Using Health Information Technology to Improve Transitions of Complex Elderly Patients from Skilled Nursing Facilities (SNF) to Home

This project developed and evaluated a medication reconciliation intervention for medication monitoring and followup of elderly patients discharged from a skilled nursing facility (SNF), with a goal of reducing the incidence of drug-induced injury. The research team evaluated the intervention through a time-series assessment to measure the efficacy of communicating key health information and alerts to outpatient primary care physicians and visiting nurses. Therapeutic monitoring guidelines were developed and integrated into the ambulatory electronic medical record (EMR) used at the Fallon Clinic. A range of outcomes were evaluated including the rate of followup office visits, the rate of appropriate monitoring for high-risk medications, the rate of hospital readmission and emergency department (ED) visits, and the incidence of adverse drug events (ADEs). In addition an analysis was completed on the development and implementation costs. 

The specific aims of the project were to:

• Evaluate the impact of automated scheduling alerts on the rate of followup office visits with an outpatient physician within 21 days of discharge from sub-acute care. 
• Evaluate the impact of automated monitoring alerts on the rate of appropriate monitoring for selected high-risk medications within 30 days of discharge from sub-acute care. 
• Evaluate the impact of a health information technology-based transitional care intervention on the incidence of ADEs within 45 days after discharge from sub-acute care. 
• Evaluate the impact of a health information technology-based transitional care intervention on the incidence of hospital readmission and emergency department visits within 30 days of discharge from sub-acute care. 

The study team did not find significant improvements in visits to outpatient providers following discharge from a SNF, laboratory monitoring in response to alerts, ADE rates, or rehospitalization rates relating to the intervention. However, ED visits were significantly lower during the intervention period. The development costs for establishing the automated system were estimated at $76,314 with the major costs and time contributions from physicians to develop content, provide overall project management, and review alerts during the test period.

The study identified several additional important issues, including that older adults discharged from SNFs to home are a highly vulnerable population. They have high rates of medical conditions, including traditionally considered comorbidities as well as serious depression and sensory impairments. Many of them were transferred to a SNF for continued in-patient care after a hospitalization triggered by an ED visit, frequently including trauma. Thirty percent were re-hospitalized within 30 days of the SNF discharge and 30 percent had an ADE within 45 days.  

For this vulnerable group, there was a lack of information in the EMR for two thirds of the discharges identified in the claims data. This suggests the possibility of a serious lack of information flowing to primary care physicians. This is reinforced by the low rates of office visits to primary care physicians, even among this better documented group. Although there were high rates of office visits to other providers, the potential lack of continuity of care would be a source of further medical difficulties for this group of patients.