From hospital to home: A model for safer transitions

Patients with multiple chronic conditions, polypharmacy and unmet social needs are often at risk for serious drug therapy problems during the transition from hospital to home. A new model has made these transitions safer and decreased hospital admissions and emergency department visits for patients.

Developed by the University of Tennessee in partnership with Methodist Le Bonheur Healthcare in Memphis, the SafeMed model uses a primary care-based team, which includes physicians, pharmacists, nurses and community health workers, to form a support network for high-risk and high-needs patients as they transition from the hospital to the outpatient setting.

The AMA’s STEPS Forward™ collection of practice improvement initiatives can help practice teams implement the SafeMed model, which enables them to work closely with patients to build strong relationships that make it easier to coordinate and manage their care.

The University of Tennessee Health Sciences Center, which contributed this STEPS Forward module after winning the AMA-MGMA Practice Innovation Challenge, saw 30 percent fewer hospitalizations, 44 percent fewer 30-day readmissions and 52 percent fewer ED visits for patients with multiple chronic conditions and frequent ED visits in just six months.

The SafeMed program starts with a report every morning that tells the clinic which of its assigned patients have been hospitalized in the last 24-72 hours. The nurse leader uses the report to determine which patients might benefit from SafeMed care transitions support so that home visits by a community health worker can be scheduled.

Community health workers meet with the SafeMed team physician, pharmacist and nurse leader to address specific medication problems or care management issues identified during home visits. They also meet with the SafeMed team leaders on a weekly or monthly basis to conduct case reviews and refine care plans.

Participating patients are invited to regular clinic-based SafeMed peer group support and education sessions, where they suggest topics for discussion and ask questions to help them better navigate the health system. Each patient is asked to remain in the program for at least three months to receive the full benefit of the approach.

The SafeMed approach used in Memphis can be adapted by individual practices to reduce drug therapy problems, patient morbidity and mortality resulting from preventable drug therapy problems, and avoidable hospital readmissions. It can also lower costs and improve medication adherence, disease management and overall patient health.

The Health Sciences Center followed four steps to implement the SafeMed program:

• Develop a care transitions plan. Regular team meetings are important in the planning process. Think about how to scale the model to fit your practice’s needs and take care of patients.
• Identify complex patients who are good candidates for the program. Pinpoint the most vulnerable patient populations that will receive the greatest benefit from intervention by the SafeMed team.
• Assemble and train the SafeMed team. First, select a leader to designate team leads and hire any additional staff you need to make the plan work. A typical team consists of three team leaders—a physician, a nurse, a pharmacist. The full team may include two community health workers, one pharmacy technician and one licensed practical nurse, medical assistant or health coach. Team members should be knowledgeable about practice work flows and chronic disease symptoms, signs, medications and treatment. All team members should receive training in motivational interviewing, patient advocacy, transitions of care and mental health issues.
• Start the transition process and refine the plan over time. Use your electronic health record (EHR) to identify patients who meet your practice’s criteria so they can be flagged for the transitions team immediately in the event of an ED visit or hospital admission. The daily report will help you identify eligible patients. Track performance to better understand the impact and make improvements to the process.

The module on using the SafeMed model for transitions of care approach is one of eight new modules recently added to the AMA’s STEPS Forward collection of practice improvement strategies to help physicians make transformative changes to their practices. Thirty-five modules now are available, and several more will be added later this year, thanks to a grant from and collaboration with the Transforming Clinical Practices Initiative.

AMA Wire explores many of the other STEPS Forward modules, including why your practice needs a health coach and four questions to ask to find out if your patients have unmet needs.