Pharmacists improving transition of care

Overview

Initiative type

Service Improvement

Status

Deliver

Published

June 2025

Summary

Patients identified as high risk for medication misadventure on discharge from hospital  were contacted by an experienced pharmacist within 72 hours following discharge. A significant unmet need was identified for consume.

1 August 2024 - 1 April 2025

Implementation sites

Queensland Children's Hospital

Aim

This project aims to improve safe transition of admitted patients to the community, and  facilitate care closer to home, by provision of discharge follow up to patients at high risk of medication misadventure.

Outcomes

  • Creation of a customized list to identify patients discharged who met referral criteria was created.
  • 430 patient referrals received to date with 78% referrals resulting in a successful consult and a 22% failure to attend rate.
  • The highest referring teams were oncology and general medicine.
  • For oncology patients- all patients had at least  one intervention made by the pharmacist. 28% of patients had a change recommended to the medication regimen requiring discussion with the treating team. 60% of patients had two or more interventions made by the pharmacist.
  • For general medicine patients-  all patients had at least one intervention made by the pharmacist. 12% of patients had a change recommended to the medication regimen requiring discussion with the treating team.

Background

Children discharged from Queensland Children’s Hospital (QCH) are often prescribed complex  and high-risk medications, with limited opportunity for follow-up. This increases the risk of medication-related harm and unplanned hospital readmissions. Providing an accurate, updated medication list at discharge — and sharing this with community healthcare  providers — is a proven strategy to improve continuity of care and reduce harm. Despite this, discharge communication to GPs is a well-known challenge at QCH, and up to 85% of patients leave hospital without an updated medication list. This further complicates  care for families managing new or changed medications at home. A recent project across three Queensland Health hospitals (Transitions of Care Pharmacy Project, TOCPP) demonstrated the benefits of pharmacist-led medication review at discharge in adult patients.

For each patient reviewed, a median of three recommendations were made to GPs, two to community pharmacists, and two to patients themselves. The project identified an average of 0.8 medication-related problems per patient and was highly valued by both consumers
and healthcare providers. While a smaller proportion of paediatric patients may require this service compared to adults, high-risk discharges are common at QCH.

For example:

  • Approximately 50-60 patients are discharged daily.
  • Only 15% receive an updated  medication list at discharge.
  • Not all patients with new medications or dose changes are reviewed by a pharmacist prior to leaving hospital.
  • Around four children are diagnosed with cancer each week, many discharged within seven days on multiple new medications.
  • In 2023, 9.6% of admissions were First Nations children, a group at higher risk of adverse outcomes. Preventable readmissions related to medication errors occur and present a clear opportunity for improvement.

Methods

Target Patient Group

The service will review a minimum of 5 patients per day, Monday  to Friday (excluding weekends and public holidays), by a dedicated Complex Discharge Care Pharmacist or an integrated pharmacist within the team. The service aims to follow up high-risk patients within 72 hours of discharge from Queensland Children’s Hospital  (QCH), to reduce medication-related harm and support safe medication use at home.

Patients identified as high risk for medication misadventure:

  • Patients prescribed more than four medications, particularly with complex medication changes during admission or on discharge.
  • Patients with complex medication regimens requiring weaning, uptitration, or specific monitoring — such as antiepileptics, steroids, or pain medicines.
  • High-risk patient groups, including new oncology diagnoses, stem cell or solid organ  transplant recipients, or patients with renal impairment.
  • Patients and carers with low health literacy or complex social situations impacting medication management. · Patients prescribed medicines requiring therapeutic drug monitoring (e.g., anticoagulants,  azoles, calcineurin inhibitors, or specific cardiac and antiepileptic medicines).

Key Activities of Pharmacist Review - The Complex Discharge Care Pharmacist consultation focuses on ensuring safe and effective medication use after hospital discharge through:

  • Providing medication counselling to ensure patient and carer understanding of the prescribed regimen.
  • Supplying medication lists for families and carers, if not already provided. · Discussing medication administration and storage, identifying barriers to adherence.
  • Monitoring for adverse effects, particularly with new or high-risk medicines.
  • Supporting continuity of medication supply in the community.
  • Communicating medication-related information to GPs, community pharmacists, and other healthcare  providers as required.
  • Coordinating therapeutic drug monitoring where needed.

Service Delivery Model

  • Patients were identified for follow-up via direct clinician referral (pharmacist, prescriber, or nurse) or through pharmacist triage of recent discharges  (a custom solution to identify high risk patients was built). Referrals were submitted using a standard approach for medical staff, email for pharmacists, with referral criteria and patient cohort regularly reviewed during the pilot. The pharmacist contacts  patients or their carers by telephone within 24-72 hours of discharge to review medication management, provide counselling, and address any emerging concerns.
  • During the consultation there was an assessment for medication adherence, clarification of instructions, provision of updated medication lists if necessary, and support for families with provision of information to promote safe and effective medicine use at home. Consult to other services (OT, social work) and resolution of issues identified from prescribers  occurred as required. This service aims to improve patient safety, reduce preventable medication-related readmissions, and support continuity of care between hospital and community settings.

Discussion

Key Success Factors

For the project to succeed, strong stakeholder engagement and  an environment focused on patient safety and health equity were essential. Support from leadership at Queensland Children’s Hospital (QCH), collaboration with pharmacy teams, and access to electronic medical records (ieMR) enabled efficient identification  of high-risk patients. Dedicated pharmacist time, referral pathways, and integration with existing discharge processes were also critical.

Lessons Learnt and Limitations

Key lessons included the need for flexible models of care (MOC) to address challenges  in patient engagement, particularly post-discharge. Initial phone follow-ups were limited by low response rates (27% of parents not contactable), prompting trials of embedded pharmacist models within inpatient teams to build rapport before discharge. However,  workload pressures meant these embedded models were unsustainable long-term without additional resourcing. Cultural safety was another key consideration, particularly for First Nations families. The project highlighted the importance of working alongside Indigenous  Health Liaison Officers (IHLOs) and exploring culturally appropriate communication strategies. Limitations included staffing constraints (part-time allocations, public holiday impacts) and IT restrictions (inability to alter caller ID). While data demonstrated  positive impacts, further work is needed to streamline processes and increase reach.

Strengths, Weaknesses, Opportunities- Strengths:

  • Enhanced patient safety through targeted medication reviews.
  • Improved communication between hospital, families, and community  healthcare providers.
  • Positive parent feedback indicating improved confidence with medication management at home.
  • Activity-Based Funding (ABF) capture through 40.04 clinical pharmacy activity supports sustainability. Weaknesses: · Limited parent engagement  post-discharge in some cohorts.
  • Capacity challenges due to staffing limitations.
  • Variability in referral uptake across clinical teams. Opportunities:
  • Expansion of the service to other high-risk patient groups beyond oncology and transplant.
  • Development of culturally safe workflows for First Nations patients, including potential recruitment of an Indigenous pharmacy cadet.
  • Further refinement of referral dashboards and integration into standard care pathways.

What Would Be Done Differently

Future implementation  would focus on optimising referral processes, increasing early engagement with families during admission, and refining models of care to balance workload with sustainability. Broader education for staff on the importance of early referral and improving visibility  of the service within clinical teams would be prioritised. A focus on culturally safe practices and resource development for First Nations families would also be strengthened.

Broader Applicability in Queensland Health- This model of care could be successfully  applied to other tertiary and regional hospitals within Queensland Health, particularly where complex paediatric or high-risk adult patient discharges occur. Hospitals managing transplant, oncology, or complex chronic disease patients would particularly benefit.

Next Steps

  • Final program evaluation, reporting on patient outcomes and readmission rates.
  • Refine and formalise the model of care based on pilot learnings.
  • Develop culturally safe resources and workflows in consultation with IHLOs.
  • Seek ongoing funding to embed the service into standard care pathways.
  • Explore expansion to other patient cohorts and Queensland Health sites.

References

Queensland Health. Transition of Care Pharmacy Project – Final Report. Queensland Government.
December, 2023. Accessed September 13, 2024. Transition of Care Pharmacy Project (health.qld.gov.au)

Key contact

Dr Rachael Lawson and Rachel Braddon

Pharmacist Clinical Lead

Children's Health Queensland

Email:  rachael.lawson@health.qld.gov.au

Last updated: June 2025

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