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New step-by-step care transition guide for GPs


Karen Burge


28/02/2025 2:32:51 PM

A first-of-its-kind, practical resource is now available to GPs, designed to help navigate the often high-risk task of moving patients between care providers.

Patient looking at medication.
The resources provide greater clarity, as well as steps to support patients, during what can be a high-risk phase in their healthcare journey.

A practical new resource will provide GPs and pharmacists with enhanced clarity on medication management when patients transition between primary care and hospitals.
 
Advanced Pharmacy Australia (AdPha) and the RACGP have partnered to develop a first-of-its-kind Medication Management at Transitions of Care resource kit to help care teams navigate one of the riskiest stages of the patient journey.
 
The toolkit’s release comes at a time when medication-related adverse events occur in around 20% of patients following discharge – two-thirds of which are considered preventable.
 
The kit comprises three resources to support clear, accurate and timely communication as patients transition through care providers, including information for both health professionals and patients:

RACGP President Dr Michael Wright said improving the transitions in care between general practice and hospitals is a priority for the college.

‘These resources are a valuable tool that will support patient safety and reduce medication mishaps when people are transitioning between the community setting and hospital,’ he said.

‘Appropriate clinical handover reduces the risk of readmission to hospital after discharge.
 
‘These resources will strengthen collaboration between specialist GPs, general practice-based pharmacists, and hospital pharmacists to ensure best practice team care and better patient outcomes.’
 
Safety concerns during transition were recently emphasised in a case before the Victorian coroner following the death of a 47-year-old woman due to mixed drug toxicity.
 
In findings published last month, the coroner recorded that the patient’s GP had not been supplied with details of a cross-titration process after a psychiatrist introduced an alternative medication regime while the patient was in a private Melbourne hospital.
 
AdPha President Tom Simpson said it is imperative that doctors, pharmacists and patients are provided with the tools and resources they need to safely navigate this complex area of a patient’s health journey.


‘Safely transitioning from primary to acute care, and back to primary care following a significant health event, relies on clear, accurate and timely communication between healthcare providers in both sectors, and with the patient and/or their carer,’ he said.

‘Often, it is the lack of clear, accurate and timely communication, and clearly defined, agreed responsibilities at transitions of care, that lead to medication-related errors and adverse events.

‘As pharmacy and medical teams work together to guide patients through care transitions, it’s fantastic they now have a resource kit to promote continuity of care, optimise medication management, and reduce the risk of medication-related issues.’

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Dr Susan Joanna Hookey   3/03/2025 9:23:41 AM

These resources are a great reminder for all involved in handover- hospital, pharmacist, patient and patient support person. I encourage all to read the Safe Medication Management at Transitions of Care, and Medication safety when moving between the community and hospital. Simple tip sheets that spell out roles of all to enhance safe medication transitions - the titles do not reflect the gold within!


Dr Jeremy Cho-Yin Chan   11/03/2025 3:26:00 PM

I just LOVE patients discharged from private hospitals - often zero information, nothing, nada, radio silence. I have direct logins to the radiology company they use to gleam some information as to what happened - and let's just say the conversation of "So what's the follow up to this X tumour you have on the scan?" "What tumour?" is not uncommon...