Combined Social Worker and Pharmacist Transitional Care Program

NCT01503554 | Completed

• 2 other identifiers: 11010702-IRB01Care Trans-IT
• Study Type: interventional
• Target: 100
• Locations: 1 country
• Sites: 1

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.

Conditions

Patient Admission; Patient Discharge

Outcome Measures

Primary Outcomes (1)

• 30-day Same Hospital Readmission Rate

  30 days following hospital discharge

Secondary Outcomes (1)

• Total Cost of Care

  30 days following hospital discharge

Study Arms (2)

Social Worker + Pharmacist Intervention

EXPERIMENTAL

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

Behavioral: Combined Social Worker and Pharmacist Program

Usual Care

EXPERIMENTAL

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

Interventions

Combined Social Worker and Pharmacist Program 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

Also known as: EDPP Plus Pharmacist

Social Worker + Pharmacist Intervention

No Intervention: Usual Care BEHAVIORAL

Patient receives usual care upon discharge from the hospital.

Also known as: Control Group

Usual Care

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: Yes
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• 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.

You may not qualify if:

• Hospice
• Solid organ transplant
• End-stage renal disease
• Current chemotherapy or radiation therapy

Sponsors & Collaborators

• Rush University Medical Center: lead

Study Sites (1)

Rush University Medical Center

Chicago, Illinois, 60612, United States

Location

MeSH Terms

Interventions

2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine; Pharmacists; Control Groups

Intervention Hierarchy (Ancestors)

Health Personnel; Health Care Facilities Workforce and Services; Epidemiologic Research Design; Epidemiologic Methods; Investigative Techniques; Research Design; Methods

Study Officials

• Shannon Sims, MD, PhD

  Rush University Medical Center

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: NON RANDOMIZED
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: MD, PhD

Study Record Dates

• First Submitted: December 30, 2011
• First Posted: January 4, 2012
• Study Start: April 1, 2011
• Primary Completion: December 1, 2011
• Study Completion: December 1, 2011
• Last Updated: May 31, 2013

Record last verified: 2013-05

Locations

US (1)