Pharmacist involvement in helping patients at discharge from hospital and the effect on their wellbeing and readmission to hospital

For patients enrolled to the intervention arm, they will be provided with the current standard of care (which involves a clinical review of medications, some may have a medicines reconciliation on admission (they qualify for this based on the local criteria for this), counselling on only specific medications such as warfarin or home intravenous antibiotics) by the ward pharmacist AND a more comprehensive, individualised discharge service by the study pharmacist. This will occur only on discharge from hospital as a single event (if the patient is to go home outside of pharmacy hours, the discharge service will occur the next working day and education will occur via telephone) The discharge service is expected to take up to an hour (however this will vary patient to patient). It will include: Patient counselling of medicines Discharge medication reconciliation Organise a compliance aid if necessary Returning patient’s own medicines Medication card and medicine information leaflets Assist with access to medication Review of the medication related information on the discharge summary Comprehensive General Physician and community pharmacist handover (including medication changes, discharge medication list, ongoing monitoring, any drug interactions) If deemed necessary, a referral to a Clinical Pharmacist working in the PHO The participants will also be asked to complete a single question health literacy test and a quality of life survey. Every intervention provided to each participant will be documented on an 'intervention' form for analysis at the end of the trial.