None listed
Conditions
Brief summary
After hospital discharge, over 90% of Australians have at least one medication-related problem. Transitions of care are a period when the risk of medication errors and adverse events is high. Improving medication safety at these transitions is one of three flagship areas of the World Health Organisation Global Patient Safety Challenge: Medication Without Harm. In Australia, an estimated 250,000 hospital admissions annually are medication-related, costing $1.4 billion per year. In particular, rural and remote Australians are up to 2.4 times more likely to have a preventable hospitalisation than non-rural Australians. Furthermore, Aboriginal and Torres Strait Islander people, who often live in rural and regional areas, are three times as likely to have a preventable hospitalisation than non-indigenous Australians. Medication-related hospital readmissions in rural and regional Australian hospitals have been shown to be due to inappropriate/suboptimal pharmacological therapy at discharge in 62% of cases and inadequate communication/monitoring in 41% of cases. Due to pharmacists’ expertise in medication management, two systematic reviews have shown that pharmacy-led transitions of care services can successfully reduce hospital readmissions. These systematic reviews showed that the combination of (i) targeting specific patient populations and (ii) utilisation of an effective transition of care stewardship (TOCS) intervention reduced 30-day readmissions with the meta-analysis showing a 32% reduction in odds for readmission. These TOCS interventions included discharge counselling, discharge medication reconciliation and medication reviews. In Australia, the Commonwealth funds pharmacist led HMRs, which have been shown to reduce medication errors and unplanned hospital readmissions if provided promptly. When high-risk patients receive a timely post-discharge HMR, the rates of unplanned readmission reduce (45% vs 28%, P<0.05). Despite this, strategies (i) and (ii) described above are not routinely implemented and the provision of HMRs to high-risk patients after discharge is unacceptably low at 1-2%. A recent study by our team (2022) explored the reasons for low uptake of post-discharge HMRs. We found many implementation issues that are reflected in the Consolidated Framework for Implementation Research (CFIR). These include the (i) outer setting (GPs not remunerated for participating in hospital-initiated medication reviews, HMR numbers capped for pharmacists, pharmacists not funded for case conferences), (ii) inner setting (limited staffing for transitions of care), (iii) processes (lack of streamlined pathways, no risk tools used) and (iv) individuals involved (poor prescriber awareness). To address these concerns, our team developed the SHPA Hospital-initiated Medication Review protocols to support hospital clinicians to facilitate timely post-discharge medication reviews.
Interventions
The intervention is based on the Consolidated Framework of Implementation Research as it has been used extensively to implement health services. The intervention will include virtual Transition of Care Stewardship pharmacists to ensure patients receive discharge counselling, discharge medical reconciliation, and communicate directly with primary care providers (GPs, practice nurses, community pharmacies and accredited pharmacists). They will provide accurate and timely medication handover to fac
The intervention is based on the Consolidated Framework of Implementation Research as it has been used extensively to implement health services. The intervention will include virtual Transition of Care Stewardship pharmacists to ensure patients receive discharge counselling, discharge medical reconciliation, and communicate directly with primary care providers (GPs, practice nurses, community pharmacies and accredited pharmacists). They will provide accurate and timely medication handover to facilitate a timely post-discharge medication review. Patients’ autonomy is central to the intervention, as they can choose whether they prefer a face-to-face HMR or a virtual HMR. HMR will our with 30 days of discharge and then follow ups at 90 and 180 days. In the study, the Research Assistant will be responsible for providing information to potential participants. Once consent is obtained, the participants will be randomly assigned to one of two groups: Usual Care Group: Participants in this group will continue to receive the usual care provided by the hospital at discharge. They will follow the standard procedures and protocols without any additional intervention. Intervention Group: Participants in this group will also go through the usual care process but will additionally have access to the TICTOC service. The TICTOC service will provide them with additional support or interventions beyond the usual care, tailored to their needs. As part of the study, regardless of the group allocation, participants will be contacted by a researcher for a brief interview either just before discharge from the hospital or once they return home. The purpose of this interview is to gather information about their hospital stay, medications, and how to effectively manage them. The interviews will be conducted by researchers who have received training in qualitative research methods, using telephone or videoconferencing as the mode of communication. In the intervention group, just before discharge, a pharmacist will have a brief conversation with the participants using the hospital computer system to arrange a Home Medicine Review (HMR). The HMR involves a consultation with a pharmacist that typically lasts between 30 to 60 minutes. Ideally, this consultation will take place at the participant's home. However, if necessary, it can also be conducted virtually or at an Aboriginal Medical Service. Following the consultation, the pharmacist will provide a report to the participant's medical service or general practitioner, and the participant will receive a summary of the consultation. The goal of the HMR is to assist the participants and their local health practitioners in effectively managing their care and medications. Researchers will compare the patient's medication list before and after the review to identify any discrepancies or changes in medication adherence. Follow-up assessments will be conducted through patient interviews or follow-up visits to evaluate their adherence to the medication regimen. Patients will also receive lay summaries of the HMR reports to empower them to take responsibility for their medication management. The data collection phase will span over a period of 6 months. This means that participants will be followed up and their data will be collected during this time frame to evaluate the effectiveness and outcomes of the intervention. Furthermore, GPs, and accredited and community pharmacists’ collaboration will be encouraged through case conferences to discuss complex patients (remunerated for their time). The intervention will also be adapted to local needs. Pharmacists caring for Aboriginal and Torres Strait Islander peoples will complete Cultural Responsiveness Training by the Indigenous Allied Health Australia at least one month prior to the intervention administered. Furthermore, this study will explore the implementation aspects of the intervention. The SHPA (Society of Hospital Pharmacists of Australia) pathway implemented in this study has the primary objective of preserving patients' existing support systems by involving their regular General Practitioner (GP). The intention is to collaborate with the GP to ensure continuity of care. However, in cases where the GP is unavailable or an urgent Home Medicine Review (HMR) referral cannot be facilitated through the GP, the study allows for a hospital-based medical specialist to make the referral instead. In such cases, the GP will be informed about the review and provided with a copy of the pharmacist's report, ensuring effective communication and coordination of care. The SHPA protocols used in this study encompass various aspects including screening and risk stratification, information sharing, home visits, follow-ups, and delineation of responsibilities for each clinician involved. These protocols serve as the foundation for the study, providing a standardized framework to guide the implementation and execution of the intervention. By incorporating these protocols, the study aims to ensure consistent and comprehensive management of participants' care, promoting collaboration among healthcare professionals and optimizing patient outcomes.
Sponsors
The Commonwealth of Australia represented by the Department of Health and Aged Care (Funding Agreement managed by The Department of Industry, Science and Resources)
Study design
Allocation
Randomised controlled trial
Intervention model
Parallel
Primary purpose
Prevention
Masking
Open (masking not used)
Eligibility
Sex/Gender
All
Age
18 Years to 100 Years
Healthy volunteers
No
Inclusion criteria
Eligible patients must be aged greater than or equal to 18 years, admitted under a medical specialty, discharged to a domiciliary setting, have a GP, have a Medicare card, and be at risk of readmission (defined as high-risk according to the PHarmacie-R risk algorithm).
Exclusion criteria
Exclusion criteria include unmanaged substance use disorder or mental health condition, active palliative care, homelessness, admission for planned dialysis, unsafe home environment (domestic violence or aggression), and planning to change residence in six months, or previously recruited.
Outcome results
None listed