Using Health Information Technology (HIT) to Improve Transitions of Complex Elderly Patients From Skilled Nursing Facility (SNF) to Home

NCT01004328 | Completed DMC

• 2 other identifiers: 1R18HS01781713001
• Study Type: interventional
• Target: 626
• Locations: 1 country
• Sites: 1

Brief Summary

The incidence of drug-induced injury is high in the ambulatory geriatric population, especially for elders with complex healthcare needs during high risk transitions to the ambulatory setting. In a previous study funded by the National Institute on Aging and the Agency for Healthcare Research and Quality \[AHRQ\] (AG 15979), the investigators determined that drug-related injuries occur at a rate of more than 50 per 1000-patient years in older adults in the ambulatory setting and that 28% are preventable. Independent risk factors for adverse drug events among older adults in the ambulatory setting included advanced age, multiple comorbid conditions, and the use of medications requiring close monitoring. In this project, Using HIT to Improve Transitions of Complex Elderly Patients from SNF to Home (1 R18 HS017817), the investigators are testing the use of an electronic medical record (EMR)-based transitional care intervention for complex elderly patients transitioning from subacute care in a skilled nursing facility (SNF) to the ambulatory setting. The growing trend for physicians and other healthcare providers to restrict their practices to single settings and not follow complex patients as they move between settings leaves older patients discharged from subacute care particularly vulnerable. This transition is uniquely challenging because of the complex healthcare needs of this population, who often require outpatient primary care physicians to coordinate with visiting nurses in order to manage complex medication regimens and fluctuating clinical status. To facilitate high-quality transitions from the subacute to the ambulatory setting and support interdisciplinary communication, the investigators will use the EMR to assure that physicians in the ambulatory setting receive key health information and alerts.

Conditions

Adverse Outcomes

Keywords

patient safety; care transitions; therapeutic monitoring; skilled nursing facilities; Adverse outcomes after discharge from a SNF to home

Outcome Measures

Primary Outcomes (4)

• Rate of follow-up to an outpatient provider within 21 days of SNF discharge.

  1 year 3 months

• Prevalence of appropriate monitoring for selected high risk medications at 30 days from the time of SNF discharge.

  1 year 3 months

• Incidence of adverse drug events (ADEs) 45 days after discharge.

  1 year 3 months

• Rate of SNF readmission and emergency department (ED) within 30 days of discharge.

  1 year 3 months

Secondary Outcomes (1)

• Determine costs directly related to the development and installation of the HIT-based transitional care intervention

  3 years

Study Arms (1)

Intervention Group 1

EXPERIMENTAL

All participants

Other: Intervention 1: Electronic medical record (EMR)-based transitional care intervention

Interventions

Intervention 1: Electronic medical record (EMR)-based transitional care intervention OTHER

Electronic delivery of enhanced discharge information to the ambulatory physician with plans for follow-up appointment, notice of any new medications, and recommendations for laboratory monitoring

Intervention Group 1

Eligibility Criteria

• Age: 65 Years+
• Sex: all
• Healthy Volunteers: Yes
• Age Groups: Older Adult (65+)

You may qualify if:

• years and older,
• Member of the study site health plan,
• Received care from one of the study site's geriatricians during a SNF stay,
• Discharged from SNF to home.

Sponsors & Collaborators

• University of Massachusetts, Worcester: lead

Study Sites (1)

Fallon Clinic

Worcester, Massachusetts, 01605, United States

Location

Study Officials

• Terry S Field, DSc

  University of Massachusetts Medical School/Meyers Primary Care Institute

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: NA
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: SINGLE GROUP
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Associate Professor, Meyers Primary Care Institute/University of Massachusetts Medical School.

Study Record Dates

• First Submitted: July 22, 2009
• First Posted: October 29, 2009
• Study Start: April 1, 2011
• Primary Completion: June 1, 2012
• Study Completion: January 1, 2013
• Last Updated: April 24, 2014

Record last verified: 2014-04

Locations

US (1)