Introduction

National Health Service (NHS) England’s mission is to secure high-quality care for all.1 Patient discharge from hospital back into the community is an important step in the patient journey requiring high-quality care. To ensure high-quality care at discharge, communication between care settings is essential to provide safe and robust ongoing care. Hospital discharge is complex, involving aspects of both health and social care, and depends on individual patient needs. This paper will focus on the process of medication supply at discharge and transfer of any associated information to healthcare professionals in the community.

Currently, the process of medication supply at discharge begins with the creation of a discharge prescription, commonly referred to as ‘To Take Out’ (TTO). The TTO is a complete and accurate list of all medications the patient should take after discharge from hospital. A typical discharge process involves a doctor writing the TTO for a patient which is checked by a pharmacist. Any medication needed is dispensed by the hospital pharmacy based on this TTO. The nurse responsible for the patient on the ward will check the medications against the TTO before giving them to the patient. A copy of the TTO is then sent to the patient’s general practitioner (GP) within 24 hours of their discharge, along with a copy of the discharge summary containing details of the inpatient episode. Providing a complete and accurate discharge summary aids the transfer of care from hospital into the community and allows the GP to coordinate appropriate ongoing care.2 The discharge summary is not routinely provided to other healthcare professionals in the community.

A variety of issues are associated with the current discharge process. Discharging patients from acute NHS hospitals is a time-consuming process, often resulting in patients waiting for medicines and temporarily blocking beds.3 Additionally, many older patients experience medication discrepancies after transferring from hospital to home4 which can cause unnecessary harm to patients and can result in readmission to hospital.5 There are many potential sources of error at discharge,6 7 particularly with regard to the supply of discharge medication and communication between care settings. Factors thought to contribute to medication discrepancies after hospital discharge include: incomplete information on discharge summaries sent to GPs,8–11 lack of prompt transfer of information to a patient’s GP8 9 11 12 and lack of patient understanding of discharge instructions.8 9 13

Many attempts have been made to improve patient discharge with varied success. Worldwide, several large-scale programmes were designed to improve transitions of care.14–19 In the UK, smaller scale interventions have taken place, with few published studies of the findings. Improvement interventions have targeted different aspects of patient discharge. During hospital admission, interventions such as utilising pharmacist prescribers to write discharge prescriptions,3 20 pre-empting writing discharge prescriptions21 and dispensing for discharge8 have been used. Other interventions across the interface such as carrying out medication reviews after discharge22 23 and utilising community pharmacists to improve transfer of care24–28 have shown some benefit.

Development of a new model of care to improve patient discharge

Improvement is still required at discharge to ensure high-quality care across the interface and to reduce the problems that impact both patients and healthcare providers alike. Consequently, the research team opted for an innovative solution to improve patient discharge and developed a new model of care (MOC) for the supply of medication at discharge, which aimed to provide safe, quality and effective transfer for patients across the hospital-community interface. The research team consisted of a team of pharmacists with backgrounds in primary care, hospital and community pharmacy. Development of the new MOC was evidence based and involved a multistage process. This began with an exploration of the issues with the current discharge process, their causes and potential solutions. Both qualitative and quantitative methods were used to investigate the current discharge process from multiple perspectives. Numerous issues were highlighted with the discharge process. Full details can be seen in two previously published papers.6 29 Key issues highlighted by both pharmacists and patients were: the time delay between informing patients about their discharge and them leaving the hospital, the length of time taken to supply medication for discharge and the quality of patient counselling. Based on these findings and current literature, the MOC was developed and revised until the new MOC for the supply of discharge medication was finalised. This MOC can be seen in figure 1.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

New model of care for the supply of medication at hospital discharge. GP, general practitioner; TTO, To Take Out.

The MOC differs from the current discharge process significantly. The MOC involves a pharmacy-led process within the hospital, which aims to improve collaboration across the interface by sending an electronic copy of the discharge prescription to a community pharmacy of the patient’s choice to be dispensed. There are two reasons for this: to reduce the wait for discharge medication in hospital and to promote communication between hospital and community pharmacists. This should prompt patient follow-up by community pharmacists and allow them to provide appropriate patient care after discharge from hospital.

This study involved a formative evaluation of the new MOC, which looked to identify any potential issues and establish the views of relevant stakeholders involved in different aspects of the new MOC. The findings from this formative evaluation were important to facilitate the MOC’s success upon implementation.

Aim

To determine if the proposed new MOC for the supply of medication at hospital discharge was considered feasible and acceptable by stakeholders.

Method

This qualitative study involved semistructured, face-to-face interviews and focus groups with stakeholders. The data collection method chosen was dependent on availability and preference of participants, providing both options increased participation. For example, patient and carer representatives preferred to participate in a focus group. The data collection methods were both suitable to provide detailed, thought-provoking discussions about the MOC with participants and allowed the researcher to probe for more detail where appropriate. A range of stakeholders involved in different aspects of the new MOC were appropriate to identify issues and suggest improvements to different aspects of the MOC. Stakeholders included: potential service users, hospital pharmacists, pharmacy technicians, nursing staff, hospital doctors, community pharmacists and GPs. Participants were drawn from hospital staff in NHS hospitals across Cheshire and Merseyside. Non-hospital-based participants were identified from GP practices, community pharmacies and patients and public involvement groups in the Merseyside area. Participants unfamiliar with any aspect of patient discharge from hospital were excluded, as were patients or carers with no experience of discharge, as their contribution was considered to be limited.

Potential participants were identified via a snowballing sampling method through informal professional networks due to their involvement in the discharge process and invited to participate. Participants were approached either in person or via email as appropriate and were provided with study information. All those who were approached agreed to participate and were included in the study.

A topic guide was developed to meet the study aim which was suitable for use in interviews and focus groups to ensure validity of data. Each session began with an explanation of the MOC by the researcher, with questions from participants to ensure that they were clear about what the MOC involved. Key topics for discussion were based on the new MOC and included: feedback on the new MOC, suggestions for improvement, practical issues and resources required to provide the new MOC. No topics were discussed that any of the participants found distressing. Interviews and focus groups were audio-recorded. Data collection continued until data saturation was achieved.

The audio-recorded interviews and focus groups were transcribed verbatim by the researcher and checked to ensure content and meaning was maintained. All data were anonymised at the transcription stage by removing participant identifiable information. Thematic analysis was carried out using NVivo V.10 software to code transcripts.

LJMU Research Ethics Committee approval (16/PBS/002) was granted on 25 June 2016. A pilot study was undertaken with two pharmacists to verify the recruitment procedure and the topic guide prior to commencing data collection. No significant amendments were required as a result of the pilot and the pilot data were included in the main study.

Findings

A total of 37 people participated in this study. Of these, 23 were interviewed; the average duration of the interviews was 32 min (range 19–60 min). The remaining 14 participants participated in two focus groups. Both focus groups contained seven participants from similar backgrounds but with differing levels of experience. The two focus groups lasted 29 and 28 min, respectively. Participant demographics can be seen in table 1.

Data analysis revealed three main themes, providing a holistic overview of stakeholder perceptions of the new MOC. The salient points from each theme are discussed below with anonymised quotes annotated with the participants’ roles for context.

Discussion

Today’s NHS faces a range of challenges. The population is ageing and there is a significant increase in the number of people with long-term conditions requiring health and social care.30 Additionally, the NHS is under a huge financial pressure due to a lack of funding. This is a timely study, as the NHS is in the midst of a changing care environment. Many changes to the way that care is delivered are under way, which is essential to provide quality care for all patients, within the restraints of the limited resources available. This means a radical change from current ways of working. The study approach taken—to develop a new MOC to improve patient discharge—supports the current agenda as NHS England’s Five Year Forward View suggested that new models of care are required to improve care and deliver care closer to patients through integrated care models.31

The potential impact of this research is wide reaching. A seamless discharge process that will provide timely and safe transfer for patients could lead to many implications for practice. As well as improving patient flow through the hospital, the MOC could potentially lower hospital readmission rates by reducing medication errors that put patients at higher risk of harm and readmission. Additionally, a reduction in medication waste could be seen, as only appropriate supplies of medication will be provided.

Moving patient’s care from hospital into the community is a priority in the UK and internationally.32 33 The consensus is that as much care as possible should be delivered in a local, more convenient setting for patients. This is to improve patient experience and reduce the burden on the NHS by removing the focus from treating patients at expensive hospitals.32 The new MOC encourages the provision of patient care in the community and advertises the ongoing support that they can receive from their community pharmacist, as many patients are unaware of the services available.

Conclusion

This study provided a formative evaluation of the proposed new MOC for medication supply at patient discharge. Overall, stakeholders were enthusiastic about the proposed model and had many positive comments. The new MOC was therefore considered feasible and acceptable by the target population.

The findings have identified which areas of the new MOC stakeholders thought would work well and where problems may arise. Logistical issues were highlighted, mainly within two areas: pharmacists having the time to write discharge prescriptions during the ward round and the logistical issues of community pharmacists supplying discharge medication. Many of the participants suggested a variety of solutions to such problems. The knowledge, skills and resources required to deliver the new MOC were established. This study has been essential to provide feedback on the proposed new MOC which is now at a suitable stage to pilot.