Achieving safe medication management during transitions of care from hospital

[Music] Welcome to the Australian Prescriber Podcast. An independent, no-nonsense podcast for busy health professionals.

I'm Dhineli Perera, your host for this episode, and it's such a pleasure to be chatting to Adjunct Associate Professor Rohan Elliott and Deirdre Criddle today about that seemingly elusive goal of achieving safe medication management during transitions of care for patients. Rohan is a Senior Pharmacist at Austin Health Melbourne as well as an Adjunct Associate Professor at the Faculty of Pharmacy and Pharmaceutical Sciences at Monash University. Deirdre is the Complex Care Coordinator Lead at CoNeCT Mental Health Expansion at South Metropolitan Health Service in Perth, WA. A warm welcome to both of you, Rohan and Deirdre.

RE: Thanks.

DC: Thank you.

So, Rohan, perhaps you can start us off. I know that transitions of care has been very close to your heart for decades, but why is it so important? Can you tell us why this time in a patient's journey can be so hazardous?

RE: There's many reasons why transitions of care from hospital can be hazardous. For a start, there's often multiple changes to patient's medicines while they're in hospital. Australian studies generally report an average of 5 to 7 changes to your typical general medicine patient's medication regimen, and this can include medicines that are stopped, new medicines start, doses changed, which obviously creates challenges and risks when the time comes for the person to transition back to their home and back to the care of their GP, community pharmacy, and other providers such as home care nurses, aged care providers, et cetera.

A well-known and major factor contributing to medication errors after discharge is, obviously, poor communication. That's communication with the patient, their carer if they have one, their community healthcare providers. But another important factor that receives less attention from healthcare policymakers, and administrators, and clinicians to some extent, is the logistical challenges associated with ensuring that patients have timely and ongoing access to the medicines that they need after discharge.

This is particularly important for vulnerable people who rely on others to organise or administer their medicines such as people who live in residential care facilities or people who use dose administration aids that are packed by a pharmacist like Webster-paks or sachets. There can often be delays in getting medication charts written for people in aged care [and] getting Webster-paks packed and delivered from community pharmacies, et cetera. So these things can lead to gaps in care, and people can go without their medications or take the wrong medications over that period.

A third factor is there's inadequate follow-up often after discharge to ensure that the person is managing okay with the changes that have been made to their medicines and that they're not experiencing any adverse effects after discharge.

I do like the idea of focusing on some follow-up, especially because we often will assume that the changes can be trivial, and they might be trivial to a clinician, but definitely not to a patient. Deirdre, could you walk us through what the Australian Commission on Safety and Quality in Healthcare recommended on this particular topic in their 2020 publication?

DC: The Commission's publication was actually Australia's response to the World Health Organization's third Global Patient Safety Challenge which was to reduce medication related harm by 50% in 2024. Now, they prioritised embedding medication reconciliation at transitions of care to reduce avoidable medication errors, adverse drug events, and medication-related hospitalizations.

As key priority actions, they actually recommended, one, that discharge summaries be accurate, preferably standardised and provided in a timely way. 2, the use of My Health Record to improve communication and with that stretch goal of engaging patients and carers in the curation of medication regimen information. 3, broad initiatives for people with complex needs be adopted, and this includes early post discharge medication management review using hospital outreach services, community liaison pharmacy services, or cross-sector case conferencing. Finally, fourthly was exploring and refining ways to risk stratify patients, ensuring those at greatest risk access transitional care to reduce medication-related harm.

So it was quite comprehensive, but this is 2020, right? So 4 years later Rohan, how are we going with successfully implementing these recommendations? What are some of the ongoing challenges with discharge summaries, and have we made any headway in this space?

RE: Overall, I would say that our progress towards those goals that were set by the Commission have been mixed. With respect to discharge summaries, there's been some progress towards standardising the content of discharge summaries, so the Commission has done some good work in that space. Standardising the format of discharge summaries across different electronic medical record systems has proved quite challenging, so I don't think that's quite been achieved.

There's certainly been some improvements in medication reconciliation processes which can potentially feed into the accuracy of both medication charts and discharge summaries. But importantly, there are still problems with the accuracy and quality of medication information in discharge summaries even when they are electronically generated. So the move to electronic records hasn't solved the problem of poor quality medication information in discharge summaries. There's evidence from multiple Australian studies recently involving hospital pharmacists in preparing discharge medication information that populates discharge summaries can lead to significantly improved information quality, but this hasn't really been widely rolled out as a strategy.

The other challenge related to discharge summaries is timeliness, making sure they actually get done, ideally, before the person leaves the hospital or pretty soon thereafter. Some hospitals are moving toward mandatory discharge summary completion prior to discharge, but it's not an easy thing to achieve, has resource implications, and there's potential that it could then delay discharges which then has the flow-on effect of delaying patients being transferred out of ED up to the wards. So some challenges there. I guess a major gain has been that medical discharge summaries from a lot of hospitals are uploaded automatically into My Health Record. So that's an enhancement as it makes accessibility to patients, carers, and the wider healthcare team easier.

So speaking of My Health Record, do we know what the percentage uptake of this is for Australian adults?

RE: Yeah. It's pretty high now. I'd say it's over 90%.

Oh, that's pretty good.

RE: There's a lot of medication data in the My Health Record from a range of sources, like there's PBS data, pharmacy dispensing data, hospital discharge summary data, which can all be really useful at transitions of care, but with a big caveat that just like any other source of medication history data, the data in My Health Record is not always complete, doesn't always reflect the way people actually take their medicines, or what they're actually taking. So it's a great source at transitions of care, but always needs to be verified with the patient or other sources.

Yeah. So it's a piece of the puzzle, right?

RE: Correct.

I think you might have mentioned in the paper as well the ‘pharmacist shared medicines list’. What's this about?

RE: This is a relatively recent innovation. So a pharmacist shared medicines list or a PSML for short is a comprehensive and verified list of all the medicines that a person is currently using, including over-the-counter and complementary medicines, that's been compiled by a pharmacist and uploaded into My Health Record. So I mentioned before that there's a lot of medication data in My Health Record, but that data is not curated or verified like the information in a PSML. So the PSML provides a really useful snapshot of the person's complete medicine regimen at a particular point in time, and that can be very helpful at transitions of care.

These documents can be created during a Home Medicines Review, during a community pharmacy Meds Check, or during a hospital discharge. So, for example, at the hospital where I work, the patient-friendly medicine list that we provide to our patients at the point of discharge is automatically uploaded to My Health Record as a pharmacist shared medicines list.

And the fact that it's dated as well will help clinicians to understand the recency of that verification and whether it needs to be done again, I guess, as well.

RE: Yeah.

So, Deirdre, your paper touches on the low uptake of already available services, especially for this critical transition point. Such services include the hospital outreach, community liaison pharmacist services, cross-sector case conferencing, and newer direct referrals from hospital specialists for medication management reviews. Why do you think the uptake is low?

DC: There were really high hopes back in 2020 for an improvement in transitional medication management when the Commonwealth changed the business rules to enable hospitals to refer directly for medication review early post-discharge. However, there was no provision made for promotion and no resourcing to assist staff to integrate this into their usual discharge planning. Coordination for referral and follow-up was really key to the successful implementation of this new pathway. Add the COVID pandemic into that timing, with a depleted and exhausted workforce, you can see why so few hospitals opted to even trial the hospital-initiated medication review pathway. So we believe that the only way this or any of the proposed transitional medication management pathways can succeed is to have a dedicated transitions of care clinician or team to drive and guide them.

Rohan, what do you think are some of the barriers to introducing important tools like an interim medication administration chart nationwide? We've seen it introduced in some sectors, but that was a long time ago now. So what stopped us seeing it more widely used?

RE: Yeah. For listeners who aren't familiar with interim medication charts, I'll just quickly describe what they are.

Yeah.

RE: So these are hospital-provided, usually, 7-day drug charts or medication charts that enable aged care staff to administer medications that were started in hospital while they wait for the person's GP to prepare a long-term aged care medication chart which often doesn't happen until the next day or sometimes even 2 or 3 days later if it's a weekend. So it's really important to avoid missed and delayed doses, especially for people who require time-critical medicines. For example, Parkinson's medicines, pain, antibiotics, end-of-life care, et cetera. So we sometimes see patients representing to hospital after they go home to aged care over a weekend because they went without medication.

Coming to the barriers, I'd say one of the biggest barriers to the widespread rollout of these charts is that they're not explicitly mandated or even, really, recommended in accreditation standards for hospitals and aged care homes. Another recent barrier that's come about has been the move to electronic medication management systems in aged care. So a lot of facilities are moving. In fact, they're being strongly encouraged to take up the National Residential Medication Chart Electronic System, and that creates issues because the interim charts are usually paper. So some aged care homes are now saying they can't use the interim chart even when they have no other alternative. So these are not insurmountable barriers. We just need the relevant parties and regulators, et cetera to come together and work out a plan to make these things work because there is this gap that's unaddressed.

Right. So we solve one problem, and then create a new one in the process. I can see how that gap would've appeared. Deirdre, I think you had a really good point in the paper about the lines of responsibility and accountability being unclear. With so many cooks in the kitchen, how do we prevent everyone passing the buck? Is it possible and fair to expect the patient's GP and clinic to take on that role?

DC: So your question really goes to the heart of the problem, Dhineli. For decades, our messaging for medication safety across care transitions has suggested that it's everyone's business. The problem with transferring care across systems is that it actually remains no one's actual responsibility or job, and hospitals struggle both with the sheer volume and increased acuity of patients that are being pushed and pulled along the care continuum. Clinicians will readily tell you now that every patient in a hospital bed is complex, which is really what spurred my interest in risk prediction tools to try and give our health system clinicians a hand in the ability to identify which patients are most at risk of harm or indeed, readmission at the point of discharge.

In answer to your question, is it possible or preferable to expect the patient's GP and clinic to take responsibility? The short answer is yes, but it's also unfair to expect a GP to coordinate time-critical aspects of medication management, especially for these complex patients. As discharges occur 7 days a week and at any time of the day, there isn't the capacity or pathways to enable this to occur currently. Recent pilots have embedded pharmacists in GP practise and aged care homes, and this holds hope for another pathway for our patients with complex needs to gain early access to a pharmacist during transitions back to the community, but we are a really long way from getting those roles accepted, funded, and embedded. Even where they do exist, they're usually part-time, one or 2 days a week. So this too remains another hopeful possibility for the future.

But finally, having that overarching stewardship framework would take account of all the medication management options that we have currently available and especially locally, and that, to me, addresses the issue of having too many cooks. A dedicated transitional team or clinician for every patient in need could access the service that's most appropriate to their needs and preferences.

Yes, it really is the heart of the article. The approach that your team of authors have really mentioned is this stewardship approach. Rohan, what is this approach exactly, and how is it different to what is already in place? What do you see is the point of difference that the stewardship role would offer?

RE: Many listeners would already be aware of antimicrobial stewardship programs which have been incredibly successful in improving the way antimicrobials are used. The way these programs work is they take a strategic, coordinated, interprofessional approach to implementing governance, strategies and tools to optimise medicine use and reduce variations in practise with the goal of improving outcomes. So a hospital transitions of care stewardship program would take that similar sort of approach.

So, currently, what we have is the National Safety and Quality Standards for hospitals which address transitions of care in several different standards, but there's no overarching governance framework, the medication safety across care transitions. So this often leads to a lack of coordination and accountability, a limited cross-sector engagement, and a lot of variation in practise. Hospitals may have various different strategies, but there's not an overarching coordination and governance across the whole organisation to make sure that high-risk patients are identified and that the right services are delivered to the right patients. So a stewardship program could provide greater clarity around responsibility and accountability, and improve that planning, and prioritisation, and coordination of medication management during transitions of care.

Yeah, and with my own antimicrobial stewardship hat on, I would actually dare say that transitions of care would be far more complex in terms of the stewardship role mainly because in a antimicrobial perspective, you're often assuming that getting the medicine to the patient and into the patient is not a barrier. Whereas for the transition of care to all different places outside of the hospital, there are so many variables in place that can make that quite tricky to even wrap your head around. In the paper, Rohan, there were some strategies mentioned in Box 1. Which do you think are the low-hanging fruit, like the easier targets that health professionals at all stages of the patient's journey could consider implementing?

RE: That's a tricky question. If there is a low-hanging fruit, the early post-discharge medication management review that Deirdre mentioned earlier, I mean, that's an existing Commonwealth-funded program. It's available. It's just not being tapped into and used, but there are well-established barriers. We know there's lots of barriers to its implementation, but it is an example of where a stewardship model could make a huge difference by addressing those barriers, and building the processes, and putting in place the training and the resources to make it happen.

Absolutely, and if the funding is there, then that's your big barrier. Your first step is sorted. Deirdre, is there or will there be a place where clinicians can find the success stories of such implementation so that they can reach out to staff who are involved and not be left to reinvent the wheel?

DC: Yeah. Dhineli, I think this is an ongoing issue. This is not an easy problem to solve. We have our systems that work in silos and based on hierarchies. So that's why we really believe that you need to embed this in the standards. We need to understand that we have to take responsibility for it and accountability. I think our administrators really do have to embrace the fact that our hospitals need to be responsible for care beyond the discharge lounge, and our patients really should expect and demand that. So, yeah, I totally agree. Let's have those success stories, but I also think we need to start to see this involved in accreditation. That's where we need to make sure that this actually gets some teeth instead of just being a nice-to-have. It should be a must-have.

Well, that's unfortunately all the time we've got for this episode. I feel like we could keep chatting about this for a lot longer, but thank you so much for joining us today, Rohan and Deirdre.

RE: Thanks, Dhineli.

DC: Thanks, Dhineli.

[Music]

Rohan and Deirdre's article, Achieving Safe Medication Management During Transitions of Care from Hospital is available on the Australian Prescriber website. The views of the hosts and guests on the podcast are their own and may not represent Australian Prescriber or Therapeutic Guidelines.

The authors acknowledge funding received by the Australian Commission on Safety and Quality in Health Care for a literature review on the topic. Some of the authors are co-investigators on a Medical Research Future Fund, MRFF, project on timely post-discharge medication reviews in rural and regional Australia. Deirdre is also an investigator on a MRFF project, Older Persons Early Recognition Access and Treatment in Emergencies. Rohan is an editor for Australian Prescriber. He was excluded from the editorial decision-making related to the acceptance and publication of this editorial. I'm Dhineli Perera, and thanks for joining us on the Australian Prescriber Podcast.