Patient Admission, Patient Discharge
Conditions
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.
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.
Interventions
BEHAVIORALCombined 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
BEHAVIORALNo Intervention: Usual Care
Patient receives usual care upon discharge from the hospital.
Sponsors
Rush University Medical Center
Study design
Allocation
NON_RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
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
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| 30-day Same Hospital Readmission Rate | 30 days following hospital discharge |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| 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). |
Countries
United States
Outcome results
None listed