SafeMed — From hospital to home: A Collaborative 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. A new module from 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 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.
https://www.stepsforward.org/modules/safemed-transition-care