Transfer of Care Project (part of the work of the Medicines Optimisation Programme)

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Case Study Summary
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Overview summary:
Newcastle upon Tyne Hospitals worked with North of Tyne Local Pharmaceutical Committee (LPT) and Pinnacle Health to develop an electronic referral template using PharmOutcomes. Hospital pharmacy staff used the system successfully in the North of Tyne area to refer patients to their community pharmacist if considered beneficial after leaving hospital. 
Challenge identified and actions taken :
Evidence shows that 5-8% of unplanned admissions are due to medication issues and when patients are prescribed a new medicine, a third are non-adherent after 10 days and 30-50% of medicines are not taken as intended.  However on-going community pharmacist support has been shown to improve medicines adherence. 
In an attempt to improve medicine adherence, improve patient safety and improve patient outcomes, Newcastle upon Tyne Hospitals worked with North of Tyne Local Pharmaceutical Committee (LPT) and Pinnacle Health to develop an electronic referral template using PharmOutcomes. Hospital pharmacy staff used the system successfully in the North of Tyne area to refer patients to their community pharmacist if considered beneficial after leaving hospital. The AHSN NENC supported the development and implementation of this framework across the region. The project is now gaining traction nationally.
Impacts / outcomes:
Through active communication and participation in the national AHSN Medicines Optimisation network this work has been established as an exemplar model of communication between secondary care and community pharmacy.
  • Seven acute trusts are now making referrals to a potential 504 community pharmacies for follow up support with their medication after discharge from hospital;
  • Over 750 patients have received follow up support since the initiation of this service in July 2014;
  • Community pharmacists have reported nearly 90% of patients had a better understanding of their medicines as a result of their consultation and would be therefore more likely to adhere to their prescribed medicine regimes.
  • The project team have won two prestigious HSJ awards in 2015, in the categories for  ‘Enhancing Care by Sharing Data and Information’ and ' Most effective adoption and diffusion of best practice'
  • The work has directly contributed to the production of a Hospital referral to community pharmacy toolkit, distributed nationally by the Royal Pharmaceutical Society;
  • The Transfer of Care work initiated in the AHSN NENC has attracted national interest and has been adopted in a number of areas throughout the country.  
Supporting quote for the innovation from key stakeholders:
At the HSJ Awards the project was described by judges as a "beautiful, simple solution that works...developed by clinical leaders who saw potential in existing functionality". The judges went on to praise how the Trust “genuinely demonstrated adoption and diffusion of innovative practice across the region” and that "Every hospital should be doing this."
Which local or national clinical or policy priorities does this innovation address:
Health and well-being; patient experience.
Plans for the future:
  • Outcome measures collected through PharmOutcomes will help inform the direction and development of the project.
  • Further rollout of the project nationally will continue
  • The e-referral system is being further developed to involve GPs, doctors and nurses as well as pharmacists.
  • Development of Trust systems will facilitate the auto-population of the referral form, further speeding up the process.
  • The evidence base will be further enhanced through publication to the BMJ of research being undertaken by academics at Durham and Manchester Universities.
Tips for adoption:
Trust staff need the buy-in of community pharmacies.
The NENC region uses PharmOutcomes for E-referral and it helps if systems are complementary across regions but this is not a pre-requisite for the methodology to be adopted across Trusts.
Contact for further information:
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