Medication Safety During Care Transitions for Older Adults: Development of the ALICE Framework

Abstract Background Transitions of care (TOC) are high-risk periods for older adults, particularly for medication safety. When engagement between patients and healthcare systems is misaligned, it can result in miscommunication, medication errors, and avoidable readmissions. While prior research has identified the need for improved discharge processes, limited work has examined how the alignment of engagement between patients and healthcare systems shapes medication safety during TOC, specifically from the patient lens. Objective To explore older adults’ perceptions of and experiences related to medication safety during TOC and identify patterns of engagement between patients and healthcare systems. Design Rapid qualitative analysis (RQA) of patient interviews examining medication safety during TOC. Approach Semi-structured interviews were conducted with n = 26 adults aged ≥ 60 years from two urban, safety-net primary care clinics, who had been discharged within the previous 3 months. Interviews were analyzed inductively using RQA and cross-case comparison. Key Results Six overarching themes characterized participants’ medication-safety experiences during TOC: communication, discharge structure, patient involvement, social determinants of health, care coordination, and treatment understanding. Within each theme, participants described conditions that either facilitated or hindered medication safety. Across these themes, recurring patterns of alignment and misalignment emerged between patient engagement and perceived healthcare system responsiveness. These patterns informed development of the Aligned Levels of Interaction for Collaborative Engagement (ALICE) framework, a four-quadrant typology comprising Collaborative Engagement, Patient-Driven Engagement, System-Driven Engagement, and Mutual Disengagement. Conclusions Medication safety during TOC reflects the interaction between patient engagement and perceived healthcare system responsiveness. The ALICE framework offers a patient-centered lens for understanding these engagement patterns and identifying opportunities to strengthen medication safety during and after discharge.