Patient discharge from hospital is associated with an increased risk of avoidable medication related harm. The Discharge Medicines Service (DMS) was introduced as an essential service to the Community Pharmacy Contractual Framework in February 20212 and has been introduced as an indicator within the Commissioning for Quality and Innovation (CQUIN) guidance for 2022/23.
It enables NHS Trusts to refer patients to their community pharmacy at discharge for medication guidance and support. DMS builds on the work undertaken by Academic Health Science Networks around the Transfers of Care Around Medicines (TCAM), where it is well documented that effective communication during the discharge process has a significant impact on reducing medication related patient harm.
DMS is one of the first services that pioneers full cross-sector collaboration between hospitals, community pharmacy and GP practices. The involvement of Community Pharmacy and associated communication and networking required, is a positive step in the transition to Integrated Care Systems (ICSs).
The principle aims of the service include:
- Improving patient outcomes
- Preventing avoidable medicines related harm at discharge from hospital
- Reducing the risk of hospital readmission
- Improving patients’ understanding of their medicines
- Supporting collaborative working, shared decision making and ensuring better communication between teams.
Accelerating DMS implementation across an ICS
Black Country and West Birmingham ICS had undertaken work to implement the TCAM programme and subsequent DMS. Nevertheless, service referrals rates remained below target at some Trusts, with zero activity in others. The Medicines Optimisation team at Arden & GEM was tasked with working alongside key stakeholders to accelerate the uptake of DMS across the system. We utilised the concept of Genchi Genbutsu to understand potential issues or barriers through being at the location of the process. We believed this approach would enable us to tailor our solutions for implementation and accurately direct resources.
When implementing any new service or change to practice, we follow a structured approach which is underpinned by effective stakeholder engagement and robust project management.
1. Stakeholder engagement
Understanding stakeholders is vital to any project. Due to the cross-sector approach within DMS, it was important to identify key stakeholders, and their roles, from across the system.
Leadership endorsement
We were able to gain endorsement from senior stakeholders through their established Pharmacy Leadership Group (PLG), where members consisted of representatives from each pharmacy sector and across each of the four places across the Black Country and West Birmingham ICS. Our initial discussion with the group enabled the agreement of the overall project objectives and also enabled us to understand the current position and requirements, how project resources needed to be mobilised and inform the group of the benefits of undertaking an initial on-site scoping exercise.
System engagement
Arden & GEM established and chaired a bi-weekly DMS task group comprising of system stakeholders representing each of the four Place and across different sectors of pharmacy. The group had a clear governance structure, an established route for escalation (via the PLG), documented roles and responsibilities for each member, and an agreed positive focus on collaboration and sharing good practice. By raising awareness and seeking representation across the system, an increased appetite and commitment from the members became evident: It is expected that this approach will lead to system-wide ownership and a subsequent sustainable service.
The following forums were utilised to access stakeholders:
- Engagement events - aimed at those likely to be involved in the DMS process
- Support for community pharmacy contractors - through local LPC meetings
- Engaging GP practices - establishing links with the system medicines optimisation committee and Primary Care commissioning teams.
2. Approach to project delivery
Adopting a project management approach was pivotal to delivering a project across a large system with varying needs. Arden & GEM established a project team with experience of working across multiple stakeholders and who understood the systems in place.
Team structure
We utilised a combination of remote and peripatetic team members, with the remote team focusing on back-office functions, while the peripatetic team provided on-site visibility and were able to ‘walk the floor’ of the relevant Trust departments to gain a true understanding of the situation. The delivery of ward-based, one-to-one training and troubleshooting enabled Hospital teams to continue with their core duties. This helped to drive engagement while allowing the team to deliver training and provide more practical and responsive support to Hospital staff.
Baseline assessment findings
The project team arranged to undertake site visits, which included completing an assessment tool in conjunction with the relevant Trust staff, to gather a baseline understanding of the current state of DMS provision. The assessment tool acted as a prioritisation framework through its ability to score and RAG rate each descriptor, which allowed the Arden & GEM team to tailor support to meet the individual needs of Trusts.
The results were organised into common themes hindering the success of the service, including variations in processes, training, business intelligence and performance monitoring, and communications and engagement, with action plans developed and agreed with the Trust.
3. Tailored support model
Our initial scoping exercise enabled us to identify the baseline position at each Trust, and it was decided to pilot the new support model on the site with the most embedded infrastructure for DMS referrals, namely Dudley Group NHS Foundation Trust.
Tailored support focused on the common themes identified in the service baseline assessment and included:
- Standardising processes: Arden & GEM updated Standard Operating Protocols and information leaflets, identifying efficient processes that reflected the needs of the Trust, while ensuring national and local best practice was captured
- Training and coaching: training was undertaken on DMS, ensuring DMS support teams were aware of its benefits and the process required to make a referral
- Data and reporting: guidance was given on how to access referral data and monthly progress highlight reports were provided to the PLG
- Communications and engagement: as described above, the system-wide approach to stakeholder engagement enabled regular communication and networking to maintain project momentum and foster greater awareness of DMS.
Outcomes
The decision to test the proposed support model in the Dudley Group NHS Foundation Trust, and tailor this to the findings of the baseline service assessment, proved successful.
Staff within the Trust were fully engaged with the project, attendance levels at the training were high an increase in confidence in making referrals, with an instant increase in the number of referrals being made by the Trust. For April 2022, 77% of referrals were made within 48 hours of discharge, an increase of more than double upon the previous month.
The team closely monitored referral data, identifying the number of rejections and the associated reasons for rejection or being left unprocessed. The positive engagement from the Trust and ability to galvanise the adoption of this project has led to increased referrals, with lower rates of rejections. Feedback from another trust where we have delivered training has been positive, and further demonstrates Trust engagement.
“The training has been well received...I believe it has given those unfamiliar the confidence to go ahead and has also been a valuable reminder to those who had forgotten a lot of what we did before. The one-to-one training has also helped those less tech savvy and less tech confident.”
Senior Pharmacy Technician
The growing body of evidence indicates DMS significantly improves patient care and should be more widely adopted. However, work undertaken across Black Country and West Birmingham ICS, has identified that implementing large scale change at the interface requires a structured approach.
Systems should ensure both stakeholder engagement and implementation processes are factored when exploring the needs of each sector, and then tailor the delivery model accordingly. Our experience across the ICS shows a key element to achieving sustainable implementation is broad, and continued communication and engagement with system stakeholders is required, as well as anticipating and removing common barriers for all parties.
This blog was co-authored by Jo Loague and Mahesh Mistry and is taken from an article originally published in PM Healthcare Journal.
