This review has demonstrated the effectiveness of pharmacists' interventions to reduce the morbidity and mortality associated with heart failure. However, there is an on-going need for the development and evaluation of pharmacy services for these patients.

This study provides evidence for the feasibility of a post-discharge pharmacy service for patients with heart failure although barriers to implementation have been identified.

Background The period 7 to 10 days following hospital discharge is associated with a significant risk of medication misadventure, especially in high‐risk patients. Aim To investigate whether post‐discharge hospital‐initiated medication review (HIMR) pathways are more timely than the post‐discharge home medicines review (HMR) pathway. Method An implementation study conducted over 9 months in 2008/2009 of patients from 3 South Australian hospitals. A risk stratification instrument was used to identify patients at “high” risk of medication misadventure. Feasibility was assessed and time to conduct the post‐discharge medication reviews was determined for the HMR and HIMR pathways. Results Of the 97 consenting patients, 92 were stratified as “high” risk. HIMR were organised for 59 patients − 52 patients completed the HIMR process. Of the 22 HMRs organised via the patient's general practitioner, 18 patients completed the HMR process. The time from request to conducting the HIMR and HMR were statistically significantly different – HIMR and HMR took 6.5 ± 4.7 days and 11 ± 7.4 days, respectively (p = 0.02). Conclusion This study has demonstrated the feasability of alternative pathways to post‐discharge medication reviews. The HIMRs were conducted sooner than HMRs organised via existing community processes. If post‐discharge medication reviews are organised via the HIMR pathway, there is potential to reduce medication misadventure in high risk patients in a more timely manner than when post‐discharge HMRs are organised.

Background: Medication-related problems often occur in the immediate post-discharge period. To reduce medication misadventure the Commonwealth Government funds home medicines reviews (HMRs). HMRs are initiated when general practitioners refer consenting patients to their community pharmacists, who then engage accredited pharmacists to review patients' medicines in their homes. Aim: To determine if hospital-initiated medication reviews (HIMRs) can be implemented in a more timely manner than HMRs; and to assess the impact of a bespoke referral form with comorbidity-specific questions on the quality of reports. Method: Eligible medical inpatients at risk of medication misadventure were referred by the hospital liaison pharmacist to participating accredited pharmacists post-discharge from hospital. Social, demographic and laboratory data were collected from medical records and during interviews with consenting patients. Issues raised in the HIMR reports were categorised: intervention/action, information given or recommendation, and assigned a rank of clinical significance. Results: HIMRs were conducted within 11.6 ± 6.6 days postdischarge. 36 HIMR reports were evaluated and 1442 issues identified -information given (n = 1204), recommendations made (n = 88) and actions taken (n = 150). The majority of issues raised (89%) had a minor clinical impact. The bespoke referral form prompted approximately half of the issues raised. Conclusion: HIMRs can be facilitated in a more timely manner than post-discharge HMRs. There was an associated positive clinical impact of issues raised in the HIMR reports. J Pharm Pract Res 2009; 39: 269-73.

Background Medication-related hospital admissions in Australia have previously been estimated to account for approximately 3% of all hospital admissions, with hospital entry points being a point of vulnerability. The timely medication review and reconciliation by a pharmacist at the early stage of an admission for patients admitted to the Acute Medical Unit (AMU) would be beneficial. Setting The Emergency Department (ED) and AMU in a 300 bed tertiary teaching hospital, in South Australia. Objective To investigate the impact of a Medical Admissions (MA) pharmacist on the proportion of AMU patients who receive a complete and accurate medication history by a pharmacist prior to admission and within 4 h of presentation. Method This prospective observational study with a non-concurrent parallel study design examined a standard clinical pharmacist service within the AMU and ED to a Medical Admissions (MA) Pharmacist, in addition to the standard AMU and ED pharmacist service. Continuous variables were analysed using a two sample t test, whilst categorical data were analysed using Fisher's exact test. Risk ratios were also calculated for categorical data, with p < 0.05 taken as statistically significant. Main outcome measures Rates of completion of a complete medication history prior to admission and proportion of patients seen within 4 h of presentation by a pharmacist. Results The intervention resulted in more patients receiving a complete medication history prior to admission (2.7% in the control group vs 18.5%, p < 0.01) and being seen by the pharmacist within 4 h of presentation (1.6% in the control group vs 7.5%, p < 0.01). Conclusion Implementation of an extended hours clinical pharmacy service in the form of a medical admissions pharmacist based in the ED significantly increased the number of complete medication histories and clinical reviews completed for patients being admitted to an AMU. These were also completed earlier in the patients' admission. There was also a small trend toward increasing the proportion of patients discharged by 11 am in the intervention group.

Background We examined health professionals' views of a novel post‐discharge medication review model for high‐risk patients with 2 referral pathways – general practitioners (GPs) referring for home medicines reviews (HMRs) or hospital doctors referring for hospital‐initiated medication reviews (HIMRs). Aim To identify positive and negative aspects of the model, barriers and facilitators to implementation and to make recommendations for a post‐discharge home medication review program. Method 23 semi‐structured interviews were conducted with key stakeholders – hospital doctors, GPs, accredited pharmacists, hospital pharmacists and community pharmacists. Data were analysed thematically based on a conceptual framework. Results There was consensus that the availability of flexible pathways to post‐discharge home medication reviews was vital for patient care. Participants highlighted it was crucial that the patient's GP and community pharmacist are kept informed if the HIMR pathway was chosen. Barriers to implementation were time constraints experienced by health professionals to organise and conduct the review within 7 days post‐discharge and lack of awareness of the HMR process. Facilitators to implementation included existing positive working relationships and familiarity and support for the HMR process. Suggestions for future implementation included incorporating the liaison pharmacist role into the usual responsibilities of clinical pharmacists and educating medical interns about the model. Conclusion Consensus among medical and pharmacy stakeholders was that streamlined and flexible pathways to post‐discharge medication reviews would enhance quality use of medicines along the continuum of care.