1
The City Country Medslink Project
Presented by:
Deirdre Criddle
D Criddle, P Jayasuriya, R Clifford, J Benzie, K Crouchl...
2
July, 2002
Once upon a time there was
a vision…..
3
Why do CCML?
• The period 7 - 10 days following
discharge is a vulnerable time
associated with a significant risk of
med...
4
The 4 hour rule ~ all glory or unintended
consequences?
‘Reduced mortality rates and less overcrowding in the WA pilot
b...
5
A long way from home....
6
The Vision 2012
To implement a hospital coordinated framework, enabling timely
Home Medicines Review (HMR) services to b...
STAGE 1
Hospital Liaison Pharmacist (HLP)
Screens for medication misadventure (using tool)
Written informed consent from p...
8
The screening tool
Adapted from a service provided by Hospitals in Victoria and research in South
Australia
Provides a s...
9
CCML Pilot Project
• Discharge „About me and with
me‟
• Community colleagues as
partners in post discharge care
• Using ...
10
Who were the CCML cohort?
• “Elderly” 64.9 ± 16.8 years
• Multiple comorbidities 4.6 ± 2.4
• Significant polypharmacy 1...
11
The patient stories …
‘data with a soul’
From a remote
community to
SCGH via
Newman
“They told me I was going to Gerald...
12
Patient stories …
Patient with gastroenteritis, complicated
by acute kidney injury and hypoglycaemia
Patient advised to...
13
Results
• 60 patients screened for eligibility over 4
months
• 18 of the eligible 22 consented
• 16 referred for HMR
• ...
14
Results:
• 60 patients screened using validated tool
• 27 patients interviewed
• 8 patients received an HMR (7 within 1...
15
Results:
• 42/60 (70%) patients screened from the
Goldfields Midwest region were
considered to be at high risk of medic...
16
Results:
• 2 GPs did not send the referral ~ despite several requests
(1 patient newly commenced on warfarin), another
...
17
What they thought
“It was excellent seamless continuity of care, which
the patient found very reassuring and prompted t...
18
What they thought
“It was really “top drawer” service. The
pharmacist came to my home, and spent a
good deal of time ex...
19
Lessons from CCML
• Let‟s start recognising risk! A validated tool can
highlight medication misadventure
• Let‟s look a...
20
When crossing transitions of care
21
“Who’s packing our patient’s parachute”
22
Let’s make medication management post discharge
mandatory for those at most risk!
And ensure a safe landing for our mos...
23
References
1. Roughead, L and Semple S Second National Report on Patient
Safety Improving Medication Safety The Austral...
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Deirdre Criddle, Sir Charles Gairdner Hospital - City Country Medslink – A Collaborative Approach to Improve Medication Management on Discharge

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Deirdre Criddle, Consultant Pharmacist & Complex Care Coordinator, Goldfields-Midwest Medicare Local & Sir Charles Gairdner Hospital delivered the presentation at the 2014 Discharge Planning Conference.

The 2014 Discharge Planning Conference - Assisting health services to adopt an integrated and consumer directed approach to discharge planning.

For more information about the event, please visit: http://bit.ly/dischargeplan14

Published in: Health & Medicine
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Deirdre Criddle, Sir Charles Gairdner Hospital - City Country Medslink – A Collaborative Approach to Improve Medication Management on Discharge

  1. 1. 1 The City Country Medslink Project Presented by: Deirdre Criddle D Criddle, P Jayasuriya, R Clifford, J Benzie, K Crouchley and J Lack
  2. 2. 2 July, 2002 Once upon a time there was a vision…..
  3. 3. 3 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
  4. 4. 4 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?
  5. 5. 5 A long way from home....
  6. 6. 6 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…”
  7. 7. 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.
  8. 8. 8 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.
  9. 9. 9 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 •
  10. 10. 10 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)
  11. 11. 11 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.”
  12. 12. 12 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?
  13. 13. 13 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
  14. 14. 14 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
  15. 15. 15 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
  16. 16. 16 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
  17. 17. 17 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
  18. 18. 18 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
  19. 19. 19 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
  20. 20. 20 When crossing transitions of care
  21. 21. 21 “Who’s packing our patient’s parachute”
  22. 22. 22 Let’s make medication management post discharge mandatory for those at most risk! And ensure a safe landing for our most vulnerable.
  23. 23. 23 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

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