Abstract by Laura Victoria Jedig Lech

Background
Transition of care refers to the points where patients are transferred from one part of the health care system to another. Transitional care processes are complex and are therefore often prone to errors, especially in relation to drug therapy, that may change through a patients’ hospital stay. Many patients experience drug-related problems (DRPs) when they transfer from the hospital and back into the community. These problems may cause suboptimal treatment effects or readmissions if they remain unsolved. Hospital pharmacists (HPs) are to a higher extent participating in clinical pharmacy services (CPS) at the hospital wards to identify and solve DRPs and optimize drug therapy. The presence of hospital pharmacists (HPs) and community pharmacists (CPs) on each side of the care transition provides a unique possibility to explore how collaboration across the care continuum can be established and utilized to identify and solve DRPs after hospital discharge. In this PhD study the aim was to explore and assess how a cross-sectorial collaboration between HPs and CPs could be developed to aid in identifying and solving DRPs in hospital-discharged patients.

Methods
The PhD study consisted a development (sub study I) and feasibility-phase (sub study II). The development was planned using the framework available by the Medical Research Counsel (MRC). The MRC framework consisted of key actions (KAs) that is recommended to be carried out during intervention development. The resulting development consisted of a scoping review, to identify existing evidence of effective transition of care interventions, focus group interviews with HPs and CPs to identify views, perspectives and uncertainties relating to cross-sectorial collaboration, and a workshop with CPs and HPs to identify new work tasks relating to the cross-sectorial collaboration. An expert group workshop was then used to design and refine the intervention based on all available data from all available data. A mini-feasibility study was carried out at the hospital to confirm that HPs carrying out existing, implemented clinical pharmacist services (CPS) at the acute wards were able to identify eligible patients for the cross-sectorial collaboration. In the feasibility phase the developed intervention was tested. The feasibility study and data collection was planned using FRAME-IT, a framework to develop and evaluate early-stage interventions. Data was collected and analysed according to the seven constructs: Feasibility, Reach out, Acceptability, Maintenance, Efficacy, Implementability and Tailorability. This led to a data collection consisting of a mix of qualitative and quantitative data.

Results
CPs and HPs viewed cross-sectorial collaboration positively and identified mutual trust and respect between each other. Limitations were identified to the collaboration relating to the existing service in the hospital, that provided limited insight into the rest of the hospital stay and were related to admission and not discharge. Furthermore, GPs were seen as important stakeholders, that should be a part of the cross-sectorial collaboration for it to have an impact. The scoping review verified the need to involve GPs alongside also including patient counselling tailored to patient’s needs post discharge. The development process yielded a cross-sectorial collaboration, that utilized existing CPS consisting of medication reconciliation and medication review at hospital admission, and patient counselling, medication reconciliation and ad hoc collaboration with GPs post discharge by CPs. The cross-sectorial collaboration consisted of a pharmacist referral template, including information on DRPs identified at admission, admission cause and admission medication list. The intervention was expected to increase safety and satisfaction in patients and a decreased use of health care resource post-discharge. A mini-feasibility study testing the new hospital tasks identified that it was feasible for the HPs carrying out CPS to identify relevant patients. The feasibility study included five patients in five months and highlighted problems with patient inclusion. Additionally, the included patients did not receive the full patient counselling that CPs were trained to carry out. The CPs were able to tailor the conversations to fit patient needs and identify and solve DRPs.

Conclusions
The developed cross-sectorial collaboration between CPs and HPs have potential to aid in identifying and solving DRPs in hospital discharged patients and a model for collaboration between HPs and CPs have been developed and can be applied. However, feasibility was challenged by problems with identifying eligible patients, and in turn the ability of the intervention to be effective. This may lead back to incomplete development work, that did not follow a theoretical approach to intervention development. A comprehensive and in-depth needs assessment of all relevant stakeholders, especially hospital-discharged patients and GPs, needs to be carried out to understand how HPs and CPs can play a role in care transitions. Furthermore, the context concerning CPS needs to be explored to understand how and whether the service can be targeted hospital discharged patients. If a new feasibility study is carried out it should include more community pharmacies.