ABSTRACT
Background and Aims
Research to date has detailed numerous challenges and areas for potential harm surrounding medication management after hospital discharge for older adults, but few studies have directly detailed the concerns of older adults and their caregivers on these topics based on their lived experiences.
Methods
We conducted 34 structured post‐discharge interviews with older adults and their caregivers following hospitalization at the University of North Carolina Acute Care for Elders (ACE) unit using a questionnaire developed by an interprofessional working group within the division of geriatrics. All patients discharged home from the unit over a 1‐month period were contacted for an interview. Interviews were analyzed by three reviewers for themes and subthemes identified by a geriatric pharmacist, including medication communication, medication prescription process, and medication access.
Results
Patients were 78.9 ± 8.7 years of age, 64.5% women, and 74.2% White. Interviews were conducted with those who self‐reported responsibility for managing medications and included 15 patients, 15 caregivers, and 4 patient/caregiver dyads (34 total). Many participants felt that communication about medications lacked key information (62%, n = 21) or was unclear (29%, n = 10). Common concerns included potential side effects and administration instructions, including participants who expressed a lack of understanding of the duration of medication use or frequency for “as needed” medications. Several participants also reported issues with the prescription process for medication including prescriptions that lacked desired information (9%, n = 3) or were not properly sent to the patient's desired pharmacy (12%, n = 4). Fewer participants reported issues with medication access, including transportation (9%, n = 3), stock supply (9%, n = 3), and insurance/affordability (6%, n = 2).
Conclusion
Our study found that patients and caregivers frequently expressed concerns regarding communication about medications or obtaining their medications after discharge. Efforts are needed to enhance the process and reduce the risk of medication‐related harm in the period after discharge.
Keywords: discharge communication, medication access, polypharmacy, transitions of care
Summary
Navigating medication changes after discharge of older adults from the hospital can be fraught with challenges regarding communication and access.
Many older adults and their caregivers reported frequent issues with missing information about medications or unclear instructions following hospital discharge.
Efforts to better ensure clear communication about medications and access to medications are needed to minimize the risk of medication‐related harm after discharge.
1. Introduction
Care transitions for older adults following hospital discharge are fraught with challenges and often require complex care coordination. Approximately 15% of Medicare beneficiaries ≥ 65 years old who are discharged from the hospital are readmitted within 30 days [1], and previous studies have estimated that a quarter of these may be preventable [2]. At the time of discharge, care teams must relay information to patients regarding medication changes, follow‐up appointments, and disease self‐management, but previous studies have found significant gaps are often present in communication [3]. Effective communication at discharge demands time and patient‐centered skills, including adapting language to the patient or caregiver's health literacy, delivering essential information without information overload, engaging in a dialogue to ensure understanding and sustainability, and follow‐through to bridge transitions [3, 4, 5].
Tailored communication about medications at the time of discharge is particularly relevant to older patients who may be at higher risk for medication‐related harm due to polypharmacy and age‐related pharmacokinetic and pharmacodynamic changes [6]. Discrepancies in medication reconciliation at the time of discharge for older adults have been discovered on a disturbingly frequent basis [7]. Qualitative studies have found that older adults and their caregivers frequently express frustration related to the significant gaps in communication surrounding medications following hospital discharge [8, 9]. Suboptimal communication about medications contributes to 17%–51% of instances of medication‐related harm after hospital discharge among older adults, with 35%–59% of these being potentially preventable [6].
An interdisciplinary team working at the University of North Carolina Acute Care for the Elderly (ACE) unit conducted a quality improvement project that used patient and caregiver feedback to identify shortcomings in communications regarding medication changes and access to medications at the time of discharge. The objective of this study was to characterize patient and caregiver perspectives on the shortcomings of communication related to medication changes at the time of discharge.
2. Methods
2.1. Overview
This Quality Improvement Mixed‐Methods Study was conducted on a 24‐bed Acute Care for Elders (ACE) Unit. The ACE unit is located at the University of North Carolina's Hillsborough Campus, a 128‐bed community hospital, and serves as a teaching service for the UNC Internal Medicine Residency Program. The study was approved by the University of North Carolina at Chapel Hill Institutional Review Board and adheres to SQUIRE (Standards for Quality Improvement Reporting Excellence) reporting guidelines [10].
2.2. Interviews
All ACE unit patients discharged home between September 2022 and October 2022 were invited to participate in the study, resulting in 34 interviews. Interviews were completed within 3 days after being discharged home. Either the patient, the patient's caregiver, or both were interviewed, based on the self‐report of who managed medications. Demographic data were collected via extraction from the electronic healthcare record using the medical record number of the patient during the interview. In three cases, this number was recorded incorrectly preventing demographic data from being extracted though this missingness was felt to have been at random and unlikely to meaningfully impact results.
A structured interview guide was developed a priori (see Supporting Information S1) to evaluate experiences of learning about and accessing medications prescribed at discharge for patients and caregivers. Additionally, to better understand the patient perspective, participants were also asked about their experience with the after‐visit summary (AVS), a written document used to summarize the hospitalization and discharge instructions, which was prepared by the discharging physicians and reviewed with patients by their nurse.
The interview guide was created based on the expertise of seven multidisciplinary ACE unit healthcare professionals, including a physician (D. L.), nurse practitioner (J. G.), clinical pharmacist (R. D.), registered nurses (K. F., C. M., R. F., C. A.), and one quality improvement specialist (K. L. B.). A PhD candidate in nursing who had been trained in patient communication through previous nursing education and qualitative research methods as part of her PhD took part in training with the primary investigator regarding the use of the structured interview methodology of the study. She conducted interviews via telephone, transcribed the participants’ answers, and entered them directly into a database.
2.3. Qualitative Data Analysis
A geriatric pharmacist (R. D.) reviewed the responses and developed categories for qualitative themes and subthemes using past clinical experience and previous internal survey findings using thematic analysis of the interview responses. Two reviewers (R. D., C. A.) then analyzed transcripts according to themes and subthemes. Themes included medication communication, medication process, and medication access. Within medication communication, subthemes included “missing information,” “unclear instructions,” the “process being too quick,” and “medication purpose not being explained.” Within the medication process theme, subthemes included “incorrect information,” “missing information,” and “issues with the prescription not being sent to the pharmacy.” Within medication access, subthemes included “transportation,” “medication not being in stock,” “insurance issues,” and “affordability.”
There was high inter‐rater reliability, and discrepancies were resolved by the principal investigator (D. L.), who independently coded transcripts and acted as a tiebreaker. All three reviewers met to discuss the results and reach consensus.
3. Results
3.1. Patient Characteristics
Patients were 78.9 ± 8.7 years of age, 64.5% women, and 74.2% White (Table 1). Among 34 total interviews, 15 were conducted with the patient alone, 15 with the patient's caregiver, and 4 with the patient and caregiver together, based on who reported managing medications. When asked if anyone talked to patients or their caregivers about medications before discharge, more participants mentioned nurses (38%, n = 13) than doctors (18%, n = 6), though several (12%, n = 4) mentioned discussing changes with both.
Table 1.
Patient characteristics.
| Characteristic | N = 31a |
|---|---|
| Age | 78.9 ± 8.7 years |
| Interview with patient | 73.8 ± 8.7 years |
| Interview with caregiver | 84 ± 3 years |
| Interview with patient and caregiver | 82.5 ± 7.3 years |
| Gender | |
| Female | 20 (64.5%) |
| Interview with patient | 9 (69.2%) |
| Interview with caregiver | 8 (53.3%) |
| Interview with patient and caregiver | 3 (100%) |
| Race | |
| Total White | 23 (74.2%) |
| Interview with patient | 9 (69.2%) |
| Interview with caregiver | 13 (86.7%) |
| Interview with patient and caregiver | 1 (33%) |
| Total Black | 7 (22.6%) |
| Interview with patient | 4 (30.7%) |
| Interview with caregiver | 1 (6.7%) |
| Interview with patient and caregiver | 2 (66%) |
| Total Asian | 1 (3.2%) |
| Interview with Caregiver | 1 (100%) |
Due to errors in recording the medical record numbers (MRNS) at the time of the interviews, demographic data could not be obtained for 3 of the 34 participants.
3.2. Medication Communication
According to patient and caregiver reports in structured interviews, the most discussed theme following a patient's transition from hospital to home was communication about medications (Figure 1). Medication communication was most often felt to be missing information (62%, n = 21) or to have unclear instructions (29%, n = 10).
Figure 1.
Total number and percentage of interviews in which participants expressed concerns about each subtheme related to post‐discharge medications stratified by overall themes.
3.3. Missing Information About Medication
The most frequent area of missing information, according to participants, was regarding potential side effects of new medications (53%, n = 18). One discharged patient who was prescribed furosemide discussed the lack of communication regarding side effects as the top area for communication improvement:
They had told me it might be some side effects with the Lasix, but it could have been my fault because I did not ask.
‐Participant #29
3.4. Unclear Instructions
Among those who discussed unclear instructions, the timing of medications emerged as an important area of confusion. Participants reported a lack of necessary details regarding the timing of administration, and whether “as needed” (PRN) medications could be taken at any time or just once daily. One caregiver reported inadvertently administering a bedtime PRN trazodone multiple times per day, noting persistent somnolence as an adverse effect. A different patient noted that he had been prescribed a nasal spray but
They didn't explain to me how long I should take the nasal spray for.
‐ Participant #2
One patient noted that last‐minute changes made by the treatment team were not consistently communicated, leaving them feeling confused and forced to clarify things with their outpatient doctor:
We understood everything about the medication, but the doctor that came in while we were in the process of being discharged said we could go ahead and double up what we have and take two 10 mg pills in the morning and 10 mg in the evening which totals to 40 mg. We have an appointment with our heart doctor on Friday and he will tell us what to do.
‐ Participant #5
3.5. Medication Purpose Not Explained
Other interviewees (15%, n = 5) noted that they felt that the purpose of medications was not clearly communicated at the time of discharge. One caregiver noted that she returned home without understanding why a new medication was started and called the hospital the next day.
After the nurse explained, I understand why she is on aspirin, but I did not know why before the call.
‐Participant #1
3.6. Medication Communication Was Too Quick
The sense that medication communication was too quick was noted by 12% of participants, with one participant reflecting that
Going over the discharge instructions seemed rushed.
‐Participant #32
3.7. Medication Process
3.7.1. Missing and Incorrect Information
A total of 9% (n = 3) of participants noted that missing or incorrect information led to a delay in obtaining medications after discharge. Most were related to the issues with the process of obtaining over‐the‐counter medications, such as those that they were covered by Medicare or medications being sent to the wrong pharmacy. One participant noted that some necessary information was unresolved at discharge.
The Voltaren gel and Lidocaine patches the pharmacist said have to be written in some kind of way for Medicare to pay for them. He said they would reach out to the doctors tomorrow.
‐Participant #27
3.8. Rx Not Sent to Pharmacy
A total of 12% (n = 4) of participants discussed that prescriptions were either sent to the pharmacy with issues, were sent to the wrong pharmacy, or not sent to the pharmacy at all:
There was only one thing that I did not understand. I think it was a misunderstanding from my side. I thought someone was supposed to call in the 40 mg to Walgreens. I called them but they said they do not have it.
‐Participant #5
4. Medication Access
4.1. Medication Affordability and Insurance
Most participants had no issues acquiring medications after discharge, but 6% (n = 2) noted unanticipated issues with insurance or affordability with one saying
My issue was they ordered a medication that isn't covered by her insurance…we have to pay $125 for her nausea medication.
‐Participant #7
4.2. Transportation and Medications Not in Stock
There were additional issues with the logistics of picking up medicines including transportation issues (9%, n = 3) and stock supply issues (9%, n = 3). One participant noted that she could not pick up medications for 2 days after discharge because she could not leave her husband by himself, while others noted that their pharmacy did not have their medication in stock.
4.3. The Use of After Visit Summary (AVS)
The AVS was viewed by the majority of participants (74%, n = 25) as an important tool for medication communication. Its utility was mediated by the quality of the AVS. One participant expressed appreciation for the completeness of information that clearly highlighted changes in medicines. Among those who did not feel they benefited from the AVS, two participants noted that it was not properly provided or reviewed.
The only thing [was] it said I had 9 pages, but I was only given 4 pages.
‐Participant #6
We did not receive the after visit summary, but I saw it on his MyChart (electronic healthcare record account).
‐Participant #19
5. Discussion
In this single‐site quality improvement initiative, patients and caregivers had mixed levels of satisfaction regarding medication communication and access at the time of discharge from our ACE unit. These findings have implications for future efforts to improve the discharge process for older adults and their caregivers, especially in the setting of significant medication burden.
There is an expansive body of qualitative research on issues surrounding medications after hospital discharge [11, 12, 13, 14, 15]. However, our work builds on the smaller subset of existing studies that have explored challenges specifically for older adults after hospital discharge. This nuance is important, as previous work has documented that older adults face unique complex needs and vulnerabilities in acute care settings [16]. They are also at higher risk of medication‐related harm with communication breakdown frequently identified as a modifiable risk factor for such adverse events [6]. Such harm may put older adults at risk of repeated hospitalization in short duration, which previous studies have associated with higher mortality risk [17]. Previous qualitative studies have explored shortcomings surrounding communication about medications at the time of discharge for older adults and their caregivers. Knight et al. found that inadequate explanations of medicines at discharge were commonly reported by patients and their caregivers. In some instances, they found this resulted in incorrect medication administration and confusion [8]. Tomlinson et al. found that patients and caregivers felt that information surrounding post‐discharge medications often lacked sufficient detail leading to disrupted knowledge and medication management [9]. Similarly, work by Pereira et al. found that older adults often identified concerns about communication, collaboration, and coordination, though they explicitly noted that participants did not cite obtaining medications or medication side effects as major stressors [18]. Interestingly, our study found that most concerns were related to omission of desired information including side effects or unclear medication administration instructions. These findings were uniquely identified by our study and have not been previously discussed in other settings. This suggests that further explicit study of patient understanding of medication side effects at the time of discharge may improve patient satisfaction and safety.
Quality communication that ensures patients are able to continue recommended medical care after discharge is a complex process that does not occur in a vacuum. Systemic factors such as health literacy, access to transportation, and socioeconomic status have the potential to lead to varied outcomes for different patients even when the same information is presented. Unclear discharge communication that relies on jargon‐filled discharge instructions that fail to appreciate the lived realities of patients may create gaps in care after discharge. These gaps can compromise well‐intentioned efforts to improve care transitions.
Identification of similarly identified gaps has prompted the creation of several different types of interventions to better support communication at the time of discharge including additional patient education, medication reconciliation, telephone follow‐up, and patient‐centered discharge documents [5, 19, 20, 21, 22]. Although our unit's use of the AVS was reviewed by a nurse who sought to bridge these gaps, our study showed that detail and implementation were inconsistent, leading to confusion and the potential for patient harm. While the underlying drivers for omission of the AVS at discharge were not studied, one could hypothesize that the complexity of discharge coordination and the workplace demands of nurses may create opportunities for lapses in remembering to provide the document or review it in detail. Creating a standardized template for discharge instructions that explicitly ensures medication instructions, follow‐up appointments, and expected guidance are included holds promise for ensuring AVS materials meet the needs of patients and families. Further, a standardized discharge process with an easily accessible checklist for nurses to ensure discharge instructions are reviewed, and clarification can be provided if needed, may be helpful. Additionally, ensuring families and patients know that AVS materials may be accessed electronically through our healthcare system's online patient portal may aid with access to materials if paper copies are lost. Creation of a nursing discharge checklist to ensure an AVS with a standardized template was reviewed and provided to the patient and caregivers were implemented following the study.
Our study has several limitations. A nursing student trained in basic qualitative methods for the project conducted the interviews. The interviewer's lack of additional advanced training in qualitative data collection may have limited clarification of responses that were vague or seemingly unrelated. Additionally, the interviewer's status as a nurse in training may have influenced respondent's responses regarding satisfaction with communication performed by nurses or the healthcare team overall compared with a non‐clinical interviewer, given possible desire on the part of interviewees to maintain rapport with clinical teams. Discussion of discharge instructions in the hospital were not observed and thus left room for recall bias. Surveys were conducted over a single month, which may have led to limitations in further generalizability than a longer study. At our institution, attending physicians rotate weekly and resident physicians rotate every 2 weeks. As such, communication generalizability may have enhanced by a longer time frame that would have allowed for a greater diversity of physicians to rotate on the service.
Our sample size was small, and participants were predominantly white, therefore the generalizability to the broader population may be limited. A more diverse population may face different challenges, such as language barriers (e.g., concerns if the entirety of the AVS was not in English) or cultural differences that may emphasize a greater need for family involvement. While we did not collect income data for participants, only 2 of 34 participants noted challenges in affording medications, suggesting fewer financial concerns than may be present in other settings. Thus, it is possible that our findings do not reflect the full range of challenges regarding medication communication and access or that certain challenges may be under‐ or overrepresented. The need for clear communication regarding medication instructions and access is likely applicable across populations, though the specific needs may vary across subgroups. The population studied was discharged home rather than to a skilled nursing facility or other rehabilitation setting and thus may not represent the overall needs of older adults discharging from the hospital.
6. Conclusion
This qualitative study provides further insight into the experiences of older adults and their caregivers surrounding medication communication and access after discharging from a single‐center inpatient ACE unit. Many participants felt that communication regarding the administration of medications and possible side effects needed improvement, as breakdowns led to confusion and, at times, improper administration of medications. Despite these communication challenges, most participants were able to access medications after discharge, with few reporting an inability to pick up their medications in a timely manner. The use of a written summary of medication changes provided in an AVS provided to patients and their caregivers at discharge was well received though not always provided to patients on discharge. Overall, this study highlighted the need for clear communication surrounding medications for older adults and their caregivers post‐discharge to ensure effective medication management and avoid medication‐related harm after discharging from the hospital. Future efforts to improve communication about how to take and acquire medicines after discharge are needed through standardization of processes that engage physicians and nurses in this essential phase of care, and lead to clearer and more consistent oral and written communication.
Author Contributions
Brian S. Wood: formal analysis, investigation, methodology, writing – original draft, writing – review and editing. Caroline Buse: conceptualization, formal analysis, investigation, methodology, visualization, writing – original draft, writing – review and editing. Joshua D. Niznik: conceptualization, formal analysis, investigation, methodology, writing – review and editing. Kimberly J. Mournighan: conceptualization, formal analysis, investigation, methodology, writing – review and editing. J. Ronald Davis: conceptualization, formal analysis, investigation, methodology, writing – review and editing. David H. Lynch: conceptualization, formal analysis, investigation, methodology, supervision, writing – original draft, writing – review and editing.
Disclosure
The authors have nothing to report.
Ethics Statement
I, on behalf of all co‐authors, state that the work being submitted has been done in accordance to Wiley's Best Practice Guidelines on Publishing Ethics, in an ethical and responsible way, with no research misconduct, which includes, but is not limited to data fabrication and falsification, plagiarism, image manipulation, unethical research, biased reporting, authorship abuse, redundant or duplicate publication, and undeclared conflicts of interest.
Conflicts of Interest
The authors declare no conflicts of interest.
Transparency Statement
The lead author Brian S. Wood, David H. Lynch affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.
Supporting information
Supporting S1: A structured interview guide to evaluate patient experiences of learning about and accessing medications prescribed at discharge.
Acknowledgments
This project would not have been possible without the interdisciplinary efforts of our project working group including John Gotelli, MSN, GNP, Kittra Felton, RN, Christina Martin, RN, Rebecca Fenner, RN, and Kara Lingley‐Brown, MHA.
Contributor Information
Brian S. Wood, Email: bswood96@gmail.com.
David H. Lynch, Email: David_lynch@med.unc.edu.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supporting S1: A structured interview guide to evaluate patient experiences of learning about and accessing medications prescribed at discharge.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.