Improving care transitions between hospital and residential aged care facilities: a pharmacist perspective

John C. Kao

BPharm (Hons), GradCertClinPharm | Pharmacist¹ |  John.kao@monashhealth.org 

Eugene Ong

BPharm (Hons), GradCertPharmPrac, MClinPharm |  Intern Coodinator^{1, 2}

Julie E. Stevens

BSc, BPharm (Hons), PhD |  Program Manager, Senior Lecturer ^{3, 4, 5}

Samanta Lalic

BPharm (Hons), GradCertPharmPrac, MPharmPrac, PhD |  Assistant Deputy Director of Pharmacy - Education, Research and HITH^{1, 2}

1. Pharmacy Department, Monash Health, Melbourne Australia
2. Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
3. Pharmacy, School of Health and Biomedical Sciences, RMIT University, Melbourne, Australia
4. Clinical and Health Sciences, University of South Australia, Adelaide, Australia
5. Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia

[Pharmacy GRIT Article No: 20231367]

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Abstract

Background: Medicine management at transitions of care (TOC) is a priority area for improvement in healthcare. However, optimising pharmacist workflow with pharmacy-specific tools at care transitions needs further research.

Aim: To develop an information tool containing information on residential aged care facilities (RACF) and their servicing pharmacy (SP) and evaluate the effects on pharmacist workflow at TOC.

Method: Eligible RACFs were identified, and telephone interviews conducted with facilities and the SPs to develop the tool. Surveys were conducted with pharmacists for pre- and post-intervention data for analysis.

Results: Pre-intervention, 73 information acquisition processes were conducted by pharmacists (RACF = 33, SP = 40). Of these 73 processes, 27% (n = 20) required between 10–30 mins to complete. Notably in these 20 processes, pharmacists took comparatively more time to gather SP information (n = 16) in comparison to RACF information (n = 4). Post-intervention, 21 pharmacists piloted the tool and 18 pharmacists (86%) found the tool ‘very easy’ to use, and 19 (90%) found it ‘very useful’ or ‘extremely useful’ during the admission/discharge process. All 21 pharmacists perceived an improvement to their workflow and patients’ TOC.

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Introduction

Improving transitions of care (TOC) is a major focus within the health system to ensure patient safety and continuum of care.^1–4 TOC is defined as the transfer of care from one service or setting to another.¹ Suboptimal TOC may lead to poor patient outcomes and increased demand on services and expenditure, and inefficient.²

TOC during admission/discharge between hospital and residential aged care facilities (RACF) are particularly susceptible to a high risk of medication errors,^1,2 clinical deterioration,^1,3,4 and rehospitalisation.^1–4 Numerous studies have highlighted the negative impact of subpar communication in coordinating care,^1–3 compounded by the high prevalence of polypharmacy,^4,5 multiple comorbidities,⁵ and complex medical needs^1,2,4,5 among residents. These factors collectively contribute to the challenges faced in optimising care transitions and outcomes. Australia is facing an ageing population, with more people entering residential services later in their lives than ever before; consequently, many patients are more frail with a higher likelihood of complex conditions.⁶ Optimisation of TOC is even more critical in this demographic to reduce the risk of harm from poor care transitions.

There are numerous studies highlighting the integral role of pharmacists (such as pharmacist-acquired medication histories and admission/discharge reconciliation) in improving the continuity of care during TOC.^2,4,7–9 However, there are no publications investigating the effect of optimising pharmacist workflow at the point of TOC. Poor workflow can impede communication and coordination of care between the acute hospital sectors and primary care.^3,10 Optimising workflow can lead to timely patient care that is more consistent and safe.¹⁰ Therefore, the aims of this study were (a) to assess the current pharmacist workflow during the admission/discharge information acquisition process of an RACF resident, (b) to develop a tool containing RACF and servicing pharmacy (SP) information, and (c) to evaluate pharmacists’ perception of the tool on workflow and their patients’ TOC.

Method

Ethics Statement

This research was assessed as a quality improvement activity by the Monash Human Health and Ethics Research Committee and was considered exempt from ethical review per local guidelines (Reference No: RES-20-0000-572Q).

Study design and setting

A two-phase quantitative and qualitative mixed methods study was undertaken at Monash Health, a multi-site, metropolitan teaching hospital network with over 2000 beds in Melbourne, Australia.

Intervention

The proposed intervention was the development of a tool that displays information about the RACFs and their SP to assist pharmacists to complete the admission/discharge process of RACF residents. The hypothesis was the use of the tool by pharmacists during TOC would improve perceived workflow by enabling a streamlined information collection process.

Phase I: Tool development

Phase Ia Initial survey: To identify the type of information to include in the RACF/SP information tool, a 5-point Likert scale survey was distributed via email to the pharmacists and data collected over a one-week period in August 2020. The survey included a list of information categories where participants gave a usefulness rating to indicate how useful they thought each category was (Appendix 1–2). The survey results were used to inform the design of the questions for the structured interview with RACFs and SPs in Phase Ib (Table 1) (Appendix 3–4).

Table 1. Information categories in the RACF and SP information tool

Residential aged care facility information	Servicing pharmacy information
Name of RACF	Name of SP
Address	Address
Phone number	Phone number
Fax number	Fax number
Operating hours	Operating hours
Name of contracted SP	Type of DAA provided
Type of DAA used	Preferred cut-off time for same day packing and delivery of DAA
Able to administer injectable medication?	Medications hospital pharmacy must supply
Able to administer from original packaging?	Perferred method of communication
RACF procedures for new residents (non-respite)	Pharmacy procedures for new RACF residents (non-respite)

DAA = dose administration aid; RACF = residential aged care facility; SP = servicing pharmacy 

Phase Ib RACF selection and data collection: RACFs within a 15 km radius of each hospital site in the network were included in the tool. This criterion was chosen due to the high likelihood of residents from these facilities to be sent to a Monash Health site. In August 2020, four final year pharmacy students were provided training and context of the study and interview questions. The students conducted telephone interviews with the RACF managers over a one-week period. From these interactions, facility information and contracted SPs were identified. The SPs were then contacted over another week to gather their information. To boost response rates and accommodate busy work schedules, RACFs/SPs were asked the most appropriate time to call or given the option to complete the questionnaire via email. RACFs/SPs that did not answer the call or opted for the email questionnaire were contacted three more times over two weeks before they were excluded.

The data was compiled using Microsoft Word (Microsoft Corporation, Redmond, Washington, USA) and Excel, then converted to PDF (Adobe Inc., San Jose, California, USA) format to generate the RACF/SP information tool. The information was organised in a comprehensive table, with the RACF details presented first, followed by the SP information, all listed in alphabetical order based on facility/pharmacy names.

Phase II: Pharmacist Surveys

Phase IIa Pharmacist survey pre-intervention: To evaluate current practice workflow, a 16-question Microsoft Forms survey (Appendix 5) was distributed via email to pharmacists in September 2020. Over six weeks, participants were requested to complete the survey for each encounter with a patient from an RACF (admission or discharge).

Phase IIb Pharmacist survey post-intervention: The developed tool was introduced and distributed via email to participants to use over a three-week period in January 2021. A 31-question Microsoft Forms survey (Appendix 6) was emailed to pharmacists in February 2021 to investigate the effects of the tool on pharmacists’ workflow and TOC. As surveys were anonymous, individual results from phase IIa and IIb could not be linked during analysis.

Inclusion and exclusion criteria

Geriatric and general medicine pharmacists (intern pharmacists excluded) across the network were invited to participate by email at each phase. These pharmacists were selected due to their higher rates of encounters with patients from RACFs. In phase IIa, encounters involving patients from all RACFs were included. However, if the patient was admitted for temporary respite or opted for their own pharmacy for their medicine supply, these encounters were excluded.

Data analysis

Descriptive statistics were used to describe the data.

Results

Phase Ia Initial survey: In total, 19/31 (61%) pharmacists completed this phase, providing their usefulness rating for each RACF/SP information category (Table 1). The results showed all SP information categories were rated ‘very useful’ or higher with majority, 9/13 (69%), rated as ‘extremely useful’. Most RACF information categories, 12/15 (80%), were considered ‘moderately useful’ and ‘very useful’. ‘Name of contracted SP’ and ‘SP phone number’ categories were unanimously deemed ‘extremely useful’ by all pharmacists.  

Phase Ib RACF selection and data collection: In total, 156 facilities were identified in the catchment area. During the interviews, 17/156 (11%) facilities either did not answer the call, stated they were too busy or failed to respond after opting for the email questionnaire. All 45 identified SPs that serviced the remaining 139 RACFs were willing to provide their details for the tool.

Phase IIa Pharmacist survey pre-intervention: Overall, 50 encounter surveys were completed (Table 2), of which 40/50 (80%) used their facility’s contracted SP for medicine supply. Of these, 28/40 (70%) encounters were completed at admission and 12/40 (30%) at discharge. The majority of the encounters, 33/40 (82%), required information from both RACF and SP. Among the 73 information acquisition processes conducted by pharmacists (RACF = 33, SP = 40), 27% (n = 20) required between 10–30 minutes to complete. Notably in these 20 processes, pharmacists took comparatively more time to gather SP information (16 processes) in comparison to RACF information (4 processes). In the cases that consumed the most time (15–60 minutes), 50% (3/6) of these occurred on weekends. In more than half of the encounters, 22/40 (55%) respondents found the information acquisition process smooth/easy; however, a significant portion, 18/40 (45%), still experienced moderate to high difficulty with the process.

Table 2. Phase IIa: Pharmacist pre-intervention survey results (total of 50 encounters)

Survey results	Encounters (proportion)
Encounters utilising RACF's contracted SP for medicine supply	40/50 (80%)
Admission encounter	28/40 (70%)
Discharge encounter	12/40 (30%)
RACF and/or SP information required
Encounters requiring RACF information	33/40 (82%)
Encounters requiring SP information	40/40 (100%)
Encounters requiring both RACF and SP information	33/40 (82%)
Information available on site*, no further investigation required
RACF information available on site	25/33 (76%)
SP information available on site	14/40 (35%)
Information not available on site*, further investigation required
Investigation required for RACF information	8/33 (24%)
Investigation required for SP information	26/40 (65%)
Estimated consumed time for RACF information acquisition (Monday to Sunday)
Total encounters	33
<5 mins	21/33 (64%)
5–10 mins	7/33 (21%)
10–15 mins	3/33 (9%)
15–30 mins	1/33 (3%)
>1 h	1/33 (3%)
Estimated consumed time for SP information acquisition (Monday to Sunday)
Total encounters	40
<5 mins	20/40 (50%)
5–10 mins	3/40 (8%)
10–15 mins	12/40 (30%)
15–30 mins	4/40 (10%)
Could not be obtained (SP closed)	1/40 (2%)
Resources utilised to obtain the required RACF and SP information
EMR	7/40 (18%)
Internet search	20/40 (50%)
My Health Records	2/40 (5%)
Phone call	26/40 (65%)
SMR	3/40 (8%)
Transferred RACF patient profile	15/40 (38%)
Ward clerk/Nurse in charge	9/40 (23%)
Single source utilised	14/40 (35%)
Multiple sources utilised	26/40 (65%)
Difficulty rating for the information acquisition process
Very easy	9/40 (22%)
Easy	13/40 (33%)
Moderate	13/40 (33%)
High	5/40 (12%)
Day of the week encounter occurred
Monday to Friday	32/40 (80%)
Saturday and Sunday (weekend)	8/40 (20%)
Saturday and Sunday (weekend) results
Total encounters occurred on the weekends	8
Weekend encounters requiring RACF information	7/8 (88%)
Weekend encounters requiring SP information	8/8 (100%)
Weekend encounters requiring both RACF and SP information	7/8 (88%)
Weekend - Estimated consumed time for RACF information acquisition
<5 mins	2/7 (29%)
5–10 mins	3/7 (42%)
10–15 mins	2/7 (29%)
15–30 mins	0/7 (0%)
Weekend - Estimated consumed time for SP information acquisition
<5 mins	2/8 (25%)
5–10 mins	1/8 (12%)
10–15 mins	1/8 (12%)
15–30 mins	3/8 (38%)
Could not be obtained (SP closed)	1/8 (12%)

* = In patient's medical folder, documentations, electronic medical records (EMR) etc; EMR = electronic medical record; RACF = residential aged care facility; SMR = scanned medical record; SP = servicing pharmacy

Phase IIb Pharmacist survey post-intervention: Of the 68 eligible pharmacists, 21 (31%) completed the evaluation survey for the tool. The majority of respondents 18/21 (86%) agreed the tool was ‘very easy’ to use and nearly all 19/21 (90%) found the tool ‘extremely useful’ or ‘very useful’ in assisting them during the admission/discharge process. A large number of participants, 19/21 (90%), reported using the tool at least once or twice a day and a third of them, 7/21 (33%), used it at least three to five times per day. Having access to the tool, all pharmacists (21/21) perceived an improvement of varying degree to their workflow and their patients’ TOC, with 4/21 (19%) noting ‘slightly/somewhat improved’, 11/21 (52%) ‘much improved’, and 6/21 (29%) ‘exceptionally improved’. All participants noted they would like the tool introduced into the hospital network. The tool has been successfully integrated into our daily clinical practice, enabling pharmacists to conveniently access it through the hospital’s secure pharmacy policies and procedures database.     

Discussion

To our knowledge, this is the first study to develop an RACF/SP information tool and evaluate pharmacists’ perceived workflow during TOC before and after implementation of the tool. The results demonstrate the value of the tool in improving workflow and patients’ TOC as perceived by pharmacists.

Much research has focused on pharmacists’ roles to improve TOC targeting medicine information dissemination^9,11,12 with the majority of these centred on pilot programs and pharmacy-driven services.^9,13,14 However, there has been no research focused on development of tools with the aim of improving pharmacists’ workflow during TOC. RACF/SP information acquisition in the absence of a tool can be a time-consuming task; our study demonstrated 27% of the acquisition process taking between 10–30 minutes to complete. With multiple admissions/discharges completed by pharmacists on a daily basis, the accumulated time can be substantial. These are reflective of the results from a time-and-motion study showing a large proportion (27.5%) of a pharmacists’ workday was consumed completing admissions/discharges.¹⁵

Delays or problems with TOC can lead to medicine misadventure including errors in prescribing, preparing, administering, or monitoring medicines.¹¹ TOC requires complex interactions between health professionals and necessitates effective communication. During transitions, there are often barriers and challenges to information dissemination between hospital pharmacists and RACFs/SPs, with constant back and forth communication between the settings as information is exchanged.¹¹ This is particularly apparent on weekends, where our results showed half (50%) of the most time-consuming acquisition process occurred during this period. Reduced RACF staffing, as well as shorter operating hours of SPs (certain SPs are closed) over the weekend, presents pharmacists with significant challenges in obtaining required information which can lead to a delayed and problematic admission/discharge workflow.

Our study suggests the tool has value in streamlining this information dissemination processes to improve workflow. The potential time saved by this tool will also enable pharmacists more opportunities to complete other essential tasks during transitions such as medication reconciliation, education/counselling, and discharge planning which are critical to preventing medication errors, adverse drug events, and readmissions.^2,4,7–9 These results from this large pharmacy department in a multisite healthcare network are generally applicable to other hospitals within Australia particularly those covering large geographical areas of RACFs. The development and implementation of an RACF/SP information tool may merit further considerations in other healthcare networks.

Limitations

There were some limitations to this study. Firstly, a small number of RACFs did not respond despite offering several questionnaire options, which could be attributed to the additional pressures faced by RACFs during the COVID-19 pandemic. Secondly, due to workforce challenges during this period, it was not possible to acquire an adequate sample size to conduct a statistically powered analysis and determine whether the tool could save time pre- and post-intervention. Furthermore, the length of the survey and the overall strain of the pandemic may have contributed to lower completion rates among pharmacists. Thirdly, the demonstrated benefits of the tool are confined to patients using RACF contracted SP for medication supply. However, this impact is minimal as shown in this study, the majority of residents (80%) were already using the contracted SPs. Lastly, with SP details being available in RACF transfer information, pharmacist having to contact the SP to confirm supply requirements and the continual need to check the tool for accuracy may limit the sustainability of the tool.

Quality of care at transitions is imperative to ensure patient safety and continuity of care. This study demonstrates the benefits of the RACF/SP information tool in streamlining pharmacists’ information acquisition process during TOC. Pharmacists perceived the information tool assisted them in their daily practice, enhanced their workflow efficiency as well as improved the TOC for their patients from RACFs. Future studies at other healthcare networks are needed to validate the value of RACF/SP information tools to pharmacist’s workflow and patients’ TOC.

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Acknowledgements

 The study investigators would like to acknowledge RMIT University pharmacy students Courtney Doyle, Shyam Kannan, Stephanie Jones, and Jiahui Yang who collected the study data. We would also like to acknowledge Brindha Garuda, Louise Lord, and Marianne Jovanovic from the Monash Health Pharmacy Education Services team for reviewing the manuscript.

Conflict of Interest Statement

The authors have stated no conflicts of interest to declare.

Ethics statement

This study was assessed as a quality improvement activity by the Monash Health Human and Research Ethics Committee and exempt from ethical review (Monash Health reference: RES-20-0000-572Q).

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Appendices

Appendix 1: Phase Ia: Survey to identify information types to include in the RACF information tool

Appendix 2: Phase Ia: Survey to identify information types to include in the SP information tool

Appendix 3: Structured interview questions for RACFs

Appendix 4: Structured interview questions for servicing pharmacies

Appendix 5: Phase IIa: Pharmacist pre-intervention survey

Appendix 6: Phase IIb: Pharmacist post-intervention survey

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References