Exploring transition of care beyond hospital walls: patient perspectives, interprofessional medication management, and community pharmacists' clinical reasoning
Bibliographic record
Abstract
Background: Transitioning care from hospital to outpatient settings is a critical and high-risk period for patients. It also presents substantial challenges for healthcare professionals, who frequently operate in fragmented and uncoordinated systems. Medication safety may be jeopardised, with issues such as medication reconciliation errors, drug-related problems and medication nonadherence leading to potential hospital readmissions. Interprofessional collaborative interventions across care settings have shown promising results by reducing readmissions and enhancing integrated care for patients transitioning from hospital to home. Still, these services are rarely implemented and sustained in standard care. Community pharmacists play a key role in the interprofessional team during hospital discharge; however, their practices and roles in outpatient care at hospital discharge remain insufficiently defined. Objective: This thesis aimed to explore the perspectives, experiences, and needs of healthcare professionals and polypharmacy patients with long-term conditions during the post-hospitalisation care transition, particularly emphasising outpatient care, interprofessional collaboration, and medication management. Specifically, the ItPaDiab study explored the perspectives of discharged polypharmacy patients regarding their medications and their care journey from hospital to two months after discharge. The FGinterpro study focused on identifying and describing the current state and areas for improvement of interprofessional collaboration in medication management during the transition from hospital to outpatient care. The CPreasoning study aimed to evaluate community pharmacists’ practices and clinical reasoning regarding hospital discharge prescriptions. Methods: This thesis employed a range of qualitative methodologies to explore care transition and interprofessional and professional practices. The ItPaDiab study focused on patients with type 2 diabetes and at least two long-term conditions discharged home, using four longitudinal semi-structured interviews per participant and self-reported questionnaires over the two-month period following discharge. The FGInterpro study was conducted through interprofessional serial focus groups with patients and healthcare professionals from both hospital and outpatient settings and analysed through the Canadian Interprofessional Health Collaborative (CIHC) Framework. The CPreasoning study used simulations to explore community pharmacists’ practices and retrospective think-aloud methodologies to better understand their clinical reasoning. The clinical reasoning was analysed using the Charlin et al.'s model and the encounter structure through the Calgary-Cambridge model. All studi
Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.
How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.010 | 0.019 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.005 | 0.006 |
| Scholarly communication | 0.010 | 0.006 |
| Open science | 0.001 | 0.008 |
| Research integrity | 0.002 | 0.005 |
| Insufficient payload (model declined to judge) | 0.003 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".