- Email: [email protected]
Dementia, medication and transitions of care
Research in Social and Administrative Pharmacy j (2015) j–j
Original Research
Dementia, medication and transitions of care Louise S. Deeks, B.Sc.(Hons.), P.G.Dip.Pharm.Prac.a,*, Gabrielle M. Cooper, Ph.D.a, Brian Draper, M.D.b,c, Susan Kurrle, Ph.D.d,e, Diane M. Gibson, Ph.D.f a
Discipline of Pharmacy, Faculty of Health, University of Canberra, ACT 2601, Australia b School of Psychiatry, University of NSW, Sydney, Australia c Academic Department for Old Age Psychiatry, Prince of Wales Hospital, Sydney, Australia d Faculty of Medicine, University of Sydney, Sydney, Australia e Rehabilitation and Aged Care Service, Hornsby Hospital, Sydney, Australia f Faculty of Health, University of Canberra, ACT 2601, Australia
Abstract Background: Persons with dementia (PWD) often have complex medication regimens and are at risk of medication problems during the multiple transitions of care experienced as the condition progresses. Objectives: To explore medication processes in acute care episodes and care transitions for PWD and to make recommendations to improve practice. Method: Semi-structured interviews were conducted by two pharmacy researchers from a focused purposive sample of fifty-one participants (carers, health professionals, Alzheimer’s Australia staff) from urban and rural Australia. After written consent, the interviews were audio-recorded then transcribed verbatim for face-to-face interviews, or notes were taken during the interview if conducted by telephone. The transcripts were checked for accuracy by the pharmacy researchers. Thematic analysis of the data was undertaken independently by the two researchers to reduce bias and any disagreements were resolved by discussion. Results: Themes identified were: medication reconciliation; no modified planning for care transitions; underutilization of information technology; multiple prescribers; residential aged care facilities; and medication reviews by pharmacists. Sub themes were: access to appropriate staff; identification of dementia; dose administration aids; and staff training. Conclusions: Medication management is sub-optimal for PWD during care transitions and may compromise safety. Suggested improvements included: increased involvement of pharmacists in care transitions; outreach or transitional health care professionals; modified planning for care transitions for individuals over 80 years; co-ordinated electronic records; structured communication; and staff training. Ó 2015 Elsevier Inc. All rights reserved. Keywords: Older people; Dementia; Pharmacy; Transitions of care; Medication
* Corresponding author. Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce ACT 2601, Australia. Tel.: þ61 2 6201 2254; fax: þ61 2 6201 5727. E-mail address: [email protected] (L.S. Deeks). 1551-7411/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2015.07.002
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Introduction
Method
Persons with dementia (PWD) may be prescribed medication for dementia or for their comorbidities. Problems with activities of daily living, a decreased capacity for decision-making, confusion, disorientation, communication problems and reliance on carers make managing medication challenging for PWD. PWD in Australia is predicted to increase from 266,574 in 2011 to 942,624 in 2050.1 PWD are more likely to be admitted to hospital – annually more than 25% of PWD have hospital admissions, compared to 12% without dementia.2 The rise in prevalence of dementia, the associated risk of hospital admission and the vulnerability of PWD highlights the importance of understanding hospital admissions and other care transitions for PWD,3 particularly as they relate to medication management. Care transitions are associated with medication problems. Research suggests that 12.5% of patients have a medication-related adverse event after hospital discharge.4 Unintentional medication discrepancies,5 preventable adverse drug events,4 poor selection of medication, no discharge summary and supply problems6 have been identified in care transitions that have not focused on dementia. These problems can be detrimental to patient safety and thus may lead to hospital readmissions.4 As PWD are a vulnerable group of the population, specific dementia-friendly strategies for medication management to ensure safe, high quality transfer of care are therefore important. To date there has been limited investigation of this issue, particularly in Australia. Health care, and the roles of community and hospital pharmacists in Australia have been described previously in this journal.7,8 Briefly, Australian citizens can obtain free treatment in public hospitals and free or subsidized general practitioner (GP) appointments via universal health insurance, ‘Medicare’.7 Community pharmacy in Australia has mainly a supply role with other services negotiated as part of the Community Pharmacy Agreement.7 Hospital pharmacists in Australia provide a clinical pharmacy service in addition to their supply role whereas the role of the hospital pharmacy technician is usually limited to supply.8 This research aims to explore medication processes that occur during acute care episodes and in care transitions for PWD in Australia and to make recommendations to improve patient care.
In this qualitative study two researchers (LD, GC) conducted in-depth semi-structured interviews on topics concerning medications and care transitions for people with a diagnosis of dementia. A set of seeding questions (see Appendix 1) was used; however, the conversation was allowed to flow freely so as to explore issues important to participants. The participants were a focused purposive sample of stakeholders from acute and primary care from four sites, each a region. The fifty-one participants (#1 to #51) comprised carers, hospital doctors, nurses (specialist aged care, transitional, hospital, aged care/respite facilities), pharmacists (hospital, transitional and community), hospital occupational therapist, GPs and Alzheimer’s Australia staff (see Appendix 2). Forty-nine of the interviews were face-to-face and two were by telephone. There was one urban site in the Australian Capital Territory (ACT) (capital city, population served 350,000) that recruited 20 participants, two urban sites in New South Wales (NSW) (major city, populations served 313,000 and 205,000) that recruited 12 and 7 participants and one rural site in NSW (coastal, population served 35,000) that recruited 12 participants. After written consent, the interviews were audio-recorded then transcribed verbatim for face-to-face interviews, or notes were taken during the interview if conducted by telephone. The transcripts were checked for accuracy by the researchers (LD, GC) who conducted the interviews. LD and GC worked independently on thematic analysis to reduce any bias. The interview text was read several times by the pharmacist researchers (LD, GC). The analysis was an iterative process conducted by reading through the transcripts, adding codes to the data and then linking the codes to identify emerging themes that described the content of the data. Any disagreements were resolved by in-depth discussion and negotiated consensus. Human Research Ethics Committee approval was obtained from: University of Canberra; ACT Government Health Directorate; and South Eastern Sydney Local Health District – Northern Sector (with three Site Specific Assessments). Results Thematic analysis identified six themes and four sub themes (see Table 1). These are described in the following text with comments italicized.
Deeks et al. / Research in Social and Administrative Pharmacy j (2015) 1–11 Table 1 Themes and sub themes identified Themes
Sub themes
Medication reconciliation No modified planning for care transitions
Access to appropriate staff Identification of dementia Dose administration aids Staff training Access to appropriate staff
Underutilization of information technology Multiple prescribers Residential aged care facilities Medication review by pharmacists
No modified planning for care transitions Identification of PWD and other cognitive impairments in the hospital was cited as challenging, especially where patients were not in Geriatric Medical Wards. Suggestions included cognitive screening at admission, more individuals trained to screen for cognitive impairment, blanket modified planning for older people and using an above bed symbol to alert staff that there are cognitive issues.
Staff training Access to appropriate staff
I suspect in other parts of the hospital [away from Geriatric Medical Wards] there’s less awareness of dementia – people more likely to have dementia that’s either not diagnosed or is really ignored in terms of prescribing, and people are told things in the expectation they will remember, whereas they clearly won’t. (#13, hospital doctor)
On admission to hospital medication reconciliation (obtaining and verifying a complete and accurate list of current medication then resolving discrepancies between the list and medication taken by the patient)9 is important for informed clinical decision making. This is difficult for PWD because they may lack capacity, their carers may not be present, and they may have not brought medication into hospital. GP medication lists can be used to obtain a list of current medication but these can be inaccurate. The reasons for this include: medication not being updated in the GP database; patients having multiple GPs; there may be additional specialist prescribing; and previous inaccurate discharge information. Regular community pharmacists were acknowledged as the most reliable source of a patient’s current medication.
There was a symbols project done in a small town somewhere in New South Wales on a cognitive symbol above the bed, which didn’t alert the person . but other staff would go in and go, “right, okay.” (#16, carer)
Medication reconciliation
The doctor [GP] will just print off. They don’t do data cleaning, so it will all come in. And often we do find things that are charted that really the patient isn’t on anymore. (#24 hospital pharmacist) [The Community Pharmacist is] Most accurate, that’s where I would go. (#4 hospital pharmacist)
Reliance on hospital pharmacists to perform medication reconciliation, or any task, is compromised by lack of access due to restricted working hours in our study hospitals (usually Monday to Friday) and variability of pharmacist services between hospitals. This leads to nurses and other allied health care professionals taking on medication related roles. Occupational therapists get a bag . [of] the [discharge] medications, and you’ve got to sort it. (#10 occupational therapist)
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After discharge from hospital medication from hospitals in addition to existing supplies from community pharmacies can cause misadventure, especially where generic switching occurs. This was not a problem in the rural site where discharge medication was supplied by the patient’s usual community pharmacy. Other solutions suggested were systems that use ‘green bags’ to transfer medications between care settings, using patient’s own medication in hospital and self-administration in hospital. They come out on a generic medication of every single medication they were on plus extras and they end up completely bewildered and overwhelmed and they go, “I’ll just not take any of it.” (#11 community pharmacist) People should start to self medicate in the hospital especially rehabilitation units. (#3 specialist aged care nurse) We want them [medication from home] to get put in the big, green plastic bags and we’ve just finished installing all the patient’s own medication cupboards in all the ward areas, and the idea is it gets transferred between wards. (#4 hospital pharmacist)
Insufficient quantities of medication supplied from hospital can cause issues. Problems occur if the patient isn’t well enough to attend or cannot get an appointment with the GP or if the GP hasn’t received the discharge information.
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Deeks et al. / Research in Social and Administrative Pharmacy j (2015) 1–11 3 or 5 day appointment with the GP comes up; some of them are tired and they cancel it, and so then what can happen is they revert back [to preadmission medication]. (#3 specialist aged care nurse)
Discharge planning is difficult in public hospitals due short lengths of stay. This leads to patients not being allocated sufficient counseling time prior to discharge. It is more challenging when the discharge is outside of usual working hours without a carer. At 5 pm with 3 pages of discharge medications, new initiations of warfarin . they are actually really unsafe discharges. (#4 hospital pharmacist)
Problems with the accuracy or appropriateness of the hospital discharge medication information provided to GPs were identified. There can be difficulty establishing whether changes to medication are intentional. Discharge information can lack explanations for medication changes causing problems for ongoing patient care. Respondents linked this to the responsibility for writing discharge medications usually falling to the most junior person on the team often with a limited exposure to the patient and the care aims. In the one rural site fewer issues were reported and a contributory factor was thought to be the role hospital pharmacists have writing discharge medication summaries on that site. There was support for discharge medication changes being sent to community pharmacies to facilitate follow up but this rarely occurs. The person who knows the patient least well is writing the instruction manual for further treatment. (#35 general practitioner) Something has been ceased on the ward, and they have actually got it on their discharge summary or vice versa they’ve started it and it hasn’t been put on. (#39 liaison pharmacist)
A method to facilitate individuals to manage their own medication or be supported by carers is using a dose administration aid (DAA). In our study these were blister pack DAAs containing tablets or capsules dispensed into a weekly pack with four dosing times per day. There was support for DAAs from carers and nurses. DAAs are not without problems, such as no assessment of ability to use DAAs occurring, expense, error potential, ongoing monitoring, and the safety of DAAs from central packing locations. She got the pack from Queensland, so it’s got when to take it and you’ve got the days. As long as you
start on the Monday, it’s a great help for her and a great help for me too. (#19 carer) You do need to have a . fairly high degree of cognition to work out what days, what dates and then . be able to push the medications [out]. (#10 occupational therapist) A dementia client, she had a build up of 6. Why would you keep delivering? (#38 transitional nurse)
Discharges where the patient will be reliant on paid carers to monitor medication require more liaising and planning. This includes assessment of the need for carers, early notification of expected date of discharge to enable engagement of services and alteration of dosing schedules to facilitate prompting of medication. There were issues around communication with medication related care package providers during care transitions for PWD. It might take a package provider three days to get carers back into the home. (#16 carer) Merge all the meds together so they’re one time a day, and then you can get a paid carer to go in and support. (#16 carer)
Good practice centered on individual champions with good communication networks. These included workers that supported PWD post hospital discharge, during hospital admission and in avoiding hospital admissions. Within each hospital there were clinical nurse consultants to support PWD. Two of the sites had a community liaison pharmacist and these can be utilized to support PWD by conducting medication reviews to ensure patients receive appropriate medication during care transitions. Underutilization of information technology (IT) Participants expressed frustrations with IT systems. There are multiple unlinked systems (for example in emergency departments, mental health, hospital wards, GPs, pharmacies) leading to data not being shared. An example where this causes patient harm is during a medication-related admission where this information is not transferred to all hospital systems so is unavailable leading to the prescribing of this unsuitable medication again. Restricted access to IT systems was described. This can mean that some information relevant to patients cannot be shared, for example, their cognitive state or their correct
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medication. This causes harm where the hospital pharmacist has agreed a medication change to the discharge prescription with the ward doctor but only the doctor can alter the GP discharge communication. If the ward doctor does not activate this change, the GP will receive incorrect information. If we identify an error in that discharge prescription . we say to the doctor, you’ve got to go back and change the discharge summary . it probably in reality never happens. (#40 hospital pharmacist)
Multiple prescribers Multiple prescribers are associated with problems during care transitions. It was reported that little information was shared between private and public hospitals. Treatment delays have occurred because the communication method from specialists to the GP is a letter. Care coordinating advocates were suggested as a solution. IT was cited as an area where improvements could be made with support for a mandatory electronic health care record with automatic updating every time medication changes are made. If everybody has an electronic record coded to their Medicare number . every time you as the pharmacist changes it or me as the doctor changes it, that automatically quickly alters it. (#12 hospital doctor)
Residential Aged Care Facilities (RACFs) Medication problems were identified between acute care and RACFs. The RACFs require specific documents to give medication. RACF staff commented about lacking or inaccurate information received from hospitals whereas hospital pharmacists had difficulties with the variable clerical and clinical requirements from different RACFs. In an urban site, a GRACE CNC (Geriatric Rapid Acute Care Evaluation Clinical Nurse Consultant) is employed. One of the GRACE roles is to ensure that medication information is transferred between RACFs and hospital. There was also support for standardized information transfer in a ‘yellow envelope’ or bag. [after hospital discharge] Go through all this . phoning, faxing, faxing, phoning and then get a delivery [of medication]. That’s what holds up the administration of medication. And it could be 24, 48 hours perhaps longer [before medication can be administered]. (#42 RACF nurse)
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Some information – bowels, aperients, photocopied medication sheets. In yellow envelope. (#50 specialist aged care nurse)
Training was raised in the context of RACFs as a proportion of the workforce has limited training relating to medications. A number of respondents from RACF commented on negative attitudes to dementia that may adversely influence the quality and safety of patient management generally, and particularly during care transitions. Training could help to change these attitudes. I said to the [RACF] staff it’s really important that he’s having his LasixÔ they weren’t able to demonstrate that they understood. (#5 chronic care nurse) They [GPs] look at aged care and the related problems, dementia included, as fairly tedious, boring, a waste of time. (# 42 RACF nurse)
Medication reviews by pharmacists Pharmacists can interact with GPs with regards to care transitions within two government-funded schemes – the Residential Medicines Management Review (RMMR) and the Home Medicines Review (HMR). Accredited pharmacists have undertaken specific training to conduct this enhanced role. There was support for RMMRs from RACFs. Issues with HMRs included that the patient is unknown to the accredited pharmacist so there is no rapport or knowledge of the patient’s history compared to the regular community pharmacist or GP. Older patients may not be receptive to HMRs because they have more confidence in doctors than pharmacists. In hospitals the pharmacists do the reviews, they then put the pressure on the doctors. In Aged care we don’t have those professionals. (#41 RACF nurse) Generationally, they trust their doctors. They won’t trust a pharmacist to the same degree. (#16 carer)
Discussion Medication management for PWD is suboptimal. Errors in prescribing and administration compromise safety and therefore will add significantly to community, hospital and residential care costs.10 The lack of an ongoing systematic approach to achieve a high quality medication communication process during care transitions for dementia is a clinical governance issue.
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Despite the absence of a systematic approach, there were local examples of specialist transitional staff such as aged care services in emergency team (ASET) nurses, dementia clinical nurse consultants and GRACE nurses who were advocating for PWD, although they may not have been involved in all care transitions due to cost or availability.11 Furthermore, their focus was broader than medication issues. Utilization of pharmacists, the health care professional specifically trained in medication, could achieve better outcomes,6 but their involvement in care transitions is variable.12 Pharmacists can support PWD during care transitions in various ways. These comprise medication history taking on admission, medication reconciliation,6,9,13 assisting with medication adherence, discharge counseling,6 informationsharing with community pharmacies,5 preparing interim RACF medication administration charts14 and conducting post-discharge follow-up such as telephone calls or visits which may include an HMR or RMMR.6,15 There have not been studies specifically examining HMRs for PWD, but for older people medication reviews at home in the post-discharge period reduce the risk of readmission to hospital15,16 so a similar benefit for PWD can be anticipated. The current study recorded reservations about HMRs by carers and general practitioners so initiatives to adopt postdischarge HMRs should be accompanied by a media campaign to promote acceptance amongst the medical profession and the general public. The most comprehensive pharmaceutical transition care model described in the literature is pharmacist transition co-ordinators.6 These pharmacists supply medication-management summaries from hospitals to primary care providers, complete a comprehensive medication section on the discharge summary, arrange timely medication reviews by accredited community pharmacists and participate in case conferences with GPs.6 Pharmacist transition co-ordinators have demonstrated that they improve health outcomes for patients transferred from hospitals to RACF6 so may be expected to be beneficial for all PWD in any care transition. The pharmaceutical transition care model more widely adopted in Australia however is the community liaison pharmacist. These pharmacists visit patients at home postdischarge and have demonstrated that they can improve continuity of care.17 Two of the four sites studied have a community liaison pharmacist; we advocate that all public hospitals consider
employing pharmacist transition co-ordinators or community liaison pharmacists to support PWD. Using patients’ own medication and selfadministration schemes in hospitals has been advocated as an initiative to reduce medication issues following transition from hospital for PWD. Benefits of using patients’ own medication include decreased wastage of medicines, more patient counseling and better continuity of care, but concerns about risk and increased staff workload have limited implementation.18 There are similar concerns about staff workload and risk of harm for inpatient self-administration schemes, but this is offset by evidence that medication adherence issues can be identified by selfadministration for older patients who were planning to manage their own medicines postdischarge.19,20 Research into the risks and benefits of such schemes in PWD should be encouraged. Structured communication for a comprehensive clinical handover with respect to medication can be achieved by completing care pathways that are shared in a timely fashion with all care providers. A standardized patient transfer form may assist with the communication of advanced directives and medication lists to identify ceased, omitted or indicated medications.21 Recognition of PWD is required for medication management to be modified appropriately. Identification and communication of dementia diagnosis was poor in our study hospitals. Previous research recorded that dementia was documented in medical notes for less than half of admissions in NSW hospitals.11 Increased screening for dementia in hospital together with a positive result triggering an above bed visual alert may be useful. A visual cognitive impairment identifier was well received in Victoria as part of a hospital-wide educational package to identify dementia and modify care accordingly.22 An alternative in the interim is that medication management in hospitals is modified to be dementia friendly for all individuals over 80 years. This age threshold is suggested because dementia prevalence increases with age being above 12% at 80–84 years.1 Identifying an accurate medication record is a momentous challenge during care transitions; and this challenge could be addressed by better use of IT across the different sectors. At the time of this study, health services in NSW were in the early stages of adopting systems such as e-referral and e-discharge23 which should eventually facilitate accurate transfer of medication information between health care providers. Disappointingly the early
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evidence for improved safety following implementation of e-discharge24 and electronic medication management systems25 is equivocal. The ease of use of these systems has been acknowledged to limit effectiveness24,25 and further refinements to IT are required for potential to be realised. Development of user-friendly electronic systems that link hospitals with GPs, specialists with GPs, RACFs with hospitals and community pharmacies with hospitals are essential to improve medication management during care transitions. Electronic summaries (eHealth records) of an individual patient’s health information, giving health care providers access to patient information such as medications, test results, discharge summaries and allergies26 have the potential to resolve the medication problems. Individuals lacking capacity can nominate an authorized representative to manage the record on their behalf. To date, there has been poor uptake of the eHealth record in Australia by both health care providers and consumers. Regulatory bodies and research has identified that more dementia training is required.27–30 Various modes of training delivery have been described that include online,31 DVDs,30 didactic22 and paper-based.30 Training appeared to improve job satisfaction,22 staff knowledge28,29 and confidence22,28 but it is unclear whether they improved clinical outcomes or contained a medication component. The prospects of success are surely greater when staff training needs are accessible and inclusive of non-clinical staff. The inferior health care service provided outside of normal working hours seems to contribute to medication management issues during care transitions. Limited service by out-ofhours GPs has been linked to higher hospital admissions from RACFs in the United Kingdom.32 ASET is an NSW initiative that aims to facilitate better care and management of older people in ED by referring to appropriate hospital or primary care services.11 ASET health professionals have positive effects on patient care during care transitions but is limited by parttime working.11 The international standard time frame for medication reconciliation is within 24 hours33 of admission but many hospitals do not have 7 day pharmacy services. Although medication reconciliation should occur after a transition of care to a RACF,34 the time frame is unclear. Specifying that medication reconciliation should occur within 24 hours of admission to RACF would necessitate increased health
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professional input into RACFs. Increasing service provision by these key health care professionals in primary and acute care should improve medication management for PWD. Strengths and limitations This qualitative study recruited a diverse range of participants from four different sites, including major urban environments and a rural site. The results however may not be generalizable because, although there were four sites, the study was conducted only in two Australian states. There may also have been a selection bias, as the participants already have a commitment to dementia. The investigators were concerned that the method of data collection was not consistent because two of the interviews were conducted by telephone due to the unavailability of these participants during the site visits. This may have affected the responses due to the different communication dynamic between the researcher and the participant. It was disappointing that PWD were not recruited, as ACT law prevents individuals that lack capacity from participating in research.35 This raises complex ethical questions in terms of protecting vulnerable groups but also the right of vulnerable groups to have their voices heard in research. Despite these limitations, this is a comparatively large study and is the first to examine medication processes in acute care episodes and care transitions with a focus on dementia.
Conclusion There is scope to improve medication processes in acute care and care transitions for PWD. It is suggested here that pharmacists be routinely involved in care transitions with utilization of pharmacist transition co-ordinators or community liaison pharmacists. There should be structured communication pathways that include routine information provision to hospitals, general practice, community pharmacies and RACFs. Modified planning for all individuals over 80 years can be implemented in conjunction with adoption of better strategies to identify PWD. The results of this study suggest a need for automatic updating of medication information whenever changes are made on an electronic health care record that is accessible to all relevant practitioners. Additionally, dementia training for staff would be highly beneficial. These recommendations would help to achieve safe care transitions rather than the
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observed reliance on individual champions or random chance. Acknowledgment This project has been funded by the Dementia Collaborative Research Centre – Assessment and Better Care, University of New South Wales as part of an Australian Government Initiative. We would like to thank all the participants for their valuable insights into this topic. References 1. Deloitte Access Economics. Dementia across Australia: 2011–2050. Canberra: Alzheimer’s Australia; September 2011. 2. Australian Institute of health and Welfare. People with Dementia in Hospitals in New South Wales 2006-07. Bulletin NO. 110. Canberra: AIHW; 2012. 3. Runge C, Gilham J, Peut A. Transitions in Care of People with Dementia. A Systematic Review of the Literature. (Report). Australian Institute of Health and Welfare; 2009. 4. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003;138:161–167. 5. Duggan C, Feldman R, Hough J, Bates I. Reducing adverse prescribing discrepancies following hospital discharge. Int J Pharm Pract 1998;6:77–82. 6. Crotty M, Rowett D, Spurling L, Giles LC, Phillips PA. Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial. Am J Geriatr Pharmacother 2004;2:257–264. 7. Singleton JA, Nissen LM. Future-proofing the pharmacy profession in a hypercompetitive market. Res Social Adm Pharm 2013;10:459–468. 8. Liu CS, White L. Key determinants of hospital pharmacy staff’s job satisfaction. Res Social Adm Pharm 2011;7:51–63. 9. Chhabra PT, Rattinger GB, Dutcher SK, Hare ME, Parsons KL, Zuckerman IH. Medication reconciliation during the transition to and from long-term care settings: a systematic review. Res Social Adm Pharm 2012;8:60–75. 10. Kilcup M, Schultz D, Carlson J, Wilson B. Postdischarge pharmacist medication reconciliation: impact on readmission rates and financial savings. J Am Pharm Assoc 2013;53:78–84. 11. Australian Institute of Health and Welfare. Dementia Care in Hospitals: Costs and Strategies. Cat. No. AGE 72. Canberra: AIHW; 2013. Available from, http:// www.aihw.gov.au/publication-detail/?id¼60129542746 [cited 8.9.14].
12. Kern KA, Kalus JS, Bush C, Chen D, Szandzik EG, Haque NZ. Variations in pharmacy-based transition-of-care activities in the United States: a national survey. Am J Health Syst Pharm 2014;71. 13. Steurbaut S, Leemans L, Leysen T, et al. Medication history reconciliation by clinical pharmacists in elderly inpatients admitted from home or a nursing home. Ann Pharmacother 2010;44:1596–1603. 14. Elliott RA, Tran T, Taylor SE, et al. Impact of a pharmacist-prepared interim residential care medication administration chart on gaps in continuity of medication management after discharge from hospital to residential care: a prospective pre- and postintervention study (MedGap Study). BMJ Open 2012;2:e000918. http://dx.doi.org/10.1136/bmjopen2012-000918. 15. Roughead EE, Barratt JD, Ramsay E, et al. Collaborative home medicines review delays time to next hospitalization for warfarin associated bleeding in Australian war veterans. J Clin Pharm Ther 2011; 36:27–32. 16. Naunton M. Evaluation of home-based follow-up of high-risk elderly patients discharged from hospital. J Pharm Pract Res 2003;33:176–182. 17. Vuong T, Marriott JL, Kong DCM. Implementation of a community liaison pharmacy service: a randomised controlled trial. Int J Pharm Pract 2008;16: 127–135. 18. Lummis H, Sketris I, Veldhuyzen van Zanten S. Systematic review of the use of patients’ own medications in acute care institutions. J Clin Pharm Ther 2006;31:541–563. 19. Lam P, Elliott RA, George J. Impact of a selfadministration of medications programme on elderly inpatients’ competence to manage medications: a pilot study. J Clin Pharm Ther 2011;36:80–86. 20. Tran T, Elliott RA, Taylor SE, Woodward MC. A self-administration of medications program to identify and address potential barriers to adherence in elderly patients. Ann Pharmacother 2011;45:201–206. 21. LaMantia MA, Scheunemann LP, Viera AJ, BusbyWhitehead J, Hanson LC. Interventions to improve transitional care between nursing homes and hospitals: a systematic review. J Am Geriatr Soc 2010;58: 777–782. 22. Yates M, Theobald M, Morvell M. The Dementia Care in Hospitals Program (conference slides). Available from: https://fightdementia.org.au/sites/default/ files/08_Mark_Yates_The_Ballarat_Approach_The_ Dementia_Care_in_Hospitals_Program.pdf; [cited 23. 8.14]. 23. National e Health Transition Authority. NEHTA Strategic Plan Refresh 2011-2012. Available from: http://www.nehta.gov.au/about-us/our-strategy; [cited 11.2.15]. 24. Garrett T, McCormack C. Does an electronic discharge referral system improve the quality of medication prescribing? J Pharm Pract Res 2014;44: 29–34.
Deeks et al. / Research in Social and Administrative Pharmacy j (2015) 1–11 25. Westbrook J, Lo C, Reckmann M, Runciman W, Braithwaite J, Day R. The effectiveness of an electronic medication management system to reduce prescribing errors in hospital. In: HIC 2010: Proceedings; 18th Annual Health Informatics Conference; 2010. 26. Australian Government Department of Health, eHealth Frequently Asked Questions. Available from: http://www.ehealth.gov.au/internet/ehealth/ publishing.nsf/content/home; [cited 3.10.14]. 27. Australian Commission on Safety and Quality in Health Care. Evidence for the Safety and Quality Issues Associated with the Care of Patients with Cognitive Impairment in Acute Care Settings: A Rapid Review. Sydney; 2013. 28. Travers C, Byrne GJ, Pachana NA, Klein K, Gray LC. Prospective observational study of dementia in older patients admitted to acute hospitals. Australas J Ageing 2014;33:55–58. 29. McPhail C, Traynor V, Wikstrom D, Brown M. Improving outcomes for dementia care in acute aged care: impact of an education programme. Dementia 2009;8:142–147. 30. Elvish R, Burrow S, Cawley R, et al. ‘Getting to Know Me’: the development and evaluation of a training programme for enhancing skills in the care
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Appendix 1 Semi-structured interview questions for medication management and dementia in the acute care sector and during care transitions research
Health care professionals: (a) Can you describe your professional involvement in managing medication for patients with a diagnosis of dementia? (e.g. policy, direct supervision or identification of harm) (b) Within your area of practice, can you tell me how information about medicines is provided on transfer to another setting for patients with dementia? (c) What systems exist to avoid prescribing medicines that have previously caused harm? Comment on the effectiveness of this process. (d) Who is informed of a patient’s hospital discharge in primary care? Who do you think should be informed? And how? Comment on the effectiveness. (e) Comment on the processes that inform other members of the health care team in the community about medication related problems. (f) Comment how planning around medication changes are shared with primary care providers? (g) What issues, if any, limit the optimization of medication plans in hospital? (h) How is information about medication changes given to patients with a diagnosis of dementia? What mechanisms are there to provide this information to informants (spouse, child, sibling, friend, carer)? (i) Have you ever recommended a home medicines review by a pharmacist or GP? What prompted you? (j) Can you identify any systems that work well? (k) Can you suggest any improvements? (l) Is there anything else you would like to tell me?
Patients and informant (spouse, child, sibling, friend, carer): (a) Can you describe how you (or your informant) look after your medicines? (b) Can you describe any problems that you have had with medicines? (c) Where do you go to get support and information on medicines? (d) How are you informed of medication changes or problems by the hospital or your GP? (e) What was your impression of the system that you encountered of managing medicines in hospital or at discharge? (f) Do you think that the present systems of managing medicines in hospital and on discharge are helpful? (g) Have you ever had a home medicines review by a pharmacist or GP? Was it useful? (h) Can you suggest any improvements? (i) Is there anything else you would like to tell me?
Deeks et al. / Research in Social and Administrative Pharmacy j (2015) 1–11 Appendix 2 Characteristics of the study participants Job description
Urban Rural Total
Aged care facility nurse Admissions nurse Specialist aged care nurse (includes ASET,a GRACE,b dementia/delirium, old age psychiatry nurse) Hospital pharmacist Chronic care nurse General practitioner Rehabilitation lead Occupational therapist Community pharmacist Emergency physician Geriatric physician Paid carer Unpaid carer Hospital nurse manager Old aged psychiatrist Liaison pharmacist Carer support service Rehabilitation team co-ordinator
2 1 6
3 0 2
5 1 8
4 2 3 1 1 1 1 4 3 4 0 2 2 1 1
4 0 1 0 0 1 0 0 0 0 1 0 0 0 0
8 2 4 1 1 2 1 4 3 4 1 2 2 1 1
a b
ASET: Aged care services in emergency team. GRACE: Geriatric rapid acute care evaluation.
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Original Research
Dementia, medication and transitions of care Louise S. Deeks, B.Sc.(Hons.), P.G.Dip.Pharm.Prac.a,*, Gabrielle M. Cooper, Ph.D.a, Brian Draper, M.D.b,c, Susan Kurrle, Ph.D.d,e, Diane M. Gibson, Ph.D.f a
Discipline of Pharmacy, Faculty of Health, University of Canberra, ACT 2601, Australia b School of Psychiatry, University of NSW, Sydney, Australia c Academic Department for Old Age Psychiatry, Prince of Wales Hospital, Sydney, Australia d Faculty of Medicine, University of Sydney, Sydney, Australia e Rehabilitation and Aged Care Service, Hornsby Hospital, Sydney, Australia f Faculty of Health, University of Canberra, ACT 2601, Australia
Abstract Background: Persons with dementia (PWD) often have complex medication regimens and are at risk of medication problems during the multiple transitions of care experienced as the condition progresses. Objectives: To explore medication processes in acute care episodes and care transitions for PWD and to make recommendations to improve practice. Method: Semi-structured interviews were conducted by two pharmacy researchers from a focused purposive sample of fifty-one participants (carers, health professionals, Alzheimer’s Australia staff) from urban and rural Australia. After written consent, the interviews were audio-recorded then transcribed verbatim for face-to-face interviews, or notes were taken during the interview if conducted by telephone. The transcripts were checked for accuracy by the pharmacy researchers. Thematic analysis of the data was undertaken independently by the two researchers to reduce bias and any disagreements were resolved by discussion. Results: Themes identified were: medication reconciliation; no modified planning for care transitions; underutilization of information technology; multiple prescribers; residential aged care facilities; and medication reviews by pharmacists. Sub themes were: access to appropriate staff; identification of dementia; dose administration aids; and staff training. Conclusions: Medication management is sub-optimal for PWD during care transitions and may compromise safety. Suggested improvements included: increased involvement of pharmacists in care transitions; outreach or transitional health care professionals; modified planning for care transitions for individuals over 80 years; co-ordinated electronic records; structured communication; and staff training. Ó 2015 Elsevier Inc. All rights reserved. Keywords: Older people; Dementia; Pharmacy; Transitions of care; Medication
* Corresponding author. Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce ACT 2601, Australia. Tel.: þ61 2 6201 2254; fax: þ61 2 6201 5727. E-mail address: [email protected] (L.S. Deeks). 1551-7411/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2015.07.002
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Introduction
Method
Persons with dementia (PWD) may be prescribed medication for dementia or for their comorbidities. Problems with activities of daily living, a decreased capacity for decision-making, confusion, disorientation, communication problems and reliance on carers make managing medication challenging for PWD. PWD in Australia is predicted to increase from 266,574 in 2011 to 942,624 in 2050.1 PWD are more likely to be admitted to hospital – annually more than 25% of PWD have hospital admissions, compared to 12% without dementia.2 The rise in prevalence of dementia, the associated risk of hospital admission and the vulnerability of PWD highlights the importance of understanding hospital admissions and other care transitions for PWD,3 particularly as they relate to medication management. Care transitions are associated with medication problems. Research suggests that 12.5% of patients have a medication-related adverse event after hospital discharge.4 Unintentional medication discrepancies,5 preventable adverse drug events,4 poor selection of medication, no discharge summary and supply problems6 have been identified in care transitions that have not focused on dementia. These problems can be detrimental to patient safety and thus may lead to hospital readmissions.4 As PWD are a vulnerable group of the population, specific dementia-friendly strategies for medication management to ensure safe, high quality transfer of care are therefore important. To date there has been limited investigation of this issue, particularly in Australia. Health care, and the roles of community and hospital pharmacists in Australia have been described previously in this journal.7,8 Briefly, Australian citizens can obtain free treatment in public hospitals and free or subsidized general practitioner (GP) appointments via universal health insurance, ‘Medicare’.7 Community pharmacy in Australia has mainly a supply role with other services negotiated as part of the Community Pharmacy Agreement.7 Hospital pharmacists in Australia provide a clinical pharmacy service in addition to their supply role whereas the role of the hospital pharmacy technician is usually limited to supply.8 This research aims to explore medication processes that occur during acute care episodes and in care transitions for PWD in Australia and to make recommendations to improve patient care.
In this qualitative study two researchers (LD, GC) conducted in-depth semi-structured interviews on topics concerning medications and care transitions for people with a diagnosis of dementia. A set of seeding questions (see Appendix 1) was used; however, the conversation was allowed to flow freely so as to explore issues important to participants. The participants were a focused purposive sample of stakeholders from acute and primary care from four sites, each a region. The fifty-one participants (#1 to #51) comprised carers, hospital doctors, nurses (specialist aged care, transitional, hospital, aged care/respite facilities), pharmacists (hospital, transitional and community), hospital occupational therapist, GPs and Alzheimer’s Australia staff (see Appendix 2). Forty-nine of the interviews were face-to-face and two were by telephone. There was one urban site in the Australian Capital Territory (ACT) (capital city, population served 350,000) that recruited 20 participants, two urban sites in New South Wales (NSW) (major city, populations served 313,000 and 205,000) that recruited 12 and 7 participants and one rural site in NSW (coastal, population served 35,000) that recruited 12 participants. After written consent, the interviews were audio-recorded then transcribed verbatim for face-to-face interviews, or notes were taken during the interview if conducted by telephone. The transcripts were checked for accuracy by the researchers (LD, GC) who conducted the interviews. LD and GC worked independently on thematic analysis to reduce any bias. The interview text was read several times by the pharmacist researchers (LD, GC). The analysis was an iterative process conducted by reading through the transcripts, adding codes to the data and then linking the codes to identify emerging themes that described the content of the data. Any disagreements were resolved by in-depth discussion and negotiated consensus. Human Research Ethics Committee approval was obtained from: University of Canberra; ACT Government Health Directorate; and South Eastern Sydney Local Health District – Northern Sector (with three Site Specific Assessments). Results Thematic analysis identified six themes and four sub themes (see Table 1). These are described in the following text with comments italicized.
Deeks et al. / Research in Social and Administrative Pharmacy j (2015) 1–11 Table 1 Themes and sub themes identified Themes
Sub themes
Medication reconciliation No modified planning for care transitions
Access to appropriate staff Identification of dementia Dose administration aids Staff training Access to appropriate staff
Underutilization of information technology Multiple prescribers Residential aged care facilities Medication review by pharmacists
No modified planning for care transitions Identification of PWD and other cognitive impairments in the hospital was cited as challenging, especially where patients were not in Geriatric Medical Wards. Suggestions included cognitive screening at admission, more individuals trained to screen for cognitive impairment, blanket modified planning for older people and using an above bed symbol to alert staff that there are cognitive issues.
Staff training Access to appropriate staff
I suspect in other parts of the hospital [away from Geriatric Medical Wards] there’s less awareness of dementia – people more likely to have dementia that’s either not diagnosed or is really ignored in terms of prescribing, and people are told things in the expectation they will remember, whereas they clearly won’t. (#13, hospital doctor)
On admission to hospital medication reconciliation (obtaining and verifying a complete and accurate list of current medication then resolving discrepancies between the list and medication taken by the patient)9 is important for informed clinical decision making. This is difficult for PWD because they may lack capacity, their carers may not be present, and they may have not brought medication into hospital. GP medication lists can be used to obtain a list of current medication but these can be inaccurate. The reasons for this include: medication not being updated in the GP database; patients having multiple GPs; there may be additional specialist prescribing; and previous inaccurate discharge information. Regular community pharmacists were acknowledged as the most reliable source of a patient’s current medication.
There was a symbols project done in a small town somewhere in New South Wales on a cognitive symbol above the bed, which didn’t alert the person . but other staff would go in and go, “right, okay.” (#16, carer)
Medication reconciliation
The doctor [GP] will just print off. They don’t do data cleaning, so it will all come in. And often we do find things that are charted that really the patient isn’t on anymore. (#24 hospital pharmacist) [The Community Pharmacist is] Most accurate, that’s where I would go. (#4 hospital pharmacist)
Reliance on hospital pharmacists to perform medication reconciliation, or any task, is compromised by lack of access due to restricted working hours in our study hospitals (usually Monday to Friday) and variability of pharmacist services between hospitals. This leads to nurses and other allied health care professionals taking on medication related roles. Occupational therapists get a bag . [of] the [discharge] medications, and you’ve got to sort it. (#10 occupational therapist)
3
After discharge from hospital medication from hospitals in addition to existing supplies from community pharmacies can cause misadventure, especially where generic switching occurs. This was not a problem in the rural site where discharge medication was supplied by the patient’s usual community pharmacy. Other solutions suggested were systems that use ‘green bags’ to transfer medications between care settings, using patient’s own medication in hospital and self-administration in hospital. They come out on a generic medication of every single medication they were on plus extras and they end up completely bewildered and overwhelmed and they go, “I’ll just not take any of it.” (#11 community pharmacist) People should start to self medicate in the hospital especially rehabilitation units. (#3 specialist aged care nurse) We want them [medication from home] to get put in the big, green plastic bags and we’ve just finished installing all the patient’s own medication cupboards in all the ward areas, and the idea is it gets transferred between wards. (#4 hospital pharmacist)
Insufficient quantities of medication supplied from hospital can cause issues. Problems occur if the patient isn’t well enough to attend or cannot get an appointment with the GP or if the GP hasn’t received the discharge information.
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Deeks et al. / Research in Social and Administrative Pharmacy j (2015) 1–11 3 or 5 day appointment with the GP comes up; some of them are tired and they cancel it, and so then what can happen is they revert back [to preadmission medication]. (#3 specialist aged care nurse)
Discharge planning is difficult in public hospitals due short lengths of stay. This leads to patients not being allocated sufficient counseling time prior to discharge. It is more challenging when the discharge is outside of usual working hours without a carer. At 5 pm with 3 pages of discharge medications, new initiations of warfarin . they are actually really unsafe discharges. (#4 hospital pharmacist)
Problems with the accuracy or appropriateness of the hospital discharge medication information provided to GPs were identified. There can be difficulty establishing whether changes to medication are intentional. Discharge information can lack explanations for medication changes causing problems for ongoing patient care. Respondents linked this to the responsibility for writing discharge medications usually falling to the most junior person on the team often with a limited exposure to the patient and the care aims. In the one rural site fewer issues were reported and a contributory factor was thought to be the role hospital pharmacists have writing discharge medication summaries on that site. There was support for discharge medication changes being sent to community pharmacies to facilitate follow up but this rarely occurs. The person who knows the patient least well is writing the instruction manual for further treatment. (#35 general practitioner) Something has been ceased on the ward, and they have actually got it on their discharge summary or vice versa they’ve started it and it hasn’t been put on. (#39 liaison pharmacist)
A method to facilitate individuals to manage their own medication or be supported by carers is using a dose administration aid (DAA). In our study these were blister pack DAAs containing tablets or capsules dispensed into a weekly pack with four dosing times per day. There was support for DAAs from carers and nurses. DAAs are not without problems, such as no assessment of ability to use DAAs occurring, expense, error potential, ongoing monitoring, and the safety of DAAs from central packing locations. She got the pack from Queensland, so it’s got when to take it and you’ve got the days. As long as you
start on the Monday, it’s a great help for her and a great help for me too. (#19 carer) You do need to have a . fairly high degree of cognition to work out what days, what dates and then . be able to push the medications [out]. (#10 occupational therapist) A dementia client, she had a build up of 6. Why would you keep delivering? (#38 transitional nurse)
Discharges where the patient will be reliant on paid carers to monitor medication require more liaising and planning. This includes assessment of the need for carers, early notification of expected date of discharge to enable engagement of services and alteration of dosing schedules to facilitate prompting of medication. There were issues around communication with medication related care package providers during care transitions for PWD. It might take a package provider three days to get carers back into the home. (#16 carer) Merge all the meds together so they’re one time a day, and then you can get a paid carer to go in and support. (#16 carer)
Good practice centered on individual champions with good communication networks. These included workers that supported PWD post hospital discharge, during hospital admission and in avoiding hospital admissions. Within each hospital there were clinical nurse consultants to support PWD. Two of the sites had a community liaison pharmacist and these can be utilized to support PWD by conducting medication reviews to ensure patients receive appropriate medication during care transitions. Underutilization of information technology (IT) Participants expressed frustrations with IT systems. There are multiple unlinked systems (for example in emergency departments, mental health, hospital wards, GPs, pharmacies) leading to data not being shared. An example where this causes patient harm is during a medication-related admission where this information is not transferred to all hospital systems so is unavailable leading to the prescribing of this unsuitable medication again. Restricted access to IT systems was described. This can mean that some information relevant to patients cannot be shared, for example, their cognitive state or their correct
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medication. This causes harm where the hospital pharmacist has agreed a medication change to the discharge prescription with the ward doctor but only the doctor can alter the GP discharge communication. If the ward doctor does not activate this change, the GP will receive incorrect information. If we identify an error in that discharge prescription . we say to the doctor, you’ve got to go back and change the discharge summary . it probably in reality never happens. (#40 hospital pharmacist)
Multiple prescribers Multiple prescribers are associated with problems during care transitions. It was reported that little information was shared between private and public hospitals. Treatment delays have occurred because the communication method from specialists to the GP is a letter. Care coordinating advocates were suggested as a solution. IT was cited as an area where improvements could be made with support for a mandatory electronic health care record with automatic updating every time medication changes are made. If everybody has an electronic record coded to their Medicare number . every time you as the pharmacist changes it or me as the doctor changes it, that automatically quickly alters it. (#12 hospital doctor)
Residential Aged Care Facilities (RACFs) Medication problems were identified between acute care and RACFs. The RACFs require specific documents to give medication. RACF staff commented about lacking or inaccurate information received from hospitals whereas hospital pharmacists had difficulties with the variable clerical and clinical requirements from different RACFs. In an urban site, a GRACE CNC (Geriatric Rapid Acute Care Evaluation Clinical Nurse Consultant) is employed. One of the GRACE roles is to ensure that medication information is transferred between RACFs and hospital. There was also support for standardized information transfer in a ‘yellow envelope’ or bag. [after hospital discharge] Go through all this . phoning, faxing, faxing, phoning and then get a delivery [of medication]. That’s what holds up the administration of medication. And it could be 24, 48 hours perhaps longer [before medication can be administered]. (#42 RACF nurse)
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Some information – bowels, aperients, photocopied medication sheets. In yellow envelope. (#50 specialist aged care nurse)
Training was raised in the context of RACFs as a proportion of the workforce has limited training relating to medications. A number of respondents from RACF commented on negative attitudes to dementia that may adversely influence the quality and safety of patient management generally, and particularly during care transitions. Training could help to change these attitudes. I said to the [RACF] staff it’s really important that he’s having his LasixÔ they weren’t able to demonstrate that they understood. (#5 chronic care nurse) They [GPs] look at aged care and the related problems, dementia included, as fairly tedious, boring, a waste of time. (# 42 RACF nurse)
Medication reviews by pharmacists Pharmacists can interact with GPs with regards to care transitions within two government-funded schemes – the Residential Medicines Management Review (RMMR) and the Home Medicines Review (HMR). Accredited pharmacists have undertaken specific training to conduct this enhanced role. There was support for RMMRs from RACFs. Issues with HMRs included that the patient is unknown to the accredited pharmacist so there is no rapport or knowledge of the patient’s history compared to the regular community pharmacist or GP. Older patients may not be receptive to HMRs because they have more confidence in doctors than pharmacists. In hospitals the pharmacists do the reviews, they then put the pressure on the doctors. In Aged care we don’t have those professionals. (#41 RACF nurse) Generationally, they trust their doctors. They won’t trust a pharmacist to the same degree. (#16 carer)
Discussion Medication management for PWD is suboptimal. Errors in prescribing and administration compromise safety and therefore will add significantly to community, hospital and residential care costs.10 The lack of an ongoing systematic approach to achieve a high quality medication communication process during care transitions for dementia is a clinical governance issue.
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Despite the absence of a systematic approach, there were local examples of specialist transitional staff such as aged care services in emergency team (ASET) nurses, dementia clinical nurse consultants and GRACE nurses who were advocating for PWD, although they may not have been involved in all care transitions due to cost or availability.11 Furthermore, their focus was broader than medication issues. Utilization of pharmacists, the health care professional specifically trained in medication, could achieve better outcomes,6 but their involvement in care transitions is variable.12 Pharmacists can support PWD during care transitions in various ways. These comprise medication history taking on admission, medication reconciliation,6,9,13 assisting with medication adherence, discharge counseling,6 informationsharing with community pharmacies,5 preparing interim RACF medication administration charts14 and conducting post-discharge follow-up such as telephone calls or visits which may include an HMR or RMMR.6,15 There have not been studies specifically examining HMRs for PWD, but for older people medication reviews at home in the post-discharge period reduce the risk of readmission to hospital15,16 so a similar benefit for PWD can be anticipated. The current study recorded reservations about HMRs by carers and general practitioners so initiatives to adopt postdischarge HMRs should be accompanied by a media campaign to promote acceptance amongst the medical profession and the general public. The most comprehensive pharmaceutical transition care model described in the literature is pharmacist transition co-ordinators.6 These pharmacists supply medication-management summaries from hospitals to primary care providers, complete a comprehensive medication section on the discharge summary, arrange timely medication reviews by accredited community pharmacists and participate in case conferences with GPs.6 Pharmacist transition co-ordinators have demonstrated that they improve health outcomes for patients transferred from hospitals to RACF6 so may be expected to be beneficial for all PWD in any care transition. The pharmaceutical transition care model more widely adopted in Australia however is the community liaison pharmacist. These pharmacists visit patients at home postdischarge and have demonstrated that they can improve continuity of care.17 Two of the four sites studied have a community liaison pharmacist; we advocate that all public hospitals consider
employing pharmacist transition co-ordinators or community liaison pharmacists to support PWD. Using patients’ own medication and selfadministration schemes in hospitals has been advocated as an initiative to reduce medication issues following transition from hospital for PWD. Benefits of using patients’ own medication include decreased wastage of medicines, more patient counseling and better continuity of care, but concerns about risk and increased staff workload have limited implementation.18 There are similar concerns about staff workload and risk of harm for inpatient self-administration schemes, but this is offset by evidence that medication adherence issues can be identified by selfadministration for older patients who were planning to manage their own medicines postdischarge.19,20 Research into the risks and benefits of such schemes in PWD should be encouraged. Structured communication for a comprehensive clinical handover with respect to medication can be achieved by completing care pathways that are shared in a timely fashion with all care providers. A standardized patient transfer form may assist with the communication of advanced directives and medication lists to identify ceased, omitted or indicated medications.21 Recognition of PWD is required for medication management to be modified appropriately. Identification and communication of dementia diagnosis was poor in our study hospitals. Previous research recorded that dementia was documented in medical notes for less than half of admissions in NSW hospitals.11 Increased screening for dementia in hospital together with a positive result triggering an above bed visual alert may be useful. A visual cognitive impairment identifier was well received in Victoria as part of a hospital-wide educational package to identify dementia and modify care accordingly.22 An alternative in the interim is that medication management in hospitals is modified to be dementia friendly for all individuals over 80 years. This age threshold is suggested because dementia prevalence increases with age being above 12% at 80–84 years.1 Identifying an accurate medication record is a momentous challenge during care transitions; and this challenge could be addressed by better use of IT across the different sectors. At the time of this study, health services in NSW were in the early stages of adopting systems such as e-referral and e-discharge23 which should eventually facilitate accurate transfer of medication information between health care providers. Disappointingly the early
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evidence for improved safety following implementation of e-discharge24 and electronic medication management systems25 is equivocal. The ease of use of these systems has been acknowledged to limit effectiveness24,25 and further refinements to IT are required for potential to be realised. Development of user-friendly electronic systems that link hospitals with GPs, specialists with GPs, RACFs with hospitals and community pharmacies with hospitals are essential to improve medication management during care transitions. Electronic summaries (eHealth records) of an individual patient’s health information, giving health care providers access to patient information such as medications, test results, discharge summaries and allergies26 have the potential to resolve the medication problems. Individuals lacking capacity can nominate an authorized representative to manage the record on their behalf. To date, there has been poor uptake of the eHealth record in Australia by both health care providers and consumers. Regulatory bodies and research has identified that more dementia training is required.27–30 Various modes of training delivery have been described that include online,31 DVDs,30 didactic22 and paper-based.30 Training appeared to improve job satisfaction,22 staff knowledge28,29 and confidence22,28 but it is unclear whether they improved clinical outcomes or contained a medication component. The prospects of success are surely greater when staff training needs are accessible and inclusive of non-clinical staff. The inferior health care service provided outside of normal working hours seems to contribute to medication management issues during care transitions. Limited service by out-ofhours GPs has been linked to higher hospital admissions from RACFs in the United Kingdom.32 ASET is an NSW initiative that aims to facilitate better care and management of older people in ED by referring to appropriate hospital or primary care services.11 ASET health professionals have positive effects on patient care during care transitions but is limited by parttime working.11 The international standard time frame for medication reconciliation is within 24 hours33 of admission but many hospitals do not have 7 day pharmacy services. Although medication reconciliation should occur after a transition of care to a RACF,34 the time frame is unclear. Specifying that medication reconciliation should occur within 24 hours of admission to RACF would necessitate increased health
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professional input into RACFs. Increasing service provision by these key health care professionals in primary and acute care should improve medication management for PWD. Strengths and limitations This qualitative study recruited a diverse range of participants from four different sites, including major urban environments and a rural site. The results however may not be generalizable because, although there were four sites, the study was conducted only in two Australian states. There may also have been a selection bias, as the participants already have a commitment to dementia. The investigators were concerned that the method of data collection was not consistent because two of the interviews were conducted by telephone due to the unavailability of these participants during the site visits. This may have affected the responses due to the different communication dynamic between the researcher and the participant. It was disappointing that PWD were not recruited, as ACT law prevents individuals that lack capacity from participating in research.35 This raises complex ethical questions in terms of protecting vulnerable groups but also the right of vulnerable groups to have their voices heard in research. Despite these limitations, this is a comparatively large study and is the first to examine medication processes in acute care episodes and care transitions with a focus on dementia.
Conclusion There is scope to improve medication processes in acute care and care transitions for PWD. It is suggested here that pharmacists be routinely involved in care transitions with utilization of pharmacist transition co-ordinators or community liaison pharmacists. There should be structured communication pathways that include routine information provision to hospitals, general practice, community pharmacies and RACFs. Modified planning for all individuals over 80 years can be implemented in conjunction with adoption of better strategies to identify PWD. The results of this study suggest a need for automatic updating of medication information whenever changes are made on an electronic health care record that is accessible to all relevant practitioners. Additionally, dementia training for staff would be highly beneficial. These recommendations would help to achieve safe care transitions rather than the
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observed reliance on individual champions or random chance. Acknowledgment This project has been funded by the Dementia Collaborative Research Centre – Assessment and Better Care, University of New South Wales as part of an Australian Government Initiative. We would like to thank all the participants for their valuable insights into this topic. References 1. Deloitte Access Economics. Dementia across Australia: 2011–2050. Canberra: Alzheimer’s Australia; September 2011. 2. Australian Institute of health and Welfare. People with Dementia in Hospitals in New South Wales 2006-07. Bulletin NO. 110. Canberra: AIHW; 2012. 3. Runge C, Gilham J, Peut A. Transitions in Care of People with Dementia. A Systematic Review of the Literature. (Report). Australian Institute of Health and Welfare; 2009. 4. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003;138:161–167. 5. Duggan C, Feldman R, Hough J, Bates I. Reducing adverse prescribing discrepancies following hospital discharge. Int J Pharm Pract 1998;6:77–82. 6. Crotty M, Rowett D, Spurling L, Giles LC, Phillips PA. Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial. Am J Geriatr Pharmacother 2004;2:257–264. 7. Singleton JA, Nissen LM. Future-proofing the pharmacy profession in a hypercompetitive market. Res Social Adm Pharm 2013;10:459–468. 8. Liu CS, White L. Key determinants of hospital pharmacy staff’s job satisfaction. Res Social Adm Pharm 2011;7:51–63. 9. Chhabra PT, Rattinger GB, Dutcher SK, Hare ME, Parsons KL, Zuckerman IH. Medication reconciliation during the transition to and from long-term care settings: a systematic review. Res Social Adm Pharm 2012;8:60–75. 10. Kilcup M, Schultz D, Carlson J, Wilson B. Postdischarge pharmacist medication reconciliation: impact on readmission rates and financial savings. J Am Pharm Assoc 2013;53:78–84. 11. Australian Institute of Health and Welfare. Dementia Care in Hospitals: Costs and Strategies. Cat. No. AGE 72. Canberra: AIHW; 2013. Available from, http:// www.aihw.gov.au/publication-detail/?id¼60129542746 [cited 8.9.14].
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Deeks et al. / Research in Social and Administrative Pharmacy j (2015) 1–11 25. Westbrook J, Lo C, Reckmann M, Runciman W, Braithwaite J, Day R. The effectiveness of an electronic medication management system to reduce prescribing errors in hospital. In: HIC 2010: Proceedings; 18th Annual Health Informatics Conference; 2010. 26. Australian Government Department of Health, eHealth Frequently Asked Questions. Available from: http://www.ehealth.gov.au/internet/ehealth/ publishing.nsf/content/home; [cited 3.10.14]. 27. Australian Commission on Safety and Quality in Health Care. Evidence for the Safety and Quality Issues Associated with the Care of Patients with Cognitive Impairment in Acute Care Settings: A Rapid Review. Sydney; 2013. 28. Travers C, Byrne GJ, Pachana NA, Klein K, Gray LC. Prospective observational study of dementia in older patients admitted to acute hospitals. Australas J Ageing 2014;33:55–58. 29. McPhail C, Traynor V, Wikstrom D, Brown M. Improving outcomes for dementia care in acute aged care: impact of an education programme. Dementia 2009;8:142–147. 30. Elvish R, Burrow S, Cawley R, et al. ‘Getting to Know Me’: the development and evaluation of a training programme for enhancing skills in the care
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of people with dementia in general hospital settings. Aging Ment Health 2014;18:481–488. University of Tasmania Wicking Dementia Research and Education Centre. Understanding Dementia MOOC. Available from: http://www.utas.edu.au/ wicking/wca/mooc; [cited 2/1/15]. Ong A, Sabanathan K, Potter J, Myint P. High mortality of older patients admitted to hospital from care homes and insight into potential interventions to reduce hospital admissions from care homes: the Norfolk experience. Arch Gerontol Geriatr 2011;53:316–319. Royal Pharmaceutical Society of Great Britain. Keeping Patients Safe when They Transfer between Care Providers – Getting the Medicines Right Final Report. London; June 2012. Australian Government. Department of Health and Ageing. Guiding Principles for Medication Management in Residential Aged Care Facilities; 2012. Available from: http://www.health.gov.au/internet/ main/publishing.nsf/Content/3B17BD9642D56802 CA257BF0001AFDA5/$File/Guiding%20principles %20for%20medication%20management%20in%20 residential%20aged%20care%20facilities.pdf [cited 7. 6.15]. Australian Capital Territory. ACT Powers of Attorney Act; 2006.
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Appendix 1 Semi-structured interview questions for medication management and dementia in the acute care sector and during care transitions research
Health care professionals: (a) Can you describe your professional involvement in managing medication for patients with a diagnosis of dementia? (e.g. policy, direct supervision or identification of harm) (b) Within your area of practice, can you tell me how information about medicines is provided on transfer to another setting for patients with dementia? (c) What systems exist to avoid prescribing medicines that have previously caused harm? Comment on the effectiveness of this process. (d) Who is informed of a patient’s hospital discharge in primary care? Who do you think should be informed? And how? Comment on the effectiveness. (e) Comment on the processes that inform other members of the health care team in the community about medication related problems. (f) Comment how planning around medication changes are shared with primary care providers? (g) What issues, if any, limit the optimization of medication plans in hospital? (h) How is information about medication changes given to patients with a diagnosis of dementia? What mechanisms are there to provide this information to informants (spouse, child, sibling, friend, carer)? (i) Have you ever recommended a home medicines review by a pharmacist or GP? What prompted you? (j) Can you identify any systems that work well? (k) Can you suggest any improvements? (l) Is there anything else you would like to tell me?
Patients and informant (spouse, child, sibling, friend, carer): (a) Can you describe how you (or your informant) look after your medicines? (b) Can you describe any problems that you have had with medicines? (c) Where do you go to get support and information on medicines? (d) How are you informed of medication changes or problems by the hospital or your GP? (e) What was your impression of the system that you encountered of managing medicines in hospital or at discharge? (f) Do you think that the present systems of managing medicines in hospital and on discharge are helpful? (g) Have you ever had a home medicines review by a pharmacist or GP? Was it useful? (h) Can you suggest any improvements? (i) Is there anything else you would like to tell me?
Deeks et al. / Research in Social and Administrative Pharmacy j (2015) 1–11 Appendix 2 Characteristics of the study participants Job description
Urban Rural Total
Aged care facility nurse Admissions nurse Specialist aged care nurse (includes ASET,a GRACE,b dementia/delirium, old age psychiatry nurse) Hospital pharmacist Chronic care nurse General practitioner Rehabilitation lead Occupational therapist Community pharmacist Emergency physician Geriatric physician Paid carer Unpaid carer Hospital nurse manager Old aged psychiatrist Liaison pharmacist Carer support service Rehabilitation team co-ordinator
2 1 6
3 0 2
5 1 8
4 2 3 1 1 1 1 4 3 4 0 2 2 1 1
4 0 1 0 0 1 0 0 0 0 1 0 0 0 0
8 2 4 1 1 2 1 4 3 4 1 2 2 1 1
a b
ASET: Aged care services in emergency team. GRACE: Geriatric rapid acute care evaluation.
11