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A new Transfer of Care initiative of electronic referral from hospital to community pharmacy in England: A formative

service evaluation

Journal: BMJ Open

Manuscript ID bmjopen-2016-012532

Article Type: Research

Date Submitted by the Author: 05-May-2016

Complete List of Authors: Nazar, Hamde; Durham University, Brice, Steven ; Newcastle-upon-Tyne NHS Foundation Trust, Pharmacy Department

Akhter, Nasima; Durham University, Wolfson Research Institute for Health and Wellbeing Kasim, Adetayo; Durham University, Wolfson Research Institute for Health and Wellbeing Gunning, Ann; Newcastle-upon-Tyne Local Pharmaceutical Committee Slight, Sarah; Durham University, School of Medicine, Pharmacy and Health Watson, Neil; Newcastle-upon-Tyne NHS Foundation Trust

<b>Primary Subject Heading</b>:

Health services research

Secondary Subject Heading: Communication, Health policy

Keywords: care transitions, health boundaries, information transfer, continuity of care

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

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Title: A new Transfer of Care initiative of electronic referral from hospital to community

pharmacy in England: A formative service evaluation

Corresponding author: Hamde Nazar, School of Medicine, Pharmacy and Health, Durham

University, Queen’s Campus, Stockton-On-Tees, TS17 6BH, UK,

[email protected], 00441913340250

Steven Brice, Pharmacy Department, Newcastle-upon-Tyne NHS Foundation Trust,

Newcastle-upon-Tyne, UK

Nasima Akhter, Wolfson Research Institute for Health and Wellbeing, Durham University,

Queen’s Campus, Stockton-On-Tees, UK

Adetayo Kasim, Wolfson Research Institute for Health and Wellbeing, Durham University,

Queen’s Campus, Stockton-On-Tees, UK

Ann Gunning, Head of Services and Support North of Tyne Local Pharmaceutical

Committee, Newcastle-upon-Tyne, UK

Sarah P. Slight, School of Medicine, Pharmacy and Health, Durham University, Stockton-

On-Tees, UK

Neil Watson, Pharmacy Department, Newcastle-upon-Tyne NHS Foundation Trust,


Key words: care transitions, health boundaries, information transfer, continuity of care

Word count: 4,500

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ABSTRACT

Objectives To evaluate an electronic patient referral system from one UK hospital Trust to

community pharmacies across the North East of England.

Setting Two hospital sites in Newcastle-upon-Tyne and 207 community pharmacies.

Participants In-patients who were considered to benefit from on-going support and

continuity of care after leaving hospital.

Intervention Electronic transmission of a patient’s medicines-related information to their

nominated community pharmacy. Community pharmacists to provide a follow-up

consultation tailored to the individual patient needs.

Primary and secondary outcomes Number of referrals made to and received by different

types of pharmacies; reasons for referrals; accepted/completed and rejected referred rates;

reasons for rejections by community pharmacists; time to action referrals; details of the

follow-up consultations; readmission rates at 30, 60 and 90 days post referral and number

of hospital bed days.

Results 2,029 in-patients were referred over a 13-month period (1st

July 2014-31st

July

2015). Only 31% (n=619) of these patients participated in a follow-up consultation; 47%

(n=955) of referrals were rejected by community pharmacies with the most common reason

being ‘patient was uncontactable’ (35%, n=138). Most referrals were accepted/completed

within 7 days of receipt and most rejections were made more than 2 weeks after referral

receipt. Most referred patients were over 60 years old and referred for a Medicines Use

Review (MUR) or enrolment for the New Medicines Service (NMS). Those patients who

received a community pharmacist follow-up consultation had statistically significant lower

rates of readmissions and shorter hospital stays than those patients without a follow-up

consultation.

Conclusions Hospital pharmacy staff were able to utilise an IT platform to improve the

coordination of care for patients transitioning back home from hospital. Community

pharmacists were able to contact the majority of patients and results indicate that patients

receiving a follow-up consultation may have lower rates of readmission and shorter hospital

stays.

ARTICLE SUMMARY

Strengths and limitations of the study

• This study provides a detailed description of how an electronic referral system

between hospital and community pharmacies across the North East of England was

implemented.

• This study demonstrates that in-patients can be effectively referred to their

nominated community pharmacist and receive a follow-up consultation tailored to

their needs after discharge from the hospital.

• The study demonstrates that routine data collection during this evaluative period

requires critical analysis and additional qualitative work to understand fully the

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operational and implementation aspects of the service, e.g. complex reasons for the

recorded rates of non-completion of referrals.

• There is no routinely recorded data at the community pharmacist follow-up

consultation to allow specific economic, clinical or humanistic outcomes to be

determined. However, service continual improvements are being made towards

achieving this.

• A well-structured clinical trial of this intervention is required to investigate the

impact on patients as they transition between healthcare settings.

INTRODUCTION

The continuity of patient care when transitioning from one healthcare setting to another is a

national priority. [1] A range of interventions have been designed, trialled, and tested to

improve the quality and safety of this transfer process. [2-6] Successful interventions have

incorporated activities such as medication reconciliation; quick, clear and structured

discharge summaries; discharge planning; follow-up between hospital and community

providers; electronic discharge notifications; and Web-based access to discharge

information for general practitioners. [7] In the design of such interventions, community

pharmacists have been recognised as accessible and valuable contact points for patients in

primary care to provide additional advice and counselling, particularly on medication-

related issues and the management of chronic conditions. [8-11] A recent systematic review

highlighted how community pharmacists could help identify and rectify medication errors,

thus providing a significant impact on improving outcomes.[8] These community pharmacy

interventions included activities to improve the quality of information; coordination of care

and communication between care settings. [8] Other reported outcomes that could be

realised include: improved patient understanding of their medication and condition, [5, 12]

improved communication of accurate medication-related information between care

settings,[5] and the potential to reduce morbidity and mortality associated with targeted

conditions. [11, 13]

In 2012, the Royal Pharmaceutical Society (RPS) issued professional guidance in its

publication ‘Keeping patients safe when they transfer between care providers – getting the

medicines right’ on the core principles that underpin the safe transfer of medicines-related

information for a patient transferring between care providers in any setting. [14] Hospital

and community sites across the United Kingdom (UK) have adopted this guidance by

designing services and initiatives to specifically improve patient transitions. In a subsequent

report, [15] thirty early adopter sites provided information to the RPS on their service

designs; the barriers they faced; their results and how the initiatives will sustain change and

facilitate good practice locally going forward. Of these sites, half incorporated a specific role

for community pharmacists within their transfer of care programmes, [15] and three were

used as exemplar case studies by the RPS in their most recent toolkit [16] to support

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hospital referral services to community pharmacy. This document was issued to aid

commissioners and pharmacy leaders to design and implement an effective referral system.

[16] However, despite the valuable structure and support this document provided at an

aerial level, no evaluation has been conducted of a transfer of care initiative incorporating

active involvement of community pharmacists since the RPS professional guidance was

issued.[14] We evaluated the Transfer of Care initiative in the North East of England and

North Cumbria and present aspects of its achievement from two specific hospital sites

where the initiative has been delivered for the longest period of time and generated the

most service activity data.

METHODS

Description of the service intervention

The transfer of care initiative, the first of its kind in the UK, was launched in July 2014. It was

a collaborative project between Newcastle-upon-Tyne NHS Foundation Trust, North of Tyne

Local Pharmacy Committee (LPC) and Pinnacle Health Partnership LLP (provider of

PharmOutcomes). PharmOutcomes is a web-based platform routinely used by community

pharmacies in the North East and North Cumbria to record data on service provision. The

three parties involved in the collaboration created new hospital and community pharmacy

referral templates within PharmOutcomes to facilitate a secure method of electronic

transfer of medicines-related information between hospital and community pharmacies.

[16] Hospital pharmacy staff were shown how to use PharmOutcomes by senior pharmacy

staff and two launch events were organised for hospital and community pharmacy staff to

both inform and answer any questions about the electronic patient referral process.

Community pharmacy staff were also provided with further information in both paper-

based and electronic forms, and screenshots to help visualise the content of information

that would be received by the community pharmacists. Newcastle-upon-Tyne Hospitals

were the first hospitals to make electronic referrals to community pharmacies and it is their

service that has been analysed, however following creation of an Academic Health Science

Network (AHSN) Transfer of Care initiative (October 2014), eight other hospitals in the

North East and North Cumbria are now also making referrals using PharmOutcomes. The

service intervention has been described in further detail using the Template for Intervention

Description and Replication (TIDier) checklist and guide (See Supplemental File 1). [17] Since

its conception the service has been developed and the changes have been itemised (See

Supplemental File 2). These will be referred to as findings are discussed.

Referrals sent from the hospital system

Hospital pharmacy staff, which includes pharmacy technicians and clinical pharmacists

(approximately n=30 across the two hospital sites) identified patients who, in their clinical

judgement, would benefit from a follow-up consultation with a community pharmacist.

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These included patients who were on 4 or more medicines or had a number of medicines

changed during their hospital stay. These patients were approached, informed about the

service and asked if they would like to participate and nominate a community pharmacy of

their choice. At the time of the patient’s discharge, a member of hospital pharmacy staff

would (a) log into PharmOutcomes , (b) populate various patient demographic fields

including name; date of birth; postcode; ethnicity; NHS number; GP details, (c) select a

community pharmacy (nominated by the patient) from a drop down list, and (d)

recommend what additional pharmaceutical service, advice or general care might be useful

for the patient at the follow-up consultation (‘Reason for referral’ field). Finally, the contact

details of the member of staff making the referral were also recorded.

Referrals received by the community pharmacy system

Community pharmacists had the choice of either ‘accepting’ or ‘rejecting’ the referral sent

from the hospital. From December 2014 if a referral was rejected, the community

pharmacist was prompted to provide a reason from the drop down list, which included

‘Housebound patient’, ‘uncontactable patient’, and ‘other’. If ‘other’ was selected, then

further details were required in the free text box provided. The drop down list was changed

in June 2015 to increase the options available and to force the selection of a reason for

rejection, removing ‘Housebound patient’ as the default. Alternatively, the community

pharmacist could choose to ‘accept’ the referral and thus contacted the patient to arrange

a follow-up consultation. Further details on what medication-related questions were asked

to the patient during the consultation were collected e.g., Was the patient’s understanding

of how to take medications checked? Has the patient experienced an adverse drug reaction

(ADR)? Any pharmaceutical service(s) that were provided to the patient needed to be

recorded by the pharmacist e.g., MUR or stop smoking service, as well as any support

service(s) e.g., medicines reconciliation or review of Medidose system arrangements. Once

the consultation had been completed, the pharmacist was required to enter further details

in PharmOutcomes under the section ‘Complete the referral’. These details included: name

and address of the community pharmacy; name and professional registration number of the

community pharmacist; the reported long-term condition(s) of the patient (cardiovascular

disease; respiratory; diabetes and other). If a community pharmacist had not acknowledged

the referral in PharmOutcomes nor registered any action taken, then the status of that

referral remained recorded as ‘Referred (no action)’ on the system. Data on community

pharmacy activity was captured through PharmOutcomes.

Data Collection

Service Activity data

We evaluated this service from 1st

July 2014 – 31st

July 2015. All patient identifiable

information was removed; however, patient age; ethnicity and postcode were included. The

reasons for referrals by hospital staff, the details of the community pharmacies to which

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referrals were sent, and the subsequent acceptance/rejection and completion rate of these

referrals were extracted. Community pharmacies were categorised by type: national large

chain multiple; small regional chain multiple; supermarket pharmacy and independent

pharmacy. The referral history was tracked to investigate how many referrals were

actioned, i.e. ‘accepted’, ‘completed’ or ‘rejected’ within 7 days; 7-14 days; and more than

14 days. Where referrals were rejected, the reasons provided were collated and analysed.

Details on the long term conditions of the patients referred, their specified medication

regimen, the medicine-related questions asked by the pharmacist at the follow-up

consultation, any general patient feedback as recorded by the pharmacist, any reported

adverse drug reactions (ADRs) and the advice given as a consequence, and any additional

pharmaceutical or support services that was provided, were also collated and analysed.

Hospital readmission rates and number of bed days

On 23th

October 2015 the NHS numbers of all patients who participated in the electronic

referral service between 1st

July 2014 - 30th

June 2015 were extracted by the hospital team

and checked to see if they had been readmitted (all-cause admissions) post electronic

referral and, if so, what specific dates they had been subsequently admitted and discharged

on. Patients participating in the service after 30th

June 2015 would not have had

readmission data at 90 days post referral, hence the shorter analysis period was chosen. The

data were anonymised and sent to an independent researcher (HN). The patient population

was categorised into two groups: one received a community pharmacist follow-up

consultation (completed referrals), and one did not (either accepted but not completed,

referred (no action), and rejected referrals). The number of readmissions at 30, 60 and 90

days post electronic referral was collated and number of bed days was calculated from

length of hospital stays.

Data analysis

Quantitative data relating to the service activity was analysed using descriptive statistics and

converted to percentages where appropriate to represent proportions. Text entered into

free text boxes were collated, manually coded and then analysed. Readmission was defined

as a stay of at least 12 hours. Association between the outcome of referrals (accepted,

remain referred, completed, rejected) and type of pharmacy (e.g., supermarket,

independent, etc.) were examined using a Chi-square test. A generalised estimating

equation model was used to examine the association between readmission rate and

whether patient received consultation or not from the community pharmacies. Because

repeated readmissions per patient at 30, 60 and 90 days are likely to be correlated, this

model accounted for intra-patient correlation between the repeated data. Similarly, number

of days admitted were analysed using linear model with a structured covariance matrix to

account for repeated readmission data per patient.

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Discussion within the project team, together with hospital research ethics leads and on

consultation of the NHS Health Research Authority guidance [18] identified the study

components to be either audit or service evaluation and therefore did not require ethical

approval.

RESULTS

Service Activity Data

A total of 2,029 hospital in-patients consented to participate in the Transfer of Care Service

during the evaluative period, and were referred to their nominated community pharmacy.

The spread of these referrals over the 13 months are shown in Figure 1. This equated to

approximately 156 referrals being made each month to 207 community pharmacies across

the North of Tyne, i.e., approximately 0.75 referrals per month per pharmacy. The rate of

referrals fluctuated throughout the year but generally numbers increased, with the highest

occurring in July 2015.

Figure 1. The number of referrals made over the evaluative period.

Table 1 shows how many referrals were received by each pharmacy type and whether these

referrals were accepted, rejected or completed. Overall, Table 1 shows that outcomes of

referrals varied significantly among the various types of pharmacies (p<0.001). This pattern

was consistent for each outcome (accepted, remain referred, completed, rejected).

Completion of referrals was not only highest for multiples, but also significantly higher than

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any other type of pharmacy. Rejection was highest among small chain pharmacies, and was

significantly higher than rejection rates from all other types of pharmacy.

Table 1. The number of referrals received across the categories of community pharmacies (a-

d) and the subsequent outcomes of those referrals. (

** denotes statistically significant

difference at p<0.05 between pharmacy types)

Outcome of

referrals

Type of Pharmacy

Independent (a)

n (% )

Multiples (b)

n (%)

Supermarket (c)

n (%)

Small Chain (d)

n (%)

Total

n (%)

P-value (a-d)

Accepted 44 (8.8 ) a, c**

90 (8.5 ) b, c**

21 (16.5 ) c, d **

24 (7.0) 166 (8.2) 0.009

Remain

referred

115 (22.9) a,b; a,d

both**

175 (16.6)

b,d**

19 (15.0) c,d **

24 (7.0 ) 288 (14.2) <0.001

Completed 126 (25.1) a,b**;

a,c**

376 (35.6) b,c; b.d all**

20 (15.8 ) 75 (22.0) 619 (30.5) <0.001

Rejected 216 (43.2 ) a,d**

415 (39.3) b,c; b,d both**

67 (52.6 ) c,d**

220 (64.1) 955 (47.1) <0.001

Total 501 (24.7) 1,057 (52.1) 128 (6.3 ) 343 (16.9) 2,029

(100.0 )

<0.001

The decision to either accept or complete the referrals was largely carried out within 7 days

of the community pharmacist receiving the referral (56.1 % and 66.2% respectively) as

shown in Supplemental File 3. However, most rejections were made more than 7 days post-

discharge (66.9%).

Of the total 2,029 referrals, 45.3% (n=955) were rejected by the community pharmacy. The

389 rejections that occurred after December 2014 were accompanied with a reason, which

are listed in Supplemental File 4. The most common reason for rejection was that the

patient was uncontactable (35.5%, n=138), or that the patient was housebound (19.3%,

n=75). However, after a change made to the PharmOutcomes template in June 2015 that

removed ‘housebound’ as the default reason for rejecting a referral (see Supplemental File

2), the rate of rejection for this reason dropped from 39% to 14%.

The age range of patients who agreed to receive a referral and the reasons for these

referrals, of which there could be multiple reasons, were recorded by hospital pharmacy

staff (Table 2).

Table 2. The age of the patients and reasons for the referrals made by hospital pharmacy

staff to community pharmacy during the evaluative period. (n=2,029)

Characteristics of referrals Number (%)

Age of patient (yrs)

<10 47 (2.3)

11-19 14 (0.7)

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20-29 24 (1.2)

30-39 65 (3.2)

40-49 183 (9.0)

50-59 270 (13.3)

60-69 497 (24.5)

>70 930 (45.8)

Reason for referral

MUR 663 (32.7)

New medication(s) issued in hospital 365 (18.0)

Medidose issue 168 (8.3)

Changed dose(s) in hospital 148 (7.3)

Stopped medication(s) in hospital 142 (7.0)

Compliance issues 77 (3.8)

MUR/NMS 73 (3.6)

Technique issue 57 (2.8)

Smoking cessation follow-up 43 (2.1)

NMS 30 (1.5)

Side effect issue 26 (1.3)

Need for monitoring 24 (1.2)

Check on well-being 16 (0.8)

Repeat dispensing query 10 (0.5)

Delivery service query 10 (0.5)

Special formulation of medication 4 (0.2)

No reason provided 601 (29.6)

Only 30.5% (n=619) of referrals made resulted in a community pharmacist both “accepting”

and recording the “completion” of the follow-up consultation. Table 3 details the long term

condition or treatment of patients receiving a follow-up by a community pharmacist, the

medication-related information they were provided with during the consultation, any advice

on ADRs, and any additional pharmaceutical or support service that was also delivered.

Table 3. The details of the referrals that were followed up by community pharmacists and

recorded as completed. (n=619)

Completed referral details Number of patients

(%)

Long term condition/treatment of patient

Cardiovascular disease (CVD) 328 (53.0)

Respiratory 126 (20.4)

Diabetes 28 (4.6)

CVD and diabetes 22 (3.5)

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Pain 11 (1.8)

Cancer 9 (1.4)

Anticoagulant 8 (1.3)

CVD and other 7 (1.1)

Diabetes and other 3 (0.5)

Hypertension 1 (0.2)

None specified 76 (12.3)

Information provided

More information on medication(s) 557 (90.0)

Dose check 543 (87.8)

More information on condition 457 (73.8)

Side effect check 521 (84.2)

Advice provided on reported ADR

Manageable and non-harmful – patient to continue 106 (17.1)

Refer to GP 33 (5.4)

Patient stopped taking medication 18 (2.9)

Refer to hospital 5 (0.8)

Not applicable 457 (73.8)

Pharmaceutical/support service provided

MUR 288 (46.6)

NMS 241 (38.9)

Home delivery service 138 (22.3)

Medidose 79 (12.8)

Repeat dispensing 53 (8.5)

Medicines reconciliation 28 (4.5)

Smoking cessation 25 (4.0)

Discussion 23 (3.7)

Review of dosage form 17 (2.7)

Review of Medidose arrangements 13 (2.1)

Flu vaccination 12 (1.9)

Medication administration record 7 (1.1)

Large print labels 7 (1.1)

Easy open tops 6 (1.0)

Healthy living advice 6 (1.0)

Appliance use review 1 (0.2)

None 331 (53.4)

The majority of patients that were followed-up were those with a cardiovascular or

respiratory disease. Most patients received information from the community pharmacist on

their medication (90.0%, n=557), doses (87.8%, n=543), occurrence of side effects (84.2%,

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n=521) and their conditions (73.8%, n=457). Most patients (73.8%, n=457) did not report an

ADR to the community pharmacist during the consultation. However, of those who did,

17.1% (n=106) were considered manageable and non-harmful to the patient, and thus the

patients were advised to continue taking their medication as prescribed. Most patients did

not receive any additional pharmaceutical or support service (53.4%, n=331), but many

received a Medicines Use Review (46.6%, n=288) and/or were enrolled on the New

Medicines Service (38.9%, n=241). Of these patients who were provided with a follow-up

consultation, 40.4% (n=250) provided feedback via the pharmacist. Just over half of these

patients reported that the information was a good reconfirmation of the information

provided within hospital and at discharge (52.4%, n=131); 90 (36%) of the patients

expressed their appreciation for the contact with the community pharmacist, and the

usefulness of their advice and/or service provided through this initiative; a small number

(4.8%, n=12) refused or were reluctant to receive any form of follow-up consultation by the

community pharmacist in the future. In the remainder of cases (6.8%, n=17), pharmacists

recorded how the patient was either too ill to be spoken to or that they consulted with their

carer instead.

Hospital readmissions and number of bed days

There were a total of 1,386 hospital patients who received electronic referrals to community

pharmacy during the period 1st

July 2014 - 30th

June 2015; of these 501 (36.1%) had a record

of receiving a follow-up consultation by a community pharmacist (‘completed’ referral)

(Table 4). 607 (43.8%) of the remaining 885 patients are unlikely to have received a follow-

up community pharmacist consultation as the status of their referral on the

PharmOutcomes system remained either ‘referred (no action)’, ‘accepted’ but not

completed. A total of 278 (20.0%) were ‘rejected’ by the community pharmacist. Table 4

displays the readmissions rates and number of bed days of patients who either received or

did not receive a follow-up community pharmacist consultation. The odds of readmission

was found to be significantly higher amongst those who did not receive a follow-up

consultation from the community pharmacy. This result is consistent across the three

readmission time points (30, 60 and 90 days). Among patients readmitted, the average

duration of hospital stay at any time point (30, 60 or 90 days) was at least 5 days less for

those who received consultation.

Table 4. The readmissions and number of bed days of patients who received a follow-up

community pharmacist consultation and of patients who did not.

Patient cohort Number of readmissions post electronic

referral at

Number of bed days for

readmitted patients at

30 days

n (%)

60 days

n (%)

90 days

n (%)

30 days

mean ±

SD

60 days

mean ±

SD

90 days

mean ±

SD

Received a CP

consultation (n= 501)

29 (5.8) 17 (3.4) 18 (3.6) 7.2±1.0 7.2 ±

6.4

7.3 ±

6.7

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Did not receive CP


142 (16.0) 84 (9.5) 83 (9.4) 13.1 ±

17.4

13.7 ±

19.2

12.5 ±

16.6

Odds ratio and 95% 3.1 3.0 2.8

Confidence Intervals

(N=1386)

(2.1, 4.7) (1.8, 5.1) (1.6, 4.7)

Mean differences and

95% Confidence Intervals

(N =373)

-5.8

(-12.7,

1.0)

-6.5

(-15.4,

2.4)

-5.2

(-13.9,

3.5)

DISCUSSION

This Transfer of Care Service addressed a recognised patient need as they transition

between care settings. Our findings show how an electronic solution, in this case

PharmOutcomes, can be employed to facilitate the transfer of information between hospital

and community pharmacy teams to improve the coordination of care as patients transfer

between care settings. We have provided a detailed description of how this specific

electronic referral process worked in practice, so as to help inform future service designers

and implementers. We also provide information of the ongoing changes made during the

evaluation period which aimed to increase rates of referrals, completion and reduce

rejections. Additional changes have and are being made in response to continuing

evaluation of the service delivery and activity. We found that community pharmacy

engagment, through linking with Local Pharmacy Committees and Regional Managers of

large multiples, along with close working relationships with the developers of the eReferral

platform, were key to designing, adapting and delivering a successful process.

Over the 13 month evaluative period, 2,029 patients were referred to their nominated

community pharmacy. This is a modest number of referrals considering there was no

eligibility criteria to restrict activity. Ramsbottom et al [19] also report a very small

proportion of elgible in-patients (3.2% of over 10,000 potential patients) were identified to

receive referrals to community pharmacists for domiciliary MURs. The main reasons put

forward by the authors for these low referral rates were that the service was new and not

embedded into practice, hospital staff had other competing priorities and the patients’

poor health were reported as barriers to making referrals. [19] Further qualitative data

collection from hospital pharmacy staff could explore the reasons for low referral rates in

our study and aid in the design of solutions to increase activity. Qualitative data from

community pharmacists would also explore the low completion rate and investigate the

faciliators and barriers to the embedding of this service into normal practice. The

Normalisation Process Model, as proposed by May [20] would be an appropriate theoretical

framework to evaluate the process and context of implementation.

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Unfortunately, we did not record the details of all patients who were approached by

hospital pharmacy staff and offered an electronic referral. It would be interesting to further

investigate why patients decided to refuse these referrals. A recent study found that 32% of

elderly patients eligible to receive a visit from a pharmacist post hospital discharge refused.

The most common reasons stated in this study were the lack of perceived benefit of the

interaction with a community pharmacist and preference to see their GP. [19] Yu et al [21]

also found that once their patient population was made aware of the availability and

benefits of a post discharge pharmacist home medicines review, the majority of patients

were willing to participate. [21]

Most referrals were sent to multiple chain pharmacies (52.1%, n=1,057) as nominated by in-

patients. This category of pharmacy also had the highest completion rate of eReferrals,

significantly higher than all other pharmacy types (35.6%, n=376). The supermarket

pharmacies received the least number of eReferrals (6.3%, n=128) and also had the lowest

completion rate (15.8%, n=20), which was statistically lower than all other pharmacy types.

Further investigation is needed to explore the motivators and barriers of pharmacists to

accept/refuse eReferrals and whether the type of pharmacy at which the pharmacist was

based influenced their decision. Work carried out by Jacobs et al [22, 23] may provide a

framework in evaluating if and how the culture in various community pharmacy

organisations impact their performance in pharmaceutical services. Another evaluation of a

pharmaceutical service utilising PharmOutcomes for routine data collection suggested that

low recorded completion rates on this IT platform may have been due to the community

pharmacists not logging onto the system and documenting their actions. [24] In which case

the referrals that are listed as ‘remain referred’ or ‘accepted’ may have actually been

formally completed or rejected. Most eReferrals were ‘accepted’ or ‘completed’ within 7

days of receipt, whereas most rejections occurred after 7 days. It is important to understand

this time lag and whether the delay was due to events not under the community pharmacist

control, e.g., multiple attempts to contact the patient. The most highly reported reasons for

rejections of referrals by the community pharmacists was that the patient was

uncontactable (35.1%, n=138). Specific reasons for this needs to be explored to understand

if this is an issue with the service design and delivery, e.g. patients may not answer

unidentifiable numbers; patients may provide erroneous contact details instead of refusing

a referral, etc. A considerably large number of pharmacist rejections in our study were due

to the patients being housebound (19.3%, n=75), however, it was observed that rates of

patients registered as ‘housebound’ dropped from 39% of rejections to 14%, after the

change was made on the electronic template. Where the referral had been sent to a

pharmacy which was not routinely used by the patient (12.4%, n=48), again further

understanding is required to check if this is something that could be further improved in the

design of the service or patient deflection. It is possible that patients newly prescribed

medicines who were not taking medicines prior to admission to hospital (e.g. post MI) and

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therefore not known by the community pharmacy had their referral rejected when their

need for support was greatest. Further detailed analysis is therefore warranted.

The majority of patients that consented for an electronic referral were elderly (60 years and

over, 70.3%, n=1,427) and the most common reasons that a referral was made by hospital

staff was for medication–related problems (MUR; initation/cessation/changed medicine or

dose in hospital; medibox issue; medication compliance issue). Those patients who

ultimately received a follow-up consultation from a community pharmacist were those with

reported cardiovascular disease (53.0%, n=328) or a respiratory condition (20.4%, n=126).

This may reflect the areas in the hospital being targeted by clinical pharmacy staff, however,

empirical research is required to investiagte this. These patient demographics may be useful

to consider in defining elegibility criteria for the referral of future patients. Within the

follow-up consultation pharmacists had the opportunity to provide information on

medication, dosing, medical condition, side effects/ADRs and their subsequent

management. Most of the patients were not provided with an additional pharmacuetical or

support service (53.4%, n=331), but 46.6% (n=288) of patients received an MUR and/or

initiated the New Medicines Service (38.9%, n=241).

Routine data collection does not include a measure that meets any Economic, Clinical or

Humansitic Outcomes model [25], this means that the impact and value of the intervention

cannot be understood. Despite the tailoring of the community pharmacist follow-up

consultation to the patient’s expressed need, no subsequent outcome data associated with

the tailored pharmaceutical care and/or service is routinely recorded to demonstrate the

effect. Where MURs were performed or NMS intiated, there is no inclusion of the actions

and recommendations of the community pharmacist within routine data collection on

PharmOutcomes. The information for these two specific services have their own separate

documentation and recording process. Inclusion of this information with the eReferral

service data may provide further detail on the impact of the community pharmacist

intervention on patient outcomes, e.g. medication or condition related issues and advice,

referrals onto GPs for monitoring or consultation. Future evaluations should aim to identify

a specific parameter that can be used directly or as a proxy to measure economic,

humanistic or clinical outcomes.

Of the relatively small proportion of patients who provided ad hoc feedback via the

pharmacist about the service, just over half felt that the information received reconfirmed

what they had been previously told in hospital; some patients appreciated this and found it

useful. Our study found that those patients who received a follow-up community

pharmacist consultation as a result of a hospital eReferral demonstrated statistically lower

readmissions and shorter hospital stays as a result of any readmission. However, further

critical analysis of this positive association, e.g. explore the individual reasons for

readmissions, use of other healthcare services, etc., is required to substantiate a causal link.

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The service aimed to improve the transition of the patient between care settings which

would be best tested via a randomised control trial. However, prior to carrying this out a

feasibility study is required. This work would determine how best to design the future trial

and identify primary and secondary outcomes that would be feasible to collect and allow

assessment of effectiveness.

The strengths of this study is that it specifically describes the implementation and operation

of an electronic referral process from hospital to community pharmacy. We have

highlighted possible areas for further improvement, but feel that the lessons learnt so far

are both relevant and valuable to those considering the implementation of a similar process.

The marrying of service activity with the developmental changes also provides context to

the critical reader in understanding context and to the service planner of the continual

monitoring and malleability of the service.

A weakness of this evaluation is that there is no test for fidelity of service delivery and

implementation. An investigation of how well hospital and community pharmacy staff adher

to the recommended process might provide further insights into the relatively low referral

and completion rates that have been recorded on PharmOutcomes.

The systematic review by Hesselink at al [7] found that interventions that exhibited specific

components, e.g. medicines reconciliation, showed statistically significant effects in favour

of the intervention, i.e. reconciliation reducing the percentage of unreconciled medication

after discharge. [7] A future clinical study should ensure service data collection is

appropriate to allow assessment of intervention effect. The detailed intervention

description provided here will allow better understanding of facilitators and barriers to

outcomes that will be recorded. This study also highlights a deficiency of the intervention

itself: the lack of comprehensive discharge information routinely accompanying the referral.

Another recent systematic review concluded that those interventions that aimed to identify

and rectify drug-related problems showed the most statistically significant benefit. [8]

However to facilitate this there needs to be sufficient medication-related information

transferred between healthcare settings. With the recent announcement that Summary

Care Records, an electronic patient record derived from patients’ GP records will be

provided more widely to community pharmacists, [24] it is anticipated that the information

gradient between primary and secondary care will be reduced.

CONCLUSIONS

Patients in hospitals can be electronically referred to their nominated community pharmacy

upon discharge from hospital in order to receive a follow-up consultation tailored to their

specific need. We have shown that multiple stakeholders from the hospital, community

pharmacy organisations and IT system developers working collaboratively could design and

implement an electronic eReferral service from hospital to community pharmacy. Electronic

referral non-completion rates during the study period appear to be high. This may be due to

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this period encompassing the launching and embedding of such a pioneering service. Early

indications are that patients referred from hospital, who receive a follow-up consultation

from their community pharmacist may have lower rates of readmission and shorter hospital

stays.

A feasibility study will identify how and which outcomes will allow effectiveness of this

intervention to be measured.

ACKNOWLEDGEMENTS

COMPETING INTERESTS

None.

FUNDING STATEMENT

This research has received no specific grant from any funding agency in the public,

commercial or not-for-profit sectors.

CONTRIBUTORSHIP STATEMENT

NW, AG and SB were involved in the design and implementation of the intervention. HN

designed the service evaluation, and HN, NA and AK analysed the data. All authors discussed

the results and interpretation. All authors were involved in drafting the initial text for the

report and revising drafts prior to publication and all approved the submission.

DATA SHARING STATEMENT

There is no further unpublished data on this service.

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SUPPLEMENTAL FILE 1

Item Description

Name of

intervention

Transfer of Care initiative

Rationale of

intervention

Community pharmacists are well-placed within the primary care setting to

follow-up recently discharged patients for medication-, condition- and

health-related issues. These interactions aim to improve the continuity of

care as patients transition back to community settings from hospital

discharge.

Resources PharmOutcomes was required as the web-based tool to make referrals

from hospital to community pharmacy.

The hospital staff were provided with awareness/training on

PharmOutcomes, and on the remit of the service.

Patients were provided with a very brief chat by hospital pharmacy staff on

the opportunity to have a follow-up by a community pharmacist. (No

leaflets/advertising/informative information provided)

The community pharmacists were provided with a launch event to describe

the procedure within the hospital and what the follow-up might look like.

Area managers were contacted by Local Pharmacy Committee to inform

them of the service and ensure they encourage their community

pharmacists to check PharmOutcomes and action referrals.

Procedures Hospital procedure: All hospital pharmacy staff were responsible to

identify patients who, in their clinical judgement, would benefit from a

follow-up visit by their community pharmacist (there was no specific

eligibility criteria of the patient cohort). Such patients were approached on

the wards and asked for consent to be referred. On obtaining consent the

hospital pharmacy staff would enter the details of the patient onto

PharmOutcomes (name, date of birth, reason for referral, preferred details

of community pharmacist).

Community pharmacist procedure: Community pharmacists were required

to access their PharmOutcomes records on a regular basis (every day) to

check for referrals which they were required to ‘accept’ and commence

actioning; ‘reject’ and provide a reason or ‘complete’ if actioned. In all

cases pharmacists had to contact the patient to assess the need for or type

of follow-up intervention. Depending on patient response a variety of

pharmaceutical advice and services were provided. All activities provided

to the patient were recorded in PharmOutcomes.

Providers Hospital pharmacy staff including pharmacy technicians, and pharmacists

were provided with brief training on PharmOutcomes and directed to make

referrals to patients they thought might benefit from a follow-up upon

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discharge into community. Referrals were promoted as part of the normal

role in the care of the patients and were not provided with incentivisation

or reimbursement.

Community pharmacy staff were provided with a launch event to introduce

the service remit and description. Follow-up of referrals were promoted as

part of the normal role in the care of the patient. Services that were

entitled to reimbursement as per standard community pharmacy service

arrangements included: New Medicines Service (NMS); Medicines Use

Review (MUR); enrolment on smoking cessation programmes; flu

vaccination.

Delivery Hospital pharmacy staff approached patients admitted onto wards for

consent to be followed up by a community pharmacist.

Community pharmacists contacted the referred patients on the contact

number provided to the hospital staff. Advice, discussions and

consultations may have taken place via telephone or in person at the

community pharmacy. In some cases such interaction may have taken

place with a patient representative.

Locality If an intervention was carried out within a community pharmacy it was

undertaken within a consultation room.

Dose A patient was only approached once in the hospital to consent for a

referral to community pharmacy. In the case a referral was made,

community pharmacists would contact the patient. There was no

stipulated number of times this should be done. Also the timeframe within

which contact should be made with the patient is dependent upon how

often the PharmOutcomes messaging system is checked. Once a referral is

seen it should be actioned, and the informal guidance recommends that

community pharmacists try to contact the patient within 3 working days of

receiving the referral. The time frame for the NMS is initial patient

engagement, then intervention usually 7-14 days after engagement and

then a follow-up usually 14-21 days after the intervention.

Tailoring or

personalised

Each interaction was tailored to the patient. The community pharmacist

made contact with the patient by telephone and would simply enquire as

to the well-being of the patient. The subsequent service provision or advice

and counselling was dependent upon patient expressed need.

Modifications The referral form was modified through the course of the delivery to

reduce the amount of data required to be manually entered by the hospital

staff. Hospital staff did not have to make a recommendation for an action

by the community pharmacist, just a referral was made. An open box was

left for staff to enter details if required.

How well

(planned

Hospital staff were given motivating presentations on a regular basis to

encourage referral rates. Community pharmacists were encouraged by

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fidelity) their Local Pharmacy Network Lead to complete referrals received.

Members of the project team monitored service activity through observing

data input on PharmOutcomes.

How well

(actual

fidelity)

There was no record of how many patients that had been approached for a

referral who thence actually provided consent or desire to be followed up

in community. A project team within the hospital would access

PharmOutcomes on a monthly basis to review referral follow-ups by

community pharmacists. Action rates would be observed and if referrals

had not been actioned this would be fed back to area managers of the

community pharmacies to contact the pharmacists and investigate reasons

for not actioning.

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SUPPLEMENTAL FILE 2.

Transfer of Care – Developments made via the AHSN Project Team since July

2015

Members: Project Lead (SB) Project Manager Chair of Durham, Darlington and Tees Local Pharmacy Network Representative of North of Tyne Local Pharmacy Committee (AG) Senior Clinical Pharmacist, Northumberland Tyne and Wear Clinical Services Manager, North Tees & Hartlepool Representative of Tees Local Pharmacy Committee Practice Pharmacist, North East Commissioning Support Representative of HealthWatch England Representative of University of Durham (SPS) Clinical Pharmacist, County Durham and Darlington NHS Foundation Trust Representative of NHS England

Date Change made

Desired outcome

October 2014

Simplified the hospital referral template so only Royal Pharmaceutical Society recommended core contents for Transfer of Care records were recorded.

Reduce time spent making hospital referrals and to allow staff to focus on the quality of referral being made.

December 2014

A mandatory ‘Pharmacy Actions’ field was added to the community pharmacy template.

Provide some detail about the interventions being made by the community pharmacists and therefore help motivate pharmacy staff.

December 2014

A mandatory RiO scoring field was added to the community pharmacy template.

Make community pharmacists consider the likelihood their intervention had on preventing a hospital readmission.

December 2014

Community pharmacy template was amended so the community pharmacist had to select from a drop down menu why a referral had been rejected.

Help better understand why hospital referrals were being rejected.

January 2015

After confirming that all hospital referrals would automatically qualify for approval for a telephone or domiciliary MUR service, the required application forms and guidance notes were linked to the community pharmacy template.

Reduce rejected referrals and improve patient outcomes.

January 2015

Feedback provided to hospital pharmacy staff on the outcome of their referrals (as a consequence of changes made to the community pharmacy template in December 2015).

Motivate hospital staff to make referrals.

February 2015

Original FAQ document for community pharmacists (which is attached to the community

Reduce rejected referrals and improve patient outcomes

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pharmacy template) was updated and circulated to pharmacies highlighting changes to the service and the community pharmacy template

June 2015 The list of options why hospital referrals were being rejected was changed as the default had been set as ‘housebound’, the default is now blank and cannot be selected. If the reason for rejection was selected as ‘housebound’ additional information was provided about how to claim payment for telephone and domiciliary MURs

Correct the erroneous recording of ‘housebound’ as the reason for rejecting a referral. Increase the number of housebound patients receiving support

August 2015 Documents (e.g. discharge summaries) able to be attached to hospital referrals.

Allow community pharmacy medicines reconciliations, reduce medication errors and improve patient outcomes.

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SUPPLEMENTAL FILE 3. The number of days post-discharge for referrals to be actioned.

Number of days post-discharge to action

Outcome of referrals (number (%))

Accepted (n=166) Completed (n=619) Rejected (n=955)

< 7 93 (56.1) 410 (66.2) 316 (33.1) 7-14 33 (19.8) 110 (17.8) 232 (24.3) >14 40 (24.1) 100 (16.1) 407 (42.6)

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SUPPLEMENTAL FILE 4. The reasons for rejections of referrals by community pharmacists.

(n=389)

Reasons for rejections Number (%)

Patient was uncontactable 138 (35.5)

Patient Housebound 75 (19.3)*

Wrong pharmacy 48 (12.3)

Pharmacy unable to provide the service 36 (9.3)

Patient refused service 35 (9.0)

Patient re-admitted 21 (5.4)

MUR/NMS not appropriate 14 (3.6)

Problems with details on referral 9 (2.3)

Miscellaneous other 8 (2.0)

Patient deceased 5 (1.3)

*prior to a change being made to the PharmOutcomes template June 2015 (see Supplemental File 2) 39% of rejections were due to the patient being ‘housebound’. In the period 1

st June- 31

st July 2015 this rate

dropped to 14.3%

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A new Transfer of Care initiative of electronic referral from hospital to community pharmacy in England: A formative

service evaluation

Journal: BMJ Open

Manuscript ID bmjopen-2016-012532.R1

Article Type: Research

Date Submitted by the Author: 02-Aug-2016

Complete List of Authors: Nazar, Hamde; Durham University, Brice, Steven ; Newcastle-upon-Tyne NHS Foundation Trust, Pharmacy Department

Akhter, Nasima; Durham University, Wolfson Research Institute for Health and Wellbeing Kasim, Adetayo; Durham University, Wolfson Research Institute for Health and Wellbeing Gunning, Ann; Newcastle-upon-Tyne Local Pharmaceutical Committee Slight, Sarah; Durham University, School of Medicine, Pharmacy and Health Watson, Neil; Newcastle-upon-Tyne NHS Foundation Trust

<b>Primary Subject Heading</b>:

Health services research

Secondary Subject Heading: Communication, Health policy, Patient-centred medicine

Keywords: care transitions, health boundaries, information transfer, continuity of care


BMJ Open on N

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Title: A new Transfer of Care initiative of electronic referral from hospital to community

pharmacy in England: A formative service evaluation

Corresponding author: Hamde Nazar, School of Medicine, Pharmacy and Health, Durham

University, Queen’s Campus, Stockton-On-Tees, TS17 6BH, UK,

[email protected], 00441913340250

Steven Brice, Pharmacy Department, Newcastle-upon-Tyne NHS Foundation Trust,


Nasima Akhter, Wolfson Research Institute for Health and Wellbeing, Durham University,

Queen’s Campus, Stockton-on-Tees, UK

Adetayo Kasim, Wolfson Research Institute for Health and Wellbeing, Durham University,

Queen’s Campus, Stockton-on-Tees, UK

Ann Gunning, Head of Services and Support North of Tyne Local Pharmaceutical

Committee, Newcastle-upon-Tyne, UK

Sarah P. Slight, School of Medicine, Pharmacy and Health, Durham University, Stockton-

on-Tees, UK

Neil Watson, Pharmacy Department, Newcastle-upon-Tyne NHS Foundation Trust,


Key words: care transitions, health boundaries, information transfer, continuity of care

Word count: 4,583

ABSTRACT

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Objectives To evaluate an electronic patient referral system from one UK hospital Trust to

community pharmacies across the North East of England.

Setting Two hospital sites in Newcastle-upon-Tyne and 207 community pharmacies.

Participants In-patients who were considered to benefit from on-going support and

continuity of care after leaving hospital.

Intervention Electronic transmission of a patient’s medicines-related information to their

nominated community pharmacy. Community pharmacists to provide a follow-up

consultation tailored to the individual patient needs.

Primary and secondary outcomes Number of referrals made to and received by different

types of pharmacies; reasons for referrals; accepted/completed and rejected referred rates;

reasons for rejections by community pharmacists; time to action referrals; details of the

follow-up consultations; readmission rates at 30, 60 and 90 days post referral and number

of hospital bed days.

Results 2,029 in-patients were referred over a 13-month period (1st

July 2014-31st

July

2015). Only 31% (n=619) of these patients participated in a follow-up consultation; 47%

(n=955) of referrals were rejected by community pharmacies with the most common reason

being ‘patient was uncontactable’ (35%, n=138). Most referrals were accepted/completed

within 7 days of receipt and most rejections were made more than 2 weeks after referral

receipt. Most referred patients were over 60 years old and referred for a Medicines Use

Review (MUR) or enrolment for the New Medicines Service (NMS). Those patients who

received a community pharmacist follow-up consultation had statistically significant lower

rates of readmissions and shorter hospital stays than those patients without a follow-up

consultation.

Conclusions Hospital pharmacy staff were able to utilise an IT platform to improve the

coordination of care for patients transitioning back home from hospital. Community

pharmacists were able to contact the majority of patients and results indicate that patients

receiving a follow-up consultation may have lower rates of readmission and shorter hospital

stays.

ARTICLE SUMMARY

Strengths and limitations of the study

● This study provides a detailed description of how an electronic referral system

between hospital and community pharmacies across the North East of England was

implemented.

● This study demonstrates that in-patients can be effectively referred to their

nominated community pharmacist and receive a follow-up consultation tailored to

their needs after discharge from the hospital.

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● The study demonstrates that routine data collection during this evaluative period

requires critical analysis and additional qualitative work to understand fully the

operational and implementation aspects of the service, e.g. complex reasons for the

recorded rates of non-completion of referrals.

● There is no routinely recorded data at the community pharmacist follow-up

consultation to allow specific economic, clinical or humanistic outcomes to be

determined. However, service continual improvements are being made towards

achieving this.

● A well-structured clinical trial of this intervention is required to investigate the

impact on patients as they transition between healthcare settings.

INTRODUCTION

The continuity of patient care when transitioning from one healthcare setting to another is a

national priority. [1] A range of interventions have been designed, trialled, and tested to

improve the quality and safety of this transfer process. [2-6] Successful interventions have

incorporated activities such as medication reconciliation; quick, clear and structured

discharge summaries; discharge planning; follow-up between hospital and community

providers; electronic discharge notifications; and Web-based access to discharge

information for general practitioners. [7] In the design of such interventions, community

pharmacists have been recognised as accessible and valuable contact points for patients in

primary care to provide additional advice and counselling, particularly on medication-

related issues and the management of chronic conditions. [8-11] A recent systematic review

highlighted how community pharmacists could help identify and rectify medication errors,

thus providing a significant impact on improving outcomes.[8] These community pharmacy

interventions included activities to improve the quality of information; coordination of care

and communication between care settings. [8] Other reported outcomes that could be

realised include: improved patient understanding of their medication and condition, [5, 12]

improved communication of accurate medication-related information between care

settings,[5] and the potential to reduce morbidity and mortality associated with targeted

conditions. [11, 13]

In 2012, the Royal Pharmaceutical Society (RPS) issued professional guidance in its

publication ‘Keeping patients safe when they transfer between care providers – getting the

medicines right’ on the core principles that underpin the safe transfer of medicines-related

information for a patient transferring between care providers in any setting. [14] Hospital

and community sites across the United Kingdom (UK) have adopted this guidance by

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designing services and initiatives to specifically improve patient transitions. In a subsequent

report, [15] thirty early adopter sites provided information to the RPS on their service

designs; the barriers they faced; their results and how the initiatives will sustain change and

facilitate good practice locally going forward. Of these sites, half incorporated a specific role

for community pharmacists within their transfer of care programmes, [15] and three were

used as exemplar case studies by the RPS in their most recent toolkit [16] to support

hospital referral services to community pharmacy. This document was issued to aid

commissioners and pharmacy leaders to design and implement an effective referral system.

[16] However, despite the valuable structure and support this document provided at an

aerial level, no evaluation has been conducted of a transfer of care initiative incorporating

active involvement of community pharmacists since the RPS professional guidance was

issued.[14] We evaluated the Transfer of Care initiative in the North East of England and

North Cumbria and present aspects of its achievement from two specific hospital sites

where the initiative has been delivered for the longest period of time and generated the

most service activity data.

METHODS

Description of the service intervention

The transfer of care initiative, the first of its kind in the UK, was launched in July 2014. It was

a collaborative project between Newcastle-upon-Tyne NHS Foundation Trust, North of Tyne

Local Pharmacy Committee (LPC) and Pinnacle Health Partnership LLP (provider of

PharmOutcomes). PharmOutcomes is a web-based platform routinely used by community

pharmacies in the North East and North Cumbria to record data on service provision. The

three parties involved in the collaboration created new hospital and community pharmacy

referral templates within PharmOutcomes to facilitate a secure method of electronic

transfer of medicines-related information between hospital and community pharmacies.

[16] Hospital pharmacy staff were shown how to use PharmOutcomes by senior pharmacy

staff and two launch events were organised for hospital and community pharmacy staff to

both inform and answer any questions about the electronic patient referral process.

Community pharmacy staff were also provided with further information in both paper-

based and electronic forms, and screenshots to help visualise the content of information

that would be received by the community pharmacists. Newcastle-upon-Tyne Hospitals

were the first hospitals to make electronic referrals to community pharmacies and it is their

service that has been analysed, however following creation of an Academic Health Science

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Network (AHSN) Transfer of Care initiative (October 2014), eight other hospitals in the

North East and North Cumbria are now also making referrals using PharmOutcomes. The

service intervention has been described in further detail using the Template for Intervention

Description and Replication (TIDier) checklist and guide (See Supplemental File 1). [17] Since

its conception the service has been developed and the changes have been itemised (See

Supplemental File 2). These will be referred to as findings are discussed.

Referrals sent from the hospital system

Hospital pharmacy staff, which includes pharmacy technicians and clinical pharmacists

(approximately n=30 across the two hospital sites) identified patients who, in their clinical

judgement, would benefit from a follow-up consultation with a community pharmacist.

These included patients who were on 4 or more medicines or had a number of medicines

changed during their hospital stay. These patients were approached, informed about the

service and asked if they would like to participate and nominate a community pharmacy of

their choice. At the time of the patient’s discharge, a member of hospital pharmacy staff

(both pharmacy technicians and clinical pharmacists) would (a) log into PharmOutcomes ,

(b) populate various patient demographic fields including name; date of birth; postcode;

ethnicity; NHS number; GP details, (c) select a community pharmacy (nominated by the

patient) from a drop down list, and (d) recommend what additional pharmaceutical service,

advice or general care might be useful for the patient at the follow-up consultation (‘Reason

for referral’ field). Finally, the contact details of the member of staff making the referral

were also recorded.

Referrals received by the community pharmacy system

Community pharmacists could participate on a voluntary basis, as no contractual or service

reimbursement arrangements were made. Community pharmacists had the choice of either

‘accepting’ or ‘rejecting’ the referral sent from the hospital. From December 2014 if a

referral was rejected, the community pharmacist was prompted to provide a reason from

the drop down list, which included ‘Housebound patient’, ‘uncontactable patient’, and

‘other’. If ‘other’ was selected, then further details were required in the free text box

provided. The drop down list was changed in June 2015 to increase the options available

and to force the selection of a reason for rejection, removing ‘Housebound patient’ as the

default. Alternatively, the community pharmacist could choose to ‘accept’ the referral and

thus contacted the patient to arrange a follow-up consultation. Further details on what

medication-related questions were asked to the patient during the consultation were

collected e.g., Was the patient’s understanding of how to take medications checked? Has

the patient experienced an adverse drug reaction (ADR)? Any pharmaceutical service(s) that

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were provided to the patient needed to be recorded by the pharmacist e.g., Medicines Use

Review (MUR) or stop smoking service, as well as any support service(s) e.g., medicines

reconciliation or review of a compliance aid. Once the consultation had been completed, the

pharmacist was required to enter further details in PharmOutcomes under the section

‘Complete the referral’. These details included: name and address of the community

pharmacy; name and professional registration number of the community pharmacist; the

reported long-term condition(s) of the patient (cardiovascular disease; respiratory; diabetes

and other). If a community pharmacist had not acknowledged the referral in

PharmOutcomes nor registered any action taken, then the status of that referral remained

recorded as ‘Referred (no action)’ on the system. Data on community pharmacy activity was

captured through PharmOutcomes.

Data Collection

Service Activity data

We evaluated this service from 1st

July 2014 – 31st

July 2015. All patient identifiable

information was removed; however, patient age; ethnicity and postcode were included. The

reasons for referrals by hospital staff, the details of the community pharmacies to which

referrals were sent, and the subsequent acceptance/rejection and completion rate of these

referrals were extracted. Community pharmacies were categorised by type: national large

chain multiple; small regional chain multiple; supermarket pharmacy and independent

pharmacy. The referral history was tracked to investigate how many referrals were

actioned, i.e. ‘accepted’, ‘completed’ or ‘rejected’ within 7 days; 7-14 days; and more than

14 days. Where referrals were rejected, the reasons provided were collated and analysed.

Details on the long term conditions of the patients referred, their specified medication

regimen, the medicine-related questions asked by the pharmacist at the follow-up

consultation, any general patient feedback as recorded by the pharmacist, any reported

adverse drug reactions (ADRs) and the advice given as a consequence, and any additional

pharmaceutical or support services that was provided, were also collated and analysed.

Hospital readmission rates and number of bed days

On 23th

October 2015 the NHS numbers of all patients who participated in the electronic

referral service between 1st

July 2014 - 30th

June 2015 were extracted by the hospital team

and checked to see if they had been readmitted (all-cause admissions) post electronic

referral and, if so, what specific dates they had been subsequently admitted and discharged

on. Patients participating in the service after 30th

June 2015 would not have had

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readmission data at 90 days post referral, hence the shorter analysis period was chosen. The

data were anonymised and sent to an independent researcher (HN). The patient population

was categorised into two groups: one received a community pharmacist follow-up

consultation (completed referrals), and one did not (either accepted but not completed,

referred (no action), and rejected referrals). The number of readmissions at 30, 60 and 90

days post electronic referral was collated and number of bed days was calculated from

length of hospital stays.

Data analysis

Quantitative data relating to the service activity was analysed using descriptive statistics and

converted to percentages where appropriate to represent proportions. Text entered into

free text boxes were collated, manually coded and then analysed. Readmission was defined

as a stay of at least 12 hours. Association between the outcome of referrals (accepted,

remain referred, completed, rejected) and type of pharmacy (e.g., supermarket,

independent, etc.) were examined using a Chi-square test. A generalised estimating

equation model was used to examine the association between readmission rate and

whether patient received consultation or not from the community pharmacies. Because

repeated readmissions per patient at 30, 60 and 90 days are likely to be correlated, this

model accounted for intra-patient correlation between the repeated data. Similarly, number

of days admitted were analysed using linear model with a structured covariance matrix to

account for repeated readmission data per patient.

Discussion within the project team, together with hospital research ethics leads and on

consultation of the NHS Health Research Authority guidance [18] identified the study

components to be either audit or service evaluation and therefore did not require ethical

approval.

RESULTS

Service Activity Data

A total of 2,029 hospital in-patients consented to participate in the Transfer of Care Service

during the evaluative period, and were referred to their nominated community pharmacy.

97.9% (n= 1986) of these referrals were generated by pharmacy technicians. The spread of

these referrals over the 13 months are shown in Figure 1. This equated to approximately

156 referrals being made each month to 207 community pharmacies across the North of

Tyne, i.e., approximately 0.75 referrals per month per pharmacy. The rate of referrals

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fluctuated throughout the year but generally numbers increased, with the highest occurring

in July 2015.

Figure 1. The number of referrals made over the evaluative period.

Community pharmacies were categorised according to Bush et al: supermarket; multiple

(200 outlets or more); large chain (more than 20 outlets but fewer than 200); small chain

(20 outlets or fewer but more than 5); independent (5 outlets or fewer). [19] Table 1 shows

how many referrals were received by each pharmacy type and whether these referrals were

accepted, rejected or completed. Overall, Table 1 shows that outcomes of referrals varied

significantly among the various types of pharmacies (p<0.001). This pattern was consistent

for each outcome (accepted, remain referred, completed, rejected). Completion of referrals

was not only highest for multiples, but also significantly higher than any other type of

pharmacy. Rejection was highest among small chain pharmacies, and was significantly

higher than rejection rates from all other types of pharmacy.

Table 1. The number of referrals received across the categories of community pharmacies (a-

d) and the subsequent outcomes of those referrals. (

** denotes statistically significant

difference at p<0.05 between pharmacy types)

Outcome of

referrals

Type of Pharmacy

Independent (a)

n (% )

Multiples (b)

n (%)

Supermarket (c)

n (%)

Small Chain (d)

n (%)

Total

n (%)

P-value (a-d)

Accepted 44 (8.8 ) a, c**

90 (8.5 ) b, c**

21 (16.5 ) c, d **

24 (7.0) 166 (8.2) 0.009

Remain

referred

115 (22.9) a,b; a,d

both**

175 (16.6)

b,d**

19 (15.0) c,d **

24 (7.0 ) 288

(14.2)

<0.001

Completed 126 (25.1) a,b**;

a,c**

376 (35.6) b,c; b.d all**

20 (15.8 ) 75 (22.0) 619

(30.5)

<0.001

Rejected 216 (43.2 ) a,d**

415 (39.3) b,c; b,d both**

67 (52.6 ) c,d**

220 (64.1) 955

(47.1)

<0.001

Total 501 (24.7) 1,057 (52.1) 128 (6.3 ) 343 (16.9) 2,029

(100.0 )

<0.001

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The decision to either accept or complete the referrals was largely carried out within 7 days

of the community pharmacist receiving the referral (56.1 % and 66.2% respectively) as

shown in Supplemental File 3. However, most rejections were made more than 7 days post-

discharge (66.9%).

Of the total 2,029 referrals, 45.3% (n=955) were rejected by the community pharmacy. The

389 rejections that occurred after December 2014 were accompanied with a reason, which

are listed in Supplemental File 4. The most common reason for rejection was that the

patient was uncontactable (35.5%, n=138), or that the patient was housebound (19.3%,

n=75). However, after a change made to the PharmOutcomes template in June 2015 that

removed ‘housebound’ as the default reason for rejecting a referral (see Supplemental File

2), the rate of rejection for this reason dropped from 39% to 14%.

The age range of patients who agreed to receive a referral and the reasons for these

referrals, of which there could be multiple reasons, were recorded by hospital pharmacy

staff (Table 2).

Table 2. The age of the patients and reasons for the referrals made by hospital pharmacy

staff to community pharmacy during the evaluative period. (n=2,029)

Characteristics of referrals Number (%)

Age of patient (yrs)

<10 47 (2.3)

11-19 14 (0.7)

20-29 24 (1.2)

30-39 65 (3.2)

40-49 183 (9.0)

50-59 270 (13.3)

60-69 497 (24.5)

>70 930 (45.8)

Reason for referral

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MUR 663 (32.7)

New medication(s) issued in hospital 365 (18.0)

Compliance aid issue 168 (8.3)

Changed dose(s) in hospital 148 (7.3)

Stopped medication(s) in hospital 142 (7.0)

Compliance issues 77 (3.8)

MUR/New Medicines Service (NMS) 73 (3.6)

Technique issue 57 (2.8)

Smoking cessation follow-up 43 (2.1)

NMS 30 (1.5)

Side effect issue 26 (1.3)

Need for monitoring 24 (1.2)

Check on well-being 16 (0.8)

Repeat dispensing query 10 (0.5)

Delivery service query 10 (0.5)

Special formulation of medication 4 (0.2)

No reason provided 601 (29.6)

Only 30.5% (n=619) of referrals made resulted in a community pharmacist both “accepting”

and recording the “completion” of the follow-up consultation. Table 3 details the long term

condition or treatment of patients receiving a follow-up by a community pharmacist, the

medication-related information they were provided with during the consultation, any advice

on ADRs, and any additional pharmaceutical or support service that was also delivered.

Table 3. The details of the referrals that were followed up by community pharmacists and

recorded as completed. (n=619)

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Completed referral details Number of patients

(%)

Long term condition/treatment of patient

Cardiovascular disease (CVD) 328 (53.0)

Respiratory 126 (20.4)

Diabetes 28 (4.6)

CVD and diabetes 22 (3.5)

Pain 11 (1.8)

Cancer 9 (1.4)

Anticoagulant 8 (1.3)

CVD and other 7 (1.1)

Diabetes and other 3 (0.5)

Hypertension 1 (0.2)

None specified 76 (12.3)

Information provided

More information on medication(s) 557 (90.0)

Dose check 543 (87.8)

More information on condition 457 (73.8)

Side effect check 521 (84.2)

Advice provided on reported ADR

Manageable and non-harmful – patient to continue 106 (17.1)

Refer to GP 33 (5.4)

Patient stopped taking medication 18 (2.9)

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Refer to hospital 5 (0.8)

Not applicable 457 (73.8)

Pharmaceutical/support service provided

MUR 288 (46.6)

NMS 241 (38.9)

Home delivery service 138 (22.3)

Compliance aid 79 (12.8)

Repeat dispensing 53 (8.5)

Medicines reconciliation 28 (4.5)

Smoking cessation 25 (4.0)

Discussion 23 (3.7)

Review of dosage form 17 (2.7)

Review of compliance aid 13 (2.1)

Influenza vaccination 12 (1.9)

Medication administration record 7 (1.1)

Large print labels 7 (1.1)

Easy open tops 6 (1.0)

Healthy living advice 6 (1.0)

Appliance use review 1 (0.2)

None 331 (53.4)

The majority of patients that were followed-up were those with a cardiovascular or

respiratory disease. Most patients received information from the community pharmacist on

their medication (90.0%, n=557), doses (87.8%, n=543), occurrence of side effects (84.2%,

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n=521) and their conditions (73.8%, n=457). Most patients (73.8%, n=457) did not report an

ADR to the community pharmacist during the consultation. However, of those who did,

17.1% (n=106) were considered manageable and non-harmful to the patient, and thus the

patients were advised to continue taking their medication as prescribed. Most patients did

not receive any additional pharmaceutical or support service (53.4%, n=331), but many

received a Medicines Use Review (46.6%, n=288) and/or were enrolled on the New

Medicines Service (38.9%, n=241). Of these patients who were provided with a follow-up

consultation, 40.4% (n=250) provided feedback via the pharmacist. Just over half of these

patients reported that the information was a good reconfirmation of the information

provided within hospital and at discharge (52.4%, n=131); 90 (36%) of the patients

expressed their appreciation for the contact with the community pharmacist, and the

usefulness of their advice and/or service provided through this initiative; a small number

(4.8%, n=12) refused or were reluctant to receive any form of follow-up consultation by the

community pharmacist in the future. In the remainder of cases (6.8%, n=17), pharmacists

recorded how the patient was either too ill to be spoken to or that they consulted with their

carer instead.

Hospital readmissions and number of bed days

There were a total of 1,386 hospital patients who received electronic referrals to community

pharmacy during the period 1st

July 2014 - 30th

June 2015; of these 501 (36.1%) had a record

of receiving a follow-up consultation by a community pharmacist (‘completed’ referral)

(Table 4). 607 (43.8%) of the remaining 885 patients are unlikely to have received a follow-

up community pharmacist consultation as the status of their referral on the

PharmOutcomes system remained either ‘referred (no action)’, ‘accepted’ but not

completed. A total of 278 (20.0%) were ‘rejected’ by the community pharmacist. Table 4

displays the readmissions rates and number of bed days of patients who either received or

did not receive a follow-up community pharmacist consultation. The odds of readmission

was found to be significantly higher amongst those who did not receive a follow-up

consultation from the community pharmacy. This result is consistent across the three

readmission time points (30, 60 and 90 days). Over the same time period, the 30 day

readmission rate was 13.2%, which is higher than that of the group of patients who received the

community pharmacist follow-up and lower than that of the patients who did not receive the

community pharmacist follow-up. This correlation appears to indicate that hospital pharmacy staff

were targeting patients at greatest risk of early readmission to hospital. Among patients

readmitted, the average duration of hospital stay at any time point (30, 60 or 90 days) was

at least 5 days less for those who received consultation.

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Table 4. The readmissions and number of bed days of patients who received a follow-up

community pharmacist consultation and of patients who did not.

Patient cohort Number of readmissions post electronic

referral at

Number of bed days for

readmitted patients at

0-30 days

n (%)

31-60 days

n (%)

61-90 days

n (%)

30 days

mean ±

SD

60 days

mean ±

SD

90

days

mean ±

SD

Received a CP


29 (5.8) 17 (3.4) 18 (3.6) 7.2±1.0 7.2 ±

6.4

7.3 ±

6.7

Did not receive CP


142 (16.0) 84 (9.5) 83 (9.4) 13.1 ±

17.4

13.7 ±

19.2

12.5 ±

16.6

Odds ratio and 95% 3.1 3.0 2.8

Confidence Intervals

(N=1386)

(2.1, 4.7) (1.8, 5.1) (1.6, 4.7)

Mean differences and

95% Confidence Intervals

(N =373)

-5.8

(-12.7,

1.0)

-6.5

(-15.4,

2.4)

-5.2

(-13.9,

3.5)

DISCUSSION

This Transfer of Care Service addressed a recognised patient need as they transition

between care settings. Our findings show how an electronic solution, in this case

PharmOutcomes, can be employed to facilitate the transfer of information between hospital

and community pharmacy teams to improve the coordination of care as patients transfer

between care settings. We have provided a detailed description of how this specific

electronic referral process worked in practice, so as to help inform future service designers

and implementers. We also provide information of the ongoing changes made during the

evaluation period which aimed to increase rates of referrals, completion and reduce

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rejections. Additional changes have and are being made in response to continuing

evaluation of the service delivery and activity. We found that community pharmacy

engagement, through linking with Local Pharmacy Committees and Regional Managers of

large multiples, along with close working relationships with the developers of the eReferral

platform, were key to designing, adapting and delivering a successful process.

Over the 13 month evaluative period, 2,029 patients were referred to their nominated

community pharmacy. This is a modest number of referrals considering there were no

eligibility criteria to restrict activity. Ramsbottom et al [20] also report a very small

proportion of eligible in-patients (3.2% of over 10,000 potential patients) were identified to

receive referrals to community pharmacists for domiciliary MURs. The main reasons put

forward by the authors for these low referral rates were that the service was new and not

embedded into practice, hospital staff had other competing priorities and the patients’

poor health were reported as barriers to making referrals. [20] Further qualitative data

collection from hospital pharmacy staff could explore the reasons for low referral rates in

our study and aid in the design of solutions to increase activity. Qualitative data from

community pharmacists would also explore the low completion rate and investigate the

facilitators and barriers to the embedding of this service into normal practice. The

Normalisation Process Model, as proposed by May [21] would be an appropriate theoretical

framework to evaluate the process and context of implementation.

Unfortunately, we did not record the details of all patients who were approached by

hospital pharmacy staff and offered an electronic referral. It would be interesting to further

investigate why patients decided to refuse these referrals. A recent study found that 32% of

elderly patients eligible to receive a visit from a pharmacist post hospital discharge refused.

The most common reasons stated in this study were the lack of perceived benefit of the

interaction with a community pharmacist and preference to see their GP. [20] Yu et al [22]

also found that once their patient population was made aware of the availability and

benefits of a post discharge pharmacist home medicines review, the majority of patients

were willing to participate. [22]

Most referrals were sent to multiple chain pharmacies (52.1%, n=1,057) as nominated by in-

patients. Multiple chain pharmacies made up 50.2% of the total number of pharmacies in

the area (104 out of 207). This category of pharmacy also had the highest completion rate of

eReferrals, significantly higher than all other pharmacy types (35.6%, n=376). The

supermarket pharmacies received the least number of eReferrals (6.3%, n=128) and also

had the lowest completion rate (15.8%, n=20), which was statistically lower than all other

pharmacy types. Further investigation is needed to explore the motivators and barriers of

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pharmacists to accept/refuse eReferrals and whether the type of pharmacy at which the

pharmacist was based influenced their decision. Work carried out by Jacobs et al [23, 24]

may provide a framework in evaluating if and how the culture in various community

pharmacy organisations impact their performance in pharmaceutical services. Another

evaluation of a pharmaceutical service utilising PharmOutcomes for routine data collection

suggested that low recorded completion rates on this IT platform may have been due to the

community pharmacists not logging onto the system and documenting their actions. [25] In

which case the referrals that are listed as ‘remain referred’ or ‘accepted’ may have actually

been formally completed or rejected. Most eReferrals were ‘accepted’ or ‘completed’ within

7 days of receipt, whereas most rejections occurred after 7 days. It is important to

understand this time lag and whether the delay was due to events not under the community

pharmacist control, e.g., multiple attempts to contact the patient. The most highly reported

reasons for rejections of referrals by the community pharmacists was that the patient was

uncontactable (35.1%, n=138). Specific reasons for this needs to be explored to understand

if this is an issue with the service design and delivery, e.g. patients may not answer

unidentifiable numbers; patients may provide erroneous contact details instead of refusing

a referral, etc. A considerably large number of pharmacist rejections in our study were due

to the patients being housebound (19.3%, n=75), however, it was observed that rates of

patients registered as ‘housebound’ dropped from 39% of rejections to 14%, after the

change was made on the electronic template. Where the referral had been sent to a

pharmacy which was not routinely used by the patient (12.4%, n=48), again further

understanding is required to check if this is something that could be further improved in the

design of the service or patient deflection. It is possible that patients newly prescribed

medicines who were not taking medicines prior to admission to hospital (e.g. post MI) and

therefore not known by the community pharmacy had their referral rejected when their

need for support was greatest. Further detailed analysis is therefore warranted.

The majority of patients that consented for an electronic referral were elderly (60 years and

over, 70.3%, n=1,427) and the most common reasons that a referral was made by hospital

staff was for medication–related problems (MUR; initiation/cessation/changed medicine or

dose in hospital; compliance aid issue; medication compliance issue). Those patients who

ultimately received a follow-up consultation from a community pharmacist were those with

reported cardiovascular disease (53.0%, n=328) or a respiratory condition (20.4%, n=126).

This may reflect the areas in the hospital being targeted by clinical pharmacy staff; however,

empirical research is required to investigate this. These patient demographics may be useful

to consider in defining eligibility criteria for the referral of future patients. Within the follow-

up consultation pharmacists had the opportunity to provide information on medication,

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dosing, medical condition, side effects/ADRs and their subsequent management. Most of

the patients were not provided with an additional pharmaceutical or support service (53.4%,

n=331), but 46.6% (n=288) of patients received an MUR and/or initiated the New Medicines

Service (38.9%, n=241).

Routine data collection does not include a measure that meets any Economic, Clinical or

Humanistic Outcomes model [26]; this means that the impact and value of the intervention

cannot be understood. Despite the tailoring of the community pharmacist follow-up

consultation to the patient’s expressed need, no subsequent outcome data associated with

the tailored pharmaceutical care and/or service is routinely recorded to demonstrate the

effect. Where MURs were performed or NMS initiated, there is no inclusion of the actions

and recommendations of the community pharmacist within routine data collection on

PharmOutcomes. The information for these two specific services has their own separate

documentation and recording process. Inclusion of this information with the eReferral

service data may provide further detail on the impact of the community pharmacist

intervention on patient outcomes, e.g. medication or condition related issues and advice,

referrals onto GPs for monitoring or consultation. Future evaluations should aim to identify

a specific parameter that can be used directly or as a proxy to measure economic,

humanistic or clinical outcomes.

Of the relatively small proportion of patients who provided ad hoc feedback via the

pharmacist about the service, just over half felt that the information received reconfirmed

what they had been previously told in hospital; some patients appreciated this and found it

useful. Our study found that those patients who received a follow-up community

pharmacist consultation as a result of a hospital eReferral demonstrated statistically lower

readmissions and shorter hospital stays as a result of any readmission. However, further

critical analysis of this positive association, e.g. explore the individual reasons for

readmissions, use of other healthcare services, etc., is required to substantiate a causal link.

The service aimed to improve the transition of the patient between care settings which

would be best tested via a randomised control trial. However, prior to carrying this out a

feasibility study is required. This work would determine how best to design the future trial

and identify primary and secondary outcomes that would be feasible to collect and allow

assessment of effectiveness.

The strengths of this study are that it specifically describes the implementation and

operation of an electronic referral process from hospital to community pharmacy. We have

highlighted possible areas for further improvement, but feel that the lessons learnt so far

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are both relevant and valuable to those considering the implementation of a similar process.

The marrying of service activity with the developmental changes also provides context to

the critical reader in understanding context and to the service planner of the continual

monitoring and malleability of the service.

A weakness of this evaluation is that there is no test for fidelity of service delivery and

implementation. An investigation of how well hospital and community pharmacy staff

adhere to the recommended process might provide further insights into the relatively low

referral and completion rates that have been recorded on PharmOutcomes.

The systematic review by Hesselink at al [7] found that interventions that exhibited specific

components, e.g. medicines reconciliation, showed statistically significant effects in favour

of the intervention, i.e. reconciliation reducing the percentage of unreconciled medication

after discharge. [7] A future clinical study should ensure service data collection is

appropriate to allow assessment of intervention effect. The detailed intervention

description provided here will allow better understanding of facilitators and barriers to

outcomes that will be recorded. This study also highlights a deficiency of the intervention

itself: the lack of comprehensive discharge information routinely accompanying the referral.

Another recent systematic review concluded that those interventions that aimed to identify

and rectify drug-related problems showed the most statistically significant benefit. [8]

However to facilitate this there needs to be sufficient medication-related information

transferred between healthcare settings. With the recent announcement that Summary

Care Records, an electronic patient record derived from patients’ GP records will be

provided more widely to community pharmacists, [25] it is anticipated that the information

gradient between primary and secondary care will be reduced.

CONCLUSIONS

Patients in hospitals can be electronically referred to their nominated community pharmacy

upon discharge from hospital in order to receive a follow-up consultation tailored to their

specific need. We have shown that multiple stakeholders from the hospital, community

pharmacy organisations and IT system developers working collaboratively could design and

implement an electronic eReferral service from hospital to community pharmacy. Electronic

referral non-completion rates during the study period appear to be high. This may be due to

this period encompassing the launching and embedding of such a pioneering service. Early

indications are that patients referred from hospital, who receive a follow-up consultation

from their community pharmacist may have lower rates of readmission and shorter hospital

stays.

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A feasibility study will identify how and which outcomes will allow effectiveness of this

intervention to be measured.

ACKNOWLEDGEMENTS

COMPETING INTERESTS

None.

FUNDING STATEMENT

This research has received no specific grant from any funding agency in the public,

commercial or not-for-profit sectors.

CONTRIBUTORSHIP STATEMENT

NW, AG and SB were involved in the design and implementation of the intervention. HN

designed the service evaluation, and HN, NA and AK analysed the data. All authors discussed

the results and interpretation. All authors were involved in drafting the initial text for the

report and revising drafts prior to publication and all approved the submission.

DATA SHARING STATEMENT

There is no further unpublished data on this service.

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[24] Jacobs S, Ashcroft D, Hassell, K. Culture in community pharmacy organisations: what

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Figure 1. The number of referrals made over the evaluative period. The spread of these referrals 130x85mm (300 x 300 DPI)

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SUPPLEMENTAL FILE 1

Item Description

Name of

intervention

Transfer of Care initiative

Rationale of

intervention

Community pharmacists are well-placed within the primary care setting to

follow-up recently discharged patients for medication-, condition- and

health-related issues. These interactions aim to improve the continuity of

care as patients transition back to community settings from hospital

discharge.

Resources PharmOutcomes was required as the web-based tool to make referrals

from hospital to community pharmacy.

The hospital staff were provided with awareness/training on

PharmOutcomes, and on the remit of the service.

Patients were provided with a very brief chat by hospital pharmacy staff on

the opportunity to have a follow-up by a community pharmacist. (No

leaflets/advertising/informative information provided)

The community pharmacists were provided with a launch event to describe

the procedure within the hospital and what the follow-up might look like.

Area managers were contacted by Local Pharmacy Committee to inform

them of the service and ensure they encourage their community

pharmacists to check PharmOutcomes and action referrals.

Procedures Hospital procedure: All hospital pharmacy staff were responsible to

identify patients who, in their clinical judgement, would benefit from a

follow-up visit by their community pharmacist (there was no specific

eligibility criteria of the patient cohort). Such patients were approached on

the wards and asked for consent to be referred. On obtaining consent the

hospital pharmacy staff would enter the details of the patient onto

PharmOutcomes (name, date of birth, reason for referral, preferred details

of community pharmacist).

Community pharmacist procedure: Community pharmacists were required

to access their PharmOutcomes records on a regular basis (every day) to

check for referrals which they were required to ‘accept’ and commence

actioning; ‘reject’ and provide a reason or ‘complete’ if actioned. In all

cases pharmacists had to contact the patient to assess the need for or type

of follow-up intervention. Depending on patient response a variety of

pharmaceutical advice and services were provided. All activities provided

to the patient were recorded in PharmOutcomes.

Providers Hospital pharmacy staff including pharmacy technicians, and pharmacists

were provided with brief training on PharmOutcomes and directed to make

referrals to patients they thought might benefit from a follow-up upon

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discharge into community. Referrals were promoted as part of the normal

role in the care of the patients and were not provided with incentivisation

or reimbursement.

Community pharmacy staff were provided with a launch event to introduce

the service remit and description. Follow-up of referrals were promoted as

part of the normal role in the care of the patient. Services that were

entitled to reimbursement as per standard community pharmacy service

arrangements included: New Medicines Service (NMS); Medicines Use

Review (MUR); enrolment on smoking cessation programmes; flu

vaccination.

Delivery Hospital pharmacy staff approached patients admitted onto wards for

consent to be followed up by a community pharmacist.

Community pharmacists contacted the referred patients on the contact

number provided to the hospital staff. Advice, discussions and

consultations may have taken place via telephone or in person at the

community pharmacy. In some cases such interaction may have taken

place with a patient representative.

Locality If an intervention was carried out within a community pharmacy it was

undertaken within a consultation room.

Dose A patient was only approached once in the hospital to consent for a

referral to community pharmacy. In the case a referral was made,

community pharmacists would contact the patient. There was no

stipulated number of times this should be done. Also the timeframe within

which contact should be made with the patient is dependent upon how

often the PharmOutcomes messaging system is checked. Once a referral is

seen it should be actioned, and the informal guidance recommends that

community pharmacists try to contact the patient within 3 working days of

receiving the referral. The time frame for the NMS is initial patient

engagement, then intervention usually 7-14 days after engagement and

then a follow-up usually 14-21 days after the intervention.

Tailoring or

personalised

Each interaction was tailored to the patient. The community pharmacist

made contact with the patient by telephone and would simply enquire as

to the well-being of the patient. The subsequent service provision or advice

and counselling was dependent upon patient expressed need.

Modifications The referral form was modified through the course of the delivery to

reduce the amount of data required to be manually entered by the hospital

staff. Hospital staff did not have to make a recommendation for an action

by the community pharmacist, just a referral was made. An open box was

left for staff to enter details if required.

How well

(planned

Hospital staff were given motivating presentations on a regular basis to

encourage referral rates. Community pharmacists were encouraged by

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fidelity) their Local Pharmacy Network Lead to complete referrals received.

Members of the project team monitored service activity through observing

data input on PharmOutcomes.

How well

(actual

fidelity)

There was no record of how many patients that had been approached for a

referral who thence actually provided consent or desire to be followed up

in community. A project team within the hospital would access

PharmOutcomes on a monthly basis to review referral follow-ups by

community pharmacists. Action rates would be observed and if referrals

had not been actioned this would be fed back to area managers of the

community pharmacies to contact the pharmacists and investigate reasons

for not actioning.

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SUPPLEMENTAL FILE 2.

Transfer of Care – Developments made via the AHSN Project Team since July

2015

Members: Project Lead (SB) Project Manager Chair of Durham, Darlington and Tees Local Pharmacy Network Representative of North of Tyne Local Pharmacy Committee (AG) Senior Clinical Pharmacist, Northumberland Tyne and Wear Clinical Services Manager, North Tees & Hartlepool Representative of Tees Local Pharmacy Committee Practice Pharmacist, North East Commissioning Support Representative of HealthWatch England Representative of University of Durham (SPS) Clinical Pharmacist, County Durham and Darlington NHS Foundation Trust Representative of NHS England

Date Change made

Desired outcome

October 2014

Simplified the hospital referral template so only Royal Pharmaceutical Society recommended core contents for Transfer of Care records were recorded.

Reduce time spent making hospital referrals and to allow staff to focus on the quality of referral being made.

December 2014

A mandatory ‘Pharmacy Actions’ field was added to the community pharmacy template.

Provide some detail about the interventions being made by the community pharmacists and therefore help motivate pharmacy staff.

December 2014

A mandatory RiO scoring field was added to the community pharmacy template.

Make community pharmacists consider the likelihood their intervention had on preventing a hospital readmission.

December 2014

Community pharmacy template was amended so the community pharmacist had to select from a drop down menu why a referral had been rejected.

Help better understand why hospital referrals were being rejected.

January 2015

After confirming that all hospital referrals would automatically qualify for approval for a telephone or domiciliary MUR service, the required application forms and guidance notes were linked to the community pharmacy template.

Reduce rejected referrals and improve patient outcomes.

January 2015

Feedback provided to hospital pharmacy staff on the outcome of their referrals (as a consequence of changes made to the community pharmacy template in December 2015).

Motivate hospital staff to make referrals.

February 2015

Original FAQ document for community pharmacists (which is attached to the community

Reduce rejected referrals and improve patient outcomes

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pharmacy template) was updated and circulated to pharmacies highlighting changes to the service and the community pharmacy template

June 2015 The list of options why hospital referrals were being rejected was changed as the default had been set as ‘housebound’, the default is now blank and cannot be selected. If the reason for rejection was selected as ‘housebound’ additional information was provided about how to claim payment for telephone and domiciliary MURs

Correct the erroneous recording of ‘housebound’ as the reason for rejecting a referral. Increase the number of housebound patients receiving support

August 2015 Documents (e.g. discharge summaries) able to be attached to hospital referrals.

Allow community pharmacy medicines reconciliations, reduce medication errors and improve patient outcomes.

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SUPPLEMENTAL FILE 3. The number of days post-discharge for referrals to be actioned.

Number of days post-discharge to action

Outcome of referrals (number (%))

Accepted (n=166) Completed (n=619) Rejected (n=955)

< 7 93 (56.1) 410 (66.2) 316 (33.1) 7-14 33 (19.8) 110 (17.8) 232 (24.3) >14 40 (24.1) 100 (16.1) 407 (42.6)

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SUPPLEMENTAL FILE 4. The reasons for rejections of referrals by community pharmacists.

(n=389)

Reasons for rejections Number (%)

Patient was uncontactable 138 (35.5)

Patient Housebound 75 (19.3)*

Wrong pharmacy 48 (12.3)

Pharmacy unable to provide the service 36 (9.3)

Patient refused service 35 (9.0)

Patient re-admitted 21 (5.4)

MUR/NMS not appropriate 14 (3.6)

Problems with details on referral 9 (2.3)

Miscellaneous other 8 (2.0)

Patient deceased 5 (1.3)

*prior to a change being made to the PharmOutcomes template June 2015 (see Supplemental File 2) 39% of rejections were due to the patient being ‘housebound’. In the period 1

st June- 31

st July 2015 this rate

dropped to 14.3%

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