Program Model

This model uses a team-based approach to include nursing, pharmacy, and social work staff to address complex medical and social problems. The central tenet of this model is the use of LPN’s and pharmacy technicians as community health workers, serving as both nurse and pharmacist extenders, obtaining medication histories, assisting in medication reconciliation and identification of potential drug therapy problems (DTP), and reinforcing medication education previously provided by the pharmacist and APN/RN per protocol. Community training included patient communication skills, motivational interviewing, medication history taking, teach-back techniques, drug disposal practices, and basic disease management.

The core of the intervention lasts a total of 45 days as follows:

Timing (Week post-discharge)	Activities	Lead Staff*
Hospital-based
0
	Real time in-hospital identification, screening and enrollment of eligible patients	NP, RN
	Introduction of SafeMed team, patient engagement, and establishing relationship between patient and SafeMed team members	All SafeMed staff
	Medication reconciliation and medication therapy management	PharmD
	Enhanced discharge preparation, planning, education, and care coordination with outpatient providers and community resources	NP, PharmD, RN, SW
Community-based
1	1st Home Visit within 72 hours of discharge Symptom and physical assessment Medication reconciliation Medication therapy management Identify and address social needs	LPN-CHW CPhT-CHW PharmD (remote) SW (as needed)
2	Phone Follow-up and Care Coordination to ensure PCP follow-up within 14 days of enrollment	NP, PharmD, LPN-CHW, and CPhT-CHW
3	2nd Home Visit Symptom and physical assessment Medication reconciliation Medication therapy management Identify and address social needs	LPN-CHW CPhT-CHW PharmD (remote) SW (as needed)
4	30-day Phone Follow-up	LPN-CHW and CPhT-CHW
5	Comprehensive Medication Review (30-45 days after enrollment)	PharmD (CPhT-CHW to schedule)
6	SafeMed Support Session	All SafeMed staff
* The following abbreviations are used for lead SafeMed staff categories: Nurse Practitioner (NP), Registered Nurse (RN), Pharmacist (PharmD), Social Worker (SW), Licensed Practical Nurse–Community Health Worker (LPN-CHW), Certified Pharmacy Technician–Community Health Worker (CPhT-CHW).

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