Services Database Reablement Service (Isle of Wight Area)

While in hospital, vulnerable patients will be identified by the reablement team. These patients are those that are considered high risk of being readmitted to hospital within 30 days of their discharge. Before discharge these patients will be referred to, and assessed by the hospital pharmacy team regarding their ability to manage their medicines. A copy of the assessment carried out by the hospital team will then be forwarded to the service coordinator. The services coordinator will make every effort to contact the pharmacy that this patient uses; however, only the pharmacies that have expressed an interest in being part of the service will be contacted. If a pharmacy is not part of the service the referral will be passed to another pharmacy in that locality. This may mean that the future care of such patients, with patient consent, pass to the visiting pharmacy eg. circumstances where the existing pharmacy cannot or are not willing to provide the level of support identified as necessary.

The pharmacist will be faxed the referral forms and the pharmacist will then contact the patient and make arrangements to visit, ideally within 7 days of discharge. At the visit, the pharmacist will sit down with the patient and their carer (details of carer visiting times to patient’s home will be provided on the referral) and will:

1. conduct a full MUR;
2. complete a medicines cabinet check to ensure the patient has enough medicines to last until their next GP appointment. This is important as we know many patients initiated on medicines to treat LTC often make a decision to stop taking their medicines in the first ten days of treatment as previously stated;
3. remove medicines that are discontinued. This is important as patients often revert to previous drug regimes when they return home;
4. complete a medicines compliance chart detailing each current medicine, when this should be taken, the appearance of the drug, expected side effects if any,and all other relevant information.
5. carry out a full Capability assessment; and
6. discuss the future management of medicines for the patient taking into consideration issues such as mobility and understanding. This may see the initiation of support services such as home delivery, managed repeat services, the initiation of compliance aids, large print labels for patients that are partially sighted, easy open caps or any other aid that is relevant to the patient.

The first visit must ideally take place within seven days of discharge with two follow up reviews scheduled at this appointment to take place at 5 weeks and 90 days.

Not known