Targeted Medicines Use Reviews on hospital discharge

1. Targeted Medicines Use Reviews on hospital discharge Community Pharmacy Contract Update Event September 2011

2. Outline • STH Pharmacy services • TTO errors (NHSS audit) • Risks to patients during ‘transfer of care’/interface • Targeted MURs post discharge • Referral Process • Outcome measures?

3. STH Pharmacy Services • 74,700 items dispensed per month (avg. 500 discharges/day) • 50% requiring clarification/intervention in house • TTO audit in primary care

4. NHSS TTO audit in Primary care • CQC report: Managing patients’ medicines after discharge Oct 09 • Oct 2010 – 40 GP practices identified TTOs with medication errors or incomplete information • 226 incidents from 160 TTO forms:

5. NHSS TTO audit in Primary Care • Potential harm to patients • Main concern is lack of information • Limitations • No link as to whether there was a pharmacist clinical check on the TTO • No correlation made with medicines reconciliation on admission • Efforts to address • Improving medicines reconciliation rate on admission (80%) • Electronic discharges • Junior doctor training

6. Risks to Patients at the Interface CQC report 2009 • On admission: discrepancies between what a patient is taking and what the hospital has recorded:19-54% (40% potentially harmful) • Information provided by primary care is ‘patchy and inconsistent’ • Lack of electronic links (summary care records) • On discharge: 50% of patients experience an error with their medication • Poor communication • Lack of monitoring and review • Lack of electronic links with GPs and Pharmacies

7. Risks to Patients at the Interface • RPS: Medicines Transfer Guidance – Keeping Patients Safe (July 2011) • Between 30 and 70% of patients have either an error or an unintentional change to their medicines when their care is transferred. • Incidents of avoidable harm to patients can result in unnecessary readmissions (around four to five percent of hospital admissions are due to preventable problems with medicines). • And in some cases the impact on patients can be devastating.

8. Targeted MURs post discharge • Great opportunity • Reconcile medicines • Re-assure/educate patient • Improve adherence • Better communication • Pharmacy profession working together • Saving GP/practice time

9. Patient Groups for MURs • High risk meds • Respiratory Disease • Discharged from hospital with a medicines change • Selected high-risk medicines • Unlicensed medicines • Part way through dose escalation or reduction regimens at the point of discharge (e.g. amiodarone, gapabentin, corticosteroids etc.) • Known compliance problems • New Monitored Dosage Systems

10. Referral Process • Referrals initially by pharmacy staff, discharge liaison teams and stroke pathway team. • Referral form and TTO faxed to community pharmacy (subject to patient consent) • Patient advised of referral • Patient either presents for MUR or community pharmacy contacts to arrange appointment

11. Outcomes/assessment of impact • Important to measure outcomes of MURs post discharge – evidence for future commissioning • Pharmabase • May include outcome details on referral forms (e.g. double dosing identified, missing medication identified, taking medication no longer needed etc.)