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The scope of clinical pharmacy services available in outpatient settings, including home care, continues to expand. This review sought to identify the evidence to support pharmacist provision of clinical pharmacy services in a home care setting. Seventy-five reports were identified in the literature that provided evaluation and description of clinical pharmacy home visit services available around the world. Based on from randomized controlled trials, pharmacist home visit interventions can improve patient medication adherence and knowledge, but have little impact on health care resource utilization.
Other literature reported benefits of a pharmacist home visit service such as patient satisfaction, improved medication appropriateness, increased persistence with warfarin therapy, and increased medication discrepancy resolution. Current perspectives to consider in establishing or evaluating clinical pharmacy services offered in a home care setting include: staff competency, ideal target patient population, staff safety, use of technology, collaborative relationships with other health care providers, activities performed during a home visit, and pharmacist autonomy.
Download video file. Over the past several decades, the scope of clinical pharmacy services has expanded both in terms of skills and areas in which services are offered. Traditionally, the availability of clinical pharmacy services has been in the purview of hospitals where increased clinical pharmacy services has been associated with reduced length of stay and mortality.
For example, the Home Medicines Review HMR program that was established in Australia in provides funding for Visiting making discrete house calls to visit patients at home to assess their medication regimens. While there is evidence to suggest that pharmacist prescribing activities can improve patient outcomes in outpatient settings, 5 — 7 the evidence to support the benefit of MRs in outpatient settings is equivocal. Holland et al conducted a systematic review and meta-analysis to evaluate the impact of pharmacist-led MR in older adults and reported that there was no effect on reducing mortality or hospital admissions, but that the intervention may reduce the of prescribed drugs and improve drug knowledge and adherence.
These studies were not focused solely on clinical pharmacy services in home care and so applicability to this setting is limited. A review of clinical pharmacy services offered in the home concluded that more rigorous evaluation is needed to support the value of these services and highlighted that questions remain about optimal practice models and target patient populations.
The maturation of these services has seen the pharmacist involved in increasingly more aspects of home care services, beyond what was initially supported by evidence.
Furthermore, changes in technology, patient and provider experience, safety, and expectations for pharmacy services are possible influencers of how services are delivered Visiting making discrete house calls valued. The purpose of this review is to identify outcomes associated with clinical pharmacy services provided in the home, as well as to describe current perspectives of practice described in the literature. Two separate literature searches were undertaken to identify articles published for the time period from January to December This time frame was chosen to follow up on a review published in The search was limited to the citations published in the English language and involved human subjects.
Additionally, the gray literature and reference lists of articles found were searched for additional records. One hundred and fifty-six unique records were found, of which 54 were excluded as they were conference abstracts or the full article access was not possible. In addition, a further 27 were excluded as they did not describe pharmacists doing HVs in a unique study published in or onward, leaving 75 articles that were included in this review. Different programs and authors use different terminology to refer to similar concepts.
We will be referring to medication reconciliation MRec as the act of comparing all medication lists in order to reconcile and create a master list of what the patient should be taking. MR refers to the act of compiling a list of medications the patient is taking and assessing the appropriateness of each medication and the regimen as a whole. MRec may be included in the process of MR. We will refer to medication, therapy, or drug-related problems as drug-related problems DRPs. Five studied patients being discharged from hospital 1416181922 and four recruited from outpatient settings. Six of the studies described the qualifications of the pharmacists conducting the intervention, indicating training or experience beyond an entry to practice degree.
Two studies reported reduced health care utilization attributable to the pharmacist HV intervention: reduced prescribed medications 15 and reduced non-heart failure hospital days. The clinical outcomes reported from these RCTs indicated that these programs can improve medication understanding, knowledge, and adherence and result in increased resolution of DRPs. No benefit on quality of life was reported.
While not all of the RCTs evaluated economic outcomes, it is hard to explain the limited impact of the pharmacist interventions on health care costs. The interventions undertaken in these trails all appeared to involve pharmacists conducting MR for the purpose of identifying DRPs with subsequent communication to a physician. What is unclear is the depth of the medication regimen assessment, for example, were the recommendations in line with evidence to support reducing morbidity and mortality?
Also, the acceptance of recommendations made by the pharmacist was not always reported. Moreover, the extent of access the pharmacists had to medical and laboratory information was sometimes limited and may not have allowed for a comprehensive MR.
The most recent trial to evaluate economic outcomes was conducted by Barker et al; however, the usual care group received an extensive intervention which may have limited the impact of the study intervention. Other activities performed by the pharmacists included removing expired or discontinued medications, 1516182223 education, 14 — 1618222425 and adherence assessment.
The 17 studies using a comparison de for evaluation of a pharmacist HV intervention are outlined in Table 2. The largest proportion of studies were evaluations of the HMR in Australia. Most of the other studies were evaluations of pharmacists conducting an HV intervention similar to the HMR, 2940 except that not all reported pharmacists removed expired or discontinued medications.
The outcomes evaluated and reported in these studies are outlined in Table 3. In contrast to the RCT data, more of these studies reported reduced health care costs. The exception to this was Hanna et al, who reported an overall increase in hospital admissions; however, when they broke the study population down by age, there was a benefit of reduced hospitalizations among those aged 51—65 years.
The difference in impact of the pharmacist interventions on health care costs reported in these studies, compared with the RCTs, may be attributable to study de. The patients and settings were similar, as well as the extent of pharmacist training, to those described in the RCTs.
The evaluation time periods in the RCTs were at least 6 months or longer, whereas these studies reported economic benefits over 30 days 3640 and at 6 months. Table 4 outlines the 23 articles describing evaluations of clinical pharmacy home care services in which no comparison group was used. The majority of these articles describe a program in which a HV was conducted to undertake a MR.
Five nationwide surveys evaluating pharmacist HV services were identified. Further, only A Canadian survey received 17 responses from pharmacists who provided HVs. None of the programs was government funded, and three of the pharmacists reported charging a private home care agency for Visiting making discrete house calls services. Facilitators for HVs identified in the survey were referrals from physicians and support from management.
The barriers cited by respondents were insufficient remuneration and lack of time for completing visits. A similar survey undertaken among British pharmacists received respondents Patient preference for medication therapy management was evaluated in Thailand. In the Netherlands, an evaluation of implementing a HV service to patients after hospital discharge was undertaken using a focus group 22 pharmacists to identify barriers and facilitators, followed by a survey 20 pharmacist respondents to score the relevance and feasibility of items identified during the focus groups.
The authors reported that both the need for reimbursement and the readiness of community pharmacy to adapt daily routines to implement such a service as two barriers to implementation. In addition to the aforementioned reports, 18 articles describing clinical pharmacy services in a home care setting were identified in the literature.
The following section highlights some current perspectives based on these articles, together with those articles ly described that provided an evaluation of clinical pharmacy HV services. Training and qualifications for pharmacists, pharmacy residents and students, and pharmacy technicians involved in HV programs varied. The HMR program in Australia requires pharmacists to be accredited. In our health authority, the pharmacists working in a home care setting as part of the Medication Management Program MMP must have completed an Accredited Canadian Pharmacy Residency or equivalent in order to be hired.
They receive orientation on conducting HVs and documentation thereafter. Use of pharmacy students, residents, and pharmacy technicians highlights the use of resources to both provide learning opportunities and also extend the scope of clinical pharmacy services. Competency of personnel to provide the service influences the extent to which DRPs and issues preventing patients from achieving optimal health can be identified and resolved. It includes clinical knowledge about disease states and drug therapy and the ability to communicate to extract and provide information.
The most commonly studied patient population was patients who had recently been discharged from hospital. Several authors reported an increased identification of DRPs as a result of a HV compared with medication list review 47 or chart review 5357 and that the DRPs identified during a HV may be more likely Visiting making discrete house calls result in a medication change.
Safety for pharmacists conducting HVs was discussed in five articles. Depending upon the risk identified and whether or not it can be mitigated for the HV, either staff do not conduct the HV or conduct it with a security personnel. As patients for whom HVs are provided are typically more frail, staff safety may be overlooked in HV initiatives. Ten articles discussed the use of technology to aid in pharmacist HVs. The ePHR system would necessitate patient access to the Internet.
Pharmacist access to the Internet at patient homes is an important aspect to consider in expanding the use of technology for HV clinical pharmacy services. The majority of HV programs described in the literature involved pharmacists providing the service and connecting with other health care professionals, such as physicians in order to communicate the findings from their assessment and make suggestions for changes.
Furthermore, pharmacist and physician collaboration may not happen, even if it was the expectation of a program. Strategies to leverage existing relationships or create the opportunity for relationship building described in the studies include involving community pharmacists in providing HV programs, 27475367 inserting a pharmacist as part of a multidisciplinary team, 234248778182 or adding the HV component to an existing clinical pharmacy service.
The extent of collaboration can also depend upon the setting from which HV services are offered. Settings identified in the HV literature include: dispensing pharmacy, 24445358697176777884 home care, 28Visiting making discrete house calls36465459658183 chronic disease management or specialty service, 23254345485462757982 institutional transition service, 22373840424463647374 health care agency, 4152577072 and primary care.
A downside of HV services being offered from a community pharmacy can be limited time to conduct HVs and lack of funding.
Several authors described pharmacists providing HV services with other health care providers: paramedics, 74 nurses, 2842 social workers, 84 multidisciplinary teams, 3648687781 and with a nurse practitioner and primary care physician. For example, a pharmacist working in a palliative care team reportedly increased medication-related knowledge of team members and patients. Another important aspect of relationship and collaboration is referral. Receiving referrals from a physician may not only impact the longevity of a HV program, 68 but also may result in more collaboration for making medication changes through case conferences.
MR and MRec were the two most commonly reported HV activities, with education, adherence assessment, and removal of medications no longer used occurring often. Other activities reported less frequently were: pharmacist performing physical assessments; 3650 chronic disease monitoring; 202550555667 education for lifestyle changes; 87 falls assessment; 5052 and assessment of cognition, 52 mental health, 52 nutrition, 52 and caregiver needs.Visiting making discrete house calls
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A comparison of in-person home care, home care with telephone contact and home care with telemonitoring for disease management