Stakeholder experiences and expectations of transition of care services to reduce medication-related hospital readmission for cardiology patients.

backgroundTransition of care (ToC) for patients with cardiovascular diseases is a complex, high-risk period often leading to medication-related harm (MRH) and hospital readmissions. While specialised programs exist, a gap in individualised medication management services exist for specific cardiology patient populations. Pharmacist-led, interdisciplinary ToC services have demonstrated a positive impact on patient outcomes. The REducing hospital re-admission for high-risk CARDiology patients (RECARD) program aims to address this by co-designing, implementing, and evaluating a new pharmacist-led ToC service in post-acute myocardial infarction (AMI) or cardiac surgery patients. The current study focuses on understanding the experiences and expectations of patients and clinicians to inform the development of this service.

methodsThis qualitative study utilised semi-structured interviews and focus groups to gather data from patients and hospital and community clinicians aligned with three Queensland hospitals and surrounding primary and community care settings. Patients who had experienced an AMI or cardiac surgery in the past three months were interviewed via telephone or Microsoft TEAMS. Clinicians participated in focus groups or individual interviews. Data were audio-recorded, transcribed, and analysed using the six-phase thematic analysis method by Braun and Clarke, guided by Bradshaw's model of need to understand stakeholders' expressed and comparative needs.

resultsData were obtained from 13 patient interviews and 40 clinicians, through seven focus groups and one interview. Three main themes, with associated subthemes, emerged from the data; Patient-level issues, System and process issues and Interprofessional collaboration. Patients described information overload, medication uncertainty, and anxiety at discharge, while clinicians identified delayed discharge summaries, fragmented communication with primary care, and service gaps - particularly impacting rural patients- as key risks for medication‑related harm.

conclusionsThe study's findings highlight the critical need for a patient-centred, pharmacist-led interdisciplinary ToC service that addresses patient knowledge deficits, psychosocial barriers, and the communication gaps between hospital and community care settings. The results from this study will inform the development of the RECARD program's "Adaptive ToC Pathway," ensuring it is tailored to meet the specific needs and expectations of both patients and clinicians, ultimately aiming to reduce MRH and hospital readmissions.