PSQ3 – Transfer of care – mind the gap

Linked to EAHP Statements

Section 1 – Introductory Statements and Governance: Statements 1.1, 1.7
Section 4 – Clinical Pharmacy Services: Statements 4.1, 4.2, 4.3, 4.4, 4.5, 4.6, 4.7, 4.8
Section 5 – Patient Safety and Quality Assurance: Statements 5.1, 5.2, 5.4, 5.9, 5.10, 5.11

ACPE UAN: 0475-0000-21-027-L04-P. A knowledge-based activity. 

Abstract
Transfer of care is an integral part of a patient’s journey throughout a health care system. Managing the transition of patients effectively from the primary care into hospital care and vice versa is essential. Transitioning between hospital and primary care settings is recognised as a high-risk scenario for patient safety. The impact of problems include increase in mortality, morbidity, adverse events, delays in receiving appropriate treatment and community support as well as preventable admissions to hospital.

Several initiatives have been described to improve the transfer of care, many of which involve pharmacists. Medication reconciliation, medication therapy management, education of patients are examples of pharmacists’ interventions that could improve the care during transmission. Unfortunately, many of the interventions are mostly focused on either the inpatient or outpatient settings with a lack of collaboration between community and hospital pharmacists.

During the workshop, we will introduce a model referral system which was developed to improve the communication and transfer of information between hospital and community pharmacy. The new system model helps to identify and refer to community pharmacy patients with a special follow-up need after a discharge. Community pharmacist receives the same information as the general practitioner about the hospital treatment, discharge changes and follow-up plans. Pharmacists in a hospital feel assured that patients will get the appropriate support with a treatment. At the end, it can save time at the hospital and community, improve productivity, patient safety, medicines adherence and empower hospital and community pharmacy professional to work together.

Learning objectives
After the session, participants should be able to:
• recognise key elements of transition of care;
• list medication-related problems that can occur due to transition between settings of care;
• explain core barriers of communication between hospital pharmacist and community pharmacist;
• list possible ways which help to improve continuity of care with regard to medications on admissions as well as at the discharge from the hospital.

Educational need addressed
Transition between care settings is a time of high risk for preventable medication errors. Poor communication about medication changes on discharge from hospital can result in adverse drug events and medicines-related readmissions. During the workshop, we will discuss possible ways how communication between community and hospital pharmacist can be improved.

Keywords: transition of care, hospital pharmacist, collaboration, community pharmacist, referral system, patient’s safety, follow up, communication.