Information for Primary Care Pharmacists and Pharmacy Assistants

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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 service

  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 will be provided under the project?

  Low risk patients:

  • Usual care.

  Moderate risk patients

  • Usual care PLUS
  • Hospital pharmacist to liaise with community pharmacist to organise dose administration aid if applicable.
  • Clinical handover provided to relevant primary care pharmacist where appropriate.
  • 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 pharmacy 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 community pharmacies.

  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 (including community and general practice pharmacists) 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
      • Initiation of a dose administration aid
      • MedsCheck review
      • Home medicines review

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

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  What is the role of the community pharmacist?

  • Review the discharge medication record (DMR) and reconcile discharge medicines with pre-admission medicines to identify variation. Review GP prescriptions to identify discrepancies with discharge medicines.
  • Liaise with patient, GP, general practice pharmacist, and/or hospital pharmacist to resolve any identified issues.
  • Review the recommendations in the post-discharge medication management plan (if supplied).
  • Undertake monitoring/review/education activities (including MedsCheck review) as recommended.
  • Update patient records and supply medicines as required.
  • Send a copy of the MedsCheck action plan/advise outcomes to the hospital pharmacist as appropriate.
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  What is the role of the pharmacy assistant?

  • Identify patients that have been recently discharged from hospital and notify the community pharmacist.
  • Support administrative tasks related to the project activities carried out by community pharmacists
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  What is the role of the general practice pharmacist?

  The general practice pharmacist may have access to the DMR and medication management plan via the patient’s nominated GP.

  • Review the discharge medication record (DMR) and reconcile discharge medicines with pre-admission medicines to identify variation. Review active GP prescriptions to identify discrepancies with discharge medicines.
  • Liaise with the patient, GP, community pharmacist, and/or hospital pharmacist to resolve any identified issues.
  • Review the recommendations in the post-discharge medication management plan (if supplied).
  • Undertake monitoring/review/education activities as recommended.
  • Update patient records as appropriate.
  • Advise outcomes to the hospital pharmacist as appropriate.
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  Can primary care pharmacists contact the hospital pharmacist?

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

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  Why should I participate in the project?

  • Pharmacist-led transition of care interventions, including post-discharge follow-up and improved communication with primary health care providers, have been shown to reduce medication discrepancies, adverse drug events and readmission to hospital. [1][2]
  • The post-discharge medication management plans supplied from the hospital pharmacist will facilitate the focused review of a patients’ ongoing care needs and will highlight patients who can be targeted for MedsCheck review services.
  • Information supplied by hospital pharmacists to facilitate the ongoing management of project patients may improve primary care pharmacist capability to manage other patients discharged from hospital.
  • Prior to discharge, patients will be educated regarding the advantages of obtaining their medicines consistently from one community pharmacy. Involvement in post-discharge medication monitoring may help to establish ongoing pharmacist-patient relationships.

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  _{[1]  Daliri S, Boujarfi S, El Mokaddam A, Scholte Op Reimer WJM, Ter Riet G, Den Haan C, et al. Medication-related interventions delivered both in hospital and following discharge: A systematic review and meta-analysis. BMJ Quality and Safety. 2021;30(2):146-56.}

  _{[2] Cebron Lipovec N, Zerovnik S, Kos M. Pharmacy-supported interventions at transitions of care: an umbrella review. Int J Clin Pharm. 2019;41(4):831-52.}

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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 community pharmacies to undertake patient review activities.

  Pharmacy services that may be recommended to facilitate Transition of Care such as MedsCheck, Diabetes MedsCheck, Dose Administration Aids, Staged Supply, and Home Medicines Review, may be funded under the Seventh Community Pharmacy Agreement. Eligible claims can be made via the Pharmacy Programs Administrator.

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  How can a pharmacy get involved?

  There is no need for individual pharmacies to register to participate. When a patient nominates a community pharmacy, that pharmacy will receive all the necessary communication from the hospital pharmacist.

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  What happens if the patient does not have a regular community pharmacy?

  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 and community pharmacy.

  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 primary care pharmacist reviewing the patient following discharge.