(1169) Engaging Social Workers to Identify Patients in Need

Objectives: 1. To describe the work of a pharmacist and social worker care team in a rural and underserved community.
2. To explain the impact of this work on patient engagement, satisfaction, health, hospitalization and emergency room encounters.

Methods: Pharmacists at a rural hospital in a medically underserved area are collaborating with local social workers to identify patients with chronic conditions who are at high risk for hospitalization. Patients must meet the following inclusion criteria: age 50 years or older; at least three chronic medical conditions; taking at least five medications; and not meeting guideline-specified goals for at least one chronic medical condition. Pharmacists and social workers meet with enrolled patients together to identify medication-related problems, develop solutions, and send recommendations to local physicians. Interventions include: optimization of therapy; discontinuation of duplicate therapy; coordinating formulary requirements with clinical needs of the specific patient; and provision of educational, nutritional, and social support.

Results: Since inception of the program 18 months ago, 156 patients have been enrolled in the program. Each has been seen at least once by the pharmacist where drug-drug and/or drug-disease interactions have been identified and brought to the primary care provider. Interventions range from optimization of therapy, to discontinuation of duplicate therapy, to coordinating formulary needs with clinical needs of the specific patient, to provision of educational, nutritional, and social support. Seventy-eight percent of patients report meeting their personal goals with the help of their pharmacist and social worker. Seventy-one percent report they have improved quality of life. Eighty-five percent report an improvement in their health activation and motivation for future health improvement. Emergency room visits decreased by 38% and hospital utilization decreased by 12%.

Conclusions: Pharmacists can engage local social workers to assist in identifying patients who are at high risk for hospitalization and engage with patients to address healthcare needs. This program has been well-received by patients and has a positive impact on quality of life. The interventions of the pharmacist and consistent support of the care team led to a decrease in hospitalization and emergency room usage.