This study demonstrated the ability of appropriately trained accredited pharmacists working within the Australian HMR framework to reduce adverse events and improve persistence in patients taking warfarin following hospital discharge. Widespread implementation of such a service has the potential to enhance medication safety along the continuum of care.

Use of an existing healthcare framework overcame several systemic barriers by facilitating warfarin education in patients' homes. While the intervention was associated with better short-term warfarin knowledge, follow-up may be required to optimise its benefits. Widespread implementation of home-based warfarin education by pharmacists has the potential to contribute significantly to improved outcomes from warfarin therapy.

This education program successfully up-skilled a cohort of pharmacists for involvement in a post-discharge warfarin management service. These findings support formalization and further development of the program to facilitate widespread implementation of home-based post-discharge warfarin care.

Addressing the three identified facets of care within a new, collaborative post-discharge warfarin management service may address the perceived deficiencies in existing systems. Improvements may result in the short- and longer-term health outcomes of patients discharged from hospital taking warfarin, including a reduction in their risk of adverse events.

INR was well-controlled in this elderly cohort, comparable to that achieved in recent randomised trials involving warfarin. Pharmacist-led medication reviews were not associated with a change in INR control.