Abstract:

Seamless care also referred to as integrated care, comprehensive care, continuity of care and transmural care, is a vital part of discharge planning and involves the safe transfer of patients from the secondary to the primary care interface. This may be more important for patients with chronic conditions and may involve strategies to improve patient concordance, involving them in the monitoring of their own condition and having a follow up action plan for the multi-professional team in place. Ways in which patients may become involved in monitoring their own condition to improve outcomes include: peak flow monitoring, blood glucose monitoring, blood pressure monitoring and weight monitoring as part of a weight management programme.

At the end of the workshop, the participants will be familiar with developing a discharge care plan including ways of encouraging patient involvement as a means of improving treatment outcomes. This will involve an exploration of ways in which patients may be involved in monitoring their own condition once discharged, establishing a pathway to ensure a smooth transition of patients into the community and providing a discharge care planning framework that may be applicable in secondary care.

Teaching goals

• To provide a discharge care planning framework for secondary care pharmacists
• To demonstrate the pathway involved in achieving seamless care to ensure a smooth transition of patients into the community
• To explore ways in which patients may be involved in monitoring their own condition once discharged from hospital

Learning objectives

After participating in the workshop the participant should:

• be familiar with developing a discharge care plan including ways of encouraging patient involvement as a means of improving treatment outcomes.