The Medicines Management Mapping Project: Using risk stratification and care coordination to bridge the care continuum gap

INTERVENTION: Patients will be randomized into either the Intervention Group, or Non‐intervention Group after consenting to participate. The Clinical Pharmacy Research Team (CPRT) will collect information on all patients during the patient’s hospital stay and monthly after discharge (by phone interview.) Non‐Intervention Group will receive usual care from the treating hospital team. If any member of the hospital team believes a patient in this group needs a medicines management service such as a Home Medicines Review (HMR) after hospital discharge, the CPRT will not interfere in any way with the usual hospital referral process. Intervention Group, will receive usual care from the treating hospital team, in addition to having a risk tool applied. If any member of the hospital team believes a patient in this group needs a medicines management service such as a Home Medicines Review (HMR) after hospital discharge, the CPRT will not interfere in any way with the usual hospital referral process. The risk tool identifies and counts risk‐factors associated with medicines‐related problems in vulnerable groups. The risk tool has been developed from work conducted previously at Sir Charles Gairdner Hospital from a complex patient cohort. (http://mm2017shpa.com/wp‐content/uploads/2017/11/Poster‐145_Gupta.pdf.) If the patient scores highly on the risk tool, the patient will be triaged for referral for a Community HMR or a hospital outreach medication management review service. A HMR is a service where a pharmacist visits the patient at home and reviews all medicines. This pharmacist will contact the patient’s usual GP and Community Pharmacist, visit the patient in the home within a week from discharge and resolve any medication‐related problems. They will provide a report to the GP and the Hospital Team – where it will be put on the Patient’s Medical Record. All patients will be contacted by phone monthly for 3 months to find out what happened in the previous 30 days. For example if any Emergency department visits were needed, or if any medication management services were received. CONDITION: Medication‐related harm Multimorbidity Polypharmacy PRIMARY OUTCOME: Hospital health utilisation as measured by the composite outcome; ; Number of Emergency hospital presentations and/or ; Number of unplanned hospital admissions ; Assessed by audit of hospital records, and questions answered by patient at 30 day telephone interview. Number of medication management services provided after hospital discharge as measured by patient telephone survey and also as provided by Community Accredited Pharmacist conducting the HMR. ; Time to next emergency visit or unplanned hospitalisation (as a composite outcome). Assessed by audit of hospital records, and questions answered by patient at 30 day telephone interview. ; SECONDARY OUTCOME: Satisfaction with the explanation of medicines on leaving hospital ‐ measured by describing options on a Likert scale; ; 1 Very satisfied 2 Satisfied 3 Neither satisfied or dissatisfied 4 Dissatisfied ; 5 Very dissatisfied ; Satisfaction with the medication management service provided after hospital discharge ‐ measured by describing options on a Likert scale; ; 1 Very satisfied 2 Satisfied 3 Neither satisfied or dissatisfied 4 Dissatisfied ; 5 Very dissatisfied ; Self‐assessed quality of life ‐ as measured by the EQ‐5D‐3L Timeliness of medication management review service provided after hospital discharge. This will measure how long after discharge the medication management interview was provided. INCLUSION CRITERIA: Patients admitted to a medical ward at SCGH over an eight‐week period, who have Patients admitted to selected medical wards at Sir Charles Gairdner Hospital who have capacity to consent, hold a Medicare card, reside the Perth North Metropolitan region and are able to be contacted by phone.