Table 4.

Fundamental attributes of the process of medication management during hospital/skilled home health care transitions and associated barriers.

Emergent property of the MM process	Element from SEIPS 2.0 conceptual framework	Barriers identified in MM process during the transition	Description of barrier related to the emergent property	Illustrative quotation
Role ambiguity/confusion related to MM were ubiquitous at all process stages and for all actors	Person - Patient and informal caregiver	Level of trust in hospital-based healthcare provider care plan	Patient and/or caregiver may have a low level of trust in hospital providers, leading them to go back to home medication regimens instead of what was prescribed in the hospital	Q1: “Some patients don’t trust their physicians so they kind of just are doing their own thing, they don’t think their doctor really knows what they’re talking about or have their best interest at heart. It’s difficult.” — Setting 4
		Ambiguity of role related toMM during the transition	Patient and/or caregiver does not understand what their role should be in MM during the transition	Q2: “There were so many meds that had been changed … and the patient and family were like nobody told us that and here they’re handed a piece of paper that unless someone goes over it with them some of these people aren’t taking the time or aren’t educated enough to read it and understand it. — Setting 1
		Rapid transfer of roles	Patient and/or caregiver is required to take on full responsibility for MM immediately at the point of discharge	Q3: “[The hospital doctor] prescribed [a] new medication and took me off of some of the old ones because the two don’t work together, so when my [SHHC] nurse comes in I want to actually check ‘em, and she will tell me what to take and what not to take.” — Setting 1
		Caregiver impact on MM	Caregiver may positively or negatively affect the patient’s ability to perform MM	Q4: “At least [this patient] has someone to give him the medicine, to remind him to follow up with what the [medication regimen] is. There are people who don’t have that support. So then the only support they have is [to go] back to the hospital. — Setting 5
The MM process involved individuals performing work across system boundaries in loosely coupled teams	Person - Patient and informal caregiver	Knowledge and skills related to MM	Limited ability to understand and/or implement medication regimen	Q5: “I don’t know how clear it’s made to them when they leave the hospital that they need to stick with what’s on the discharge paperwork.” — Setting 1
		Ability to manage medication	Limited ability to cognitively or physically execute the tasks associated with MM	Q6: “At least [this patient] has someone to give him the medicine, to remind him to follow up with what the [medication regimen] is. There are people who don’t have that support. So then the only support they have is [to go] back to the hospital.” — Setting 5
	Task	Training to perform MM tasks	The level of training to perform MM tasks is not adequate to successfully execute the tasks	Q7: “Personally for me, but I know others struggle with this, the medication part of it [is the transition challenge]. Because we’re just not schooled that much in all the different medications, and reconciling those medications, and that kind of thing … we know cursory information about some of the medications and what they’re for, but when a patient starts asking us something, ‘Now what is this medication for?’ … I don’t want to lead them astray.” — Setting 3
		MM task complexity	Complexity due to the variability, unpredictability, or fluctuating nature of MM tasks	Q8: “You talk [with the hospital] about medications you’re going to take and then when you get the medications back from the drugstore, the names bear no resemblance.” — Setting 5
		SHHCP Workload	SHHPC workload does not support the current MM process	Q9: “Later on I’m gonna compare that to the paperwork that I have. I’ll probably call [primary care physician] office again and just find out for sure which medications [the patient is on] cause I didn’t have a chance [during the call at the home visit] to put it all together in my head what I wanted to ask him about the medications. — Setting 1
	Tools	Availability of tools to support teamwork during the transition	Lack of tools to support team-based MM during the transition	Q10: “Yes [the discharge paper] said resume home meds as directed but it doesn’t list them and tell me what she should be taking and what she shouldn’t be taking.” — Setting 1
		Existence of MM artifacts	Tools or technologies developed to support thinking, problem solving, or memory related to MM, e.g., pill planners, reminders, etc.	Q11: “We always want to make sure that our patients have a medication list handy, something they can really read and understand. So actually in our admission packet, we have a patient-friendly medication list. So even though they have one that comes with the discharge papers, and it’s typed up … it may be difficult for them to interpret.” — Setting 5
		Usefulness of discharge papers to facilitate MM	Discharge tools do not provide enough information on medications, it is difficult to find in the discharge papers, or it conflicts with other medication information	Q12: “We have nothing in the plan of care … there’s 14 medications written on the discharge paper. The patient had 6 prescriptions, [and] the patients don’t always give you accurate information.” — Setting 4
	Organization	SHHCP working sphere	Barriers related to the nature of the SHHCP’s mobile work environment that lead to isolation and inability to easily communicate when needed	Q13: “If we can’t get orders and we don’t, you know, we can’t just do things, you know. We have to have, we base our care off of doctors orders, so if we don’t have orders to do something we know the patient needs, then you know, our next step if it’s critical, we have to send them to the emergency room.” — Setting 4
	Physical environment	Physical environment to support MM	Safety hazards in the home, including obstacles, sanitation issues, clutter, that impede successful MM	Q14: (from observation notes) “Medication reconciliation is taking a considerable amount of time because of all the medications and the difficulty locating medications in the home.” — Setting 3
	External Environment	Sociocultural factors (e.g., socioeconomic status, culture, community)	Sociocultural factors that may negatively influence perceptions about MM and negatively affect ability to access medications, etc.	Q15: “We do see people who are just there by their self with no support. They’ll come home [from the hospital] but they haven’t had the opportunity to pick up their medicine ‘until my daughter comes to see me tomorrow at 4:00.’ But you’re CHF and you just got out of the hospital, and you need your fluid medicine. [Those are] some struggles that we see … especially in some of the lower socioeconomic [areas].” — Setting 2
Cross-boundary spanners played a key role in the execution of the MM processes	Person — hospital- and home-based SHHCP	SHHCP execution of perceived ideal role in MM	Tension between SHHCPs’ execution of routine vs. ideal roles in MM, e.g., performing tasks that go beyond the job description, or not being able to perform all ideal tasks due to some kind of restriction based on time, workload, etc.	Q16: “You know, and then they don’t have their medications and they just had open heart surgery. So you know, what do you want me to do, you know … [these types of situations are] really burning us out.” — Setting 4
		SHHCP ability to fulfill role in MM	Limited ability of SHHCP to fulfill role, because expectations of what is needed to fulfill role requirements are not met	Q17: “I [follow up with the pharmacy] because I want to make sure that the patient has everything she needs when she’s [home].” — Setting 1
	Tools	Usefulness of tools available to support MM	Lack of useful tools or technologies to support MM	Q18: “I always tell my patients to write down both names. So that when they go to the doctor they bring that form with them.” — Setting 1
	Organization	Physician accessibility	SHHCP difficulties communicating with physicians involved in medication management decisions (e.g., PCP, hospitalist)	Q19: “One of the biggest issues and problems [SHHCPs] run into is the ability to reconcile medications [due to inability] to reach a physician via the phone when you need to.” — Setting 5
		Communication breakdown during the transition	Ineffective communication and/or a disruption of the expected communication process	Q20: “Another issue is that [the patient] needs someone to bring her medications over to the pharmacy and with the aide not being here, she will need to find another way. She’s actually missed her medications for the entire day because of a miscommunication and misunderstandings related to not having someone clearly write on the discharge summary her complicated medication regimen.” — Setting 4
		Information underload	SHHCP does not have the information they need to perform MM	Q21: “If I don’t have the correct information … simple things like … the address is completely wrong, the phone number is wrong, the phone number is not in service … then I can spend the day spinning wheels calling here and there, calling emergency numbers and trying to find the patient.” — Setting 1
	Physical Environment	SHHCP feels safe in the home environment to take the time to perform MM activities	Challenges related to personal safety may lead to less time spent on MM-related tasks	Q22: (from observation notes) “When the SHHCP asks the patient for his medications, he becomes agitated and says “what is all this?” “Why do you need to do all of this?” The mother is also upset and comes into the living room. The patient says “yes mom is here to back me up.” — Setting 3

MM: Medication management; PCP: Primary Care Physician; SHHCP: Skilled home health care provider; SEIPS: System Engineering Initiative for Patient Safety.