Preventing Medication-Related Problems in Care Transitions to Skilled Nursing Facilities (Washington)

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Standardizing the hospital-to-skilled nursing facility transition by using a structured handoff between clinical teams along with a pharmacist to monitor patient medications during the transition may reduce medication-related issues for patients.

Project Details - Ongoing

Summary:

The transition of care from hospital to skilled nursing facilities (SNFs) is a complex process that can expose vulnerable patients to higher risk of complications. Delays in transitioning treatment plans along with poor communication among providers can increase hospital readmission, frequently due to medication-related problems after hospital discharge. The standard and antiquated paper-based discharge process required by The Joint Commission is insufficient, with research showing up to 75 percent of patients transferred to SNFs have at least one medication discrepancy from discharge documentation and the SNF admitting plan. Improvements to the transition coordination process is crucial to reduce medication mishaps and avoid unnecessary readmissions, while also relieving some of the emotional distress patients and caregivers experience.

In 2014, the Improving Nursing Facility Outcomes using Real-Time Metrics (INFORM) collaborative was formed to address the identified issues among transitions of care, and worked to standardize processes using best-practice recommendations for discharge. In partnership with the University of Washington (UW Medicine) health system, the Pharmacy Integrated Transitions (PIT) program was developed to standardize the transition process by adding a structured handoff between clinical teams using teleconferencing, along with a pharmacist to monitor patient medication in the process. This research will explore the effectiveness of the PIT program in reducing medication-related problems among patients transitioning from hospital to SNF, as well as measuring patient and caregiver satisfaction.

The specific aims of the research are as follows:

  • Compare the effectiveness of the PIT program and the Joint Commission transition process on medication-related problems. 
  • Compare patient-, family-, and caregiver-reported measures of quality of communication and care coordination between the PIT program and the Joint Commission transition process. 

To determine the effectiveness of the PIT program, the research team will conduct a cluster randomized trial over 5 years, comparing the standard Joint Commission transition process and the PIT program. This study will include all patients over the age of 18 years who are discharged from one of four UW Medicine hospitals to one of the 16 independent SNFs. The SNFs assigned to the PIT program will adopt the pharmacy-led transitional approach, incorporating the structured handoff into their practice. Evaluation will include the occurrence of medication-related problems 30 days following hospital discharge. A patient-reported measure, the Care Transitions Measure (CTM), will be used to capture patient and caregiver assessment of the quality of transition care.

The research team anticipates a significant decrease in medicine-related problems among patients involved in the PIT program, along with improved communication among providers and patients involved in the transition of care process. The PIT program shows promise to greatly reduce hospital readmissions and lessen patient emotional distress by appropriately addressing medication safety. If proven successful, the PIT program has promise for large implementation across the US healthcare system.