The Medicines Management Mapping Project: Using risk stratification and care coordination to bridge the care continuum gap

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Key Research question(s) 1. Will the proposed MMMP model, using a risk tool to stratify patients (The Intervention) increase access to medication management services post discharge compared with those receiving usual care? 2. Will the proposed MMMP model using a risk tool to identify “at-risk” patients (The Intervention) reduce the hospital health utilisation (emergency department visits, hospital admission and length-of-stay) at 30 or 90 days post discharge compared with those receiving usual care? This project aims to reduce the risk of medication misadventure across care transitions by increasing identification of patients at-risk, and hence referral to pharmacist led medication management services. Hypothesis: The routine application of an easy to use, bedside tool can facilitate identification of at-risk patients and trigger referral to an appropriate medication management pathway in the community following hospital discharge. Improving medication management across the continuum continues to be one of the greatest challenges in modern health care. A report to Government on the Home Medicines Review (HMR) declared strong ‘widespread’ unconditional support for hospital-initiated medication review (HIMR) early post-discharge, acknowledging this gap in care. Yet nearly a decade on, there is no nationally accepted pathway for HIMRs to ensure our most vulnerable patients are supported following a hospital admission. A recent Australian systematic review highlighted those most in need of medication review remain underserved, including indigenous and Culturally and Linguistically Diverse populations, and those recently discharged from hospital. Application of the risk tool will facilitate identification of “at-risk” patients and ensure handover to a community medication management service most suited to the individual patient. ‘Risk Stratification’ uses a process to identify people likely to suffer an unplanned hospital admission. There are currently no international or national risk stratification solutions, focused on medication misadventure that can be readily applied to the Australian context. By identifying patients at risk, appropriate coordinated care can be provided to them. The period 7-10 days after hospital discharge is a particularly vulnerable time, and associated with a significant risk of medication related problems. Studies have shown about half of the patients discharged from hospital experience a medical error, with 19% - 23% suffering an adverse event, most commonly an adverse drug event. Through use of a structured framework, actively assessing risk, hospital staff will identify and triage high-risk patients for pharmacist-led medication management services in the community setting. This should improve identification of those at risk and improve care across the continuum.

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