Using Health Information Technology (HIT) to Improve Transitions of Complex Elderly Patients From Skilled Nursing Facility (SNF) to Home

2014-07-23 21:11:56 | BioPortfolio


The incidence of drug-induced injury is high in the ambulatory geriatric population, especially for elders with complex healthcare needs during high risk transitions to the ambulatory setting. In a previous study funded by the National Institute on Aging and the Agency for Healthcare Research and Quality [AHRQ] (AG 15979), the investigators determined that drug-related injuries occur at a rate of more than 50 per 1000-patient years in older adults in the ambulatory setting and that 28% are preventable. Independent risk factors for adverse drug events among older adults in the ambulatory setting included advanced age, multiple comorbid conditions, and the use of medications requiring close monitoring. In this project, Using HIT to Improve Transitions of Complex Elderly Patients from SNF to Home (1 R18 HS017817), the investigators are testing the use of an electronic medical record (EMR)-based medication reconciliation system for complex elderly patients transitioning from subacute care in a skilled nursing facility (SNF) to the ambulatory setting. 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 outpatient primary care physicians to coordinate with visiting nurses in order 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 investigators will use the EMR to assure that physicians in the ambulatory setting and visiting nurses receive key health information and alerts. In order to evaluate the impact of their HIT-based transitional care intervention, the investigators propose a randomized controlled trial with three arms: (1) HIT-based delivery of key health information and alerts to the primary care physician; (2) HIT-based delivery of key health information and alerts to both the primary care physician and the visiting nurse; and (3) usual care.

Study Design

Allocation: Randomized, Control: Active Control, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Investigator, Outcomes Assessor), Primary Purpose: Health Services Research


Adverse Outcomes


Intervention 1: Electronic medical record (EMR)-based medication reconciliation system, Intervention 2: Electronic medical record (EMR)-based medication reconciliation system, Control Group


Fallon Clinic
United States


Not yet recruiting


University of Massachusetts, Worcester

Results (where available)

View Results


Published on BioPortfolio: 2014-07-23T21:11:56-0400

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A system of record keeping in which a list of the patient's problems is made and all history, physical findings, laboratory data, etc. pertinent to each problem are placed under that heading.

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