The aim of this project was to work across sectors liaising with GP practices, community pharmacies, PCN pharmacists, social workers and social care providers to reduce the barriers at transfer of patients from secondary to primary care with the overall aim of reducing medication related readmissions.
Our team currently consists of a frailty pharmacist and a specialist technician. We identified that there was a need for better support of patients from hospital to home which required working with other professionals.
This project involved working with the Milton Keynes Integrated Discharge hub on a frailty ward to support in identifying the gold standard transition from hospital to home for patients.
We are raising the profile of the importance of medications being safe at the point of discharge to the wider multi-disciplinary team and aiming to improve the communication that happens with regards to medication changes.
The project involves ensuring a clear discharge plan related to medications is communicated across all disciplines and to the patient. This ensures that care packages are appropriately timed for medication administration and correct documentation is provided to ensure carers or patients can administer their medications safely. This service has the ability to follow patients' home to ensure the patient is able to manage their medications in their home environment and identifying any barriers to their medication management. This holistic approach to patient care has resulted in social concerns being identified on home visits and escalated to appropriate services to ensure wherever possible the patient remains at home. The project also links in with GP colleagues to ensure medication changes are actioned in a timely manner and any monitoring is undertaken.
We ensure that every person involved in the patient's care is aware of changes. As a consequence, we have reduced the number of medication related re-admissions.
