Post-discharge medicines management: the experiences, perceptions and roles of older people and their family carers

Geriatric patients' views on a pharmacist-led follow-up programme after discharge from hospital

Background

Medication-related problems (MRPs) are common during transitions of care and can lead to hospital readmissions. This patient safety issue is especially pronounced among geriatric patients. In a randomised controlled trial (RCT), the effect of a pharmacist-led follow-up programme after discharge from hospital for people ≥75 years in the north of Sweden was investigated. One of the components in the programme was telephone calls to study participants, to find and manage MRPs.

Objective

To explore study participants' views on follow-up telephone calls by a clinical pharmacist in the RCT.

Methods

Semi-structured interviews were conducted with participants who had received an intervention in the RCT. The interviews were transcribed verbatim and thematically analysed.

Results

In total, nine participants were interviewed. Four main themes were generated: 1. Experiences of the telephone counselling by the clinical pharmacist, 2. Acceptability of receiving telephone follow-up from a clinical pharmacist, 3. Communication with health care providers, and 4. Medication management and views about medications.

Conclusions

The study revealed varying perceptions of the clinical pharmacists' telephone calls, with participants expressing diverse experiences and preferences regarding the service. Most participants said they considered the content relevant and comprehensible in the conversations. The effect of the follow-up programme may have improved if the role of the clinical pharmacist had been explained in more detail to the participants and if the service would have had a more person-centred focus. More research is needed regarding how to best support geriatric patients with their medication treatment in transitions of care.

Medication Reconciliation at Transition of Care in a Geriatric Primary Care Setting: A Pilot Program

Background: The transition from hospital to home for older individuals can be complicated, as they are more likely to have complex health and/or social care needs. Several published studies have outlined positive outcomes from pharmacist-driven transition of care programs. At our four geriatric primary care clinics affiliated with a large academic medical center, there is no medication reconciliation process to evaluate a patient's medications after being discharged from the hospital to home. Objective: The objective of this pilot program was to demonstrate the need for a pharmacist-led transition of care medication reconciliation program within a geriatric primary care setting. Design: This is a retrospective evaluation of a pilot program that took place from July 1, 2022, to June 30, 2023, within 4 geriatric primary care clinics affiliated with a 523-bed, full-service medical and surgical acute care hospital. Electronic medical records (EMR) were utilized to identify patients who were discharged from the hospital within 24 to 72 hours to their homes. Documentation in the patient's EMR by the primary care clinic's clinical pharmacist contained confirmation of a hospital follow-up appointment, completion of medication reconciliation, notification to the provider for pharmacotherapy concerns, and patient counseling on medication changes. Information on number of patients requiring clinical pharmacist intervention prior to hospital follow-up appointment, intervention type, average number of medication discrepancies per patient, and percentage of hospital follow-up appointments with a medication reconciliation completed prior to visit were also documented. Setting: Four geriatric primary care clinics affiliated with a 523-bed, full-service medical and surgical acute care hospital in Gainesville, Florida. Patients, Participants: A total of 881 unique medication reconciliations were completed for this retrospective pilot program study. Patients were included if they were discharged from the hospital to home during that time period and were active patients of a provider at the primary care clinic. Patients were excluded if they were discharged from the hospital to another acute care facility (such as a skilled nursing facility, rehabilitation facility, or hospice), if the patient expired during their hospitalization, or if they were not an active patient of a provider at the primary care clinic. Intervention: A primary care clinical pharmacist reviewed each discharged patient's EMR from the hospital to reconcile their medications with the medication list within the patient's primary care EMR. A transitions of care medication reconciliation evaluation progress note was created for each patient discharged home for documentation. Within this note, the pharmacist documented the number of medication discrepancies, medications added, medications discontinued, and medications with dosage adjustments. The pharmacist would contact the patient to clarify any urgent medication concerns and confirm that they made the appropriate medication adjustments as instructed at discharge from the hospital. If the clinical pharmacist had additional pharmacotherapy concerns, they would contact the provider prior to the hospital follow-up appointment. This was counted as an intervention. The intervention type was classified into categories based on the issue as determined by the clinical pharmacist: new medication, medication omission, high-risk medication, clarify administration frequency, clarify dose, and other reasons. Methods: Data from EMRs identified patients discharged home from the hospital within the last 24-72 hours between July 1, 2022, and June 30, 2023. Medication reconciliation was documented in the patient's EMR. The following elements were included: confirmation of a hospital follow-up appointment, notification to the provider for pharmacotherapy concerns, and patient counseling on medication changes. Results: A total of 881 patient evaluations were included in this study; and these evaluations identified 4,895 medication discrepancies with an average of 5.5 discrepancies per patient. Prior to the hospital follow-up appointment, 267 patients (30.3%) required clinical pharmacist intervention. By the end of the study period, 96.3% of hospital follow-up appointments had a medication reconciliation completed by a clinical pharmacist prior to the visit. Conclusion: This pharmacist-led medication reconciliation program within a geriatric primary care setting confirms a gap in care during transition from hospital to home. It was able to identify medication discrepancies and educate patients about medication changes.

Informing research design through patient and public involvement; patients and carers with lived experience post-hospital discharge and potential roles for general practice pharmacists

BACKGROUND

Medication safety across care transitions remains a significant burden on healthcare systems. Patient and Public Involvement (PPI) is useful at the very early stages of intervention development to inform research priorities. The aim of this PPI was to scope patients' and carers' lived experiences of medicines management post-hospital discharge to inform the design of a research proposal.

METHODS

A research planning PPI workshop and additional one-to-one discussions were undertaken with patients and informal carers who had experienced a recent discharge from hospital and were prescribed regular repeat medications.

RESULTS

The 12 public contributors identified that the priority for patients was not limited to medication management alone but rather a broader care package. Multiple themes as priorities for research emerged: (1) broader holistic and social aspects of care involving various healthcare professionals, (2) practical aspects such as timeliness of follow-up and co-ordination of medication management, and (3) communication with the patient/carer and information transfer between settings.

CONCLUSION

Valuable insights from this PPI helped inform future research design priorities and identify the need for a more holistic approach to care. Future work with multi-stakeholder engagement involving different professionals across sectors is needed to explore safer integrated transitions of care, as well as the use of ongoing PPI and co-design, considering populations that are most vulnerable.

Lived experience of affordability as a barrier to prescription medicines: A longitudinal qualitative study

Background

Lack of affordability is a major barrier to medicines access in many countries. It can result in ethnic and other inequities in medicines use and these have been documented in New Zealand. We aimed to understand the lived experience of barriers to accessing medicines faced by groups that are likely to encounter them, and to explore how they played out over time. This paper presents results related to affordability.

Methods

We carried out a longitudinal qualitative study, repeatedly interviewing 21 households about their lives and access to medicines, over a year. Participants were Māori, Pacific, former refugee, or Pākehā (New Zealand Europeans) with limited incomes.

Results

Many participants faced social disadvantage and many had physical and mental health problems. Often, they had busy and stressful lives, and this formed the backdrop to issues with medicines. Charges for GPs and medicines could directly prevent access, but also eroded relationships with healthcare providers, reducing acceptability of services. There could be confusion about charges, and when they were perceived as unreasonable participants felt aggrieved. At the time of the study, most (but not all) pharmacies had prescription charges, and limited financial resources drove some participants' choice of pharmacy. Some felt forced to choose between cost and physical accessibility or quality of care. Lack of affordability also interacted with other barriers to access, such as lack of transport, to prevent access to needed medications. Lack of affordability also made participants more vulnerable to the impact of small mistakes in prescribing and dispensing.

Discussion

Exploring lived experience provides insights into the multiple ways that lack of affordability prevents access to medicines: directly, through interaction with other barriers to access including transport, by damaging trust and reducing acceptability of services, and by making participants less able to deal with mistakes made by health professionals.

Family Involvement During Patient Hospitalisation-Developing and Testing a Clinical Decision Aid

BACKGROUND

The rising prevalence of multi-morbidity increases treatment complexity and caregiving demands, often necessitating involvement of family members as informal caregivers. While essential, this involvement can be burdensome, causing distress for family members. Shared decision-making facilitates communication and supports the alignment of patients' and families' preferences and needs with care and treatment decisions. Involving family during patient hospitalisation can be essential as the whole family is affected by illness.

AIM

This project aimed to develop and test a decision aid to systematise family involvement during patient hospitalisation.

RESEARCH METHODS

The project was based on the theoretical framework of family nursing, and the Danish Patient Decision Aid template guided the process. The decision options, pros and cons were based on 22 patient and 16 family interviews, which were thematically analysed. Six patients, two family members and nine healthcare professionals alpha tested the decision-aid prototype, which was later beta tested in real-life clinical settings at five internal medical wards.

FINDINGS

Three themes emerged: (A) 'involving family when needed', (B) 'waiting for ward rounds' and (C) 'involving family with technology', informing the decision-aid prototype which consisted of five option cards: (1) 'I will involve my family myself', (2) 'I do not want to involve my family', (3) 'Family wants to be present physically', (4) 'Family wants to participate by phone' and (5) 'Family wants to participate by video'. The cards included pros/cons of each option. Alpha testing showed high acceptability and usability, and no alterations were made to the prototype.

CONCLUSION

The structured patient decision aid enabled a systematic approach to involve the patient's family. It facilitated meaningful conversations between healthcare professionals, patients and family members. The decision aid identified and addressed patients' and family members' specific needs and preferences during hospitalisation.

Role of informal carers in medication management for people with long-term conditions: a systematic review

OBJECTIVES

To explore the literature about the role of unpaid informal carers in medication management for people with long-term conditions.

DESIGN

Systematic review designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

INFORMATION SOURCE

MEDLINE (Ovid), Embase (Ovid), PsycINFO, Cumulated Index in Nursing and Allied Health Literature (EBSCO), Scopus and Web of Science were searched from inception until April 2024. Additional papers were identified by searching backwards and forwards the reference lists of included papers.

ELIGIBILITY CRITERIA

Primary research studies were included if they reported medication-related activities undertaken by carers for people with long-term conditions. Qualitative and mixed methods studies were considered without restriction on language or country.

DATA EXTRACTION AND SYNTHESIS

Relevant data were extracted and summarised in a table. The Mixed Method Appraisal Tool was used for quality assessment. Data were narratively synthesised.

RESULTS

From 12 473 identified records, 107 underwent full text screening and 20 studies were included. Family carers were the predominant type of carer. Spouses and adult children constituted the largest caregiving dyads. Based on the required skills, two groups of roles were identified: physical roles, such as prescription management, and cognitive roles, such as decision-making. Carers used different strategies and tools to undertake medication-related activities including compliance aids and alarms. However, carers reported challenges in their experiences of caregiving, flagging up their need for additional support and education to commence such activities.

CONCLUSION

Informal carers undertake a wide variety of medication-related activities. The studies emphasised the need to support families as partners in health outcomes. This systematic review identifies the importance of bridging the gap between carers and healthcare providers. More efforts are needed to empower carers towards better and safer caregiving. Future work could address how to optimise carer involvement and engagement and provide best practice recommendations for carers' support.

PROSPERO REGISTRATION NUMBER

CRD42024506694.

Adverse drug reactions in older people following hospitalisation: a qualitative exploration of general practitioners' perspectives

BACKGROUND

Older people have greater comorbidity and medication burden. Adverse drug reactions occur in up to 30% of older people within one month of hospital discharge. General practitioners are key stakeholders in transitions of care from hospital to the community.

AIM

The study aimed to explore general practitioner perspectives of adverse drug reactions in older people after hospitalisation, investigating the medication-related issues encountered and possible approaches to reduce the risk.

METHOD

An invitation to participate in the study was sent to general practitioners in Southern Tasmania, Australia. A semi-structured interview occurred in person at their practice or online. The questions covered experiences with managing medication in older people after hospital discharge, challenges and risks involving adverse drug reactions and suggestions to prevent adverse drug reactions. The interviews were transcribed and analysed through thematic analysis.

RESULTS

Twelve general practitioners were interviewed, revealing four themes describing challenges, including (i) complex patients and acceptance of risk, (ii) patient confusion and decline in hospital, (iii) time taken to manage older patients and (iv) communication challenges. Three themes describing recommendations were identified, including (i) clear communication on discharge, (ii) patient involvement and (iii) roles for pharmacists.

CONCLUSION

Prevention of adverse drug reactions after hospital discharge may require clear and timely communication to general practitioners, patients and families to be educated and empowered to help manage their own health and risk, and pharmacists to support both patients and general practitioners in managing the risks.

A systematic review of outcomes reported in studies to optimise the medication use of patients at hospital discharge

INTRODUCTION

Care transitions, specifically hospital discharge, hold a risk for drug-related problems and medication errors. Effective interventions that optimise medication use during and after transitions are needed, yet there is no standardisation of the outcomes. This literature review aimed at collecting outcomes from studies investigating how to optimise medication use of patients following hospital discharge, and to categorise them, as a first step in the development of a core outcome set.

METHODS

We systematically reviewed quantitative and qualitative literature using Embase, PubMed, CINAHL and the EU Clinical Trial Register databases. Studies investigating the optimisation of medication use following hospital discharge were eligible. The quantitative literature review specifically included trials and protocols that evaluated the effect of an intervention for patients ≥ 65 years or multimorbid / polypharmacy patients, as they are at high risk of drug-related problems. The qualitative literature review focused on the patients' and healthcare professionals' views. Outcomes were summarised into unique outcome terms and categorised using an adapted version of the OMERACT filter 2.0.

RESULTS

The review included 75 quantitative and 20 qualitative studies. The interventions investigated in the quantitative literature mostly had multiple components performed either pre- or post-discharge. Sixty percent of the qualitative studies addressed the views of healthcare professionals, 40% the views of patients, and only one study addressed both. A median of 5 outcomes (range 1-17) were reported in the quantitative studies. In total, 91 unique outcomes were identified from the quantitative or qualitative literature, or both (73, 12 and 6 outcomes, respectively). Outcomes were categorised into five domains: 'medication' (n = 32 outcomes), 'economic impact/resource use' (n = 26), 'life impact' (n = 16), 'pathophysiological manifestations' (n = 15) and 'death' (n = 2). The top 5 most frequently measured outcomes in quantitative studies were number of readmissions (n = 54/75, 72%), mortality (n = 30/75, 40%), number of emergency department visits (n = 26/75, 35%), number of outpatient physician visits (n = 12/75, 16%), and medication adherence (n = 12/75, 16%).

DISCUSSION AND CONCLUSION

This study identified a large number of different outcomes, especially in the domains medication and economic impact/resource use. This heterogeneity impedes the identification of effective interventions and confirms the need for a core outcome set.

Promoting health literacy of older post-discharge patients in general practice - Creation of the GP-MATE communication tool through co-design

OBJECTIVE

Work with older patients and their carers to co-design a tool that improves patient - general practice communication and continuity of care following discharge of an older person from hospital.

METHODS

Experience Based Co-Design with three teams of six to seven lay people (older patients and their carers), each supported by a corresponding general practice group. The process included an implementation-focused event with participants using the intervention in a live role-play.

RESULTS

Co-design generated a patient-held tool (GP-MATE) that focuses on four areas of post-discharge care: carers/caring; continuity; medication safety and information power. Access to general practice for patients/carers post-discharge was considered to be vital to improving communication.

DISCUSSION AND CONCLUSION

The co-design process enabled patients and carers to be involved through all stages of intervention development, ensuring relevance and alignment.

PRACTICE IMPLICATIONS

The intervention is uniquely suited to general practice, comprehensive yet brief enough to be usable within a 20-minute consultation. While the domains of GP-MATE compare well with existing care transitions literature, it will be important to assess impact on already busy practice schedules and impact on care.

Implementing a Medicines at Transitions Intervention (MaTI) for patients with heart failure: a process evaluation of the Improving the Safety and Continuity Of Medicines management at Transitions of care (ISCOMAT) cluster randomised controlled trial

BACKGROUND

Heart failure is a major global health challenge incurring a high rate of mortality, morbidity and hospitalisation. Effective medicines management at the time of hospital discharge into the community could reduce poor outcomes for people with heart failure. Within the Improving the Safety and Continuity Of Medicines management at Transitions of care (ISCOMAT) programme, the Medicines at Transitions Intervention (MaTI) was co-designed to improve such transitions, with a cluster randomised controlled trial to test effectiveness. The MaTI includes a patient toolkit and transfer of discharge medicines information to community pharmacy. This paper aims to determine the degree to which the intervention was delivered, and identify barriers and facilitators experienced by staff for the successful implementation of the intervention.

METHODS

The study was conducted in six purposively selected intervention sites. A mixed-methods design was employed using hospital staff interviews, structured and unstructured ward observations, and routine trial data about adherence to the MaTI. A parallel mixed analysis was applied. Qualitative data were analysed thematically using the Framework method. Data were synthesised, triangulated and mapped to the Consolidated Framework for Implementation Research (CFIR).

RESULTS

With limited routines of communication between ward staff and community pharmacy, hospital staff found implementing community pharmacy-related steps of the intervention challenging. Staff time was depleted by attempts to bridge system barriers, sometimes leading to steps not being delivered. Whilst the introduction of the patient toolkit was often completed and valued as important patient education and a helpful way to explain medicines, the medicines discharge log within it was not, as this was seen as a duplication of existing systems. Within the CFIR the most applicable constructs were identified as 'intervention complexity' and 'cosmopolitanism' based on how well hospitals were networked with community pharmacies, and the availability of hospital resources to facilitate this.

CONCLUSION

The MaTI was generally successfully implemented, particularly the introduction of the toolkit. However, implementation involving community pharmacy was more challenging and more effective communication systems are needed to support wider implementation.

TRIAL REGISTRATION

11/04/2018 ISRCTN66212970. https://www.isrctn.com/ISRCTN66212970 .

'You're Just Thinking About Going Home': Exploring Person-Centred Medication Communication With Older Patients at Hospital Discharge

BACKGROUND

The hospital discharge process poses significant safety risks for older patients due to complexities in communication and coordination among stakeholders, leading to potential drug-related problems post-discharge. Adopting a person-centred care (PCC) approach in medication communication by healthcare professionals (HCPs) is crucial to ensure positive health outcomes. This study aimed to explore the practice of PCC in medication communication between older patients and HCPs during the hospital discharge process.

METHODS

We conducted a qualitative study using non-participatory direct observations of patient-HCP consultations during hospital discharge, followed by semi-structured interviews with observed patients and, when applicable, their informal caregivers. Data collection occurred from October 2020 to May 2021 at two Swedish hospitals. We gathered data using an observational form and audio-recorded all consultations and interviews. The data were analysed thematically using the systematic text condensation method.

RESULTS

Twenty patients were included (median age: 81 years [range: 65-94]; 9 female) in observations and 13 of them participated in interviews. Two patients were accompanied by an informal caregiver during the interviews. Three main themes were identified: (1) The impact of traditional authoritarian structures, depicts power dynamics between patients and their HCPs, showing how traditional structures influence the practice of PCC in medication communication during hospital discharge; (2) Consultation timing and mode not on patients' terms, describes suboptimal times and settings for consultations, along with the use of complex language that hinders effective communication; and (3) Discrepancy in expectations of self-care ability, illustrates a mismatch between the self-care guidance provided by HCPs during hospital discharge and the actual needs and preferences of patients and informal caregivers.

CONCLUSION

Medication communication between older patients and HCPs during hospital discharge is frequently inconsistent with the practice of PCC. Not only must HCPs improve their communication strategies, but patients and their informal caregivers should also be better prepared for discharge communication and encouraged to participate in their care. This involvement would give them relevant knowledge and tailor communication to their individual needs, preventing problems in managing their medications after discharge.

PATIENT OR PUBLIC CONTRIBUTION

An advisory group of six patients and/or informal caregiver contributors provided input on the study design, edited the consent forms, and helped develop the interview guide.

Keeping patients safe through medication review and management in the community

BACKGROUND

There are numerous publications on inpatient medication errors. However, little focus is given to medication errors that occur at home.

AIMS

To describe and analyse the types of medication errors among community-dwelling patients following their discharge from an acute care hospital in Singapore.

METHOD

This is a retrospective review of a 'good catch' reporting system from December 2018 to March 2022. Medication-related errors were extracted and analysed.

FINDINGS

A total of 73 reported medication-related error incidents were reviewed. The mean age of the patients was 78 years old (SD=9). Most patients managed their medications independently at home (45.2%, n=33). The majority of medications involved were cardiovascular medications (51.5%, n=50). Incorrect dosing (41.1%, n=39) was the most common medication error reported. Poor understanding of medication usage (35.6%, n=26) and lack of awareness of medication changes after discharge (24.7%, n=18) were the primary causes of the errors.

CONCLUSION

This study's findings provide valuable insights into reducing medication errors at home. More attention must be given to post-discharge care, especially to preventable medication errors. Medication administration and management education can be emphasised using teach-back methods.

Qualitative Insights Into Patients' and Family Members' Experiences of In-Hospital Medication Management After a Critical Care Episode

Background

Patient recovery after a critical illness can be protracted, requiring a care continuum that extends along a patient pathway from the critical care unit, hospital ward, and into the community care setting. High-quality care on patient transfer from critical care, including medication safety, is facilitated by education for patients and families, family engagement, support systems, and health care professional (HCP)-patient communication. Currently, uncertainty exists regarding how HCPs can and should engage with critical care patients and family members about their medication.

Research Question

What are the views and experiences of critical care patients and family members about their involvement in, communication about, understanding of, and decision-making related to their medication after transfer from critical care to the hospital ward?

Study Design and Methods

This qualitative study used semistructured interviews, conducted with critical care patients and family members after transfer from critical care to a hospital ward in a large National Health Service hospital trust. Anonymized transcripts of interviews were analyzed thematically using a coding framework developed from understandings of patient and family engagement in medication administration.

Results

Twenty-seven participants (15 patients and 12 family members of patients) completed the interviews. We identified five themes and 15 subthemes, providing an overview of patients' and family members' views on medication management during acute illness and ongoing recovery. Themes identified were: impact of acute illness and treatment burden on preexisting illness, preexisting knowledge and capability, beliefs about persons roles and expectations, care continuity and individualized information exchange, and engagement in practice.

Interpretation

This study demonstrated that critical care patients and family members want to engage with HCPs about medication administration. HCPs must take an individualized approach to communication and timing, acknowledging the dynamic interplay between patients and family members, using multimodal forms of communication.

Reducing Sternal Wound Infection Rates in Patients Undergoing Cardiothoracic Surgery with Sternotomy

LOCAL PROBLEM

Sternal wound infections (SWIs), whether superficial or deep, are associated with increased morbidity, mortality, and costs. From 2016 to 2017, our facility saw a 50% decrease in SWIs among patients undergoing cardiothoracic surgery with sternotomy. From 2017 to 2018, however, we identified a 33% increase in SWIs, prompting us to address our cardiac nurses' sternal wound care education and practice.

PURPOSE

The purpose of our quality improvement (QI) project was to identify opportunities for improvement in postoperative sternal incision care and to implement evidence-based processes to reduce the incidence of SWIs among cardiothoracic surgery patients.

METHODS

A literature review was performed to identify interventions focused on evidence-based SWI reduction. During the first quarter of 2019, our postoperative incision care guidelines were revised and released to staff, a new surgical wound cleansing product was supplied, and RN education was provided. Cardiac nurses were surveyed in April 2019 to identify any remaining knowledge and practice deficits and to assess their adherence to the new guidelines. The survey responses helped us to further improve our nurse education. We also provided periodic nurse reeducation and enhanced patient and family education. All such interventions were implemented by the end of June 2019.

RESULTS

Between January and June 2019, we had one SWI. From July 2019 through December 2020, an 18-month period, we experienced zero SWIs. Although beginning in 2021, we saw an increase in SWIs-four in 2021 and five in 2022-our incidence rates remain below 0.5% and we continue to work toward an SWI goal of zero.

CONCLUSION

This QI project identified opportunities for improvement, implemented evidence-based strategies for wound care and education, and successfully achieved a zero SWI rate for a period of 18 months.

Older adults experience of transition to the community from the emergency department: a qualitative evidence synthesis

AIM

Older adults comprise a growing proportion of Emergency Department (ED) attendees and are vulnerable to adverse outcomes following an ED visit including ED reattendance within 30 days. Interventions to reduce older adults' risk of adverse outcomes following an ED attendance are proliferating and often focus on improving the transition from the ED to the community. To optimise the effectiveness of interventions it is important to determine how older adults experience the transition from the ED to the community. This study aims to systematically review and synthesise qualitative studies reporting older adults' experiences of transition to the community from the ED.

METHODS

Six databases (Academic Search Complete, CINAHL, MEDLINE, PsycARTICLES, PsycINFO, and Social Science Full Text) were searched in March 2022 and 2023. A seven-step approach to meta-ethnography, as described by Noblit and Hare, was used to synthesise findings across included studies. The methodological quality of the included studies was appraised using the 10-item Critical Appraisal Skills Programme (CASP) checklist for qualitative research. A study protocol was registered on PROSPERO (Registration: CRD42022287990).

FINDINGS

Ten studies were included, and synthesis led to the development of five themes. Unresolved symptoms reported by older adults on discharge impact their ability to manage at home (theme 1). Limited community services and unresolved symptoms drive early ED reattendance for some older adults (theme 2). Although older adults value practical support and assistance transporting home from the ED this is infrequently provided (theme 3). Accessible health information and interactions are important for understanding and self-managing health conditions on discharge from the ED (theme 4). Fragmented Care between ED and community is common, stressful and impacts on older adult's ability to manage health conditions (theme 5). A line of argument synthesis integrated these themes into one overarching concept; after an ED visit older adults often struggle to manage changed, complex, health and care needs at home, in the absence of comprehensive support and guidance.

DISCUSSION/ CONCLUSION

Key areas for consideration in future service and intervention development are identified in this study; ED healthcare providers should adapt their communication to the needs of older adults, provide accessible information and explicitly address expectations about symptom resolution during discharge planning. Concurrently, community health services need to be responsive to older adults' changed health and care needs after an ED visit to achieve care integration. Those developing transitional care interventions should consider older adults needs for integration of care, symptom management, clear communication and information from providers and desire to return to daily life.

Advanced-scope pharmacist roles in medical outpatient clinics: a cost-consequence analysis

BACKGROUND

There is a growing body of evidence that supports the clinical effectiveness of pharmacist roles in outpatient settings. However, limited studies have investigated the economic efficiency of advanced-scope outpatient pharmacist roles, particularly in the Australian setting. Assessing the overall costs and benefits of these outpatient pharmacist roles is needed to ensure service sustainability.

AIMS

To use a cost-consequence approach to evaluate the advanced-scope outpatient pharmacist roles across multiple clinic disciplines from the hospital perspective.

METHODS

A cost-consequence analysis was undertaken using data from a previous clinical-effectiveness study. All outpatient pharmacist consults conducted from 1 June 2019 to 31 May 2020 across 18 clinic disciplines were evaluated. Consequences from the pharmacist services included number of consults conducted, number of medication-related activities and number of resolved recommendations.

RESULTS

The overall cost to the hospital for the outpatient pharmacist service across all clinics was AU$1 991 122, with a potential remuneration of AU$3 895 247. There were 10 059 pharmacist consults undertaken for the 12-month period. Medication-related activities performed by pharmacists primarily included 6438 counselling and education activities and 4307 medication list activities. When the specialist pharmacist roles were added to the outpatient clinics, several health service benefits were also realised.

CONCLUSIONS

The addition of pharmacist roles to outpatient clinics can increase the cost of services; however, they also can increase medication optimisation activities. Future research should examine a societal perspective that includes broader cost and effectiveness outcomes. This study could justify the implementation of advanced-scope outpatient pharmacist roles in other Australian hospitals.

Thrown in at the deep end: a qualitative study with physicians on the purpose and challenges of discharge interviews

OBJECTIVES

Against the backdrop of poor discharge communication in hospitals, this study explores the purpose of discharge interviews from the physicians' perspective and the challenges they are confronted with. Discharge interviews are legally required in Germany as part of the discharge management. Led by the ward physician, the discharge interview should summarize relevant information about the hospital stay, medication, lifestyle interventions and follow-up treatment.

METHODS

Semi-structured interviews with n = 12 physicians were conducted at Heidelberg University Hospital between February and April 2020. Qualitative content analysis was carried out using MAXQDA.

RESULTS

Physicians reported gaining information, providing information, and answering open-ended questions as the purpose of the discharge interview. Challenges in conducting discharge interviews were related to finding a common language, patient-related challenges, conditions of everyday ward life, and lack of training. Physicians reported receiving no explicit training on discharge interviews. While professional experience seems to mitigate the lack of training, some physicians expressed a prevailing sense of insecurity.

CONCLUSION

The lack of preparation for discharge interviews in medical school makes it particularly challenging for physicians to translate their theoretical knowledge into patient-centered discharge communication. Medical training on discharge interviews should be expanded in terms of theoretical input on the ideal content, its purpose and potential (e.g. in reducing readmissions), as well as practical exercises.

'It's a job to be done'. Managing polypharmacy at home: A qualitative interview study exploring the experiences of older people living with frailty

INTRODUCTION

Many older people live with both multiple long-term conditions and frailty; thus, they manage complex medicines regimens and are at heightened risk of the consequences of medicines errors. Research to enhance how people manage medicines has focused on adherence to regimens rather than on the wider skills necessary to safely manage medicines, and the older population living with frailty and managing multiple medicines at home has been under-explored. This study, therefore, examines in depth how older people with mild to moderate frailty manage their polypharmacy regimens at home.

METHODS

Between June 2021 and February 2022, 32 patients aged 65 years or older with mild or moderate frailty and taking five or more medicines were recruited from 10 medical practices in the North of England, United Kingdom, and the CARE 75+ research cohort. Semi-structured interviews were conducted face to face, by telephone or online. The interviews were recorded, transcribed verbatim and analysed using reflexive thematic analysis.

FINDINGS

Five themes were developed: (1) Managing many medicines is a skilled job I didn't apply for; (2) Medicines keep me going, but what happened to my life?; (3) Managing medicines in an unclear system; (4) Support with medicines that makes my work easier; and (5) My medicines are familiar to me-there is nothing else I need (or want) to know. While navigating fragmented care, patients were expected to fit new medicines routines into their lives and keep on top of their medicines supply. Sometimes, they felt let down by a system that created new obstacles instead of supporting their complex daily work.

CONCLUSION

Frail older patients, who are at heightened risk of the impact of medicines errors, are expected to perform complex work to safely self-manage multiple medicines at home. Such a workload needs to be acknowledged, and more needs to be done to prepare people in order to avoid harm from medicines.

PATIENT AND PUBLIC INVOLVEMENT

An older person managing multiple medicines at home was a core member of the research team. An advisory group of older patients and family members advised the study and was involved in the first stages of data analysis. This influenced how data were coded and themes shaped.

The complexities of communication at hospital discharge of older patients: a qualitative study of healthcare professionals' views

BACKGROUND

Hospital discharge of older patients is a high-risk situation in terms of patient safety. Due to the fragmentation of the healthcare system, communication and coordination between stakeholders are required at discharge. The aim of this study was to explore communication in general and medication information transfer in particular at hospital discharge of older patients from the perspective of healthcare professionals (HCPs) across different organisations within the healthcare system.

METHODS

We conducted a qualitative study using focus group and individual or group interviews with HCPs (physicians, nurses and pharmacists) across different healthcare organisations in Sweden. Data were collected from September to October 2021. A semi-structured interview guide including questions on current medication communication practices, possible improvements and feedback on suggestions for alternative processes was used. The data were analysed thematically, guided by the systematic text condensation method.

RESULTS

In total, four focus group and three semi-structured interviews were conducted with 23 HCPs. Three main themes were identified: 1) Support systems that help and hinder describes the use of support systems in the discharge process to compensate for the fragmentation of the healthcare system and the impact of these systems on HCPs' communication; 2) Communication between two separate worlds depicts the difficulties in communication experienced by HCPs in different healthcare organisations and how they cope with them; and 3) The large number of medically complex patients disrupts the communication reveals how the highly pressurised healthcare system impacts on HCPs' communication at hospital discharge.

CONCLUSIONS

Communication at hospital discharge is hindered by the fragmented, highly pressurised healthcare system. HCPs are at risk of moral distress when coping with communication difficulties. Improved communication methods at hospital discharge are needed for the benefit of both patients and HCPs.

Development of a patient-centred medication management model for polymedicated home-dwelling older adults after hospital discharge: results of a mixed methods study

OBJECTIVE

This study aimed to investigate medication management among polymedicated, home-dwelling older adults after discharge from a hospital centre in French-speaking Switzerland and then develop a model to optimise medication management and prevent adverse health outcomes associated with medication-related problems (MRPs).

DESIGN

Explanatory, sequential, mixed methods study based on detailed quantitative and qualitative findings reported previously.

SETTING

Hospital and community healthcare in the French-speaking part of Switzerland.

PARTICIPANTS

The quantitative strand retrospectively examined 3 years of hospital electronic patient records (n=53 690 hospitalisations of inpatients aged 65 years or older) to identify the different profiles of those at risk of 30-day hospital readmission and unplanned nursing home admission. The qualitative strand explored the perspectives of older adults (n=28), their informal caregivers (n=17) and healthcare professionals (n=13) on medication management after hospital discharge.

RESULTS

Quantitative results from older adults' profiles, affected by similar patient-related, medication-related and environment-related factors, were enhanced and supported by qualitative findings. The combined findings enabled us to design an interprofessional, collaborative medication management model to prevent MRPs among home-dwelling older adults after hospital discharge. The model comprised four interactive fields of action: listening to polymedicated home-dwelling older adults and their informal caregivers; involving older adults and their informal caregivers in shared, medication-related decision-making; empowering older adults and their informal caregivers for safe medication self-management; optimising collaborative medication management practices.

CONCLUSION

By linking the retrospective and prospective findings from our explanatory sequential study involving multiple stakeholders' perspectives, we created a deeper comprehension of the complexities and challenges of safe medication management among polymedicated, home-dwelling older adults after their discharge from hospital. We subsequently designed an innovative, collaborative, patient-centred model for optimising medication management and preventing MRPs in this population.

Improving inpatient discharge workflows through pharmacist pending discharge medication orders

PURPOSE

Hospital discharge represents a difficult care transition for patients, with the potential for medication-related problems (MRPs) and adverse events. Medication reconciliation is widely accepted as a best practice to minimize MRPs at the time of discharge. Pharmacists can play a key role in identification and resolution of MRPs, although pharmacist reconciliation usually occurs after provider medication reconciliation. This workflow is often inefficient and results in duplication of work within the care team. A prospective pharmacist-led pilot program with preparation of discharge medication orders for provider review, also known as pended medication orders, was investigated to determine its impact on MRPs and discharge processing time.

SUMMARY

Patient discharges from February through April 2022 were compared for 2 hospital medicine services at a large academic medical center. One group participated in the pilot workflow, while the other used standard discharge workflows. The pilot group had a significant decrease in the average number of clinical interventions made by a pharmacist after provider orders were placed (52.4% decrease; P = 0.03) and a nonsignificant reduction in the time from provider order entry to completion of the final pharmacist medication reconciliation (47.6% reduction; P = 0.18) compared to the group using standard workflows.

CONCLUSION

Pharmacist-led, prospective discharge medication reconciliation with pending of medication orders for provider review increases overall discharge efficiency. Data from this project and previous studies support an expanded pharmacist role in the discharge process and continued high-level collaboration between pharmacists and providers.

Older patient participation in discharge medication communication: an observational study

OBJECTIVE

To describe the extent to which older patients participate in discharge medication communication, and identify factors that predict patient participation in discharge medication communication.

DESIGN

Observational study.

SETTING

An Australian metropolitan tertiary hospital.

PARTICIPANTS

173 older patients were observed undertaking one medication communication encounter prior to hospital discharge.

OUTCOME

Patient participation measured with MEDICODE, a valid and reliable coding framework used to analyse medication communication. MEDICODE provides two measures for patient participation: (1) Preponderance of Initiative and (2) Dialogue Ratio.

RESULTS

The median for Preponderance of Initiative was 0.7 (IQR=0.5-1.0) and Dialogue Ratio was 0.3 (IQR=0.2-0.4), indicating healthcare professionals took more initiative and medication encounters were mostly monologue rather than a dialogue or dyad. Logistic regression revealed that patients had 30% less chance of having dialogue or dyads with every increase in one medication discussed (OR 0.7, 95% CI 0.5 to 0.9, p=0.01). Additionally, the higher the patient's risk of a medication-related problem, the more initiative the healthcare professionals took in the conversation (OR 1.5, 95% CI 1.0 to 2.1, p=0.04).

CONCLUSION

Older patients are passive during hospital discharge medication conversations. Discussing less medications over several medication conversations spread throughout patient hospitalisation and targeting patients at high risk of medication-related problems may promote more active patient participation, and in turn medication safety outcomes.

A rapid review of interventions to improve medicine self-management for older people living at home

BACKGROUND

As people age, they are more likely to develop multiple long-term conditions that require complicated medicine regimens. Safely self-managing multiple medicines at home is challenging and how older people can be better supported to do so has not been fully explored.

AIM

This study aimed to identify interventions to improve medicine self-management for older people living at home and the aspects of medicine self-management that they address.

DESIGN

A rapid review was undertaken of publications up to April 2022. Eight databases were searched. Inclusion criteria were as follows: interventions aimed at people 65 years of age or older and their informal carers, living at home. Interventions needed to include at least one component of medicine self-management. Study protocols, conference papers, literature reviews and articles not in the English language were not included. The results from the review were reported through narrative synthesis, underpinned by the Resilient Healthcare theory.

RESULTS

Database searches returned 14,353 results. One hundred and sixty-seven articles were individually appraised (full-text screening) and 33 were included in the review. The majority of interventions identified were educational. In most cases, they aimed to improve older people's adherence and increase their knowledge of medicines. Only very few interventions addressed potential issues with medicine supply. Only a minority of interventions specifically targeted older people with either polypharmacy, multimorbidities or frailty.

CONCLUSION

To date, the emphasis in supporting older people to manage their medicines has been on the ability to adhere to medicine regimens. Most interventions identify and target deficiencies within the patient, rather than preparing patients for problems inherent in the medicine management system. Medicine self-management requires a much wider range of skills than taking medicines as prescribed. Interventions supporting older people to anticipate and respond to problems with their medicines may reduce the risk of harm associated with polypharmacy and may contribute to increased resilience in the system.

PATIENT OR PUBLIC CONTRIBUTION

A patient with lived experience of medicine self-management in older age contributed towards shaping the research question as well as the inclusion and exclusion criteria for this review. She is also the coauthor of this article. A patient advisory group oversaw the study.

Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study

Introduction

Improving medication safety during transition of care is an international healthcare priority. While existing research reveals that medication-related incidents and associated harms may be common following hospital discharge, there is limited information about their nature and contributory factors at a national level which is crucial to inform improvement strategy.

Aim

To characterise the nature and contributory factors of medication-related incidents during transition of care from secondary to primary care.

Method

A retrospective analysis of medication incidents reported to the National Reporting and Learning System (NRLS) in England and Wales between 2015 and 2019. Descriptive analysis identified the frequency and nature of incidents and content analysis of free text data, coded using the Patient Safety Research Group (PISA) classification, examined the contributory factors and outcome of incidents.

Results

A total of 1121 medication-related incident reports underwent analysis. Most incidents involved patients over 65 years old (55%, n = 626/1121). More than one in 10 (12.6%, n = 142/1121) incidents were associated with patient harm. The drug monitoring (17%) and administration stages (15%) were associated with a higher proportion of harmful incidents than any other drug use stages. Common medication classes associated with incidents were the cardiovascular (n = 734) and central nervous (n = 273) systems. Among 408 incidents reporting 467 contributory factors, the most common contributory factors were organisation factors (82%, n = 383/467) (mostly related to continuity of care which is the delivery of a seamless service through integration, co-ordination, and the sharing of information between different providers), followed by staff factors (16%, n = 75/467).

Conclusion

Medication incidents after hospital discharge are associated with patient harm. Several targets were identified for future research that could support the development of remedial interventions, including commonly observed medication classes, older adults, increase patient engagement, and improve shared care agreement for medication monitoring post hospital discharge.

Plain language summary

Study using reports about unsafe or substandard care mainly written by healthcare professionals to better understand the type and causes of medication safety problems following hospital discharge Why was the study done? The safe use of medicines after hospital discharge has been highlighted by the World Health Organization as an important target for improvement in patient care. Yet, the type of medication problems which occur, and their causes are poorly understood across England and Wales, which may hamper our efforts to create ways to improve care as they may not be based on what we know causes the problem in the first place.What did the researchers do? The research team studied medication safety incident reports collected across England and Wales over a 5-year period to better understand what kind of medication safety problems occur after hospital discharge and why they happen, so we can find ways to prevent them from happening in future.What did the researchers find? The total number of incident reports studied was 1121, and the majority (n = 626) involved older people. More than one in ten of these incidents caused harm to patients. The most common medications involved in the medication safety incidents were for cardiovascular diseases such as high blood pressure, conditions such as mental illness, pain and neurological conditions (e.g., epilepsy) and other illnesses such as diabetes. The most common causes of these incidents were because of the organisation rules, such as information sharing, followed by staff issues, such as not following protocols, individual mistakes and not having the right skills for the task.What do the findings mean? This study has identified some important targets that can be a focus of future efforts to improve the safe use of medicines after hospital discharge. These include concentrating attention on medication for the cardiovascular and central nervous systems (e.g., via incorporating them in prescribing safety indicators and pharmaceutical prioritisation tools), staff skill mix (e.g., embedding clinical pharmacist roles at key parts of the care pathway where greatest risk is suspected), and implementation of electronic interventions to improve timely communication of medication and other information between healthcare providers.

Pharmacists reducing medication risk in medical outpatient clinics: a retrospective study of 18 clinics

BACKGROUND

The role of pharmacists in hospital inpatient settings is well recognised; however, pharmacists are relatively new to outpatient clinic settings in Australia. Evidence to justify the clinical effectiveness of pharmacists, in terms of identifying and resolving medication-related problems in an outpatient setting in Australia is limited.

AIMS

To investigate the clinical effectiveness of outpatient clinic pharmacists across multiple medical disciplines.

METHODS

A retrospective observational study was conducted by auditing medical records for patients who had an outpatient clinic pharmacist consult between June 2019 and February 2020 in a large quaternary hospital. All pharmacist recommendations targeting a medication-related problem were audited. Recommendations were considered 'resolved' if accepted and actioned by the patient and/or a clinician. The resolved recommendations were risk rated using a validated tool for medication-related patient harm.

RESULTS

There were 18 clinic pharmacist roles across multiple medical disciplines, of which 46 pharmacists conducted outpatient consults. A total of 7599 consults was conducted and a purposeful random sample of 572 (8%) consults was audited for 552 unique patients. There were 399 recommendations recorded in the notes by clinic pharmacists, a mean (standard deviation) of 0.95 (0.97) per patient. Of these, 328 (82%) were resolved; 269 (82%) were classified as low or moderate risk and 59 (18%) were classified as high-risk recommendations.

CONCLUSIONS

Clinic pharmacists in multidisciplinary outpatient clinics are effective at identifying and resolving medication-related problems. Our research demonstrated that 18% of these resolved recommendations prevented a high-risk medication-related harm event.

Collaborative medication management for older adults after hospital discharge: a qualitative descriptive study

BACKGROUND

Safe medication management for older adults after hospital discharge requires a well-coordinated, interprofessional, patient-centered approach. This study aimed to describe the perceived needs for collaborative medication management for older adults taking several different medications at home after hospital discharge.

METHODS

A qualitative descriptive study was conducted using semi-structured interviews with older adults (n = 28), informal (n = 17), and professional caregivers (n = 13).

RESULTS

Findings revealed four main needs: older adults and informal caregivers' perceived needs for greater involvement in discharge planning; older adults' perceived needs to be informed, listened to, and to be actively involved in decision-making; informal caregivers' perceived needs for help in supporting and coordinating medication management; and older adults' and informal and professional caregivers' perceived needs for better communication and coordination between professional caregivers.

CONCLUSION

This study revealed two underutilized pathways towards improving collaborative medication management: medication follow-up involving a community healthcare professional taking an overarching responsibility and empowering older adults and their informal caregivers in medication management after hospital discharge.

Informal carers' support needs, facilitators and barriers in the transitional care of older adults: A qualitative study

INTRODUCTION

Inclusion of informal carers in transitional care is challenging because of fast throughput and service fragmentation. This study aimed to understand informal carers' needs during the care transitions of older adults from inpatient care to the community.

METHODS

A qualitative exploratory design was used with mixed-methods data collection. Seventeen semi-structured telephone interviews were conducted with family carers; one focus group was conducted by videoconference with two family carers and three community-based advocacy and aged care providers; and eight semi-structured telephone interviews were undertaken with healthcare practitioners from rehabilitation services. Data were thematically analysed.

FINDINGS

All carers described the main social challenge that they needed to address in transitional care as 'Needing to sustain family'. Carers reported their social needs across five solutions: 'Partnering with carers', 'Advocating for discharge', 'Accessing streamlined multidisciplinary care', 'Knowing how to care' and 'Accessing follow-up care in the community'. Focus group participants endorsed the findings from the carer interviews and added the theme 'Putting responsibility back onto carers'. All healthcare practitioners described the main social challenge that they needed to address as 'Needing to engage carers'. They reported their social solutions in three themes: 'Communicating with carers', 'Planning with carers' and 'Educating carers'.

DISCUSSION

Findings highlight the importance of reconstructing the meaning of transitional care and relevant outcomes to be inclusive of carers' experiences and their focus on sustaining family. Transitional care that includes carers should commence at the time of hospital admission of the older adult.

CONCLUSIONS

Future sustainable and high-quality health services for older adults will require transitional care that includes carers and older adults and efficient use of inpatient and community care resources. Healthcare professionals will require education and skills in the provision of transitional care that includes carers. To meet carers' support needs, models of transitional care inclusive of carers and older adults should be developed, implemented and evaluated.

PUBLIC CONTRIBUTION

This study was conducted with the guidance of a Carer Advisory Group comprising informal carers with experience of care transitions of older adults they support and community-based organizations providing care and advocacy support to informal carers.

Interventions for self-management of medicines for community-dwelling people with dementia and mild cognitive impairment and their family carers: a systematic review

Background

people with dementia or mild cognitive impairment (MCI) and their family carers face challenges in managing medicines. How medicine self-management could be supported for this population is unclear. This review identifies interventions to improve medicine self-management for people with dementia and MCI and their family carers, and the core components of medicine self-management that they address.

Methods

a database search was conducted for studies with all research designs and ongoing citation search from inception to December 2021. The selection criteria included community-dwelling people with dementia and MCI and their family carers, and interventions with a minimum of one medicine self-management component. The exclusion criteria were wrong population, not focusing on medicine management, incorrect medicine self-management components, not in English and wrong study design. The results are presented and analysed through narrative synthesis. The review is registered [PROSPERO (CRD42020213302)]. Quality assessment was carried out independently applying the QATSDD quality assessment tool.

Results

13 interventions were identified. Interventions primarily addressed adherence. A limited number focused on a wider range of medicine self-management components. Complex psychosocial interventions with frequent visits considered the person’s knowledge and understanding, supply management, monitoring effects and side effects and communicating with healthcare professionals, and addressed more resilience capabilities. However, these interventions were delivered to family carers alone. None of the interventions described patient and public involvement.

Conclusion

interventions, and measures to assess self-management, need to be developed which can address all components of medicine self-management to better meet the needs of people with dementia and MCI and their family carers.

Supporting medicines management for older people at care transitions - a theory-based analysis of a systematic review of 24 interventions

BACKGROUND

Older patients are at severe risk of harm from medicines following a hospital to home transition. Interventions aiming to support successful care transitions by improving medicines management have been implemented. This study aimed to explore which behavioural constructs have previously been targeted by interventions, which individual behaviour change techniques have been included, and which are yet to be trialled.

METHOD

This study mapped the behaviour change techniques used in 24 randomised controlled trials to the Behaviour Change Technique Taxonomy. Once elicited, techniques were further mapped to the Theoretical Domains Framework to explore which determinants of behaviour change had been targeted, and what gaps, if any existed.

RESULTS

Common behaviour change techniques used were: goals and planning; feedback and monitoring; social support; instruction on behaviour performance; and prompts/cues. These may be valuable when combined in a complex intervention. Interventions mostly mapped to between eight and 10 domains of the Theoretical Domains Framework. Environmental context and resources was an underrepresented domain, which should be considered within future interventions.

CONCLUSION

This study has identified behaviour change techniques that could be valuable when combined within a complex intervention aiming to support post-discharge medicines management for older people. Whilst many interventions mapped to eight or more determinants of behaviour change, as identified within the Theoretical Domains Framework, careful assessment of the barriers to behaviour change should be conducted prior to intervention design to ensure all appropriate domains are targeted.

Using experience-based co-design with patients, carers and healthcare professionals to develop theory-based interventions for safer medicines use

BACKGROUND

Experience-Based Co-Design (EBCD) is a participatory design method which was originally developed and is still primarily used as a healthcare quality improvement tool. Traditionally, EBCD has been sited within single services or settings and has yielded improvements grounded in the experiences of those delivering and receiving care.

METHOD

In this article we present how EBCD can be adapted to develop complex interventions, underpinned by theory, to be tested more widely within the healthcare system as part of a multi-phase, multi-site research study. We begin with an outline of co-design and the stages of EBCD. We then provide an overview of how EBCD can be assimilated into an intervention development and evaluation study, giving examples of the adaptations and research tools and methods that can be deployed. We also suggest how to appraise the resulting intervention so it is realistic and tractable in multiple sites. We describe how EBCD can be combined with different behaviour change theories and methods for intervention development and finally, we make suggestions about the skills needed for successful intervention development using EBCD.

CONCLUSION

EBCD has been recognised as being a collaborative approach to improving healthcare services that puts patients and healthcare staff at the heart of initiatives and potential changes. We have demonstrated how EBCD can be integrated into a research project and how existing research approaches can be assimilated into EBCD stages. We have also suggested where behaviour change theories can be used to better understand intervention change mechanisms.

Personal Health Information Management Among Older Adults: Scoping Review

BACKGROUND

Older adults face growing health care needs and could potentially benefit from personal health information management (PHIM) and PHIM technology. To ensure effective PHIM and to provide supportive tools, it is crucial to investigate the needs, challenges, processes, and tools used by this subpopulation. The literature on PHIM by older adults, however, remains scattered and has not provided a clear picture of what we know about the elements that play a role in older adults' PHIM.

OBJECTIVE

The goal of our review was to provide a comprehensive overview of extant knowledge on PHIM by older adults, establish the status quo of research on this topic, and identify research gaps.

METHODS

We carried out a scoping review of the literature from 1998 to 2020, which followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) framework. First, we executed a broad and structured search. We then carried out a qualitative analysis of papers pertinent to the topic taking into consideration the five elements of the patient work system as follows: (1) personal-level factors, (2) PHIM tasks, (3) tools used, (4) physical settings of PHIM activities, and (5) socio-organizational aspects.

RESULTS

The review included 22 studies. Consolidated empirical evidence was related to all elements of the patient work system. Multiple personal factors affected PHIM. Various types of personal health information were managed (clinical, patient-generated, and general) and tools were used (electronic, paper-based, and others). Older adults' PHIM was intertwined with their surroundings, and various individuals participated. The largest body of evidence concerned personal factors, while findings regarding the physical environment of PHIM were scarce. Most research has thus far examined older adults as a single group, and scant attention has been paid to age subgroups.

CONCLUSIONS

Opportunities for further PHIM studies remain across all elements of the patient work system in terms of empirical, design science, or review work.

Post-discharge medicines management: the experiences, perceptions and roles of older people and their family carers

Background

Multiple changes are made to older patients’ medicines during hospital admission, which can sometimes cause confusion and anxiety. This results in problems with post‐discharge medicines management, for example medicines taken incorrectly, which can lead to harm, hospital readmission and reduced quality of life.

Aim

To explore the experiences of older patients and their family carers as they enacted post‐discharge medicines management.

Design

Semi‐structured interviews took place in participants’ homes, approximately two weeks after hospital discharge. Data analysis used the Framework method.

Setting and participants

Recruitment took place during admission to one of two large teaching hospitals in North England. Twenty‐seven participants aged 75 plus who lived with long‐term conditions and polypharmacy, and nine family carers, were interviewed.

Findings

Three core themes emerged: impact of the transition, safety strategies and medicines management role. Conversations between participants and health‐care professionals about medicines changes often lacked detail, which disrupted some participants’ knowledge and medicines management capabilities. Participants used multiple strategies to support post‐discharge medicines management, such as creating administration checklists, seeking advice or supporting primary care through prompts to ensure medicines were supplied on time. The level to which they engaged with these activities varied.

Discussion and conclusion

Participants experienced gaps in their post‐discharge medicines management, which they had to bridge through implementing their own strategies or by enlisting support from others. Areas for improvement were identified, mainly through better communication about medicines changes and wider involvement of patients and family carers in their medicines‐related care during the hospital‐to‐home transition.