Transitional care of older patients utilising community pharmacists via the dMUR service
Student thesis: Doctoral Thesis
Background: Post-discharge Medicines Use Reviews (dMURs) were introduced into the English community pharmacy contract in 2011, with the aim of improving understanding and use of medication by patients who have experienced changes to their medicines in hospital. Early evidence showed uptake of dMURs to be poor. Furthermore, despite being a nationally commissioned service, there is little evidence of the benefit of dMURs to patients. In light of the documented medication problems that occur in older people on transfer of care, a randomised controlled feasibility study was devised to investigate the feasibility and potential outcomes of a transitional care service for older patients which utilises community pharmacists via the dMUR service Methods: Hospital pharmacists identified in-patients aged over 65 years who could potentially benefit from a dMUR. Participants were randomised to be referred for a dMUR with their usual community pharmacist or to receive standard discharge care. Results and Contribution: This study is the first to report on patient outcomes following dMUR referrals. Through interventions made by community pharmacists, referrals may provide a 4-fold return on investment to the NHS in terms of improved quality of care. There were trends towards a shorter length of stay on readmission and reduction in A&E visits in the months following dMUR, and they may also prevent medication related readmissions and deterioration in medication adherence and physical health over time. However this work revealed significant challenges in providing dMUR referral services to older patients. Being housebound due to poor mobility or health is a major barrier, due to difficulties experienced by community pharmacists with providing domiciliary dMURs. Carer management of medication is another. It is proposed that the provision of domiciliary dMURs should be facilitated by simplifying and clarifying the process for community pharmacists. Proxy dMURs with carers should be allowed in certain cases. Another key proposal is that the dMUR service should be re-designed to involve at least two parts. Remuneration should reflect the complexity and time needed for dMURs compared to 'standard' MURs. Lack of time of hospital pharmacists is a barrier to recruiting appropriate patients for dMUR referral and making good quality referrals. Electronic referral from hospital to community pharmacy may assist and should be implemented more widely. It is also suggested that hospital pharmacies should be remunerated for making referrals.