改，我们的网站上也会自动更新.