Readmission to primary care: the role of community pharmacists post-discharge

Abstract

Receiving care in multiple health care settings often means that patients obtain medication from different prescribers. Unfortunately, medication information is often poorly documented and poorly transferred between health care settings. These suboptimal transitions introduce the risk on drug-related problems (DRPs) and consequently jeopardises patients’ safety. Previous studies often focused at medication incongruities at hospital admission. This thesis focused on hospital discharge. As community pharmacists are transforming from traditional medication dispensing towards patient counselling, they may contribute to a smooth readmission to primary care after hospital discharge. In this thesis we aimed to disentangle the problems with continuity of care at time of readmission to primary care and to investigate the role of the community pharmacist within this process. We showed that 92% of the hospital discharge prescriptions presented to Dutch community pharmacies led to one or more problems. These problems were nearly equally divided between (1) medication discrepancies, which mainly resulted from missing pre-admission medication and dose regimen changes on the discharge prescription, (2) administrative problems, which mainly originated from prescription incompleteness or supply issues, and (3) need for patient education due to patients’ lack of medication or regimen knowledge post-discharge. We developed a new three-phase approach to address these problems; the Home-based Community pharmacist-led Medication management (HomeCoMe) program. First, we established a structured transfer of up-to-date medication discharge information from the hospital to the community pharmacists. This includes information on DRPs identified during hospitalization. Second, the key phase of this approach consists of adequate post-discharge follow-up during a home visit from the community pharmacist to identify and address DRPs. Finally, the community pharmacists closely collaborated with general practitioners within the primary care setting to resolve the identified DRPs. All home visit were guided by a semi-structured protocol an all pharmacists received a training program to perform the home visit. On average, we identified 4.9 DRP per patient who received the HomeCoMe program. The “Need for additional education or information and compliance issues were the most common types of DRPs. The majority of DRPs were identified (83.6%) and solved (91.6%) by the community pharmacist during the home visit. Furthermore, 52.5% of the DRPs identified during hospitalization were solved during the post-discharge home visit. During the home visits, pharmacists discussed protocolled issues regarding (1) the administration and use of medication, e.g. regimen and actual drug-taking issues, (2) patients’ knowledge regarding their medication and (3) patients’ health most frequently, followed by issues concerning (4) medication logistics and (5) medication effectiveness and finally (6) patients’ beliefs about their medication and adherence. In general, pharmacists were positive about performing the home visits. We showed that the key items that influenced community pharmacists’ adoption of the home visit in daily clinical practice were (1) the necessity of dedicated time for performing pharmaceutical care, (2) the implementation of the home visit in pharmacists’ daily routine and (3) an adequate reimbursement fee for the home visit.