How will this module help me use the SafeMed model in my practice?
Four STEPS to develop and implement the SafeMed model.
Answers to common questions about SafeMed.
Tools to develop training materials and track progress.
Quiz Ref IDComplex patients, such as those with multiple chronic conditions, polypharmacy, and unmet social needs, are particularly at risk for serious drug therapy problems during transitions from hospital to home. The SafeMed care transitions model uses intensive medication reconciliation and home assessments to manage high-risk/high-needs patients in the primary care practice who tend to be heavy utilizers of inpatient and emergency services. The SafeMed model leads to decreased hospital and emergency department utilization, and improved outcomes for the target patient population.
The SafeMed model1 was originally developed at the University of Tennessee/Methodist Le Bonheur Healthcare and funded by a Health Care Innovation Award from the Centers for Medicare and Medicaid Services (CMS). The model was designed with the strengths of primary care in mind and relies on primary care-based team members, including physicians, pharmacists, nurses, and community health workers, to form a support network for high-risk/high-needs patients as they transition from the hospital to outpatient setting. These team members work closely with patients to forge strong relationships that make it easier to coordinate and manage their care. This module provides guidance, tools, and resources at no cost so you can adapt the SafeMed model for your practice.
Four STEPS to building a SafeMed care transitions team
Develop your care transitions plan.
Identify complex patients who are candidates for the program.
Assemble and train your SafeMed team.
Start the transition process and refine the plan over time.
Step 1 Develop your care transitions plan.
Start holding regular team meetings to plan for the implementation of SafeMed. Think about how to scale the SafeMed model to fit your practice's needs and to best take care of the patients who will benefit from your new program. You may want to consider working with multiple practices in your area to pool resources and create a SafeMed team as a shared community resource.
When you have a good idea of your practice's capabilities and how you intend to work with a partner, review and think about how to modify SafeMed job descriptions, protocols, and procedures to meet your target patients' needs.
Step 2 Identify complex patients who are candidates for the program.
Identify the most vulnerable patients who will receive the greatest benefit from intervention by the SafeMed team. If you have a smaller practice or only a few high-risk/high-needs patients, consider partnering with another practice to increase the size of your target population.
Example: Mr. S. was a 58-year-old Caucasian man with multiple chronic conditions and a history of depression and cocaine use. With the intensive support of all members of the SafeMed care transitions team at University of Tennessee/Methodist Le Bonheur Healthcare, he was able to get assistance with medications and homemaker services, meet his self-identified health goals, develop positive relationships with his providers, and subsequently avoid rehospitalization.
Step 3 Assemble and train your SafeMed team.
Quiz Ref IDQuiz Ref IDSelect a leader to champion the effort, designate team leads, and hire any additional staff you need to make your care transitions plan work. The typical SafeMed team consists of three team leaders: a physician, nurse, and pharmacist, plus two community health workers (CHWs), one pharmacy technician, and one licensed practical nurse (LPN), medical assistant (MA), or health coach.
The SafeMed team will work with the rest of the primary care practice team and local pharmacies to help patients effectively manage their conditions and medications; therefore, team members should be knowledgeable about practice workflows and chronic disease symptoms, signs, medications, and treatment. All SafeMed team members should receive training in motivational interviewing, patient advocacy, transitions of care, and mental health issues.
The resources below can help you implement SafeMed within your practice as you develop your transitional care program.
SafeMed protocols and procedures (894 KB) Patient Continuity of Care Questionnaire (881 KB)
Step 4 Start the transition process and refine the plan over time.
Quiz Ref IDUse your electronic health record (EHR) to identify high-risk/high-needs patients who meet your practice's criteria so that they can be flagged for the transitions team immediately in the event of an ED visit or hospital admission. Running a daily report will help you to identify eligible patients in real-time and begin the transition process.
Key performance metrics will indicate the impact of the care transitions team, and highlight areas for further development or improvement. Use your results to make rapid cycle or longer-term improvements to the process.
The SafeMed model draws on existing primary care strengths and targets high-cost, high-risk/high-needs patients with a focus on medication and chronic disease management. By using proven methodology and team-based care approaches, practices can use SafeMed to simultaneously improve care and patient health while reducing costs.