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Transitions of Care Case Report: University of Tennessee Health Sciences Center

SafeMed is an initiative developed by the University of Tennessee in partnership with Methodist LeBonheur Healthcare and funded by a Center for Medicare and Medicaid Services (CMS) Health Care Innovation Award. The University of Tennessee Health Sciences Center in Memphis, TN, was the original SafeMed site. The program used in Memphis can be adapted by individual practices to:

  • Reduce drug therapy problems

  • Reduce patient morbidity and mortality resulting from preventable drug therapy problems

  • Reduce avoidable hospital readmissions

  • Lower costs

  • Improve medication adherence

  • Improve disease management

  • Improve patient health

As part of the SafeMed program, a report is run every morning that indicates to the clinic which of its assigned patients has been hospitalized within the last 24 to 72 hours. This allows the SafeMed nurse leader to help determine which patients might benefit from SafeMed care transitions support so that home visits can be scheduled. Regular home visits are typically scheduled at two and four weeks post-discharge. The community health workers (CHW) are the primary point of contact for patients. The CHW meet with the SafeMed team physician, pharmacist and nurse leaders on a daily basis, both in person and by phone, to address specific medication problems or care management issues identified during home visits. The CHW also meet with the SafeMed team leaders as a group on a weekly or monthly basis to conduct case reviews and refine care plans.

Program participants are invited to regular clinic-based SafeMed peer group support and educational sessions. Support session topics can be suggested by patients to meet their needs and may include speakers and discussions, but should primarily employ group problem-solving techniques. The support sessions are used to empower patients to ask questions and help them better navigate the health system. It is recommended that each patient remain in the program for a minimum of 3 months to receive the maximum benefit from the approach.

The SafeMed experience in Memphis reported by the University of Tennessee Health Science Center suggests that using a care transitions team model can have a very positive effect on a practice and its patients.

Emergency department visitsRecently hospitalized super-utilizing patients with multiple chronic conditions experience on average six ED visits resulting in more than three hospitalizations in a 12-month periodRecently hospitalized super-utilizing patients with multiple chronic conditions experience 30 percent fewer hospitalizations, 44 percent fewer 30-day readmissions, and 52 percent fewer ED visits in a 6-month period
Primary care visits46 percent of patients report not having a regular primary care provider (PCP); fewer than 50 percent follow-up with a PCP within 30 days after dischargeMore than 80% of recently hospitalized super-utilizing patients follow-up with their PCP or patient centered medical home (PCMH) within 30 days of discharge and most patients follow-up with their physician within 72 hours of discharge
Information from PCPPatients perceive that the information from their PCP or specialist is not tailored enough to their situation and is inconsistentPatients perceive that the information given by their providers is more tailored to their situation and consistent
Non-adherence or non-compliance issuesProviders are frustrated with patients who appear to be noncompliantProviders are less frustrated with patients because they now understand the underlying social problems contributing to nonadherence
Provider relationshipsPatients perceive that their relationship with their provider needs to improvePatients perceive that their relationship with their provider is improved
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