Combined Social Worker and Pharmacist Transitional Care Program

NCT ID: NCT01503554

Last Updated: 2013-05-31

Basic Information

• Recruitment Status: COMPLETED
• Clinical Phase: NA
• Total Enrollment: 100 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2011-04-30
• Study Completion Date: 2011-12-31

Brief Summary

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.

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.

Conditions

Patient Admission; Patient Discharge

Study Design

• Allocation Method: NON_RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: HEALTH_SERVICES_RESEARCH
• Blinding Strategy: NONE

Study Groups

Social Worker + Pharmacist Intervention

Intervention arm offering enhanced services from a social worker and a pharmacist post-discharge

Group Type: EXPERIMENTAL

Combined Social Worker and Pharmacist Program

Intervention Type: BEHAVIORAL

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

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.

Group Type: EXPERIMENTAL

No Intervention: Usual Care

Intervention Type: BEHAVIORAL

Patient receives usual care upon discharge from the hospital.

Interventions

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

Intervention Type: BEHAVIORAL

No Intervention: Usual Care

Patient receives usual care upon discharge from the hospital.

Intervention Type: BEHAVIORAL

Other Intervention Names

EDPP Plus Pharmacist; Control Group

Eligibility Criteria

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

• Minimum Eligible Age: 18 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: Yes

Sponsors

Rush University Medical Center

OTHER

Sponsor Role: lead

Responsible Party

Shannon Sims, MD

MD, PhD

Responsibility Role: PRINCIPAL_INVESTIGATOR

Principal Investigators

Shannon Sims, MD, PhD

Role: PRINCIPAL_INVESTIGATOR

Rush University Medical Center

Locations

Rush University Medical Center

Chicago, Illinois, United States

Countries

United States

Other Identifiers

Care Trans-IT

Identifier Type: OTHER_GRANT

Identifier Source: secondary_id

11010702-IRB01

Identifier Type: -

Identifier Source: org_study_id