1. Using the SafeMed model for transitions of care approach
Increase engagement and adherence for complex patients

2. What is the SafeMed model?
The SafeMed care transition 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.

3. How does the SafeMed model work?
High-risk patient for emergency department readmission
SafeMed team works closely with patients to forge strong relationships and make it easier to coordinate and manage their care.
Extend primary care from the hospital to the home

4. Benefits of the SafeMed model
Reduce drug therapy problems
Reduce patient morbidity & mortality resulting from preventable drug therapy problems
Reduce avoidable hospital admissions
Lower costs
Improve medication adherence
Improve disease management
Improve patient health

5. Four STEPS to building a SafeMed care transitions team1
Develop your care transitions plan 2
Identify complex patients who are candidates for the program 3
Assemble and train your SafeMed team 4
Start the transition process and refine the plan over time

6. How is it working in other practices?
Memphis, TN
Steps in Practice Summary = UT Health Sciences Center in Memphis, TN
SafeMed developed by University of Tennessee in partnership w/ Methodist LeBonheur Healthcare – funded by a CMS Health Care Innovation Award
Original Site of SafeMed – UT Health Sciences Center in Memphis, TN
SafeMed runs a morning report every day to check for assigned patients who have been hospitalized within the last 24 to 72 hours
Nurse Leader uses the report to determine patients who’d benefit from SafeMed care transitions
Patients indicated have home visits scheduled 2 and 4 weeks post-discharge
Community Health Worker (CHW) becomes patients primary contact point
CHW communicates with all members of the care team on a daily basis, as well as weekly or monthly meetings with SafeMed team leaders
SafeMed members invited to regular clinic-based peer group support & educational sessions
Used to empower patients to ask questions & navigate health system
Recommended minimum 3 month participation for max. benefits
Positive effects of SafeMed experience in Memphis reported by the University of Tennessee Health Science Center
Patient experience – “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 pf 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.”

7. For additional resources, frequently asked questions and implementation support, visit