Improving the transition of elderly patients with multiple comorbidities into the community: impact of a pharmacist in a General Medicine outpatient follow‐up clinic

Aim To investigate the impact of extending the traditional roles of pharmacists from that of providing a service to inpatients under the General Medical Unit in the acute hospital setting, to the enhancement of continuity of care and reduction in medication misadventure by implementing clinical pharmacy services in the outpatient follow‐up clinic. Method A prospective pilot study was conducted in the General Medical Unit post‐discharge follow‐up clinic between March 2012 and February 2014. Each patient enrolled in the study was reviewed by a pharmacist through a scheduled 20 min consultation after their appointment with the medical doctor. Patient's demographic data, number of days from discharge to clinic review and number of regular medications were collected. Drug‐related problems ( DRPs ) identified by the pharmacist were recorded. Any discrepancies from the discharge medication plan identified by the pharmacist were also recorded, in addition to compliance issues, initiation of dose‐administration aids and referrals to the outreach pharmacy service. Results Eighty‐seven patients were enrolled (average age: 73 years) with an average time between discharge and clinic review of 25 days. The most frequent intervention made by the pharmacist was therapeutic drug monitoring (74%) followed by counselling on new or changed medications (49%). The pharmacist identified a number of patients who had continued taking medications that were ceased during their admission (15%) and patients who were not taking medications which had been initiated during hospitalisation (15%). Ten patients (11%) were taking the wrong dose of at least one medication. At least one DRP was identified in 77 (89%) patients, and discrepancies between the discharge medication plan and what the patient was taking at the time of the clinic visit were identified in 33 patients (38%). Conclusion Medication discrepancies often occur at transitions of care. Our data highlight the potential role of a pharmacist in this setting and the importance that the medication management plan put in place at the time of discharge should be communicated to the appropriate healthcare practitioners and the patient.