1. Discharge planning – reducing admissions/re- admissions Jo Clarke, CPPE tutor 1

2. Housekeeping 2 Comfortable See and hear Fire alarm & exits Toilets Phones and devices Evaluation forms

3. Aim 3 To provide learners with a better understanding of how, by making transfer of care safer and more effective on discharge from hospital, pharmacy teams can improve patient outcomes and reduce hospital admissions.

4. Learning objectives 4 On completion of this workshop you should be able to: describe the potential impact of poor transfer of care on discharge from hospital on patients and the health service as a whole identify steps in the discharge process where pharmacy professionals can improve transfer of care for patients identify patients who may benefit from advance planning for discharge due to pharmaceutical care issues outline a ‘transfer-of-care friendly’ discharge summary

5. What’s the problem? 5  There is a less than 10 percent likelihood that an elderly medical patient will be discharged on the same medicines that they were admitted on.  Approximately 45 percent of medicines prescribed at discharge are new for that patient.  Around 60 percent of patients will have three or more medicines changed during their hospital stay.  Unintended discrepancies in medicines after discharge from hospital affect up to 87 percent of patients.

6. NHS England safety alert Aug 14 6 Risks arising from breakdown and failure to act on communication during handover at the time of discharge from secondary care Communication on handover accounts for approx 33% of the 10,000 reported toNRLS National workstream part of Patient Safety Domain at NHS England

7. What does this mean for patients and the NHS? 7  Safety and quality of care  Waste  Adverse drug events

8. Poor discharge examples 8 Watch this video clip of a GP describing two problematic discharges which had an impact on patient care. Think about what you or another pharmacy professional could have done to improve the outcomes for these patients Video clip

9. What could have prevented these problems? 9 Discussion on the key points / what could have been done? Examples from others where admissions have been potentially avoided – discuss in small groups and then be prepared to feedback

10. Transition from hospital to community 10  How can this transition be safe and well managed?  Discharge planning – which patients need advance planning due to pharmaceutical care issues?  Are local drug charts and discharge summaries transfer-of- care friendly? How can they be improved?  Routine referral of patients to their community pharmacist for post-discharge support – Hospital referral to community pharmacy: An innovator’s toolkit from the RPS and NHS PrescQIPP webkitHospital referral to community pharmacy: An innovator’s toolkitNHS PrescQIPP webkit  Is additional support available for high-risk groups post- discharge? Is this part of commissioning plans? How will you identify and prioritise those at risk of re-admission?

11. Prior to admission 11 What is our role in primary care? Discuss in small groups What can we do to improve information to hospitals on admission? Consider summary care records, doses eg insulin / warfarin and problems / solutions

12. On admission or first contact 12 The pharmacy team provides the leadership, systems support and expertise that enables a multidisciplinary team to identify potential medicines problems affecting discharge (or transfer to another care setting) so that they can be accommodated to avoid extending patients’ stays in hospital’.

13. Discharge planning 13  Are you based in your GP practice all or most of the time?  Does your hospital pharmacy know of your role?  Suggest they do so that they can contact you for patients being discharged who are at-risk of medicines-related issues.

14. Discharge planning 14  Adherence concerns  Patients using MCAs  Other concordance support required  Swallowing difficulties/NG/PEG  Children on unlicensed medicines  Home care  Shared care required  Unlicensed specials  PREVENT referral tool

15. Multi-compartment compliance aids (MCAs) 15  Is the patient actually able to use the MCA? Is the MCA for the patient or to support the carer?  What is the hospital policy on starting a patient on a MCA or filling one they have brought in?  Is there local agreement on medicines that should not normally be stored in a MCA?  Does the patient need additional support to use the MCA eg, large- print labels?

16. Multi-compartment compliance aids (MCAs) 16  Is there local agreement on the inclusion of high risk medicines such as warfarin or lithium in MCAs?  What is the local social services policy in terms of care workers prompting patients to take their medicines from normal packaging versus MCAs?

17. Communication 17  Are local drug charts and discharge summaries transfer-of-care friendly?  How can they be improved? Who can you talk to about this?  Take 5 mins to look at this example of an electronic discharge summary – identify 5 changes you could make to improve the transfer of information about medicines.

18. Referral for dMUR/NMS 18  How can you support the hospital team to refer for dMUR/NMS? Are there projects in your area?  RPS toolkit - http://www.rpharms.com/unsecure- support-resources/referral-toolkit.asphttp://www.rpharms.com/unsecure- support-resources/referral-toolkit.asp  NHS PrescQIPP Transfer of Care webkit - http://www.prescqipp.info/transfercare#enabling- community-pharmacy http://www.prescqipp.info/transfercare#enabling- community-pharmacy  Working with GPs and understanding their challenges regarding interface

19. Additional support for high risk groups? 16 NICE guideline 5 – Medicines optimisation: Organisations should consider arranging additional support for some groups of people when they have been discharged from hospital, such as pharmacist counselling, telephone follow-up, and GP or nurse follow-up home visits. These groups may include: Adults, children and young people taking multiple medicines (polypharmacy) Adults, children and young people with chronic or long-term conditions Older people

20. Consultation skills 20  Every time we have an interaction with a patient  National Standards for pharmacy professionals  Patient-centred  Shared decision making www.consultationskillsforpharmacy.com

21. Resources 21

22. Resources 22  www.Patientsafetyfirst.nhs.uk www.Patientsafetyfirst.nhs.uk  Specialist pharmacy services - http://www.medicinesresources.nhs.uk/en/Communit ies/NHS/SPS-E-and-SE-England/ http://www.medicinesresources.nhs.uk/en/Communit ies/NHS/SPS-E-and-SE-England/  CPPE e-learning programme – Transfer of care: supporting patients moving into and out of hospital - www.cppe.ac.uk – section 3 describes range of resources available to support good transfer of care

23. www.cppe.ac.uk info@cppe.ac.uk 0161 778 4000 Follow us on Twitter, Facebook, LinkedIn and YouTube: www.twitter.com/cppeengland www.facebook.com/cppeengland www.linkedin.com/company/centre-for-pharmacy-postgraduate-education www.cppe.ac.uk/youtube 23