A new care transition model developed by the University of Tennessee Health and Sciences Center in partnership with Methodist Le Bonheur Healthcare in Memphis helped reduce 30-day readmissions by 44 percent at the Health and Sciences Center over a six-month span by improving medication adherence.
The SafeMed program, which is a part of the American Medical Association's STEPS Forward collection of practice improvement initiatives, is designed to assist patients with multiple chronic conditions taking several medications by maintaining appropriated drug adherence during the transition from hospital to home. The SafeMed model uses a collaborative team of physicians, pharmacists, nurses and community health workers to establish a network of support for at-risk patients in transition.
At the Health and Sciences Center, the program was also associated with a 30 percent reduction in overall hospitalizations and a 52 percent reduction in emergency department visits for patients with multiple chronic morbidities.
Here are four steps to successfully implement the SafeMed model:
1. Hold regular team meetings and develop a transitional care plan tailored to suit the needs and size of a particular institution.
2. Identify and enroll vulnerable patients who would benefit the most from the SafeMed program.
3. Assemble and train a team to implement SafeMed strategies. Typical team leadership would be headed by a physician, a nurse and a pharmacist.
4. Refine the plan over time by flagging patients in the program to track hospital and emergency department admissions, assess the team's performance accordingly.
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