Combined Social Worker and Pharmacist Transitional Care Program

This study has been completed.
Sponsor:
Information provided by (Responsible Party):
Shannon Sims, MD, Rush University Medical Center
ClinicalTrials.gov Identifier:
NCT01503554
First received: December 30, 2011
Last updated: May 30, 2013
Last verified: May 2013

December 30, 2011
May 30, 2013
April 2011
December 2011   (final data collection date for primary outcome measure)
30-day Same Hospital Readmission Rate [ Time Frame: 30 days following hospital discharge ] [ Designated as safety issue: No ]
Same as current
Complete list of historical versions of study NCT01503554 on ClinicalTrials.gov Archive Site
Total Cost of Care [ Time Frame: 30 days following hospital discharge ] [ Designated as safety issue: No ]
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).
Same as current
Not Provided
Not Provided
 
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.

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.

Interventional
Not Provided
Allocation: Non-Randomized
Endpoint Classification: Efficacy Study
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Health Services Research
  • Patient Admission
  • Patient 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 Name: EDPP Plus Pharmacist
  • Behavioral: No Intervention: Usual Care
    Patient receives usual care upon discharge from the hospital.
    Other Name: Control Group
  • Experimental: Social Worker + Pharmacist Intervention
    Intervention arm offering enhanced services from a social worker and a pharmacist post-discharge
    Intervention: Behavioral: Combined Social Worker and Pharmacist Program
  • 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.
    Intervention: Behavioral: No Intervention: Usual Care
Not Provided

*   Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
 
Completed
100
December 2011
December 2011   (final data collection date for primary outcome measure)

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
Both
18 Years and older
Yes
Contact information is only displayed when the study is recruiting subjects
United States
 
NCT01503554
11010702-IRB01, Care Trans-IT
No
Shannon Sims, MD, Rush University Medical Center
Rush University Medical Center
Not Provided
Principal Investigator: Shannon Sims, MD, PhD Rush University Medical Center
Rush University Medical Center
May 2013

ICMJE     Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP