Pharmacist-Led SDoH Screening Intervention During Transitions of Care in an Acute Care Setting

NCT06802393 | Completed DMC

• 2 other identifiers: STUDY00007867K23HL153582
• Study Type: interventional
• Target: 58
• Locations: 1 country
• Sites: 1

Brief Summary

The study is a quasi-experimental pilot study conducted at Buffalo General Medical Center (BGMC). It aims to evaluate the feasibility, acceptability, and effectiveness of a pharmacist-led intervention addressing health-related social needs (HRSN) during transitions of care in the emergency department. The intervention involves: 1) pharmacist led medication review, 2) screening patients using the Accountable Health Communities (AHC) HRSN tool, connecting them to local community-based organizations, and 3) conducting follow-up to assess outcomes. The study will recruit 150 patients (50 intervention and 100 control) and assess healthcare utilization metrics, including hospital readmissions and emergency department visits.

Conditions

Health Related Social Needs (HRSN); Pharmacy; Medication Reconciliation

Keywords

health related social needs; pharmacists; hospital; emergency department; medication reconciliation

Outcome Measures

Primary Outcomes (1)

• Healthcare Utilization

  The primary outcome measure of the study is the composite rate of unplanned, all-cause hospital readmissions or emergency department (ED) visits within 30 days of hospital discharge.

  30 days post discharge

Secondary Outcomes (3)

• Intervention feasibility and fidelity metrics

  Through study completion and up to 30 day post discharge

• Intervention Acceptability

  Through study completion and up to 30 days post-discharge

• Rates of unplanned hospital readmissions and emergency department visits

  Up to 90 days post-discharge

Study Arms (2)

Intervention

EXPERIMENTAL

Intervention

Other: Intervention

Control

OTHER

Control

Other: Control

Interventions

Intervention OTHER

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.

Intervention

Control OTHER

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

Control

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Age: Patients must be at least 18 years old.
• Status: Patients being seen at Buffalo General Medical Center (BGMC).

You may not qualify if:

• Cognitive Impairment: Patients who are cognitively impaired and unable to consent will be excluded.
• 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

Sponsors & Collaborators

• State University of New York at Buffalo: lead
• National Heart, Lung, and Blood Institute (NHLBI): collaborator

Study Sites (1)

Buffalo General Medical Center

Buffalo, New York, 14203, United States

Location

MeSH Terms

Conditions

Emergencies

Interventions

Methods

Condition Hierarchy (Ancestors)

Disease Attributes; Pathologic Processes; Pathological Conditions, Signs and Symptoms

Intervention Hierarchy (Ancestors)

Investigative Techniques

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: Associate Professor

Model Details: The intervention study employs a quasi-experimental pre-post design with a non-equivalent control group to evaluate the impact of a pharmacist-led health-related social needs (HRSN) screening and referral intervention in an acute care setting.

Study Record Dates

• First Submitted: January 23, 2025
• First Posted: January 31, 2025
• Study Start: October 1, 2024
• Primary Completion: July 15, 2025
• Study Completion: September 15, 2025
• Last Updated: September 17, 2025

Record last verified: 2025-01

Data Sharing

• IPD Sharing: Will not share

Locations

US (1)