Shared learning database

Leeds Teaching Hospital NHS Trust (LTHT)
Published date:
August 2015

Pharmacy staff identified older people at high-risk of developing problems with their medicines post-discharge on the older people admission wards at Leeds Teaching Hospitals NHS Trust (LTHT) using clinical judgement. Where a medicines-related need post-discharge was identified, a medicines care plan (MCP) was added to the patient's discharge communication and patients (and or their carers) were also educated and signposted to healthcare professionals in Primary Care for follow-up where appropriate e.g. community pharmacists, practice pharmacists, practice nurses, district nurses, GPs, and community matrons. This relates to the NICE guidance on medicines optimisation specifically medicines-related communication systems when patients move from one care setting to another, medication review and medicines-related models of organisational and cross-sector working.

Supporting material

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

Aim: Improve medicines optimisation for older people and reduce medicines-related re-admissions to hospital


  • Identify older people at high risk of developing problems with their medicines post-discharge
  • Improve education on medicines for older people and/or their carers
  • Improve quality of information on medicines on the discharge letter including more specific follow up in primary care where appropriate
  • Sign-post or refer older people to healthcare professionals in primary care to provide post-discharge medicines support
  • Reduce medicines-related re-admissions to hospital

Reasons for implementing your project

Prior to the project starting, we could not always identify older people who might have problems with their medicines post-discharge. We were aware that some patients were coming back into hospital unnecessarily because of issues with their medicines. Whilst, we already used electronic discharge advice notes and tried hard to ensure all medicines changes were documented on these discharge advice notes, often requests for follow up in primary care were not specific, especially in relation to timescales. Therefore, monitoring of parameters such as blood pressure or blood tests was sometimes not performed or actioned in a timely manner.

In addition, some patients who needed support with their medicines or monitoring after discharge did not have any follow up information documented on their discharge advice note. This then left it to the GP to decide what support or monitoring might be required for the patient when reconciling their medicines post-discharge. Therefore, follow up actions post-discharge were variable. The percentage 30 day re-admission rate for the older people’s admission wards prior to the project starting was 22%.

LTHT is a large acute teaching hospital that has multiple sites and approximately 120 inpatient wards. It has a catchment of approximately 5.4 million for regional specialist  services and a population of 780,000 for intermediate services.

How did you implement the project

Patients admitted to the older people’s admission wards at LTHT were assessed by clinical pharmacists and pharmacy technicians to determine if they had a medicines-related need post-discharge. Initially, pharmacists used the PREVENT tool1 to identify high-risk patients but the pharmacy staff felt that the majority of patients admitted to the admission ward were high-risk using this particular tool and therefore clinical judgement was used in practice instead.

Where a medicines-related need post-discharge was identified, a medicines care plan (MCP) was added to the patient's discharge communication. This included specific advice on medicines follow up post-discharge. Patients (and or their carers) were also educated and signposted to healthcare professionals in Primary Care for follow-up where appropriate. These included community pharmacists, practice pharmacists, GPs, district nurses, community matrons and practice nurses.

Examples of signposting included referrals to community pharmacists for the new medicines service and post-discharge medicines use reviews, to practice pharmacists for clinical medication reviews and to practice nurses for review of inhaler technique. Some healthcare professional referrals were sent via fax or e-mail depending on the professional involved. Some patients were followed up by pharmacy technicians from LTHT via phone or via domiciliary visit, mainly for medicines support issues.

The project was funded by the Leeds Clinical Commissioning Groups for 6 months and £130000 was used to fund locum staff to implement the project, to measure performance and assess the project results and to make recommendations on how the project work could be continued after the initial work was completed. As the funding was part of a wider city-wide initiative, the Clinical Value in Prescribing workstream, key stakeholders were already supportive of the project and were updated on a monthly basis on progress.

1. Barnett N, Athwal D, Rosenbloom K. Medicines-related admissions: you can identify patients to stop that happening. Pharm J 2011; 286: 471-2

Key findings

Between October 2012 and March 2013, 204 acute older patients were assessed as requiring additional support post-discharge and were provided with a specific Medicines Care Plan (MCP). 175 (86%) of patients had a clinical need e.g. monitoring, dose titration or medication review. 73 (36%) of patients had medicines support needs e.g. compliance aids, prompting of medicines. Some patients had both clinical and medicines support needs. There were 285 re-admissions in the project period. 33 (16%) of the 204 MCP patients were re-admitted compared to 252 (22%) of the 1161 non-MCP patients.2 A retrospective case review of all the patients with a MCP and who were re-admitted within 30 days was performed by a consultant physician for older people and a consultant pharmacist to determine whether the re-admission was drug-related. The case review of the 33 MCP patients who were re-admitted showed that 6 patients had a medicines-related re-admission, none of which could have been anticipated. This aspect of the project was presented as a poster at the British Geriatrics Society meeting in November 2013.3

The IMPACT project resulted in improved medicines support and optimisation for older patients and improved communication and teamwork across the interface with healthcare professionals in primary care. This was a service development and not designed or powered to be a research project but there did appear to be a reduced re-admission rate for the IMPACT patients with a MCP.

2. Acomb C, Laverty U, Smith H, Fox G, Petty D. Medicines optimisation on discharge. The Integrated Medicines oPtimisAtion on Care Transfer (IMPACT) project. Int J Pharm Pract 2013; 21 (supp 2) 123-124

3. Smith H, Fox G, Khan I, Acomb C, Laverty U. Review of patients re-admitted post IMPACT pharmacist intervention designed to reduce medicines-related re-admissions. Age & Ageing 2014; 43:i1-i18


Key learning points

We were lucky to have key stakeholders in the city on board from the start as the project was part of the Clinical Value in Prescribing workstream. Stakeholders included the 3 Leeds CCGs, Leeds & York Partnership Foundation Trust (Mental Health), Leeds Community Healthcare Trust and Community Pharmacy West Yorkshire. These organisations provided a wealth of experience and support for the project and enabled the benefits of the project to be shared widely across the city. We were also able to obtain pump-priming funding for the initiative.

We regularly shared data on progress of the project and patient stories although we were only able to obtain primary care follow up data for 37% project patients. The patient stories were very powerful and were especially helpful in engaging clinical staff from other organisations. The project also highlighted a number of pathway issues which provided a platform for further collaboration and work on interface issues following the project’s completion. Part of the funding was used to employ locum pharmacists to do the project work. In hindsight, it would have been better to use the locum staff to backfill existing pharmacists to complete the work. Existing staff reported that they did not feel very engaged with the project and felt somewhat excluded. This then required additional work in engaging staff after the project was completed to continue the work and subsequently to roll out the initiative to other older people’s wards.

We used our existing technicians to follow up patients post-discharge during the project. After the project was completed, this work was then undertaken by technicians from Leeds Community Healthcare Trust. This was disappointing for the LTHT technicians involved who had really enjoyed the project work and who have subsequently moved into positions in primary care.

In summary, we could have given more thought to what would happen after the project was completed rather than focusing on the project itself. The project work was subsequently rolled out to all the older people’s wards at LTHT as a new project Care by Optimising Medicines for Elderly Patients on care Transfer (COMET) and is now business as usual on the older people’s wards at LTHT (see summary document attached for details).

Contact details

Heather Smith
Consultant Pharmacist
Leeds Teaching Hospital NHS Trust (LTHT)

Primary care
Is the example industry-sponsored in any way?

£130,000 was received for the project from CCG commissioners and supported by key stakeholders in Leeds including community and mental health Trusts and Community Pharmacy West Yorkshire.