Information for General Practitioners

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  Which patients are included in the project?

  Eligible patients are those admitted to an inpatient treating team in the following services:

  • Royal Brisbane and Women’s Hospital: Internal Medicine Services (selected teams)
  • Princess Alexandra Hospital:  Vascular Surgical patients
  • Townsville University Hospital: Gerontology services

  Patients will be risk assessed as low, moderate, or high risk and managed in accordance with the ToCPP Model of Care (PDF 2158 kB). The model of care is limited to patients discharging to home.

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  How are patients risk assessed?

  Patient risk will be calculated using the LACE index for readmission (see the patient risk assessment on the project information page).

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  What additional services are provided under the project?

  Low risk patients:

  • Usual care.

  Moderate risk patients

  • Usual care PLUS
  • Patient provided with a discharge medication record (DMR) generated by the hospital pharmacist.
  • Copy of the DMR* sent (by fax or email) to the patient’s nominated GP and community pharmacy. The DMR:
    • Provides information regarding medication changes, including rationale for change and indications for new medicines.
    • Can be used to facilitate medicines reconciliation to ensure changes made in hospital are, where clinically appropriate, continued in the community.
    • Can assist with updates to patient records.

  * It should be noted that patients do not need to be included in the project to receive a DMR. These records are routinely provided to patients across all Queensland Health facilities. It is not, however, currently standard practice to send them directly to GPs.

  High risk patients

  • Care as per moderate risk patients PLUS
  • Telehealth/telephone review of the patient by the hospital pharmacist within 7 days of discharge. The hospital pharmacist will:
    • Perform medication reconciliation, adherence assessment, and medication monitoring activities.
    • Attempt to resolve any identified concerns.
    • Liaise with hospital teams and primary healthcare providers as appropriate.
    • Generate a post-discharge medication management plan which will be sent to the patient’s nominated GP and community pharmacy. The plan will contain targeted recommendations for ongoing care including:
      • Medication efficacy and adverse event monitoring
      • Adherence monitoring
      • Patient education
      • Supply advice
      • Home medicines review

  To encourage a collaborative care approach, GPs will be able to see the recommendations made to community pharmacists and vice versa.

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  Will there be any change to the discharge summary?

  A hospital discharge summary will be communicated to GPs in the usual way. Hospital pharmacists may add medication-specific information in the ‘recommendations to GP’ section.

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  What is the GP’s role?

  • Review the discharge summary and discharge medication record. Reconcile discharge medicines with pre-admission medicines to identify variation.
  • Contact the hospital pharmacist for clarification/provision of medicines information as required.
  • Undertake shared decision-making and education with the patient. Update medical/medication records and generate prescriptions, as appropriate, for ongoing supply.
  • Respond to requests from the hospital pharmacist to resolve medication-related concerns identified in post-discharge follow up (high risk patients).
  • If clinically appropriate, undertake relevant monitoring or actions identified in post-discharge medication management plan (high risk patients).
  • If clinically appropriate, undertake relevant activities identified in any plan generated by the community pharmacist (e.g., MedsCheck action plan).
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  Can GPs contact the hospital team?

  GPs have requested improvements in the two-way communication between hospital and primary healthcare settings. This project will enable GPs to contact hospital teams regarding post-discharge medication-related problems.

  The hospital pharmacist will provide a contact phone number in any correspondence sent directly to the patient’s GP. The contact number will also be on the DMR and post-discharge medication management plan.

  It is suggested that any medication-related questions regarding the admission are initially directed to the hospital pharmacist. If unable to answer the questions, the hospital pharmacist will liaise with the treating team.

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  What happens if the patient does not have a regular GP?

  Patients will be advised to follow-up with their GP following discharge. Every effort will be made to encourage the patient to attend a regular GP and nominate both a GP and community pharmacy for ongoing care.

  All moderate and high risk patients will be provided with a DMR, and high risk patients will still be offered a post-discharge review even if they do not have a regular GP.

  The hospital pharmacist’s contact number will be on the patient’s copy of the DMR, and the hospital pharmacist can be contacted by any GP reviewing the patient following discharge.

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  Do I receive any funding for participating in the project?

  The project model of care aims to improve communication and sharing of information between tertiary and primary health care settings. The Department of Health, Queensland, will not be providing funding to GPs to undertake patient review activities.

  If appropriate, GPs may organise and coordinate a multidisciplinary case conference for patients who:

  1. have at least one medical condition that:
     1. has been (or is likely to be) present for at least 6 months; or
     2. is terminal; and
  2. require ongoing care from a multidisciplinary case conference team which includes:
     1. a medical practitioner; and
     2. at least two other members, each of whom provides a different kind of care or service to the patient and is not a family carer of the patient, and one of whom may be another medical practitioner.

  Hospital or community pharmacists may be included in such case conferences. (Item numbers 735, 739, 743). See MBS Online.

  Recommendations for ongoing care may include referring the patient to a community pharmacy or an accredited pharmacist for a Home Medicines Review and this may be claimable as a Domiciliary Medication Management Review service (Item number 900). See MBS Online.