Background: The transition from hospital to outpatient care is a particularly vulnerable period for patients as they move from regular health monitoring to self-management. This study aimed to map and investigate the journey of patients with polymorbidities, including type 2 diabetes (T2D), in the 2 months following hospital discharge and examine patients’ encounters with healthcare professionals (HCPs). Methods: Patients discharged with T2D and at least two other comorbidities were recruited during hospitalization. This qualitative longitudinal study consisted of four semi-structured interviews per participant conducted from discharge up to 2 months after discharge. The interviews were based on a guide, transcribed verbatim, and thematically analyzed. Patient journeys through the healthcare system were represented using the patient journey mapping methodology. Results: Seventy-five interviews with 21 participants were conducted from October 2020 to July 2021. The participants had a median of 11 encounters (min–max: 6–28) with HCPs. The patient journey was categorized into six key steps: hospitalization, discharge, dispensing prescribed medications by the community pharmacist, follow-up calls, the first medical appointment, and outpatient care. Conclusions: The outpatient journey in the 2 months following discharge is a complex and adaptive process. Despite the active role of numerous HCPs, navigation in outpatient care after discharge relies heavily on the involvement and responsibilities of patients. Preparation for discharge, post-hospitalization follow-up, and the first visit to the pharmacy and general practitioner are key moments for carefully considering patient care. Our findings underline the need for clarified roles and a standardized approach to discharge planning and post-discharge care in partnership with patients, family caregivers, and all stakeholders involved.

Background: Continuity of care is under great pressure during the transition from hospital to outpatient care. Medication changes during hospitalization may be poorly communicated and understood, compromising patient safety during the transition from hospital to home. The main aims of this study were to investigate the perspectives of patients with type 2 diabetes and multimorbidities on their medications from hospital discharge to outpatient care, and their healthcare journey through the outpatient healthcare system. In this article, we present the results focusing on patients’ perspectives of their medications from hospital to two months after discharge. Methods: Patients with type 2 diabetes, with at least two comorbidities and who returned home after discharge, were recruited during their hospitalization. A descriptive qualitative longitudinal research approach was adopted, with four in-depth semi-structured interviews per participant over a period of two months after discharge. Interviews were based on semi-structured guides, transcribed verbatim, and a thematic analysis was conducted. Results: Twenty-one participants were included from October 2020 to July 2021. Seventy-five interviews were conducted. Three main themes were identified: (A) Medication management, (B) Medication understanding, and (C) Medication adherence, during three periods: (1) Hospitalization, (2) Care transition, and (3) Outpatient care. Participants had varying levels of need for medication information and involvement in medication management during hospitalization and in outpatient care. The transition from hospital to autonomous medication management was difficult for most participants, who quickly returned to their routines with some participants experiencing difficulties in medication adherence. Conclusions: The transition from hospital to outpatient care is a challenging process during which discharged patients are vulnerable and are willing to take steps to better manage, understand, and adhere to their medications. The resulting tension between patients’ difficulties with their medications and lack of standardized healthcare support calls for interprofessional guidelines to better address patients’ needs, increase their safety, and standardize physicians’, pharmacists’, and nurses’ roles and responsibilities.

This case report explores the experience of a newly diagnosed type 2 diabetes (T2DM) patient transitioning from passive non-adherence to active adherence over a two-month period following hospital discharge. During this two-month period, he participated in four exploratory, non-interventional research interviews investigating his medication adherence, beliefs, and self-management strategies. His feedback on these research interviews highlighted the role of key communication strategies—such as patient partnership, non-judgmental communication, and interprofessional active listening—in fostering self-reflection and behavioural change. While these techniques are well-documented, there remains an urgent need to translate them into routine practice by integrating behavioural science and interprofessional collaboration into healthcare pregraduate and postgraduate education in order to increase awareness and skills in clinical environments.

Purpose: Poor coordination and communication during care transitions can lead to medical errors, patient dissatisfaction, and hospital readmissions. The transition period from hospital to the first medical appointment is a high-risk and vulnerable time for patients, and a complex one for healthcare professionals. While interprofessional collaboration can improve the quality and safety of care, its implementation remains underexplored. This study examines the current state and areas for improvement in interprofessional medication management during the hospital discharge transition (from hospital discharge to first medical appointment) for patients self-managing their medications. Methods: A qualitative study was conducted using a serial focus group methodology with patients and healthcare professionals from hospital and community settings. Participants were sampled purposively. Discussions were audio-recorded, transcribed verbatim, and analysed using inductive thematic analysis. Thematic findings were categorised using the 2010 Canadian National Interprofessional Competency (CIHC) Framework, distinguishing between current practices and areas for improvement. Additionally, a classification questionnaire, adapted from the nominal group technique, was used to rank proposed improvement strategies based on their perceived impact and feasibility. Results: Twelve participants (10 healthcare professionals and two patients) contributed to four focus groups. The study identified strengths and areas for improvement in five of the six CIHC 2010 competency domains: 1. Interprofessional communication: present but needing better structure and proactivity; 2. Patient partnership: recognised but requiring more consistency; 3. Role clarification: unclearly defined, causing inefficiencies; 4. Team functioning: common in hospital settings, but inconsistent during transition; 5. Collaborative leadership: present but lacking clear coordination at handover. An overarching category, “Macro-level improvements” was introduced to highlight system-wide changes and the need for policy support to implement and sustain interprofessional collaboration. Conclusion: While existing practices emphasise interprofessional communication and patient involvement, role clarity and collaborative leadership remain significant challenges. Healthcare professionals are motivated and ready to collaborate, but policy and coordinated efforts among healthcare meso- and macro-entities are needed to implement sustainable interprofessional practice models, to increase quality of pharmaceutical care, and improve patient outcomes during care transition from hospital to home.

Background: The roles of community pharmacists have evolved from dispensing medications to clinical decision makers. This shift requires a clearer understanding of pharmacists’ clinical reasoning. Managing hospital discharge prescriptions requires analytical reasoning to ensure patient safety through medication reconciliation and patient education. Aim: This study assessed community pharmacists’ practices and their clinical reasoning towards hospital discharge prescriptions. Method: This mixed-method study consisted of two phases. First, community pharmacists participated in a simulated encounter in their pharmacy, where a patient presented a discharge prescription. Their practices and the structure of the encounter were assessed using a structured checklist of practices adapted from the MEDICODE checklist. Following the simulation, participants verbalised their thought processes in a retrospective think-aloud session. These semi-structured interviews were transcribed and analysed using both inductive and deductive qualitative methods. Charlin et al.’s model was used to assess clinical reasoning, while the Calgary–Cambridge model evaluated communication structure. Results: Among 14 participating pharmacists, 13 performed medication reconciliation, and 10 contacted the simulated prescriber to address discrepancies. While most provided adherence aids, only seven assessed non-adherence, and five actively collaborated with the patient. Pharmacists exhibited diverse interview structures, often revisiting previous discussion points. Clinical reasoning misconceptions, such as assumptions or premature closure, were observed at multiple stages of the clinical reasoning process. Conclusion: Community pharmacists demonstrate strong medication-related skills but face challenges in clinical reasoning for discharge prescriptions. Clinical reasoning training, semi-structured consultations, and greater patient engagement would help tailor and improve post-discharge care.