Title: Optimising post-discharge medicines-related care for older people living with long term conditions
Funder: Department of Health and Social Care

Abstract: Background Medicines-related problems and discontinuity of medicines management occur frequently when patients are discharged from hospital. This includes medicines reconciliation errors, patient confusion over which medicines to take, inappropriate continuation of short-term medicines, lack of monitoring and of dose titration. These medicines-related problems have the potential to cause significant patient harm, increase the risk of readmission and lead to a poorer quality of life, subsequently resulting in higher healthcare utilisation and costs to the State. Scoping of the literature has identified ageing, long-term conditions (such as Type II Diabetes Mellitus (T2DM) and frailty), and polypharmacy as risk factors for frequent, unplanned hospital admissions. Hospital stays involving these patients are likely to result in medication changes, increasing the risk of medicines-related problems following discharge. Patient and Public Involvement Discussions with patients and carers highlight that this topic is relevant and pertinent, partly because the quality of follow-on medicines-related care provided by health and social services is perceived to be inconsistent. Gaps in the literature and work with our Patient and Carer-led Steering group (PCLSG) have identified two research questions to be addressed by this project: i) How is post-discharge medicines-related care experienced by older T2DM patients living with frailty? ii) How might an intervention be designed to reduce medicines-related problems and support post-discharge medicines continuity? Aim To co-design and user-test an intervention to reduce medicines-related problems and promote continuity of medicines-related care for older T2DM patients living with frailty after discharge from hospital to home. Objectives Phase 1: 1. To map and critically appraise the current medicines-related care pathways for this patient group. 2. To explore the medicines-related problems that occur post-discharge, their human factors and root causes. 3. To examine the self-care behaviours and support mechanisms which allow these people and/or their carers to manage medicines safely post-discharge. Phase 2a: 4. To use patient experience and perspective to create a complex multi-component intervention that supports post-discharge medicines-related care with a view to reducing inappropriate hospital admission and improving quality of life (using Experience Based Co-Design (EBCD) methodology). Phase 2b: 5. To user-test the intervention by iterative rounds of usability and acceptability assessment with groups of potential intervention users. Research Plan This project involves Bradford and Leeds health economies. Phase 1 (Months 1 &ndash; 15): In-depth case studies describing the medicines-related pathways and problems which older people living with T2DM and frailty experience following hospital discharge will be developed. This work focuses on patient experiences of post-discharge medicines management and optimisation within primary care and the medicines support received from health and social care providers. Pathway mapping techniques, participant diaries and interviews, case note analysis and primary care data extraction will be utilised. Phase 2a (Months 16 - 22): Patients, carers, policy makers and healthcare professionals will be brought together as equal partners, using EBCD methodology to explore and evaluate phase one results. They will generate ideas about what might work better to reduce medicines-related problems, readmission and improve quality of life. Phase 2b (Months 23 &ndash; 30): Findings will be used to inform co-development of a complex intervention that is underpinned by behaviour change theory. The intervention will undergo iterative rounds of user-testing with potential intervention users to assess acceptability and usability. Protocols for feasibility testing, data collection tools and intervention training guides will be developed, ready for future trial. Potential benefits to patients and NHS The output will be an acceptable, co-designed intervention, ready for a feasibility trial. This intervention will benefit patients by supporting continuity of medicines post-discharge, improving quality of life. Fewer readmissions will be caused by medicines-related problems, benefitting patients and NHS by reducing healthcare utilisation.

Lay abstract: Background Older adults aged 75 plus, often have significant medicines changes when they have a stay in hospital. This can lead to confusion and anxiety, resulting in medicines-related problems e.g. medicines taken incorrectly. These problems can lead to harm, hospital readmission and poorer quality of life. Older people taking multiple medicines for long-term conditions and living at home are at greater risk. Aim We aim to improve the follow-on medicines-related care for older patients after their stay in hospital and associated quality of life, by reducing medicines-related adverse effects including costly hospital readmission. Patient and public involvement Discussions with patients and carers highlight that this topic is important to patients, partly because the quality of follow-on medicines-related care provided by health and social services is inconsistent. A patient and carer-led steering group meets regularly to guide all stages of the project including research question development, design and dissemination. Plan We will study older people (i.e. 75 and older) living with Type II Diabetes and frailty &ndash; chosen because careful monitoring and individualised medicines support are required. Step 1: We will work closely with patients and their carers to fully understand where and why medicines-related problems occur by following 36 older participants for six months after a hospital stay, using interviews and information within medical records. Step 2: We will bring together patients, carers, policy makers and healthcare professionals to explore and evaluate these results as equal partners. They will generate ideas about what might work better to reduce readmission and improve quality of life. Step 3: We will use these findings and ideas to develop new tools and user-test them to see if they are acceptable and useable. Dissemination Results will be presented to patients, healthcare professionals, policy makers and academics at local health events, in peer-reviewed journals and conferences.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: METABOLIC AND ENDOCRINE;GENERIC HEALTH RELEVANCE