Transfer of care - the secondary/primary care interface on discharge

Question 1

what are the various discharge destination for patients

Answer 1

Usual place of residence

Temporary place of residence

Other NHS hospital

Non-NHS hospital

Residential accommodation where health care is provided

Foster care

Court

Prison

Question 2

list the types of discharge

Answer 2

1. simple discharge

2. complex discharge

Question 3

Define simple discharge

Answer 3

Patient discharged to own home with simple ongoing health needs which can be met without complex planning.

~80% of patients

Compatible with nurse-led discharge

Question 4

Define complex discharge

Answer 4

Patient needs more specialist care after leaving hospital e.g.
Have ongoing health and social care needs
Need community care services
Discharged to a residential home or care home
Need intermediate care

~20% of patients

Question 5

What is intermediate care

Answer 5

Range of needs led, transitional and integrated services delivered in partnership between primary and secondary care.
Aims to provide integrated services to:
promote faster recovery from illness,
prevent unnecessary acute hospital admissions,
support timely discharge from hospital,
maximise independent living.
Target older people at highest risk of entering institutional care following acute conditions such as
pneumonia
hip fracture
stroke

Question 6

State the aim of intermediate care

Answer 6

Aims to provide integrated services to:
promote faster recovery from illness,
prevent unnecessary acute hospital admissions,
support timely discharge from hospital,
maximise independent living.
Target older people at highest risk of entering institutional care following acute conditions such as
pneumonia
hip fracture
stroke

Question 7

List the types of intermediate care

Answer 7

1. Reablement
2. Home- based
3. Bed-based
4. Crisis- response

Question 8

What is reablement

Answer 8

Support in own home to help person live independently.

Question 9

Define home-based intermediate care

Answer 9

Community-based assessments and interventions to people in own home or care home.

Question 10

Define bed-based intermediate care

Answer 10

Temporary stay in care home or community hospital for assessments and interventions.

Question 11

Define crisis response intermediate care

Answer 11

Prompt assessment at home or on arrival at A&E, to avoid unnecessary hospital admission by providing short-term care at home or in a care home

Question 12

What medicines-related problems occur on transfer of care within hospital?

Answer 12

Administration errors
Omitted or delayed administration
Medication not transferred
Medication transferred, but form/route changed
Route of administration not available
e.g. NBM, no IV access
New medicine
Patient not on ward (in transit)
Duplicate administration
Incomplete administration record
Failure to retrieve all MAR charts
Wrong drug/dose/frequency/route of administration 
Wrong preparation, method or device

Question 13

What medicines-related problems occur on transfer of care within hospital?

Answer 13

Prescribing / monitoring errors
Omitted medicine
Wrong medicine
Wrong dose/frequency/route
Transcribing errors
Failure to review treatment plans/follow up
Medication changes / discrepancies
Intentional
Unintentional
Poor communication of treatment plans between teams
Incomplete or incorrect handover documentation

Question 14

What medicines-related problems occur on discharge from hospital

Answer 14

Prescribing and administration errors.
Incomplete or incorrect discharge medicines prescribed/supplied.
New devices e.g. MDS
Non administration of medicines or incorrect / duplicate medicines.
Poor communication about medicines on discharge from hospital.
Incomplete/inaccurate
Medication changes
Timeliness/distribution of information about discharge medicines.
Lack of monitoring or follow-up on discharge.

Question 15

What can pharmacists do during hospital discharge

Answer 15

Medicines reconciliation on admission.
Complete and accurate drug history is foundation on which discharge medication is based.
Re-using PODs / dispensing for discharge
Reduce risk of duplicate or discontinued medication being taken.
Patient self-administration of medicines.
Medication review.
Changes and additions to medications?

Question 16

What pharmacist can do contd

Answer 16

Timely discharge prescriptions.
Available when needed
Medication counselling.
Adherence
Pharmacist-written discharge prescriptions.
Electronic prescriptions.
Improve transfer of information
Timely, complete and accurate discharge summary to GP.
Reduce risk of unintentional changes
Protocols in GP surgeries for updating records of medicines.

Question 17

NICE NG5 states….

Answer 17

Section 1.2 Medicines-related communication systems when patients move from one care setting to another
If possible send medicines discharge information to nominated community pharmacy and consider additional support after hospital discharge e.g. pharmacist counselling

Section 1.3 Medicines reconciliation
Includes all transfers within and between organisations
In primary care, carry out MR for all people discharged from hospital as soon as possible, within 1 week of GP receiving information and before prescription or new supply of medicines issued

Question 18

Optimising discharge from hospital

Answer 18

Clinical pharmacy services can include:

Pharmacists or pharmacist prescribers writing discharge prescriptions
Pharmacy pre-admission clinics
Near patient pharmacy discharge teams
Pharmacy technicians embedded in ward teams
Pharmacy staff on board rounds
Pharmacy working hours matching work demands
Seven day clinical pharmacy services
Community pharmacy referral

Question 19

Discharge from hospital

Answer 19

Medicines reconciliation on admission.
Complete and accurate drug history is foundation on which discharge medication is based
Discharge medication (TTO / TTA / TTH)
Prescribing
Supply combining use of PODs and one-stop dispensing
Patient Information Leaflet – 28 day original pack
Counselling
Other written information - medication record
Medicines reconciliation on discharge
TTO v inpatient chart – right medicines
TTO v drug history – right information

Question 20

Discharge from hospital contd

Answer 20

Effective communication about medicines
Discharge summary and discharge medication
Information about medicines is essential content
Must be complete, accurate and timely
Shared care guidelines / care pathway
Electronic data transfer
Timeliness
Post-discharge information
Hospital Pharmacy helpline
Hospital referral to community pharmacy

Question 21

facts about discharge summary

Answer 21

One of the most common methods used by hospital doctors to transfer information and communicate with GPs when patient discharged.
Ensuring continuity of care

Several studies have found discharge summaries to be deficient in content, accuracy and timeliness.

Electronic discharge summaries used

Information about discharge medications is essential content.

Question 22

Medicines-related information in discharge summary..

Answer 22

Allergies
Allergies, drug allergies and ADRs
Discharge medications
Name of drug, formulation, route, current dose, frequency and duration
Medication changes
Drug changed, stopped or started (with reasons and dates where relevant)
Medication recommendations
Suggestions for starting, stopping, changing or avoiding medications
Requirements for adherence support e.g. compliance aids
Other relevant information
E.g. Date and time of last dose for weekly or monthly medicines
Information given to patient and/or representative
If additional information on transfer e.g. community pharmacy post discharge referral for MUR

Question 23

Hospital referral to community pharmacy

Answer 23

Signposting

Phone and Fax referral

Electronic referral
TCAM