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Case Study Three

Level 3 clinical medication reviews after hospital discharge, Huntingdon PCT

Participating in the MMS programme led to a pilot clinical medication review scheme for patients aged 65 years or over recently discharged from hospital, because of their particular vulnerability to medicines related problems.
  • Reduce potential pharmaceutical care problems and improve concordance in medicine taking following hospital discharge
  • Increase safety and effectiveness by:
    • comparing pre-admission and post-discharge medicines, including non-prescribed medicines
    • allowing the pharmacist and patient to discuss practical aspects of medicine-taking and patient understanding of their medicines
    • agreeing recommendations with the patient and communicating them to the GP.
Reviews are undertaken by a clinical pharmacist in patients' homes and funded by Huntingdonshire PCT. All patients aged 65 years or over who have recently been discharged from the local hospital with discharge medication are identified by the practice using the discharge summary from the hospital, and referred for review. The discharge summary and patient's pre-admission medication summary and medical history (from the GP clinical system) are then e-mailed or faxed to the PCT. The practice contacts the patient to explain the scheme and ask for their consent to be visited. If the patient agrees, they are contacted by the PCT to arrange a suitable time and date for review. At the review visit the patient is given an information leaflet about the scheme and relevant contact details. The review usually takes 30-45 minutes. Following the review, feedback is sent to the patient's GP. The practice is responsible for Read coding the medication review and deciding on appropriate follow-up.
The scheme was piloted with 5 general practices starting in February 2002. 100 medication reviews were carried out (average patient age 77 years).
  • In 27% of cases, the discharge letter did not match the medicines being taken
  • 28% of patients needed help taking their medicines
  • 27% were confused about which medicine to take when
  • 11% could not read the labels
  • 20% could not open their containers easily
  • 18% had problems swallowing capsules/tablets
  • 44% thought they were experiencing side effects from their medicines
  • 49% did not understand the reason for taking one or more of their drugs.
A total of 430 points were fed back to the patients' GPs following the review. A further development has been the production of a guide to medication review in the elderly, which lists all the drugs that have been encountered so far and potential pharmaceutical care problems or checks to be made for each drug. It is hoped that this will be a tool for other pharmacists to adopt or adapt.
Giving patients information about the medication review in advance and a clear consent process are particular strengths of this scheme, which targets patients at a point when medication related risk is high and takes patients' own experiences of their medicines as a key component.
Sati Ubhi, Prescribing Advisor/Project Pharmacist, Huntingdonshire PCT
Jessica Stokes, Project Facilitator, Huntingdonshire PCT