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Combined Social Worker and Pharmacist Transitional Care Program

Sponsor
Rush University Medical Center (Other)
Overall Status
Completed
CT.gov ID
NCT01503554
Collaborator
(none)
100
Enrollment
1
Location
2
Arms
8
Duration (Months)
12.5
Patients Per Site Per Month

Study Details

Study Description

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.

Condition or Disease Intervention/Treatment Phase
  • Behavioral: Combined Social Worker and Pharmacist Program
  • Behavioral: No Intervention: Usual Care
 N/A

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.

Study Design

Study Type:
Interventional
Actual Enrollment :
100 participants
Allocation:
Non-Randomized
Intervention Model:
Parallel Assignment
Masking:
None (Open Label)
Primary Purpose:
Health Services Research
Official Title:
Multidisciplinary Care Transition Intervention - Cardinal Health Grant
Study Start Date :
Apr 1, 2011
Actual Primary Completion Date :
Dec 1, 2011
Actual Study Completion Date :
Dec 1, 2011

Arms and Interventions

Arm Intervention/Treatment
Experimental: Social Worker + Pharmacist Intervention

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

Behavioral: 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
Other Names:
  • EDPP Plus Pharmacist

    		•
    Experimental: 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.

    Behavioral: No Intervention: Usual Care
    Patient receives usual care upon discharge from the hospital.
    Other Names:
  • Control Group

    		•

    Outcome Measures

    Primary Outcome Measures

    1. 30-day Same Hospital Readmission Rate [30 days following hospital discharge]

    Secondary Outcome Measures

    1. Total Cost of Care [30 days following hospital discharge]

      Outcome measure seeks to capture the total cost of care within 30 days of discharge (i.e., costs associated with hospital readmissions, ED visits, outpatient visits, and program costs, if applicable).

    Eligibility Criteria

    Criteria

    Ages Eligible for Study:
    18 Years and Older
    Sexes Eligible for Study:
    All
    Accepts Healthy Volunteers:
    Yes
    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

    Contacts and Locations

    Locations

    Site City State Country Postal Code
    1 Rush University Medical Center Chicago Illinois United States 60612

    Sponsors and Collaborators

    • Rush University Medical Center

    Investigators

    • Principal Investigator: Shannon Sims, MD, PhD, Rush University Medical Center

    Study Documents (Full-Text)

    None provided.

    More Information

    Publications

    None provided.
    Responsible Party:
    Shannon Sims, MD, MD, PhD, Rush University Medical Center
    ClinicalTrials.gov Identifier:
    NCT01503554
    Other Study ID Numbers:
    • 11010702-IRB01
    • Care Trans-IT
    First Posted:
    Jan 4, 2012
    Last Update Posted:
    May 31, 2013
    Last Verified:
    May 1, 2013

    Study Results

    No Results Posted as of May 31, 2013