Health-care systems are typically divided in different sectors providing different levels of care. Patients particularly those with chronic conditions move between these sectors. In order to create a continuum of care, the episodes should be linked. Such integrated care, however, is difficult to achieve in daily practice. Disruption and fragmentation are often the reality and cause adverse health outcomes.

At transitions from one sector to another, therapy changes may be overlooked or not implemented due to poor communication between health-care providers and insufficient knowledge of the patient. Unintended medication discrepancies may result which – in consequence – increase the risk of adverse drug events causing unplanned health resource utilization including early hospital readmission.

To improve the situation, research is needed to evaluate quantitatively and qualitatively the existing problem and to investigate the effects of improvement measures. But also, development is needed to create and validate instruments that help identifying patients at risk or facilitate and support the process of transitions. For this purpose, we developed a framework for research and development, called MOSAIC: Medicines Management Optimisation by structured assessment in integrated care.

Within the MOSAIC framework, an important aspect is the possibility to stratify patients according to their risk of developing a significant drug related problem. In order to perform such a risk stratification, instruments are needed which are easy to apply in daily routine and are of appropriate sensitivity and specificity. Identification of high-risk patients would allow to allocate the workforce of clinical pharmacist and other health-care professionals to those who are most in need of intensified pharmaceutical care. The development of such a risk stratification tool is presented in this work: the DART (Drug associated risk tool) is a self-assessment questionnaire with 34 items addressing risk factors for drug-related problems. A high specificity and sensitivity (88% resp. 67%) allow a reliable detection of existing risk factors.

Since communication between the different settings is crucial to achieve continuity of care, the second project that is outlined in here aimed at developing a standardised classification for pharmaceutical interventions using a common terminology along the patient’s pathway. The PharmDISC (Pharmacist’s documentation of interventions in seamless care) classification resulted from a development process using a mixed methods approach. The classification is validated in terms of feasibility, acceptability, appropriateness, and interpretability and reaches substantial interrater reliability (Fleiss’ Kappa 0.61).

The DART questionnaire and the PharmDISC classification system are just two new elements that may contribute to a better medicines management. The MOSAIC framework helps to identify further elements of integrated care by finding gaps of evidence and asking the right research questions. It ensures the overview of the whole process in order to link the different episodes of a patient’s journey, and to coordinate the different health-care providers.