Objectives 

Both social and medical factors can negatively affect health outcomes, especially in vulnerable populations. To address these 2 types of factors in a postdischarge population, 2 nonprofit organizations collaborated to combine their novel decision support programs and address the question: Could combined programs have greater potential for improved health outcomes?

Methods 

HomeMeds, a social health program in which trained social services staff make home visits to vulnerable clients, was combined with MedSafety Scan, a medical health, clinical decision support tool. Data captured in the home visits were entered into the HomeMeds and MedSafety Scan programs to detect those patients at the greatest risk of adverse health outcomes because of medications.

Results 

Patients (n = 108; mean age, 77 years; multiple comorbidities and LACE+ (length of stay, acuity, comorbidities, emergency department visits [hospital index]; score >29) received a postdischarge home visit by trained social services staff. The number of drugs reported as being taken was 10.4 ± 5.1 (range, 1–26), which was less than prescribed at discharge in 62% of patients (range, 1–8). Both programs detected a serious risk of medication-induced harm, mostly from different causes such as drug-drug interactions or for use not recommended in the elderly.

Conclusions 

Combined analysis of data from 2 novel decision support programs yielded complementary findings that together address both medical and social determinants of health. These have the potential to reduce medication-induced harm, costly rehospitalization, and/or emergency department visits and support the further evaluation of this combined approach in other vulnerable populations such as the seriously mentally ill, frail, those confined to home, opioid dependent, or otherwise impaired.