The evidence suggests that a discharge plan tailored to the individual patient probably brings about reductions in hospital length of stay and readmission rates for older people admitted to hospital with a medical condition. The impact of discharge planning on mortality, health outcomes and cost remains uncertain.
Evaluation of a hospital-based community liaison pharmacy service in Northern Ireland.
To evaluate the impact of a hospital based community liaison pharmacy service on a range of outcomes in patients aged more than 55 years and taking more than 3 prescribed drugs, who had been admitted to the medical unit of a district general hospital in Northern Ireland.
                Having recruited 243 patients, a total of 162 patients completed the full protocol (81 randomly assigned to intervention and 81 to control; mean age of control patients 75 years; mean age of intervention patients 73 years). The interventions by the community liaison pharmacist included: preparation of an accurate medication record following a full review of current medication use; medication counselling; provision of a medicines record sheet informing the patient how to take their drugs; provision of a pharmaceutical discharge letter detailing changes made to drug therapy (this was faxed to the patient's GP and community pharmacist on the day of discharge); provision of a Medicines Helpline.
                The key findings were as follows: problems were identified in 80% of the intervention patients' prescription charts, 49% of which related to drug omissions from the patients' domiciliary prescriptions. The GP practice record was the most accurate (mean error rate 12.6%) while the GP referral letter was the least accurate (mean error rate 47.3%) source of medication information. Drugs patients brought to hospital were also an inaccurate source (mean error rate 44.0%). The intervention group patients, when compared with control patients, had a significant reduction (P = 0.005) in drug mismatch between drugs prescribed at discharge and taken at home, and had a greater knowledge of their drug regimen 10-14 days after discharge (P < 0.001). The vast majority of patients (96%) felt that the provision of a medicine helpline was a useful service.
                The study indicated clear benefits from the involvement of a hospital based community liaison pharmacist in achieving seamless pharmaceutical care between the primary and secondary healthcare settings.