Coping with medicines after hospital discharge—the “belt and braces” approach

We must support our patients to plan what they will do with their medicines after they leave the hospital, writes Justine Tomlinson

Since I am a pharmacist researcher, it will come as no surprise that I’m interested in medicines management—namely, the processes and behaviours that support safe and effective medication use. I have recently been exploring the topic of post-discharge medicines management, and it never ceases to amaze me how much effort older patients (aged 75 and above) and their carers have to put in to ensure the optimum management of their medicines. 

Changes to medication regimens are incredibly common when an older person has an admission to hospital. On average, older people will have two new medicines, 0.8 discontinuations, 0.7 frequency changes, and 0.5 dose changes per admission. These changes, often coupled with reduced ownership of medication administration during their stay, can mean patients quickly become deskilled in managing their medicines. It is easy to see why and how one in three older patients experience medicines related harm within eight weeks of hospital discharge, costing the NHS approximately £400million each year. 

As healthcare professionals, we are all working tirelessly to do our bit, but is it enough? A recent study I co-authored, which explores this post-discharge period, suggests not, as patients and carers must proactively and frequently reach in and prop up the system to make it work for them. I interviewed 27 older patients who returned home after a hospital stay to find out how they were coping with their treatment changes. Whether they knew it or not, they enacted multiple safety strategies to help themselves manage their medicines on a daily basis. Every participant highlighted undertaking some degree of “medicines work.” I make no mistake in calling it “work”; these tasks often require much mental and physical effort to obtain a positive outcome—if one is ever reached.  

These safety strategies employed adaptation, system support, and error avoidance techniques. Patients, for example, had to adapt long established medicines routines in order to increase their confidence with new regimens and treatment changes. Some tried their best to interpret discharge information sheets filled with jargon to enact these changes, or to help them repack their own multi-compartment compliance aid. Sadly, some felt they could no longer cope “doing” their own medicines and had to succumb to the timings of carers, or ask a kind relative to put their medicines out. Many found the removal of old medicines from the house a useful activity, however, this relied on having the capability (and motivation) to do so. 

Patients and their carers frequently reached in to support the system. They acted as conduits for information—taking discharge letters to the GP and/or pharmacy. In some cases, they stressed the medicines changes to their pharmacist, sometimes by taking their new medicines in with them and having a face to face conversation. Medication supply was a priority for patients, and it often caused them stress and anxiety when medicines did not arrive on time. They therefore felt it was important to alert their pharmacist that they had been discharged, so that the usual supply arrangements could be restarted in a timely fashion. Wouldn’t it be great if hospitals could do this for them reliably?

Finally, patients and carers performed their own checks and balances to ensure that errors did not occur. They sought information, taking the time to study their medicines and information leaflets or by asking Google. Any remaining questions they had from their admission motivated them to contact their GP in the hopes of finding answers. Participants also described conducting a reconciliation of their old and new regimens. Finally, based on previous experiences, many were able to anticipate potential gaps in or specific worries for their post-discharge care, and mitigate against them by preparing themselves for discharge home. One carer, who described this as a “belt and braces” approach, had a list of questions prepared for the discharge team and ensured she kept in constant conversation with them. 

These strategies demonstrate that patients show great resilience, and much can be learnt from them about what does and does not work for this population group with complex needs. What is troubling to me, however, is that these patients were mostly willing and able to engage with their own medicines management, albeit to differing levels. What about those patients who lack the capability, skills, or knowledge to take on this role? What about those who have no supporting peers to advocate for them? How do we help the people that can’t help themselves? 

For me, it’s about thinking beyond the four walls of the hospital ward or primary care practice and considering the patient and their medicines within the context of their home environment. How will they obtain, store, sort, administer, and reorder them? It would help if we could move towards having more patient centred, medicines focused conversations, which are tailored to the patient’s level of capability and engagement. We must support our patients to plan what they will do with their medicines after they leave the hospital. A holistic assessment of their specific needs for managing their medicines is also vital. Next, it’s important to explore and share the potential barriers the patient may face with their medicines management once they’re discharged to make sure that they are better prepared for transitioning from the hospital to home. 

Ultimately, key messages about medicines changes need to be reinforced frequently, throughout a person’s care journey and not just at discharge. This will rely on all members of the multidisciplinary team, across the interface, engaging with the patient. Medication safety is, after all, everyone’s responsibility.

Justine Tomlinson is a practising pharmacist and doctoral training fellow within the Medicines Optimisation Research Group at the University of Bradford. Her role includes research, clinical practice at Leeds Teaching Hospitals NHS Trust, and teaching activities at the university. Her research interests involve medicines safety at transitions of care and her qualitative research explores medicines management and continuity for older adults after hospital discharge. Twitter @Just_Greenwood

This independent research is funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) programme (Grant Reference Number PB-PG-0317-20010). The views expressed are those of the author and not necessarily those of the NIHR or the Department of Health and Social Care.

Competing interests: Nothing further to declare.