Criteria pharmacists use to refer patients to a post discharge pharmacist review clinic

Background: The transition from hospital discharge to primary care is a critical period in a patient's healthcare journey. Health system errors occur, due to a breakdown in communication or lack of structured planning which can lead to medication related harm or hospital readmission. At a quaternary referral hospital in Australia, pharmacists refer Internal Medicine patients to a pharmacist-led clinic for post-discharge medication review. While clinical resources exist to guide identification of at-risk patients, it remains unclear if and to what extent, pharmacists incorporate these criteria into their referral. Aim: To determine the criteria and reasons used by pharmacists to refer Internal Medicine patients to a post discharge pharmacist review clinic. Methods: Semi-structured interviews were conducted with hospital pharmacists who had worked in Internal Medicine and previously referred patients to the post discharge review clinic. Interviews were conducted until data saturation was obtained. Interviews were audio recorded, transcribed and coded using NVivo®. Themes and subthemes were identified through inductive thematic analysis and finalised via discussion within the research team. Results: Eleven pharmacists were interviewed. Five themes emerged describing referral criteria and reasons: (1) medication criteria including the use of high-risk medications and adjustments; (2) patient criteria including health status, frailty and social aspects of health including carer supports; (3) system pressures including patient flow and time constraints in care delivery; (4) post-discharge care including medication liaison and evaluation of tolerability and; (5) clinical judgement described as "worry" about the patient, highlighting the role of clinical reasoning. Conclusion: Pharmacists used established criteria from clinical resources to identify high-risk patients for referral; however, they also relied on clinical judgement. Referrals aimed to prevent medication related harm and improve communication with patients and healthcare providers. Future research should evaluate the effectiveness of clinical judgement to ensure high-risk patients are identified for transition of care services.