“It’s very complicated”: a qualitative study of medicines management in intermediate care facilities in Northern Ireland

The aims of this study were to describe the current provision of medicines management services in IC facilities in NI and to determine HCWs’ and patients’ views of and attitudes towards these services. This study uncovered disparities between the concept of IC and many aspects of the reality of the services. The setting in which IC was provided was found to be a crucial factor in determining prescribing responsibilities and consequently, arrangements for the supply of medicines to patients. A lack of a standardised approach to the provision of medicines management services including the clinical review of medicines was identified. The lack of integration of pharmacists in IC was evident, and HCWs suggested that increased pharmacy input could offer a potential solution to the identified medicines management deficiencies.

The theme of ‘concept and reality’ symbolised the contrast between the key principles of IC and the service reality. IC is a relatively new concept within the UK, yet it has been integrated into the healthcare system in a variety of models [14]. Community hospitals (non-acute hospital facilities) represent one such model which pre-date the term ‘IC’ but are increasingly being used as IC facilities in the UK [15]. Despite this re-designation, HCWs felt that although IC may be considered a new concept, in reality, the service provided within such facilities remained largely unchanged, providing support to the suggestion that the IC concept is ‘an old idea rebranded’ [16]. Additionally, the confusion surrounding terminology is not unique to NI and has been the subject of previous discussion in the literature [17].

The concept of IC describes services aimed at both preventing unnecessary hospital admissions and providing ‘step-down’ care, however, in NI, the majority of patients are admitted to IC following a period in hospital. The preventative concept of IC is not being realised perhaps due to a lack of awareness of the role of such services within the wider healthcare system. Disengagement with and lack of awareness of IC on the part of both GPs and hospital doctors has been highlighted previously [16,18]. The unfamiliarity of IC, coupled with pressures faced by acute hospitals to discharge people sooner may contribute to the reported inappropriate admissions to IC in this study. There have been calls to promote awareness among those who refer patients to services, however, evidence is needed to support IC as a care setting [19].

Another concept of IC is the multidisciplinary team. In actuality, this study found that multidisciplinary teams varied considerably between facilities, particularly in relation to medical care provision and pharmacy involvement. If IC is to be a service that seeks to address all aspects of a patient’s care needs including their medicines management needs, a standardised approach to multidisciplinary team working and integration of pharmacists is required. Despite these contrasts between the concept of IC and the reality of the services, patients in this study compared IC favourably to the traditional hospital setting. The perceived benefits of IC for patients were often linked to the ‘home-like’ environment of IC, and have been described previously [20–22].

The theme of ‘setting and supply’ illustrates the impact of the IC setting on medicines management provision and specifically, the supply of medicines. The settings in which IC was delivered within NI were found to be varied, differing not only in the care environment but also the medicines management processes within. The supply of medicines was by far the most frequently voiced medicine-related concern amongst IC staff. Securing a prescription and obtaining medicines from a pharmacy, where a supply was unavailable on-site, presented many difficulties for HCWs. Such gaps in continuity of care have been associated with adverse patient outcomes [23–25]. Conversely, in the non-acute hospital facilities where both prescribers and medicine stock were accessible on-site, such supply issues were practically non-existent. A solution suggested by many HCWs, was to have medication stock available in all IC facilities, thereby eradicating the logistical barriers described. The difficulty with such a proposal would be the requirement for a significant change in the longstanding medication supply arrangements within the nursing and residential homes. Nonetheless, it is evident that the current mode of medication supply within such facilities is not effectively catering for IC patients.

Responsibility for prescribing and reviewing patients’ medicines in the IC facilities varied depending on the setting. There was no standardised approach to the review of patients’ medicines and in the majority of facilities, HCWs noted that medication reviews were not conducted unless explicitly requested. This therefore poses a risk that medication discrepancies and/or ADEs may go undetected amongst older adults in IC facilities. Another barrier to medication review was the assumption of medication optimisation in the acute setting. Caring for older people in residential and nursing home settings is known to have significant workload implications for GPs responsible for their care [26]. The reluctance of GPs to visit patients in institutional settings has been discussed previously and factors such as a desire amongst GPs to maintain strict practice boundaries and the perceived trivial nature of visiting requests have been cited as barriers to the provision of general medical services to older people in these settings [27].

Self-administration of medicines was not promoted in the IC setting. HCWs represented the main barrier to self-administration as they felt the need to be in control of patients’ medicines, citing patient safety as their primary concern. Further resistance to self-administration of medicines came from patients themselves, who were happy to let staff take control of their medicines. There was an expectation among patients of the loss of autonomy when entering a healthcare facility. The same power dynamic between healthcare staff and patients has been described in the traditional nursing home setting [28]. Self-administration of medicines is synonymous with encouraging independence and thus patient empowerment, which itself is associated with improved healthcare outcomes [29]. Specifically, self-administration programmes have been shown to improve compliance with and knowledge of patients' medications post hospital discharge [30,31]. Despite patients’ indifferent attitudes towards self-administration in this study, it has been demonstrated that following participation in a self-administration programme, the vast majority of patients report a preference for this method over usual nurse administration of medicines [30]. In order to successfully implement self-administration programmes with the view of increasing patient independence, there needs to be a re-examination and acknowledgement of responsibility from not only HCWs but patients as well.

Medication counselling was not routinely provided to patients in IC. A perceived lack of confidence amongst HCWs surrounding knowledge of medications and a view that many older people would not benefit from medication counselling were the two main barriers described. Similar findings have been discussed previously with the result of nurse-patient communications being criticised for often being brief and superficial in nature [32]. Patients’ attitudes proved to be an additional barrier to medication counselling, with many feeling it was simply unnecessary. Medication counselling should be an integral part of patient care, especially in the IC setting where patients are rehabilitating and regaining skills to ensure their independence. Patient education has been shown to improve patients’ ability to remain autonomous with their medications and is frequently a part of interventions aimed at improving adherence to medicines [33]. It has also been associated with a decreased incidence of avoidable adverse drug events post hospital discharge [13], therefore the importance of increasing patients’ understanding of their medicines in the IC setting cannot be underestimated considering that the goal of IC is to promote independence.

Facilitating the supply of medicines, reviewing medicines [34], promoting self-administration [35], and medication counselling [36] are all roles associated with pharmacists. However, it was evident that pharmacists were not integrated members of the IC multidisciplinary team as the pharmacy presence throughout the facilities was minimal. Most facilities referred to community pharmacists as being their sole pharmacy contact who served only to facilitate the supply of medicines. The clinical pharmacists who assumed enhanced pharmacist roles in IC experienced challenges integrating as part of the multidisciplinary team. This may be due to a lack of awareness of the pharmacists’ role, which has previously been identified as a barrier to pharmacist integration in such team [37]. In those facilities without clinical pharmacy input, staff readily identified a range of roles for pharmacists that were currently being unmet. These included medicines reconciliation, liaising with primary and secondary care stakeholders, medicines appropriateness reviews and patient and staff education. Conversely, a minority of HCWs could not see a role for pharmacists in IC, despite identifying several unresolved medicines management challenges. Again, such views may be due to a misunderstanding of the role and stereotypical business orientated image traditionally associated with the profession [38]. There is, therefore, a need for more work to evaluate the role of pharmacists within IC and to raise awareness of the roles of clinical pharmacists.