NCT01503554

Combined Social Worker and Pharmacist Transitional Care Program

Multidisciplinary Care Transition Intervention - Cardinal Health Grant

• Status: Completed
• Phase: N/A
• Study type: Interventional
• Enrollment: 100 (actual)
• Sponsor: Rush University Medical Center · Academic / Other
• Sex: All
• Age: 18 Years
• Healthy volunteers: Accepted

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.

Conditions

• Patient Admission
• Patient Discharge

Interventions

Type	Name	Description
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
BEHAVIORAL	No Intervention: Usual Care	Patient receives usual care upon discharge from the hospital.

Timeline

• Start date: 2011-04-01
• Primary completion: 2011-12-01
• Completion: 2011-12-01
• First posted: 2012-01-04
• Last updated: 2013-05-31

Locations

1 site across 1 country: United States