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Bevan Exemplar Cohort 4 Projects

Medicines management support for recently discharged patients: a co-ordinated, needs-assessed approach

Amanda Powell and Stuart Gray

Cardiff and Vale University Health Board and Llwyncelyn Practice, Whitchurch

This Bevan Exemplar project aimed to assess and meet the medicines management needs of every patient discharged to a GP practice.


It is recognised that not enough support is given to patients to manage their medicines after discharge from hospital. Most at risk are the frail elderly who may not be able to access the usual community pharmacy resources.

The intervention

All recently discharged patients (105) were assessed over 4 months in one GP practice.

Patients were assessed as needing one of the following interventions:

  • Home visit by pharmacist or pharmacy technician (14, 13%).
  • Referral to the Community Pharmacy Discharge Medicines Review (DMR) service (58, 55%).
  • No additional medicines management support (33, 32%).

Criteria for assessment included age, number of admissions in past 6 months, duration of admission, co-morbidities, number of medicines and number of medicines changes at discharge.


Only 39% of DMR referrals were acted upon by the community pharmacy. Reasons included patient not contactable, patient declined, time constraints, no internal communication of referral, IT issues.


For very little time investment (1-2 hours of a pharmacy technician band 5) per week, it was possible to assess all discharges. A small proportion of patients, those with the greatest need, were visited at home where their understanding and adherence to their medicines regimen could be assessed and adapted as necessary. Every patient visited at home had input from the pharmacy team.

Home Visit – Stan’s Story:

  • 83 year old gentleman discharged after admission for anaemia due to bleed (NSAID stopped prior to admission) and chest infection.
  • Partially sighted, lives with wife.
  • Concerned about whether his inhaler works when he is breathless. Inhaler difficult to use.
  • Inhaler device changed to suit patient preference.
  • Previous inhalers taken away (stockpiled as not used).
  • Advice given to not use NSAIDs in future.
  • Citalopram dose reduced after discussion with Stan, his wife and the GP (dose higher than recommended for age).

Discharge Medicines Review (DMR) In Action: Kenneth’s Story

Discharged after a Total Knee Replacement on strong opioids and apixaban.

Part 1: Explanation to patient that apixaban short course and strong opioids only in first few weeks after operation.

Part 2: Follow up with patient regarding pain control. Strong opioids now stopped.

Next steps

Reliance on referrals from hospital staff to the DMR service may not be the way forward. The DMR service does not tend to help those most in need of support post discharge. This small project has shown that there is potential for assessment, and delivery, of patients’ medicines management needs within primary care – where they are known best.

Working within Primary Care Clusters, this assessment could be streamlined in the future.