Beyond the Hospital: Redefining the Role of Pharmacists in Transitions of Care
Authors: Hussain Dewi Azura , Cheong Kah Mun , Lee Elena , Lim Agnes , Low Bee Geok , Rahman Kamsiah Abdul , See Qin Yong 
Published: January 2024

Unjustifiable medication discrepancies or inconsistency are responsible for more than half of medication errors occurring at transitions in care and up to one-third could have the potential to cause harm. Studies have shown that pharmacist-led medication reconciliation programmes are effective at improving post-hospital healthcare utilisation. In Singapore, the Hospital-to-Home (H2H) programme in Changi General Hospital (CGH) focuses on providing care to vulnerable patients transitioning from different settings, who are exposed to gaps in care and lapses in quality and safety. The Home Medical Service by Pharmacists was pioneered in CGH and Singapore in October 2020 to enhance provision of pharmacy-related services by certified collaborative prescribing pharmacists in the home setting. The purpose of this quality improvement project is to identify provider and patient characteristics that are predictive of the response towards this new pharmacy service, which in turn influences the referrals to the service.
A fishbone diagram was used to analyse and categorise the problems into different factors – pharmacist-, nursing-, physician-, patient-, and process-related. Pharmacist-, nursing- and physician-related factors include poor awareness of the potential value-added roles of pharmacists due to the lack of prescribing experience in the home setting. Patient-related factors include difficulty in establishing the appropriate criteria to identify patients who need pharmacist’s intervention. Process-related factors include potential additional cost to patients.
Based on the Model of Improvement, several changes were implemented in two Plan-Do-Study-Act (PDSA) cycles. The first cycle was to perform roadshows to the H2H team comprising of physicians and nurses, to raise awareness of the new pharmacy service and pharmacist's roles (more in-depth medication reconciliation, drug information, and prescribing). After three months, the second cycle was initiated by conducting regular monthly case audits with the H2H team to monitor progress, identify lapses, and receive feedback to further improve processes and explore potential areas that pharmacists can contribute.
After implementing PDSA cycle 1, the average number of unique home visits by pharmacists per month increased from 1 visit to 4 visits, and subsequently increased to 8 visits after implementing PDSA cycle 2. A survey was also conducted to determine if the changes implemented were satisfactory to the team. Overall, 80% of responses were satisfied with the Home Medical Service by Pharmacists in managing patients under the H2H programme.
This project had enabled us to achieve improvements in several processes which facilitated the refinement of pharmacist’s roles in the H2H programme to complement the team’s current roles and increased awareness of these roles within the team. Lastly, we will continue to further improve other problem areas yet be addressed and together with the H2H team, close the gaps in care for patients undergoing transitions of care.