Post-discharge care: Closing the loop

There is strong evidence that hospital patients benefit from pharmacists being involved in post-discharge care. But pharmacists face multiple barriers when it comes to conducting post-discharge medication reviews.

If you’ve ever run or watched a relay race you’ll know just how crucial the baton change is. Even at Olympic level, years of training and world record splits can fall away in the heart-stopping instant that the baton passes from one runner’s hand and slips out the other’s.

Life is more a journey than a race but transfers of care are critical moments for a patient’s care.

The problem

Poor medication management during or immediately after hospital admission has been found to result in a 28% increased chance of patient re-admission within 30 days1 and a 50% likelihood of a return visit within a year.2

This contributes to the fact that between 2%3 and 5.6%4 of all hospital admissions are due to Adverse Drug Events (ADEs), costing the Australian health system billions of dollars annually. But medication misadventure post-discharge costs much more than just healthcare dollars, said University of South Australia Adjunct Senior Research Fellow, Dr Manya Angley FPS.

‘There’s also an impact on quality of life – patients are missing out on empowerment and clarity and getting confusion and illness,’ she said. ‘Often they revert back to the medication they were on prior to admission and end up back in hospital.’

Medication reviews

There is an established and growing body of evidence that medication reviews improve the identification and resolution of medication-related problems,5 improve medicines reconciliation,6 extend the period between hospitalisations6 and reduce healthcare costs. Economic and clinical analysis has shown that the average post-discharge Home Medicines Review (HMR) saves 46 days of health loss, prevents 0.19 days in hospital, and results in $206 of financial savings to the health sector.7

As many as 74% of GPs agree that an automatic post-discharge medication review should be undertaken for patients at risk of medication misadventure, one Australian study showed.7

But the very same survey found that GPs implemented just 29% of recommendations made by accredited pharmacists.

The politics

Despite clear in-principle support within the sector, there is little agreement on how post-discharge medication management should be delivered and funded, said PSA Project Pharmacist Trish Russell MPS.

‘There is aspiration for post-discharge HMRs to happen because there seems to be enough research to say that they will bene­fit patients, improve medication reconciliation, and reduce ADEs and rehospitalisation,’ she said. ‘The struggle is getting a referral pathway within a model that people will accept.’

Dr Angley was one of many who had hoped a solution was imminent some eight years ago. In 2010, the Federal Government and Pharmacy Guild of Australia announced that post-discharge medication reviews would be funded in 5CPA.

‘Disappointingly, no progress was made for the duration of the 5CPA other than some small trials that did not produce any meaningful outcomes,’ Dr Angley said.

‘It’s been a comedy of errors and in the meantime lives are being lost, quality of life is being diminished and it’s costing the system.’

Home Medicines Reviews

Many post-discharge medicine reviews are currently conducted via Medicare Bene­fits Scheme item number 900: Domiciliary Medication Management Review, referred to as a HMR.

This requires a GP to refer the patient to an accredited pharmacist who then carries out a comprehensive clinical review of a patient’s medicines in their home.

But post-discharge HMRs face numerous hurdles, including medico-legal problems, said PSA’s Ms Russell.

‘If you’re asking a hospital liaison pharmacist or the leader of a clinical team in the hospital to initiate the HMR referral then the GP may not accept the result because they haven’t been involved in the process,’ she said.

Post-discharge GP-initiated HMRs can also su­ffer from a lack of timeliness, said Dr Angley. ‘Discharge summaries take a while to filter through. Sometimes they take a few days, other times they take weeks and even months,’ she said.

‘So sometimes the first time the GP hears their patient has been in hospital is when the community pharmacist calls up requesting prescriptions for new medicines based on the medication pro‑ le given to the patient when discharged from hospital so they can fill the blister pack and ensure continuity of supply.’

Dr Angley added that one HMR was never enough to provide a comprehensive service for patients at risk of medication misadventure.

‘But the HMR business rules only allow one HMR every two years. Although a HMR can be conducted more frequently if the GP deems there is a clinical need, this is not well understood by GPs,’ she said. ‘Many GPs are fearful they will be accused of over-servicing if they make more than one referral every two years if they are audited.’

Patients also su­ffer from delays due to the cap on accredited pharmacists which restricts them to just 20 HMRs a month. Perth clinical pharmacist Deirdre Criddle FPS was dismayed at the cap’s introduction in 2014. ‘That was such a tragedy, a real tragedy for continuity of care,’ said Ms Criddle, Complex Care Coordinator and Pharmacist at Sir Charles Gairdner Hospital’s Complex Needs Coordination Team (CoNeCT).

Alternative models

CoNeCT is one service that has developed ways for pharmacists to deliver excellent post-discharge care, despite the barriers.

It’s a public hospital-based, state government funded multi-disciplinary outreach service designed to respond to the needs of complex patients who are frequent presenters to the acute hospital setting.

‘An increasing part of my role in the last couple of years has been across transitions of care,’ Ms Criddle said.

CoNeCT’s medication management solution uses a strati­fied risk assessment tool to screen for high-risk patients.

‘If someone meets a high-risk criterion then ward pharmacists or nurses can call CoNeCT – we’ve got a phone referral system in place,’ she said. The CoNeCT clinical pharmacist then coordinates a medication review once the patient returns home.

‘We try to use patients’ usual primary healthcare providers wherever possible, but if they don’t have capacity to do a HMR in a timely fashion, then CoNeCT will follow up within a week of discharge,’ said Ms Criddle. CoNeCT also works to ensure all stakeholders are on the same page.

‘If a patient has that utopia that we talk about – the medical home – nothing is more warming to my heart than being able to close the loop so that the pharmacy knows what the patient is taking and what’s been changed, the doctor knows, the patient knows and the carers know,’ she said.

Victoria’s Hospital Admission Risk Programs (HARP) leverages a similar model of state-funded, hospital-based multidisciplinary care. Katie Phillips, a HARP Pharmacist at the Royal Melbourne Hospital, said the outreach service helped navigate the ‘well-known mine­field’ of transition from hospital to community setting.

‘HARP sits in the middle. We have access to all the hospital information – not only the medical records but we can also liaise with the treating team,’ she explained.

‘We also have the ability to go to the outpatient clinic or GP with the patient and help to ­fill in the blanks that are often left when people are transitioned.’ The funding structure also meant HARP pharmacists could visit patients multiple times, Ms Phillips said. ‘The HMR program doesn’t really provide adequate resources and remuneration to allow the pharmacist to spend time problem-solving for the patient,’ she said.

‘HMRs tend to focus on patient education and identi­ cation of issues, whereas with HARP we have time and resources to problem-solve, implement strategies then monitor and follow-up to make sure our interventions have been successful.’

Programs like HARP and CoNeCT, however, only see the ‘tip of the ice-berg’ – the most vulnerable patients. As part of the Society of Hospital Pharmacists of Australia’s Primary Care and Transition Care Committee, Dr Angley is currently undertaking a mapping project to determine what kind of post-discharge medication management is being provided around the country.

‘There’s some really good pockets of work happening but post-discharge care is pretty ad-hoc and patchy across the country,’ she said. In her frustration with the current HMR pathway, she’s moved into post-discharge medication management from what she called ‘the other end’ – as GP pharmacist. ‘In the general practice where I work we prioritise doing timely post-discharge HMRs for high risk patients,’ she said.

My Health Record

Funding for general practice pharmacists, in conjunction with the roll-out of My Health Record (MyHR), could deliver signi­ficant post-discharge care improvements in coming years. Tim Perry, who works as a consultant general practice pharmacist in Western Sydney, said the community stood to bene­fit from the GP pharmacist’s timely access to information and GPs.

‘MyHR gives us access to the patient records – hospital reports, discharge summaries – as soon as the patients come out of hospital. And then if there’s anything we need to do, I’m on the ground and the GP is next door or in the same room,’ he said.

That said, there is still no routine practice for ensuring a timely post-discharge medication review.

One possible solution would be to automate that process, as UTAS Professor of Pharmacy Gregory Peterson MPS tried to do with ‘Med eSupport’, a software solution prototype that automatically referred suitable patients for an HMR after discharge from hospital.

Completed in 2006, the project looked at post-discharge medicine reviews conducted under a usual care scenario (no HMR recommendation or a sticker on a patient’s discharge summary suggesting a HMR) and compared those outcomes with two intervention groups.

One group was given a streamlined HMR recommendation via the computer program (all the GP had to do to refer was check the information, sign it and send it to the clinical pharmacist). The other group received an automatic post-discharge medication review (PDMR).

‘The automated PDMR arm of the trial achieved a high performance (96%) of medication reviews within 30 days after discharge,’ Prof Peterson said.

‘The uptake of HMRs in the streamlined referral group was still reasonable at 22%.’

‘This suggests that a program that is not GP-dependent for the medication review referral, but uses standard criteria for identifying patients at risk of medication misadventure, can be implemented with success,’ the report stated.

Prof Peterson said it would be bene­ cial if the MyHR could be similarly programmed to trigger such a review.

The figures

Every day, millions of Australians take their medicine, knowing it will keep them safe, well and comfortable.

Sadly though, a small proportion of people experience exactly the opposite – pain, fear and illness – due to medicine meant to help them.

As many as 2%9 to 5.6%10 of all admissions to Australian hospitals annually are due to ADEs and medication misadventure costs Australia a staggering $1.2 billion to $2.7 billion a year.

Those at the highest risk of ADEs are older Australians, people taking multiple medications or high-risk medications.

High-risk medications

In the general adult population, the following medications are associated with the highest risk of adverse events: cardiovascular drugs, antithrombotic agents, analgesics, antibiotics, oral antidiabetic agents, antidepressants, anti-epileptic drugs and chemotherapeutic agents.11

Older Australians

Among those aged 65 and over, as many as 20% and 30% of all hospital admissions are medication-related12 and up to 75% are believed to be preventable.13 The rate may be even higher for older people living in the community, where one in every four are hospitalised for a medication-related problem over a five-year period.

At least 25% of those admissions may be preventable.14 Medications associated with high risk of ADEs in this population also included anticholinergics, benzodiazepines, antipsychotics, sedatives and hypnotics, and oralcorticosteroids.15

Other at-risk communities

Other high-risk communities include young people and those from culturally and linguistically diverse communities16 or Indigenous backgrounds.17

One 2015 study of Aboriginal and Torres Strait Islander perspectives found the community was underserviced by the Home Medicine Reviews program.18 ‘Aboriginal and Torres Strait Islander people are the most likely of all Australians to miss out on HMRs despite their high burden of chronic disease and high rates of hospitalisation due to medication misadventure,’ the report stated.

Of all paediatric general admissions each year, 4.3% are linked to ADEs.19 The drugs most commonly associated with ADEs are respiratory drugs, antibiotics, antihistamines and analgesics.20

Non-acute events

Of course, for every medicine-related hospital stay, there are many more Australians at risk of ADEs.

One recent study at a large, urban, public mental health service in Queensland showed that more than 90% of patients had at least one medication record discrepancy, with an average of 4.9 errors per patient.21

Overseas tactics

Financial penalties – US

Via the Hospital Readmission Reduction Program, the Centres for Medicare & Medicaid Services penalises hospitals that have a higher-than-expected 30-day readmission rate for targeted conditions. The program has been credited with reducing national readmission rates by 8% (2010-2015). In 2017, it levelled more than 2500 hospitals a combined US$546 million in fines.

Insurer-initiated programs – US

A study of an insurer-initiated medication reconciliation transition program22 found that participants had ‘a 50% reduced relative risk of readmission within thirty days of discharge and an absolute risk reduction of 11.1%’.

‘The program’s combination of in-home consultations for higher-risk members and less costly telephone consultations for members at moderate-to-high risk saved $2 for every $1 … the total mean savings per member was $1,347,’ the report found. Some have called for a similar model to be adopted in Australia.

Medicine Use Reviews (MUR) – UK

A MUR is a free service funded by the NHS and carried out by an accredited pharmacist. It involves reviewing the patient’s medication use, checking they understand how and why medicines should be used, and identifying any problems that might limit adherence.

Post-discharge patients are one of four MUR national target groups and pharmacy contractors are expected to complete at least 70% of their annual MURs on patients from these groups. One study shows post-discharge MURs improved clinical care in almost 60% of cases.23

Discharge Medicines Review (DMR) – Wales

Building on the MUR, a DMR is a two-part community pharmacist intervention at the point of transfer of care. The first part involves patient identification and medicines reconciliation and the second part is support for adhering to medication.

There are some eligibility guidelines but community pharmacists can also complete a DMR for any patient they have ‘reason to consider … would benefit from the service’.

DMRs are a free service funded by NHS Wales. An assessment of the program found DMRs delivered a 3:1 return on investment, and that 39% of pharmacist interventions had the potential to prevent future accident and emergency presentations.24

Hospital-initiated solutions

‘I’ve been around the block a few times about what the solution is. At the moment I think it has to be hospital-led,’ said Dr Angley, who led a study evaluating dual pathways for high-risk patients: a HMR pathway and a Hospital-Initiated Medication Review (HIMR) pathway.8

The study found that with involvement of a hospital-based liaison pharmacist it took an average 6.54 days (+/- 4.73 days) for a HIMR to be conducted, versus 11.11 days (+/- 7.44 days) for a HMR. But Dr Angley said that HMRs didn’t necessarily need to be the end-goal.

‘Maybe we shouldn’t be too wedded to the whole HMR thing and just take a step backwards and see what really needs to be done,’ she said. ‘The two things that need immediate attention following discharge are reconciliation and communication.’

Ms Criddle’s voice is among those calling for a dedicated hospital-based professional to perform a role similar to facilitate post-discharge medication management.

‘I would contend that because medication errors in transitions of care are no-one’s job, it’s everyone’s business. It needs to be someone’s job,’ she said.

7CPA and MBS changes?

Meanwhile there are many who are advocating for the removal of funding barriers. Ms Russell said: ‘The cap on the HMRs isn’t based on a clinical finding – it was based on a funding model. So if we’re looking at outcomes for patients you really should be looking at the clinical need.’

‘Certainly PSA’s Accredited Pharmacist group has always recommended that the HMR referrals have a targeted criteria for clinical need.’

She said that once HMRs were more targeted to people with clinical need, it made sense for caps to be removed. The King Review of Pharmacy Remuneration and Regulation agreed, recommending that caps on HMRs be abolished, but the Federal Government’s official response to the review was non-committal.

‘Revised program guidelines for the HMR program have been applied to support the collection of additional information to allow assessment of the effectiveness of this program,’ stated the response released in May.

‘This will inform government’s consideration of payments provided to pharmacists for the provision of HMRs, in connection with the negotiation of future CPAs.’

The response also brushed off the review’s suggestion that HMRs be removed from the CPA and instead be defined and remunerated ‘through alternative mechanisms such as the MBS’.

The government responded: ‘reform to extend a pharmacist’s role to a clinical service that could potentially duplicate an existing MBS-funded service otherwise provided by a general practitioner or nurse practitioner in the primary care setting would need an appropriate assessment by the Medical Services Advisory Committee’.

Patient-centred future

Going forward, it seems fair to say that efforts to expand pharmacists’ roles in post-discharge care should focus on what’s best for the patient. ‘I can’t believe we’ve got so many initiatives and none of them are working because they’re not patient-centered. They’re all based on business rules and pots of funding,’ said Ms Criddle.

‘We’ve got to stop thinking in terms of which profession’s toes we’re treading on and start seeing the problem through the patient’s eyes.’

After all, just as the only thing in common throughout the patient’s healthcare journey is the patient, you can’t complete a relay race if one person wants to hold on to the baton.

Dr Angley warned: ‘We need to be proactive about managing the inevitable turf wars and focus on our common goal – best outcomes for patients.’

Further resources


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  2. Davies E, Green C, Mottram D, et al. Emergency re admissions to hospital due to adverse drug reactions within 1 year of the index admission. BJCP 2010;70(5):749 -755.
  3. Australian Commission on Safety and Quality in Health Care. Literature Review: Medication Safety in Australia. 2013. At: medication-safety-in-australia/
  4. Easton K, Morgan T, Williamson M. Medication safety in the community: A review of the literature. 2009. At:
  5. Andrew L Gilbert, Elizabeth E Roughead, Kathy Mott, et al. Collaborative medication management services: improving patient care. Med J Aust 2002;177(4):189-192.
  6. Roughead E, Barratt J, Ramsay E, et al. The effectiveness of collaborative medicine reviews in delaying time to next hospitalization for patients with heart failure in the practice setting. Circ Heart Fail 2009;2:424-8.
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  11. Easton K, Morgan T, Williamson M. Medication safety in the community: A review of the literature. 2009. At:
  12. Roughead EE, Semple SJ. Medication safety in acute care in Australia: Where are we now? Part 1: A review of the extent and causes of medication problems 2002-2008. Australia and New Zealand Health Policy 2009;6(1).
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  15. Easton K, Morgan T, Williamson M. Medication safety in the community: A review of the literature. 2009. At:
  16. Ajdukovic M, Crook M, Angley C, et al. Pharmacist elicited medication histories in the Emergency Department: Identifying patient groups at risk of medication misadventure. Pharm Pract 2007; 5(4):162–168.
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