: The incidence of drug-induced injury is high in the ambulatory geriatric population, especially for older adults with complex healthcare needs during high risk transitions to the ambulatory setting. In response to the AHRQ RFA Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs Through Health IT, an electronic medical record (EMR)-based medication reconciliation system that enhances medication monitoring and follow-up for complex elderly patients discharged from subacute care in a skilled nursing facility to the ambulatory setting is proposed. The growing trend for physicians and other healthcare providers to restrict their practices to single settings and not follow complex patients as they move between settings leaves older patients discharged from subacute care particularly vulnerable. This transition is uniquely challenging because of the complex healthcare needs of this population, who often require coordinated care from outpatient primary care physicians together with visiting nurses to manage complex medication regimens and fluctuating clinical status. To facilitate high-quality transitions from the subacute to the ambulatory setting and support interdisciplinary communication, the intervention will use the EMR to assure that physicians in the ambulatory setting receive key health information and alerts and will use EMR-to-fax technology to provide parallel information to visiting nurses without EMR access. To evaluate the impact of this intervention, a randomized controlled trial with three arms is proposed: 1) Health IT (HIT)-based delivery of health information and alerts to the primary care physician;2) HIT-based delivery of health information and alerts to both the primary care physician and the visiting nurse;and 3) usual care.
The specific aims are to evaluate the impact of the HIT-based transitional care intervention during discharge from subacute care to the ambulatory setting on: 1) the rate of follow-up office visits within 21 days of discharge;2) the rate of appropriate monitoring for high risk medications within 30 days of discharge;3) the incidence of adverse drug events within 45 days after discharge;and 4) the incidence of hospital admissions and emergency department visits within 30 days after discharge. The secondary aim is to determine the costs directly related to the development and implementation of the HIT-based intervention. The results from this study will provide important insights into the effective use of clinical alerts and coordinated delivery of actionable information to improve the quality of care delivered to complex elderly patients transitioning from subacute care to the ambulatory setting.

Public Health Relevance

Using HIT to Improve Transitions of Complex Elderly Patients from SNF to Home Older adults with complex medical conditions and medication regimens who return home after discharge from skilled nursing facilities are at high risk of adverse events. Coordinated delivery of health information from clinicians managing patients in skilled nursing facilities to their outpatient physicians and visiting nurses can improve the quality and safety of medication management and follow-up care. We propose a randomized trial to evaluate a health information technology transitional care intervention with enhanced medication reconciliation and monitoring alerts to improve medication safety among older patients during transitions from skilled nursing facilities to home.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Demonstration and Dissemination Projects (R18)
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Special Emphasis Panel (ZHS1-HSR-A (01))
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Roper, Rebecca
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University of Massachusetts Medical School Worcester
Internal Medicine/Medicine
Schools of Medicine
United States
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Donovan, Jennifer L; Kanaan, Abir O; Gurwitz, Jerry H et al. (2016) A Pilot Health Information Technology-Based Effort to Increase the Quality of Transitions From Skilled Nursing Facility to Home: Compelling Evidence of High Rate of Adverse Outcomes. J Am Med Dir Assoc 17:312-7
Field, Terry S; Garber, Lawrence; Gagne, Shawn J et al. (2012) Technological resources and personnel costs required to implement an automated alert system for ambulatory physicians when patients are discharged from hospitals to home. Inform Prim Care 20:87-93
Tjia, Jennifer; Fischer, Shira H; Raebel, Marsha A et al. (2011) Baseline and follow-up laboratory monitoring of cardiovascular medications. Ann Pharmacother 45:1077-84
Tjia, Jennifer; Field, Terry S; Fischer, Shira H et al. (2011) Quality measurement of medication monitoring in the ""meaningful use"" era. Am J Manag Care 17:633-7
Tjia, Jennifer; Field, Terry S; Garber, Lawrence D et al. (2010) Development and pilot testing of guidelines to monitor high-risk medications in the ambulatory setting. Am J Manag Care 16:489-96