Nela Roncevic Ashton, Senior Clinical Pharmacist from the Network Integrated Practice Pharmacist team in Salford talks to us about Transfer of Care – Supporting patients with their medicines as they change throughout their life journey.

Most of us spend a fraction of our time on active healthcare, while the rest of our life is dominated by other events, family, relationships, work, money, transport, leisure activities, pets…

When a healthcare issue that upsets our regular daily routine happens, it inevitably causes the stress levels to rise to some degree and it takes us a little time to adjust. When it impacts us in ways that it alters our daily functioning, it takes longer. Understanding what is happening to us is an emotional process and it can be difficult regardless of if we have the clinical understanding of the conditions or not. In addition, when stressed, our mind is programmed to the survival mode which makes us less able to focus on learning new things. Starting new medication or altering an existing medication regimen is precisely what is then required of us to take in as well as figure out how to implement this new aspect of our life in practice.

Having worked as a pharmacist in hospital and community settings for over 20 years, I have been involved in supporting patients in this transition from different ends of the spectrum. I have also witnessed the services evolve over this period, how they work in several organisations across the North-West of England, as well as how the modern information technology and electronic transfer of data is utilised to ensure safe and accurate patient information transfer from one care setting to another. I am also on a receiving end on daily basis in my current role, not infrequently experiencing frustration due to time it takes to clarify information when inaccurate, incomplete, or illegible while handling patient expectation as well as professional duty to deliver on care in timely manner and duty to all my patients.

In other words, there is a very human factor involved when a professional is working across the boundaries to try and resolve the issues that seem minor, but in the long run could affect patient lives to a great degree by increasing the proportion of their time they will have to spend in active healthcare in a consequence.

As a pharmacist and a prescriber, I am trained to think of medicines in a particular way when writing them down:

1. Name (Generic or Branded)
2. Strength
3. Dose
4. Frequency
5. Duration/plans for a review (quantity)
6. Indication (and or reason for change)

I have to satisfy myself that this information is clear and specific and for that, it needs to be legible and organised in a clear format to avoid any confusions with greatest risk being the potential for incorrect medication being dispensed and administered.

When carrying out medication reconciliation, I look at the medication in the same way, as I ultimately have to put my name to the prescription. There are additional aspects that I have to check as I take the responsibility for a prescription:

1. Is the item on formulary, RAG status on GMMMG and is there a valid Shared Care Protocol (SCP) if relevant?
2. Who is the original prescriber (and their credentials to prescribe a particular medication for the indication they have recommended it) and how are the responsibilities distributed between the care settings for the continuation of care (eg. mutually agreed and signed SCP or medication prescribed and supplied in hospital by a hospital team)
3. Do I have relevant competence and authorisations to prescribe that medicine? (…and for this I need to be clear about 2.)
4. Ensure that the relevant diary dates are added to the Clinical System for any monitoring and patient informed about what they need to do.
5. Ensure that the records are updated, including when the medication is being prescribed and supplied by the hospital, to ensure that this is taken in account when any new medication is prescribed in the Primary Care

All this then needs to be communicated and coached to a patient so that they understand and recall how to continue obtaining their medicine, what monitoring is required, how to make appointments for it and where, who to contact in case there is an issue with medication or their condition changes, possible adverse effects of the medication, and then how do they implement all this into their daily life (are they in social care setting, do they need support with compliance in form of medication chart or compliance aids, do they need training on administration of injectables or inhaler technique etc…)

One of the commonly forgotten communications about medicine changes are related to the medications being stopped and the reasons why. This is an important aspect from the point of a practitioner that needs to understand if there is a reason why this medication should not be prescribed again (eg a severe adverse reaction, patient intolerability, allergy status, contraindication).

Hospital colleagues will provide this information, too, patients will often need to go through it all more than once as there is often a lot to take in. The primary care contact will also provide a sense of security that this is in hand with their regular care provider.

This aspect is all about the discharge from hospital, but similar process applies to the reconciliation on admission. This is more difficult to obtain accurately for any patient that doesn’t actively understand their medicine. Even with the transfer of data from the Primary Care setting, this needs to be put into context of compliance, what medication is the patient actually taking compared to what is on the medication list and in some instances can be critical to understand when the last time was, they have taken certain medication, which only the patient can tell us. Needless to say, a hospital admission is also a stressful position to be in and it is likely that anyone, let alone for unresponsive, elderly or patients with mental health conditions, this kind of information may be difficult to recall.

As a hospital prescriber is attempting to juggle a lot of information in, no doubt, limited time available, having to address the clinical issues at hand while the patient is there, it is difficult to then think about all of aspects I listed I go through as a pharmacist. After all, we are trained to think differently and complement each other. It is greatly appreciated if the any correspondence has a clear and easily accessible contact details, including email address, for the department, service and prescriber to be able to follow on any queries that may arise from a brain of a pharmacist or GP.

The Information Technology can assist us with but cannot resolve for us. This is a work in progress and it continues every day in the lives of all of us who care for patients.