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The City Country Medslink Project

Presented by:

Deirdre Criddle

D Criddle, P Jayasuriya, R Clifford, J Benzie, K Crouchley and J Lack

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July, 2002

Once upon a time there was

a vision…..

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Why do CCML?

• The period 7 - 10 days following

discharge is a vulnerable time

associated with a significant risk of

medication misadventure, especially in

high-risk patients.

• Studies show ~ 50% of adults

discharged experience a medical error;

19 - 23% suffering an adverse event,

most commonly an adverse drug event.

Kriplani, Jackson, Schnipper et al, 2007

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The 4 hour rule ~ all glory or unintended

consequences?

‘Reduced mortality rates and less overcrowding in the WA pilot

but also led to some staff – especially junior doctors – coming

under increased stress and pressure.

Presents challenges with resources and staffing

Focus of attention is moved from some parts of the hospital to new

parts of the hospital and resources may need to be redirected’

Professor Bryant Stokes

Are our patients being discharged sicker and quicker?

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A long way from home....

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The Vision 2012

To implement a hospital coordinated framework, enabling timely

Home Medicines Review (HMR) services to be provided early

post discharge for rural patients identified at high risk of

medication misadventure.

“….the goal of the

City Country Medslink Project is to

reduce the risk of medication

misadventure and to ensure the safe

transition from hospital to community-

based care is seamless…”

STAGE 1

Hospital Liaison Pharmacist (HLP)

Screens for medication misadventure (using tool)

Written informed consent from patient & GP

HLP liaises with GP and Rural Accredited Pharmacist (RAP)

• referral, patient‟s latest medication list, DC Summary and

Inpatient Med Chart – Tell the hospital story!

STAGE 2

RAP coordinates: Date/venue for Home Medicines Review (HMR)

Conducts HMR and resolves medication related problems

STAGE 3

RAP provides: Report to GP within 7 days of HMR visit.

GP provides: Medication Management Plan (MMP) to RAP & Community

Pharmacist after patient visits to discuss HMR report and visit.

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The screening tool

Adapted from a service provided by Hospitals in Victoria and research in South

Australia

Provides a system to stratify risk. Examples of risk factors for medication

misadventure identified in this tool include:

• Lives alone and manages own medicines (3 points).

• Cognitive impairment and manages own medicines (3 points).

• Multiple medications on admission (1.5 points).

• Recurrent admissions to hospital (eg. 2 in 6 months (3 points).

• Changes in medications/dose during the admission (1.5 points.

• Clinical impression of the medical team that a post-discharge HMR is

warranted (5 points).

• Other (1 point). eg. using multiple GPs, English is a second language,

having a low education, or a preference for alternative/complementary

medications).

Patients who score 5 or more on screening assessment are considered „High

Risk‟ for medication misadventure.

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CCML Pilot Project

• Discharge „About me and with

me‟

• Community colleagues as

partners in post discharge care

• Using the „patient‟s own

medicines team‟ for handover

seems a logical safety initiative

•

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Who were the CCML cohort?

• “Elderly” 64.9 ± 16.8 years

• Multiple comorbidities 4.6 ± 2.4

• Significant polypharmacy 10.3 ± 4.5 medicines

• Extended length of hospital stay 12.7 ± 9.6 days

(compared with Australian Average 6.0 days 2009)

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The patient stories …

‘data with a soul’

From a remote

community to

SCGH via

Newman

“They told me I was going to Geraldton.

They said they would „fix‟ my leg, so I

thought, OK – it will be worth the

hassle.”

“But their idea of rehab is 10 minutes

with a physio and the rest of the time, I

am stuck here, looking out the window,

sitting on this bed.”

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Patient stories …

Patient with gastroenteritis, complicated

by acute kidney injury and hypoglycaemia

Patient advised to avoid taking oral

hypoglycaemics until further GP review.

Patient to make appt. Check sugars and if

BSL >20 seek medical attention. Will

require U&Es to check for recovery from

AKI.

Doctor visits community once a week

Discharge summary; Patient, Consultant,

Medical Records

Who are you?

Where are you from?

Who can help at

home?

Do you understand?

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Results

• 60 patients screened for eligibility over 4

months

• 18 of the eligible 22 consented

• 16 referred for HMR

• 2 for Medscheck

Reasons for admission

Cardiovascular, GI, falls

and systemic infections,

Average age

65 years (Range: 35-91)

Locations

Geraldton

Dongara

Meekatharra

Kalgoorlie

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Results:

• 60 patients screened using validated tool

• 27 patients interviewed

• 8 patients received an HMR (7 within 10 days of

discharge)

• 2 HMRs Goldfields / 6 HMRs Midwest

• Eight discharge summaries (44%) had incorrect or

insufficient information ~ would have resulted in GPs not

receiving them

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Results:

• 42/60 (70%) patients screened from the

Goldfields Midwest region were

considered to be at high risk of medication

misadventure

• 17 patients High Risk – ineligible

• Post stroke/trauma/dementia (7)

• Declined (3)

• Language barrier (1)

• “Staying in the city” (6)

• Renal/Chemo/Liver

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Results: • 2 GPs did not send the referral ~ despite several requests

(1 patient newly commenced on warfarin), another

disillusioned about „new programs in health‟.

• A Change to Business Rules ~ 4 identified, consented and

eligible patients were unable to access an HMR post

discharge in rural and remote communities

• Goldfields Outreach HMR service – delivering HMR to

rural and remote communities, which was „just beginning‟

had to be shelved

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What they thought

“It was excellent seamless continuity of care, which

the patient found very reassuring and prompted the

appropriate medication changes required without

delay”. Dr James Quirke, GP, Geraldton

“Was a great idea but more difficult to institute than

we thought. Was a positive experience for the

patients on all accounts, namely the experience with

Deirdre and the follow up with us and their GP”.

Ross McKay, Community Pharmacist, Geraldton

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What they thought

“It was really “top drawer” service. The

pharmacist came to my home, and spent a

good deal of time explaining my tablets.”

“I had never had that before. She didn‟t hurry

me – and at the end, I really understood why I

had been put on all these extra tablets and how

important it was to keep taking them.”

Mr QS ~ CCML Patient, post AMI; Kalgoorlie

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Lessons from CCML

• Let‟s start recognising risk! A validated tool can

highlight medication misadventure

• Let‟s look at our patients! Who are you? Where

are you from? What are you going home to?

• Let‟s acknowledge complexity! Take

responsibility for collaborative medication

management services across transitions of care.

• Let‟s acknowledge the remote community gap!

Improve access to culturally appropriate

medication management solutions in our remote

communities

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When crossing transitions of care

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“Who’s packing our patient’s parachute”

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Let’s make medication management post discharge

mandatory for those at most risk!

And ensure a safe landing for our most vulnerable.

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References

1. Roughead, L and Semple S Second National Report on Patient

Safety Improving Medication Safety The Australian Council for

Safety and Quality in Health Care July 2002

2. Kripalani, S. Roumie, C.L. Dalal, A.K. Cawthon, C, Businger, A

Eden,S.K et al Effect of a pharmacist intervention on clinically

important medication errors after hospital discharge: A randomised

trial. PIL-CVD Study Group Ann Intern Med. 2012;157:1-10

3. Criddle, D Effect of a pharmacist intervention Ann Intern Med.

2013;158:137

4. Angley, M Ponniah, AP, Spurling, LK et al Feasibility and Timeliness

of Alternatives to Post-Discharge Home Medicines Reviews for

High-Risk Patients J Pharm Pract Res 2011; 41: 27-32.

5. Harris, N.M. Dickinson, H, Rorison, F et al, Hospital and after:

experience of patients and carers in rural and remote north

Queensland, Australia. Rural and Remote Health Online 2004:246;

6. Budnitz DS Lovegrove MC Shehab, N et al Emergency

hospitalisations for adverse drug events in older Americans NEJM

2011:365;2002-2012

www.gmml.org.au