Decision-making about changing medications across transitions of care: Opportunities for enhanced patient and family engagement.

Background: Older patients often have complex medication regimens, which change as they move across transitions of care. Engagement of older patients and families in making medication decisions across transitions of care is important for safe and high-quality medication management.

Aims: To explore decision-making between health professionals, older patients and families about medication changes across transitions of care, and to examine how patient and family engagement is enacted in the process of decision-making in relation to these medication changes.

Methods: A focused ethnographic design was undertaken with semi-structured interviews, observations, and reflective focus groups or interviews. Reflexive thematic analysis was conducted on transcribed data. The study was undertaken at a public teaching acute care hospital and a public teaching community hospital in Australia.

Results: In all, 182 older patients, 44 family members and 94 health professionals participated. Four themes were conceptualised from the data: different customs and routines, medication challenges, health professional interactions, and patient and family involvement. Environments had differences in their customs and routines, which increased the potential for medication delays or the substitution of unintended medications. Medication challenges included health professionals assuming that patients and families did not need information about regularly prescribed medications. Patients and families were informed about new medications after health professionals had already made decisions to prescribe these medications. Health professionals tended to work in disciplinary silos, and they had views about their role in interacting with patients and families. Patients and families were expected to take the initiative to participate in decision-making about medication changes.

Conclusions: Patient movements across transitions of care can create complex and chaotic medication management situations, which lacks transparency, especially for older patients and their families. A greater focus on pre-emptive and planned discussions about medication changes will contribute to improving patient and family involvement in medication decision-making.