Pharmacist-Led SDoH Screening Intervention During Transitions of Care in an Acute Care Setting
NCT ID: NCT06802393
Last Updated: 2025-09-17
Study Results
The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.
Basic Information
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COMPLETED
NA
58 participants
INTERVENTIONAL
2024-10-01
2025-09-15
Brief Summary
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Detailed Description
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The intervention includes: 1) pharmacist led medication reconciliation, 2) providing patients with tailored referrals to community-based organizations identified through the 211 WNY resource database, based on their specific social needs and geographic location and 3) follow-up phone calls within one month will assess whether participants contacted the referred organizations and whether these services were helpful. A patient satisfaction survey will also be conducted during these follow-up calls to gauge attitudes toward the intervention.
The historical control group will include patients admitted or discharged from the ED during the same timeframe as the intervention group but without HRSN screening. Control group data, including healthcare utilization outcomes, will be extracted from the electronic health record (EHR). Outcomes of interest include feasibility measures such as recruitment rates and data completeness, acceptability metrics like patient satisfaction, and secondary outcomes such as unplanned hospital readmissions and ED visits at 30 days and 3 months post-discharge.
Data analysis will involve statistical comparisons of demographic and clinical characteristics between the intervention and control groups using Chi-square tests for categorical variables and Wilcoxon Rank-sum or t-tests for continuous variables. Multivariable logistic regression will assess the impact of the intervention on healthcare utilization outcomes.
The study expects to recruit 50 patients in the intervention group and 100 in the control group over eight months, with a total study duration of 12 months, including follow-up and data analysis. By integrating pharmacists into HRSN screening and referral processes, the study aims to address critical social determinants of health, improve care transitions, and reduce healthcare utilization in underserved populations.
Conditions
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Study Design
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NON_RANDOMIZED
PARALLEL
HEALTH_SERVICES_RESEARCH
NONE
Study Groups
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Intervention
Intervention
Intervention
The intervention incorporates a multifaceted pharmacist-led approach to addressing health-related social needs (HRSN) during transitions of care in the emergency department (ED) at Buffalo General Medical Center (BGMC). The intervention includes: 1) pharmacist-led medication reconciliation, and 2) HRSN screening using the Accountable Health Communities (AHC) HRSN tool. Based on the results, patients receive tailored referrals to community-based organizations using the 211 WNY database, which provides localized resources aligned with their social needs. Each patient is given a printed handout detailing the referral information. Within one month, a follow-up phone call is conducted to follow up with patients and assess additional needs as well as collect feedback through a patient satisfaction survey.
Control
Control
Control
The control arm of the study consists of a historical cohort of patients who were admitted to or discharged from the emergency department (ED) at Buffalo General Medical Center (BGMC) during the same timeframe as the intervention arm but did not receive the pharmacist-led health-related social needs (HRSN) screening or referral intervention. These patients are identified through the electronic health record (EHR) based on the same inclusion criteria as the intervention group, such as age, geographic location, and discharge disposition. Control participants are matched 1:1 with intervention participants using demographic and clinical characteristics, including age (within 5 years), zip code, insurance type, discharge status, and race. Data for the control arm include healthcare utilization metrics such as 30- and 90-day unplanned hospital readmissions and emergency department visits. The control arm serves as a comparator to evaluate the effectiveness of the intervention
Interventions
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Intervention
The intervention incorporates a multifaceted pharmacist-led approach to addressing health-related social needs (HRSN) during transitions of care in the emergency department (ED) at Buffalo General Medical Center (BGMC). The intervention includes: 1) pharmacist-led medication reconciliation, and 2) HRSN screening using the Accountable Health Communities (AHC) HRSN tool. Based on the results, patients receive tailored referrals to community-based organizations using the 211 WNY database, which provides localized resources aligned with their social needs. Each patient is given a printed handout detailing the referral information. Within one month, a follow-up phone call is conducted to follow up with patients and assess additional needs as well as collect feedback through a patient satisfaction survey.
Control
The control arm of the study consists of a historical cohort of patients who were admitted to or discharged from the emergency department (ED) at Buffalo General Medical Center (BGMC) during the same timeframe as the intervention arm but did not receive the pharmacist-led health-related social needs (HRSN) screening or referral intervention. These patients are identified through the electronic health record (EHR) based on the same inclusion criteria as the intervention group, such as age, geographic location, and discharge disposition. Control participants are matched 1:1 with intervention participants using demographic and clinical characteristics, including age (within 5 years), zip code, insurance type, discharge status, and race. Data for the control arm include healthcare utilization metrics such as 30- and 90-day unplanned hospital readmissions and emergency department visits. The control arm serves as a comparator to evaluate the effectiveness of the intervention
Eligibility Criteria
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Inclusion Criteria
Status: Patients being seen at Buffalo General Medical Center (BGMC).
Exclusion Criteria
Non-English Speakers: Non-English speaking individuals are excluded due to the nature of the intervention requiring direct communication between the clinical pharmacist and participants
18 Years
ALL
No
Sponsors
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National Heart, Lung, and Blood Institute (NHLBI)
NIH
State University of New York at Buffalo
OTHER
Responsible Party
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David Matthew Jacobs
Associate Professor
Locations
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Buffalo General Medical Center
Buffalo, New York, United States
Countries
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Other Identifiers
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STUDY00007867
Identifier Type: -
Identifier Source: org_study_id
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