title: Interprofessional Collaboration to Improve Discharge from Skilled Nursing Facility to Home: Preliminary Data on Postdischarge Hospitalizations and Emergency Department Visits.
abstract: An interprofessional collaborative practice model was established at Hennepin County Medical Center to improve discharge management from the transitional care unit of the skilled nursing facility (SNF) to home. The practice model involves a geriatrician, nurse practitioner, and pharmacist who care for individuals at a community-based SNF. Before SNF discharge, the pharmacist conducts a chart and in-person medication review and collaborates with the nurse practitioner to determine the discharge medication regimen. The pharmacist's review focuses on assessing the indication, safety, effectiveness, and convenience of medications. The pharmacist provides follow-up in-home or over the telephone 1 week after SNF discharge, focusing on reviewing medications and assessing adherence. Hospitalizations and emergency department (ED) visits 30 days after SNF discharge of individuals who received care from this model was compared with those of individuals who received usual care from a nurse practitioner and geriatrician. From October 2012 through December 2013, the intervention was delivered to 87 individuals, with 189 individuals serving as the control group. After adjusting for age, sex, race, and payor, those receiving the intervention had a lower risk of ED visits (odds ratio (OR) = 0.46, 95% confidence interval (CI) = 0.22-0.97), although there was no significant difference in hospitalizations (OR = 0.47, 95% CI = 0.21-1.08). The study suggests that an interprofessional approach involving a pharmacist may be beneficial in reducing ED visits 30 days after SNF discharge.
authors.affiliation: College of Pharmacy, University of Minnesota, Minneapolis, Minnesota. reid0113@umn.edu.|Hennepin County Medical Center, Minneapolis, Minnesota. reid0113@umn.edu.
authors.forename: Shannon L
authors.initials: SL
authors.lastname: Reidt
authors.affiliation: Hennepin County Medical Center, Minneapolis, Minnesota.
authors.forename: Haley S
authors.initials: HS
authors.lastname: Holtan
authors.affiliation: College of Pharmacy, University of Minnesota, Minneapolis, Minnesota.
authors.forename: Tom A
authors.initials: TA
authors.lastname: Larson
authors.affiliation: Comprehensive Pharmacy Services, Minneapolis, Minnesota.
authors.forename: Bruce
authors.initials: B
authors.lastname: Thompson
authors.affiliation: Hennepin County Medical Center, Minneapolis, Minnesota.
authors.forename: Lawrence J
authors.initials: LJ
authors.lastname: Kerzner
authors.affiliation: College of Pharmacy, University of Minnesota, Minneapolis, Minnesota.
authors.forename: Toni M
authors.initials: TM
authors.lastname: Salvatore
authors.affiliation: College of Pharmacy, University of Minnesota, Minneapolis, Minnesota.
authors.forename: Terrence J
authors.initials: TJ
authors.lastname: Adam
mesh_terms: D000046:Academic Medical Centers; D015897:Comorbidity; D003266:Continuity of Patient Care / Q000458:organization & administration*; D057286:Electronic Health Records; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D033183:Interdisciplinary Communication; D000070516:Intersectoral Collaboration; D059065:Medication Reconciliation / Q000458:organization & administration; D008910:Minnesota; D010348:Patient Care Team / Q000458:organization & administration*; D010351:Patient Discharge; D012866:Skilled Nursing Facilities; D000069341:Transitional Care / Q000458:organization & administration; D014600:Utilization Review / Q000706:statistics & numerical data
keywords: medication-related problem; skilled nursing facility; transitions of care