Table 3.

Building patient capacity and engagement in self-managing medications at home.

Sub-theme	Barriers	Strategies	Example Clinical Team Member Quotes
Patient self-efficacy and activation in medication self-management	- Patients not feeling empowered - Lack of patient investment - Patient/ caregiver understanding of medication regimen	- Education/ teach-back of patient/ caregiver	“I just think that patients don't come to the hospital empowered to give us the right information. …So I think that a lot of patients come in and they just assume that because we're a hospital, we have all their records and that everything we have is up to date. But that's relying on so many people in the process to make sure that things are the right way.” (Pharmacist)
Individual factors impeding medication self-management	- Cognitive or physical limitations - Costs - Incomplete information - Clinical role ambiguity/ role ownership	- Having meds “in hand” at discharge - Teach-back with patients/ caregivers - Clarity of clinical roles - Increased education	“I think the other thing is working with the caregivers … the nurse might come in or the discharging physician and go through the med list. Well, that’s not the person doing the meds. The patient may not – It might be the caregiver who’s assembling all the meds, so the patient may be a little confused or whatever or tired, sleep deprived, not getting any of this in… and then the wrong person’s being taught.” (HM) “We’re navigators in trying to help them to keep their things in order, but we don’t want to do it for them. We want to make them as independent as possible. So I’ll sit there and say, ‘Okay, now, take the paper he gave you and okay, he made that change. Now take that pill and put it in a box and let me see you. Because we want them to do it and not us do it for them.’” (Transition Nurse) “So I think that's one of the biggest things I find frustrating is that we have so much poly-pharmacy… I mean, sometimes they need all those medications, but they're understanding of what their medicines are and they're understanding of how to take them, why they take them, and what they're for, is really lost. They don't have good insight into what they're taking, and also cost. Cost is a huge issue, that patients can't afford their medicines. You know, their insurance ran out so they stopped taking it. So cost is a big problem, too.” (Pharmacist)
System factors impeding medication self-management	- Financial/ Insurance barriers - Poly-pharmacy - Cost	- Social support - Transportation - Education - Coordination of care	“I would say with the elderly population they're on very limited incomes, so we have to be really mindful of that, and many times they'll come in here and we'll tweak their medications is what they like to call it, change it just a bit. Very confusing to an elderly person. …” (Case Manager) “I think it would help to have, obviously more social support for these patients through case management and social work. …You know, when it comes to the complex care of these patients, the complex comorbid conditions … I think we need more education and more patient education, more patient outreach. You know, handing them a list on discharge and hoping that the nurse, while she's taking care of five patients, has the time to review all the medications and that she actually knows all the medications. I think that's a huge what if. I don't know if that's the safest process. … I'd love to see pharmacists counsel everyone on discharge, just to be able to be that person to answer all those questions and just know the answers to those questions, or at least, know how to figure them out quickly.” (Pharmacist)