Improving Integrated Care for Older People with Frailty and their Carers: An Ethnographic Study of Medicines-Related Care within Integrated Services

Background: Older people with frailty (OPFs) often live with multiple long-term conditions and manage multiple medications, increasing treatment burden-the workload and impact of managing healthcare. Frailty further alters medication response, increasing their vulnerability to adverse reactions such as falls and confusion. Poorly coordinated transitions between hospital and community settings increases the risk of medication-related harm and hospitalisation for OPFs, highlighting the importance of coordinated, person-centred care to optimise therapeutic outcomes and ensure medication safety.

 

Medicines-related care, encompassing health and social care interventions and support involving medicines, provides a valuable lens for examining integrated care (IC) for OPFs. However, little is known about how OPFs, their family carers, and health and social care professionals (HSCPs) experience medicines-related care within IC services. This study addressed this gap to identify areas for improvement.

 

Approach: Guided by Burden of Treatment Theory, this qualitative study explored how the organisation and delivery of medicines-related care within IC services affected the workload and capacity (resources and abilities) of OPFs and their carers. A longitudinal focused ethnographic design captured experiences across IC services encompassing hospital care, discharge planning, multidisciplinary community-based services delivered in OPFs’ homes, general practices, pharmacies, and a voluntary organisation. Over 12 months, 69 care observations (over 100 hours) and interviews with 10 OPFs, two carers, and 52 HSCPs were thematically analysed, supported by process mapping of older participants’ care journeys.

 

 

 

Results: Integrated care reforms expanded the roles of therapists and social workers into medicines-related tasks traditionally managed by pharmacists, such as medicines reconciliation and medication support assessments, often beyond their training or scope of practice. This expansion increased the burden of treatment and the risk of medication errors for OPFs. Multidisciplinary teams frequently relied on OPFs and their carers as primary sources of medication information due to limited access to discharge summaries and up-to-date medication lists, revealing weaknesses in digital systems and communication processes.

 

 Workforce shortages, insufficient funding, and weak continuity in care relationships further limited coordinated care. Responsibility for safe medication use often shifted to OPFs without adequate support, increasing their burden of treatment. Nevertheless, good practice included involvement of specialist therapy assessment teams in hospital discharge planning, integrated pharmacy team input, co-location of community health and social care staff, volunteer support, shared electronic records, and geriatricians spanning hospital and community services.

 

Implications Findings: highlight the need for IC services to ensure therapists and social workers are appropriately trained and supported to work safely within their scope. Current NICE guidance on medicines reconciliation should be updated to reflect the expanding roles of these professionals in IC services. Although OPFs and their carers actively manage medicines, they should be supported, not relied upon, to compensate for system weaknesses. While treatment burden is acknowledged in national multimorbidity policy, it was not prioritised by HSCPs, revealing a policy–practice gap and highlighting the need to embed treatment burden as a quality-of-care priority within IC services. This study also indicates that policies often overlook practical and nuanced needs of OPFs, emphasising the importance to better align policy with practice.