When a patient came into Heart Pharmacy holding a paper prescription for two diuretics and directions to blister pack, pharmacy manager Andrea Silver thought nothing of it.
It was only when the patient asked if he needed to continue taking his antibiotics after being discharged from hospital that the Victoria pharmacist discovered a red flag. After checking CareConnect, B.C.’s view-only Electronic Health Record (EHR), she discovered the patient had an episode of acute kidney injury which led him to be held an additional day, and he was directed verbally to stop taking the diuretics that had been prescribed previously. The handwritten prescription had not been changed, and the client did not understand or remember the new directions.
From that moment, the Heart Pharmacy team implemented a practice policy change: When a patient is discharged from hospital, they will always check CareConnect.
Some patients arrive to their community pharmacy with a paper prescription of medications. Some have medications dispensed from the hospital pharmacy to last the evening. Some may carry or have discharge papers faxed with omissions of medications or no directions on use. Some may not even tell their community pharmacist they’ve been in the hospital.
“When people come out of the hospital, they’re unwell and confused and they don’t always understand what has happened with their medications,” Silver said.
For B.C.’s community pharmacists, a patient who has had a transition in care — from hospital back to community, into a weekend respite facility, or a discharge from another facility — is one of the most challenging parts of their job.
Andrea Silver (centre, in white), pharmacy manager at Heart Pharmacy IDA at Shelbourne Plaza, poses for a photo with her pharmacy team members. She regularly serves patients who are transitioning back to community care after receiving services from Island Health's Hospital at Home program.
“These cases are more complex and require far more diligence. It takes up a large cognitive capacity. In our pharmacy, we have licensee overlap most of the day, but uninterrupted focus is not a reality that many pharmacies can meet,” she said.
While the 2023 changes in allowing pharmacists to do more therapeutic substitutions have helped address changes due to formulary, there continue to be challenges in medication reconciliation, communication of intentional changes versus omissions, compliance packaging that needs to be built quickly and often delivered that evening, follow up requiring changing frequency from monthly to weekly and back again, and simply knowing how to contact the prescriber with questions.
An ideal fix would be the standardization of hospital discharge prescription preparation, Silver said. Each one should specify the date/time the patient is going home and list their medications in a way that specifies whether the patient is continuing a previously prescribed medication, if the prescription was changed, or if it is a new prescription. Additionally, these discharge prescriptions should indicate if the patient was sent home with medication.
“If they are being discharged late in the afternoon, ideally they should be sent home with at least an evening and morning dose, so that the pharmacy has time to safely review the medication, check for and resolve errors, build a compliance package, and arrange for delivery according to standards,” she said.
Pharmacist Anthony Lee, Associate Owner of Shoppers Drug Mart #0204 at Kingsgate Mall and #2245 at Robson and Burrard, sees the same thing in discharges from Mount Saint Joseph Hospital and St. Paul’s Hospital.
The most common issue he and his team face is understanding the medication changes made in the hospital and not having a complete picture of where the patient stands after their time in care.
"We don’t know if a medication was changed on purpose or if it was simply excluded,” Lee said. “It depends on the physician or if the patient had a medication reconciliation. More often than not, a prescription has disappeared and nothing is known about it.”
This delays patient care when Lee and his team must try to reach hospital physicians to clarify the prescriptions. Often patients are released mid-day or near the end of the day and come into the pharmacy to fill prescriptions. By the end of the day, physicians are challenging to reach.
Some prescriptions are faxed two days before a patient is discharged, and by that point, a patient’s medication could have changed.
“What would make both the lives of the patients and pharmacists better would be a unified process,” Lee said. “A unified process in timing so that a patient has social care and referrals all completed would be ideal. We at the pharmacy would get discharge prescriptions 12 to 24 hours in advance with a list of all medications. That would be ideal.”
Other transitions in care
For Heart Pharmacy in Victoria, some patients transition back to community care after receiving services from Island Health’s Hospital at Home program, which allows patients to receive hospital-level care in their home rather than a traditional hospital ward. While this service allows for patient and family comfort and frees up bed space, it’s another challenge for pharmacists, Silver said.
“Sometimes it’s not clear to family that this patient is a hospital patient, and the hospital doesn’t use PharmaNet even though they are now providing medications to a person living in community which makes communication and problem-solving challenging. Their clinical notes aren’t posted on CareConnect until discharge, either,” Silver said.
“It would be helpful for PharmaNet and CareConnect to work together. That way we could see from one point of access whether a person is admitted to hospital, whether they’ve been discharged, what their care plan includes, and the intended changes for medications.
“These are clients that are used to receiving advice and care from our pharmacy team and often use us as a trusted, accessible point of care, but we are not notified when clients are admitted to hospitals or moved into hybrid programs served through the health authority.”
While patients are receiving in-home supportive care, there can be confusion with changes to medication administration care plans, as case managers often communicate with the pharmacy through the patient, rather than directly.
“We will receive vague last-minute requests to make major changes to compliance packages to align with home visits, often requiring recommendations to the doctor for changes to formulations that can be taken less frequently or to those that can be liquid or crushed,” said Silver. “These requests may require changes to previously dispensed compliance packs, and include coordination of delivery, use of a health-authority lockbox, etc.”
Weekend respite care for seniors or children with high needs can be another pain point. Pharmacists must transfer medications to blister packs for the weekend and then back again after.
There is significant work in creating and sending medication administration records for the facility’s nurses, handling OTCs and blister packing medications that patients have already purchased, with no mechanism of reimbursement. And then pharmacists must change it back after a patient has been moved out of the respite home again.
“Respite care is so important,” Silver said. “Caregivers need a break and time.”
Pharmacists play an important role in understanding medication changes made while a patient is in hospital, which often requires connecting with hospital physicians to ensure they have all the information about a patient's medications.
Long-term and Assisted Living
At Apex Pharmacy, which sits directly across the street from Abbotsford Regional Hospital, the pharmacy team specializes in serving patients in long-term care and assisted living facilities and handles many transitions from hospital directly into care facilities.
“People don’t realize the challenges we face as pharmacists,” said pharmacy manager and co-owner Elke Groening.
A patient transferring from the hospital into a long-term care facility might have a discharge prescription with a low quantity of a single week which doesn’t give the patient or pharmacist enough time to make sure they have enough medication. The patients’ new physician at the facility will say they don’t know the patient and can’t write a new prescription, so Groening will have to dispense an emergency supply of medication to allow the patient to transition.
Another challenge for discharge prescriptions is the sheet itself, which has checkboxes listing whether a medication is a new prescription, should be discontinued or if a patient should use their home supply. When “use home supply” is marked, it doesn’t work for a patient going directly from hospital to a long-term facility, because they won’t be going home.
Groening and her team then must ensure the patient has a new prescription, which means the pharmacists must contact the patient’s family physician to write a new prescription for the same medication. Like others, discharges at the last minute or the end of the day are a challenge for long-term and assisted living. Nurses require specialized packaging to be able to provide the medication. And working to reconcile prescriptions that may have information omitted or seeking special authority when physicians have gone home is hard.
“It can cause a delay in treatment,” she said. “It’s quite stressful. Of course we want to make sure the patient has the medication.”