Transitions of Care in Medication Management Project OutcomesComplexities of communication processes for managing medications in older people across transitions of care
What is already known
As patients move across transitions of care, they are more likely to experience medication errors. The major reason for these medication errors are breakdowns in communication because of the diverse range of health professionals with whom patients come into contact, and the nature of patients' medical conditions, often requiring complex treatment regimens that may result in serious harm.
Common transitions of care involve moving between acute hospital, geriatric rehabilitation and residential aged care settings, patients' homes and primacy care clinics. Older patients are often less able to communicate adequately if they experience medication errors and they also have a more limited physiological ability to counteract problems relating to medications.
As older patients move across settings, organisational and social dynamics often alter, the level of complexity of health care needs can change, and the composition of health professional support also varies.
What we wanted to know
We sought to examine how health professionals, older people and family members communicated with each other in managing medications as older people move through transitions of care.
The project involved the development of new knowledge about the culture across these transitions of care, and examined how health professionals addressed gaps in communication. We wanted to know the sociocultural and environmental influences that shaped communication processes about how medications were managed as older people move across different environments; to describe the characteristics of the actual communication encounters across transition points of care; and to explore the opportunities older people and family members have to engage in communicating about medications.
Outcomes were the development of strategies for improving how individuals communicate with each other about managing medications for older people across different clinical settings of care.
What we did
We completed an ethnographic project involving interviews, focus groups and observations at a tertiary care metropolitan teaching hospital, and a geriatric rehabilitation hospital in Melbourne, Australia.
Our project involved semi-structured interviews with 50 older patients, 31 family members and 38 health professionals. Health professionals comprised doctors, nurses and pharmacists. We also completed 203 hours of observations of communication encounters involving health professionals, older patients and families in diverse settings.
Focus groups were undertaken with 20 older patients, 13 family members and 27 health professionals where we asked them to reflect on what was important to them in making decisions about medications across transitions of care.
What we found
Challenges existed in establishing patient-centredness in medication communications across transitions of care. Older patients were often hesitant to express their opinions about prescribed or changed medications because they did not want to conflict with doctors in decision making. Some older patients and families developed their own medication lists or wrote key questions to act as aide memoirs in communication, which greatly assisted in patient and family engagement.
Families were often absent from bedside discussions , which was particularly problematic for patients who were confused or who were not fluent in English. If older patients received clear information about medication changes, they were more likely to be actively involved in decision making. Health professionals often tracked back-and-forth between settings, checking for possible medication errors after patient transfers, but health professionals of different disciplines rarely communicated with each other.
Instead, communication tended to take place with health professionals of the same discipline as patients moved across various settings. Nurses and pharmacists at transferring settings regularly checked with those at receiving settings to make sure they received updated changes in medication regimens.
Communication processes across transferring and receiving settings were at times unreliable, which led to health professionals introducing additional routine measures to reduce the risk of communication breakdowns and medication harm. Medication safety was sometimes compromised across transitions of care due to unclear processes for disseminating information and transfer of accountability.
When older patients had opportunities to ask questions, either through the use of self-created medication notes or health professionals spending the time to find out their preferences, expectations and goals of care, older patients and their families were encouraged to voice their views. Creating these opportunities enabled a more active role in medication decision making for older patients and families across transitions of care.
Attention is needed at the time of patient transfer to improve communication through effective clinical handovers. Clear processes for distributing discharge summaries to community doctors are needed. Enhanced levels of communication are needed between various health professional disciplines and not just those of the same discipline group.
Older patients should be encouraged to create notes to act as aide-memoires and enable opportunistic discussions with health professionals, especially if they lack confidence or where their contributions are not perceived as important. Health professionals should identify older patients' preferences for both managing medications and including themselves in medication communications at different time points. Health professionals need to organise education sessions with family members or interpreters for older patients with language barriers or cognitive issues.
We have developed three sets of tips for health professionals, older patients and their families as research outputs of this project. The tips for health professionals and those for older patients and families are available a range of languages below.
We have also published our work in the academic journal and policy literature here:Academic journal and policy literature (PDF, 952KB)
Please feel free to follow us or contact us on Twitter in relation to our project:
@emanias1; @IHT_Deakin; @DeakinQPS; @nursedecisions; @jorm_christine; @GuncagOzavci