Transitions of care

Transitions of care are pivotal moments in healthcare delivery, where patients move between different healthcare settings. Whether transitioning from hospital to home, or from home to an aged-care facility or respite care, these transitions can introduce complexities and risks that require careful management. Poor transitions of care can increase the risk of medication errors. The main factors contributing to poor transitions are lapses in communication, inadequate documentation, lack of coordination between teams, insufficient follow up, poor monitoring processes and unclear protocols. Pharmacists play an essential role in bridging these gaps and ensuring seamless transitions for patients across hospital, community pharmacy, aged care facilities and beyond.

A typical scenario illustrating challenges in transitions of care is as follows. A patient is admitted to hospital, where their medication regimen is adjusted. The patient is advised to have their medicines reviewed by the general practitioner on discharge, however the general practitioner is on extended leave. The specialist overseeing the patient’s care is not informed of the hospital admission. The pharmacy continues to dispense medicines into a Dose Administration Aid (DAA) for the patient per the discharge summary. According to the Australian Commission on Safety and Quality in Healthcare, poor transitions of care are associated with adverse events such as higher rates of readmission to hospital and medication errors. In fact, over 50% of all medication errors occur when people move from one healthcare setting to another. This poses significant risks, potentially leading to negative outcomes such as deterioration in the patient’s health and increased healthcare costs.

Hospital to community

Discharge from a hospital is often accompanied by a significant number of changes to a person’s medication regimen. During this process, pharmacists play a pivotal role in medication reconciliation. They are responsible for:

• ensuring that the medications prescribed upon discharge are cross-checked with the patient’s pre-existing regimen;
• providing an explanation for any medication changes; and
• providing follow-up with a medication management plan.

It is crucial for community pharmacists to thoroughly examine a patient’s medication profile as occasionally there may be omissions or items that require further clarification. Each healthcare practitioner is autonomous and should exercise their clinical judgement independently of previous healthcare practitioners involved in a patient’s care.

Pharmacists should provide counselling to patients, educate them about their medications, potential side effects and the importance of adherence to their prescribed regimen. This promotes quality use of medicines (QUM) and ensures patients can take their medicines safely while minimising the risk of adverse drug events.

Collaboration between the patient, hospital and community providers (community pharmacists, general practitioners, specialists, aged care staff) enables a seamless continuum of care. This allows patients to continue to access their medications with ease, including DAA, and receive other treatment and ongoing support for their health needs. Unrealistic timeframes to prepare a discharge medication profile, see a GP or pack a DAA can increase the risk of errors, underscoring the importance of considering feasible timelines.

Hospital and community pharmacists play important roles in patient care, particularly during the transition from hospital to a community setting. The process of transition can impact patient safety and wellbeing. The institutional imperative to discharge patients in a timely manner may place pressure on hospital pharmacists completing discharge services, while also impacting community pharmacists required to assist with the supply of discharge medicines and DAA. Consideration around realistic timelines and effective communication and collaboration can help navigate these competing priorities, ultimately benefitting patient care.

Community to aged care facilities

Transitioning from community pharmacy to aged care facilities introduces its own set of complexities. Polypharmacy is prevalent in elderly patients, making medication management particularly challenging. Optimisation of medication regimens can be achieved by conducting comprehensive medication reviews and deprescribing to minimise drug interactions, adverse effects and promote quality of life. Simplifying regimens to align with what may be feasible from a dosing perspective for the nursing team should be considered. Risk mitigation may also involve reviewing medicines that may be high-risk in this population.

The introduction of eNRMC and timely access to prescribers can sometimes be a barrier to timely provision of medicines. Effective communication between pharmacists and the healthcare teams within aged care facilities can streamline medication administration processes, ensure accurate documentation and promote resident safety. Pharmacists can contribute to the quality of care for elderly residents while fostering a collaborative approach to healthcare delivery.

PDL would like to highlight some of the risks that pharmacists may encounter during transitions of care and strategies to mitigate them:

• Medication discrepancies: Changes in medication regimens during transitions increase the likelihood of errors such as incorrect dosing, drug interactions or omissions. Conducting comprehensive medication reconciliation to identify discrepancies between current and newly prescribed medications is essential.
• Communication breakdown: Poor communication between healthcare providers can lead to misunderstandings, incomplete information transfer and missed follow-up care instructions. Implementing standard communication protocols and leveraging technology, such as My Health Record can facilitate seamless information exchange. Some practical and actionable strategies that can be implemented include a phone call to supplement written information, ensuring clarity and understanding during handover. Sharing contact details and availability for further discussions and ensuring up-to-date contact details are maintained also prove beneficial. Clear communication and protocols for prescription requests between the aged care facility, pharmacy and prescriber should be considered. These strategies are relevant for GP pharmacists and HMR pharmacists alike. Additionally, pharmacists may overlook the value in speaking directly to the patient. Patients are an important and accessible source of information and engaging with them in conversation about their care can lead to improved outcomes.
• Loss of continuity: Disruptions to continuity of care may cause gaps in monitoring, delayed interventions or lead to redundant tests and procedures being ordered. Care coordination across multidisciplinary teams can promote collaboration. It is good practice to inform the patient’s next provider, indicating when the patient was last reviewed, highlighting any important pathology findings or flag any actions needed. This ensures alignment and clarity among all clinicians responsible for the patient’s care. It is important not to make any assumptions about actions of other health care professionals, but rather proactively share information to uphold continuity of care.
• Patient and caregiver engagement: Challenges in understanding and adhering to post-transition care plans can result in medication non-adherence, missed appointments, or lack of follow-up. Provide clear, understandable information to empower patients and caregivers in managing their health post-transition.
• Technology: While technology can streamline processes, differing interfaces may lead to inefficient information exchange and challenges for healthcare providers. It is important to be aware of the limitations of technology and implement strategies to mitigate these risks.
• Awareness: Heightened awareness about risks associated with transitions of care can increase vigilance and collaboration among healthcare practitioners.

Pharmacists should consider these strategies with their local key stakeholders to foster a multidisciplinary patient-centred care approach, and effectively minimise risks during transitions of care, ensuring continuity, safety and quality across healthcare settings.

Additional resources

• Australian Commission on Safety and Quality in Health Care – Principles for safe and high-quality transitions of care
• PSA Training Plan: Pharmacists bridging gaps and filling cracks at transitions of care
• PSA Training Plan: Unlocking the power of effective communication in medicines reviews
• AdPha – Standard of practice for pharmacy services specialising in transitions of care

PDL would like to acknowledge the contribution of Local Advisory Committee members Jeffery Wang and Jack Janetzki to this article.

For immediate advice and incident support, call PDL on 1300 854 838 to speak to one of our Professional Officers. We are here to support our pharmacist members 24/7, Australia-wide.

Article last updated on 15 November 2024