1. Simon Mynes – Director of Pharmacy Derriford PHNT
Improving Medicines Information on Transfer of Care between Hospital and Community Pharmacy
Simon Mynes – Director of Pharmacy Derriford PHNT
Tom Kallis – Vice Chairman, Devon LPC
Deborah Wassell – Derriford PHNT Pharmacy Clinical Governance
Oksana Riley - Senior Medicines Optimisation Pharmacist
Northern, Eastern & Western Devon CCG
Tristan Frame - Medicines Optimisation Pharmacist, Northern, Eastern & Western Devon CCG

2. Agenda
Time - Topic Slide Nos Buffet Housekeeping: Phones on silent/fire exits/Tweets Welcome, introductions and thank-you’s – Simon Mynes – Working together to improve transfer of care – Simon Mynes – GP practice process –Oksana Riley Community pharmacy process – Tom Kallis – Why engage - Tom Kallis Workshop – Simon Mynes/Tom Kallis – – Questions – Simon Mynes Tour and networking Derriford Pharmacy – Simon Mynes Finish

3. Aim of the evening
Understand the Medicine Support Service Understand the expectations from both sides Opportunity to view the hospital pharmacy Provide a forum to network with your pharmacy colleagues You may wish to create a WhatsApp group to aid networking?

4. What are the problems?
Evidence shows when patients move between care providers they are at risk of miscommunication and unintended changes to their medication Patients are being readmitted where there is a lack of understanding or communication around medicines stopped and /or started in hospital. Faxing discharge documentation carries a significant Information Governance Risk Paper copies of a discharge summary may not be taken to a Community Pharmacy. Further supplies may not be timely or accurate.

5. Around 30-50% of medicines are not taken as intended by the prescriber
Around 30-50% of medicines are not taken as intended by the prescriber. Between 5-8% of unplanned admissions to hospital are due to medication issues. Around 87% of patients have an unintended discrepancy in their medicines discharge information. £300million of medicines are wasted each year

6. What is the ‘Medicines Support Service’
The medicines support service is designed to enhance patients’ discharge experience by referring them on discharge from hospital to their community pharmacy for onward support. Derriford are piloting MDS patients.

7. Why do we need a Medicines Support service
Keeping patient safe when they transfer between care providers (RPS, 2011) Hospital Referral to community pharmacy (RPS,2014) Medicine Optimisation: the safe and effective use of medicines to enable the best possible outcomes (NICE, 2015) Medicine adherence: involving patients in decisions about prescribed medicines and supporting adherence (NICE, 2009)
Need some stories here???? Or in workshop????
1 - Keeping patient safe - miscommunication and unintended changes to medicines remain a significant problem when patients move between care providers. Improving the transfer of information about medicines across all care settings should help to reduce incidents of avoidable harm to patients, improving patient safety
and contributing to a reduction in avoidable medicines related admissions and readmissions to hospital. One of the core principles developed was for providers to help design safe systems for the transfer of information.
2 – Hospital referral - The system we’re introducing facilitates referral of patients from their hospital bedside to their community pharmacist either for some sort of pharmaceutical consultation post-discharge, or to ensure changes to a person’s medicines are known and acted upon in order to
improve medicines safety and efficacy when they return to their home. Resulting in a safer, better co-ordinated discharge of patients home from hospital. We will be using PharmOutcomes to alert a community pharmacist that a patient is being discharged and needs a medicines follow-up. It allows the hospital team to create
an auditable e-record of a referral and the community pharmacist can feedback to the hospital the outcome of any intervention. Patients are supported to get the most from their medicines, fewer hospital readmissions, reduced risk of medication errors.
3 – Medicine Optimisation - Relevant information about medicines should be shared with patients, and their family members or carers, where appropriate, and between health and social care practitioners when a person moves from one care setting to another, to support high‑quality care. Consider sending a person's medicines discharge information to their nominated community pharmacy, when possible and in agreement with the person.
4 – Medicine adherence - Healthcare professionals involved in prescribing, dispensing or reviewing medicines should ensure that there are robust processes for communicating with other healthcare professionals involved in the patient's care

8. PharmOutcomes is the programme of choice for our Medicines Support Service
Reference: BMJ open article in October inpatients referred over 13 months via PharmOutcomes 31% participated in follow-up consultation (228 MURs, 241 NMS) Results Those who received a community pharmacist follow-up consultation had: significant lower rates of readmissions at 30,60 and 90 days post referral than those without a follow-up consultation and reduced length of stay
PharmOutcomes for discharge summaries is relatively new, approved by NHSE and gathering momentum giving hospital pharmacy and community pharmacy the opportunity to work together optimising medicines for patients discharged from hospital.
Extract what you want to sell the project

9. Readmission data Do we need this table???
Number of readmissions post electronic referral at: Number of bed days for readmitted patients at : days days days days days days n (%) n (%) n (%) mean ± SD mean ± SD mean ± SD Received a CP consultation (5.8) (3.4) (3.6) ± ± ± 6.7 (n =501) Did not receive CP consultation (16.0) (9.5) (9.4) ± ± ± 16.6 (n=855) OR and 95% Cls (N=1386) (2.1 to 4.7) (1.8 to 5.1) (1.6 to 4.7) Mean differences and 95% Cls (-12.7 to 1.0) (-15.4 to 2.4) (-13.9 to 3.5) (N=373)
Do we need this table???
Shorter version or just narrative from previous screen???

10. How will we work together?
Web based approach with long term aim to go fully integrated Pilot will run with blister packs. Patient consents to Medicine Support Service. Community pharmacy will be phoned to agree new blister patients. Discharge summary sent to community pharmacy via PharmOutcomes. Community pharmacy receives notification . Discharge summary referral viewed on PharmOutcomes. Discharge summary referral acted on (or rejected) and outcome communicated to hospital pharmacy via PharmOutcomes
Emphasize: As before we will phone to check when a new MCA is indicated that you are happy to take on.
Previously phoned to say a fax is coming as that was part of the information governance fax policy but will no longer need to do that since this is a secure method of transferring information.
Also confirm that new blister packs only recommended following an assessment by a pharmacist (and/or technician??). The CP can of course re-do this but they might just want to accept the assessment of the hospital pharmacist.

11. GP practice process
eDischarge received into patient’s notes and added to GP document management list
Any follow ups for GP are completed
GP/Pharmacist carries out Meds Reconciliation (within 72 hours)
Drugs stopped
Doses amended
New drugs added…….. ‘issue later’
Await contact from patient to request new items
eDischarge filed in patients notes
I think we need to emphasise that GPs may not have looked at e-discharge instantly and so pharmacy might see it before the GP has so, if you have to contact the practice, be aware of this.
I can see if a practice manager will do this but otherwise I can speak to this slide.

12. Community Pharmacy An opportunity to capture Discharge MURs
Direct referral pushes patients to community Pharmacist
Simple process using Pharmoutcomes (PO) - Check daily/receive
Use professional judgment to decide appropriate action
Set up a system to follow up next Rx - have the changes been followed through?
A chance to work collaboratively with primary and secondary care teams for the safety of our patients
Tom – I’ve copied your slide across as per your -Deb
Say they should use your professional expertise to decide how to manage the patient.
This information empowers you to identify the support needed for individual patients.
Log in regularly to check if any referrals. - Oksana

13. Why engage? Improved patient safety
Opportunity for you to review a patients discharge documentation and follow up appropriately.
Opportunity to provide an improved medicines service to your patients.
Is the way of the future when Community Pharmacy should be more involved in pathways of care.
Toms probably best place to reinforce the incentive/why while he's talking through the community pharmacy screen.

14. Workshop View the log in process from Hospital and Community Pharmacy.
View a Multi-compartment Compliance Aid discharge referral
Rejecting a referral
Discussion
Regardless of whether the discharge summary was received via PharmOutcomes or faxed what will you do next……

15. Examples of Factors to consider :
Short-term
Clopidogrel, atorvastatin 80mg
Titration
Beta-blockers in heart failure
Modified release; Hospital will always use generic names
Lithium
Omitted during hospital stay
HRT, Didronel PMO
Anticoagulants
Aspirin replaced
Medication stopped
Highlight to patient and invite them to return any they have at home to the pharmacy
Toms probably best placed to run through the factors to consider - links into encouraging professional judgment around MURs NMS on the previous slide.

16. Thank you for attending tonight
The medicines support service is designed to enhance patients’ discharge experience by referring them on discharge from hospital to their community pharmacy for onward support.
Derriford are piloting MDS patients.
All MDS discharge summaries will be coming to you via PharmOutcomes from November 6th
Please log in on a regular basis to check for referrals

17. Any Questions

18. Hospital tour
A relaxed and informal opportunity for you to gain insight into Hospital Pharmacy
Ask questions
Forge relationships