Medication and discharge planning

As discharge can be an overwhelming time for patients and families, there is high risk for medication errors and misunderstandings. We can help patients make a smooth transition from the hospital to their home or care facility by providing comprehensive and clear information.

Prepare a discharge summary

Discharge summaries should include:

• a comprehensive discharge medication list
• detailed medication information (generic medication name, dosage form, dose, directions, route of administration, regular and PRN medication)
• indication and duration for new medication
• explanation of any changes that may have been made to their usual medications (differences to pre-admission medications)
• details of ongoing medication management plan and medication management needs (issues with taking the medications, recommendations for home medication reviews).

Educate patients and carers

• Provide the patient, and family and carers with an accurate list of medications
• Educate the patient and family and carers prior to discharge, including
  • proper storage and use of medications – demonstrate where possible
  • what to do if a dose is missed
  • potential side effects
  • when to call the GP or pharmacist about any concerns
  • refill information.
• Provide a written copy of all information that is given verbally.
• Consider what strategies will assist the patient to take their medication properly.
• Ensure the patient is able to follow medication instructions.
• Sometimes, pharmacists in hospitals can arrange a medication trial. This is a good way to see if the patient can take their medications independently before they are discharged home.
• Some Victorian hospitals have a pharmacy outreach service that can visit patients at home after discharge to review their medication management, provide education and facilitate continuity of care. These services do not require a GP referral. Link the patient to this service if needed. This is especially important if the patient lives alone and is socially isolated.

Make medication use simple

• Medication regimens should be as simple as possible – ideally with once or twice daily dosages.
• Medication instructions and dosages should be clearly written.
• Consider if the patient would benefit from the use of dose administration aids (DAAs), such as monitored dosage boxes. Remember that DAAs are not suitable for all patients, for example, patients with cognition impairments, vision impairments or limited dexterity. Assess the need and suitability first¹.

Simplify medication supply

• Ensure the patient has enough medications to last to their next GP visit.
• Encourage the patient and their family and carer to:
  
  • always carry an up-to-date list of medications
  • use only one pharmacy and visit only one GP.
• Synchronise medication quantities so the patient can make repeat orders at the same time.

Inform the GP

• Ensure discharge information is accurate and reaches the GP in a timely manner.
• Provide the following information to the GP:
  
  • medication changes and the reasons why
  • need for follow up or review
  • need for a GP-initiated Home Medicines Review (HMR). Commonwealth Government-funded HMRs must be initiated by the patient’s GP and carried out by an accredited pharmacist.

Inform the pharmacy

Ensure discharge medication information is provided to the patient’s community pharmacy, especially if a pharmacy-packed DAA will be used after discharge.

Inform the care services

If the patient is being discharged to a residential aged care facility or a community nursing service, ensure that a medication chart will be available to facilitate continuity of medication administration (usually this requires provision of an interim medication chart from the hospital).

Practise person-centred care

Medicine safety is best achieved in partnership with older people and the risk of error is greatly reduced with patient involvement. Older people place great importance on maintaining independence in self-management of medicines and have a strong sense of responsibility for this².

1. Elliott, R.A. Appropriate use of dose administration aids. Australian Prescriber 2014. 37: pp. 46-50.

2. Campbell Research & Consulting, Home medicines review program qualitative research project: final report 2008: Department of Health and Ageing, Canberra.