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Combined Social Worker and Pharmacist Transitional Care Program

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

Condition Intervention
Patient Admission
Patient Discharge
Behavioral: Combined Social Worker and Pharmacist Program
Behavioral: No Intervention: Usual Care

Study Type: Interventional
Study Design: Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Health Services Research
Official Title: Multidisciplinary Care Transition Intervention - Cardinal Health Grant

Resource links provided by NLM:

Further study details as provided by Rush University Medical Center:

Primary Outcome Measures:
  • 30-day Same Hospital Readmission Rate [ Time Frame: 30 days following hospital discharge ]

Secondary Outcome Measures:
  • Total Cost of Care [ Time Frame: 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).

Enrollment: 100
Study Start Date: April 2011
Study Completion Date: December 2011
Primary Completion Date: December 2011 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
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 Name: 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 Name: Control Group

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.

Ages Eligible for Study:   18 Years and older   (Adult, Senior)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   Yes

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
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its identifier: NCT01503554

United States, Illinois
Rush University Medical Center
Chicago, Illinois, United States, 60612
Sponsors and Collaborators
Rush University Medical Center
Principal Investigator: Shannon Sims, MD, PhD Rush University Medical Center
  More Information

Responsible Party: Shannon Sims, MD, MD, PhD, Rush University Medical Center Identifier: NCT01503554     History of Changes
Other Study ID Numbers: 11010702-IRB01
Care Trans-IT ( Other Grant/Funding Number: Cardinal Health )
Study First Received: December 30, 2011
Last Updated: May 30, 2013 processed this record on April 28, 2017