Evaluating a Collaborative Approach for Reducing harm and optimising Medication outcomes through partnered prescribing: The CARe-Med study.

The intervention will be Partnered Pharmacist Medication Prescribing (also known as “PPMP”). Partnered Pharmacist Medication Prescribing refers to the prescribing for administration of patient medicines by a credentialled pharmacist, after patient engagement and a documented clinical conversation with a medical officer responsible for the patient’s care. In the CARe-Med study Partnered Pharmacist Medication Prescribing may occur on admission, during the inpatient stay and on discharge. The intervention will be performed by credentialled partnered prescribing pharmacists and will encompass partnered prescribing on admission, partnered prescribing during the inpatient stay, and partnered prescribing on discharge, as described in detail below. Intervention pharmacists will be employed to work the standard 37.5 h per week, this includes five 7.5 h shifts on Monday-Friday each week, typically between the hours of 8am-5pm, with precise shift start and finish times dependent on workflows within the clinical unit. The intervention pharmacist will not provide a service after hours or over the weekend. At times, the appointed intervention pharmacist may require sick leave and/or personal leave. For periods of planned leave extending beyond 5 consecutive days cover will be provided by an alternative suitably trained pharmacist where available. The intervention will primarily be performed by the intervention pharmacist deployed as part of this trial, however supplementary partnered prescribing may also be performed by the existing usual care pharmacist during the intervention period, if they are appropriately credentialled to prescribe. The intervention will be performed in accordance with the the local approved frameworks and procedures for Partnered Pharmacist Medication Prescribing (PPMP) within SA Health and Metro South Health. The intervention will be implemented in addition to usual care. This means patients who receive the partnered pharmacist prescribing intervention may also have medicines prescribed by doctors. All pharmacists delivering the intervention will be employed by the appropriate health service (SA Health or Metro South Health) and will be trained and credentialled to undertake collaborative partnered pharmacist prescribing in line with the locally approved credentialing procedures. These processes have been through multidisciplinary consultation and have been endorsed through formal governance processes within each health service. In line with local credentialling processes, employers will be responsible for ensuring all pharmacists delivering this model of care remain appropriately credentialled throughout the intervention period. Not fixed timing of the credentialling process (which includes training) is set relative to the CARe-Med study, if a pharmacists credentials remain current per the local requirements, they are sufficiently qualified to deliver the partnered pharmacist medication prescribing intervention. Partnered pharmacist prescribing for inpatient administration: On admission, the partnered prescribing pharmacist (or another pharmacy team member) conducts a best possible medication history. The partnered prescribing pharmacist then discusses the medication-related treatment goals and preferences with the patient and/or their family/carer as clinically appropriate. The conversation with the patient and/or family/carers is anticipated to take up to 15 minutes, although the duration required will be dependent the complexity of the medication regimen and other patient-specific factors. Next the pharmacist reviews the medication history in the context of the patient’s current admission, preferences and goals and creates a shared medication management plan, which is discussed with the patient and the treating medical officer, documented in the progress notes and co-signed by the treating medical officer and the partnered prescribing pharmacist. The plan may include medications the patient was taking prior to admission (with or without modifications) and/or new medications, depending on the clinical need. A copy of documentation of this medication plan and/or goals discussed will not routinely be provided to the patient, in line with local practice for documenting inpatient clinical care decisions. Deprescribing, as part of good prescribing process, may occur when determining the medication plan, with partnered prescribing pharmacists encouraged to consider the CEASE framework in their medication assessment. Finally, the partnered prescribing pharmacist prescribes the patients medications as per the co-signed medication management plan in the electronic medical record and communicates with the nursing staff regarding the prescribed medicines as necessary. This process may be repeated from the point of discussing, documenting and co-signing a medication management plan onwards at any time during the inpatient stay, for example, during ward rounds. The initial partnered pharmacist medication prescribing on admission will occur as soon as practical after admission, ideally within 12 hours. If partnered prescribing is not feasible in a timely manner independent medical prescribing will take place, as the intervention is in addition to usual care. Electronic medical record data will be reviewed regularly during the transition and intervention periods to monitor adherence to this component of the intervention. Partnered pharmacist prescribing on discharge: In the CARe-Med intervention, partnered pharmacist medication prescribing may also occur during the discharge process. In this situation, the pharmacist reviews the patients medication regimen in the context of the patient’s current admission, preferences and goals and creates a shared medication management plan for discharge. The conversation with the patient and/or their family/carer(s) is anticipated to take up to 15 minutes, although the duration required will be dependent the complexity of the medication regimen and other patient specific factors. The medication management plan for discharge is discussed with the medical team, documented in the progress notes and co-signed by the treating medical officer and the partnered prescribing pharmacist. As for inpatient prescribing, the plan may include medications the patient was taking prior to admission (with or without modifications) and/or new medications, depending on the clinical need. The partnered prescribing pharmacist prescribes the patients medications as per the co-signed medication management plan to create a discharge prescription using the electronic medical record. The partnered prescribing pharmacist then liaises with the usual care pharmacist and/or other staff to have the prescription dispensed. This prescription will not be eligible for subsidy via the Pharmaceutical Benefits Scheme and thus to prevent unnecessary financial burden on the patient, the prescription must be dispensed at the subsided rate by the hospital dispensary prior to discharge. The partnered prescribing pharmacist then includes a summary of the medication management plan in the transition of care communication documents, in line with local discharge processes. The partnered prescribing pharmacist then includes a summary of the medication management plan in the transition of care communication documents, in line with local discharge processes. Typically, a copy of the relevant transition of care documents (which will include a summary of the medication managment plan) is provided to the patient on discharge. If the clinical unit is within a hospital that does not have an on-site dispensary, or for sites where local authorisation for prescribing on discharge cannot be obtained, the pharmacist will complete all steps above to create a collaborative medication plan for discharge and will liaise with the medical team to ensure the discharge prescription is prepared accordingly. Electronic medical record data will be reviewed regularly during the transition and intervention periods to monitor adherence to this component of the intervention. In this stepped-wedge trial the duration of each "step" is one month, i.e. the intervention will be implemented at each subsequent site after a one month interval.