REVIEW PAPER COMMUNITY LIAISON PHARMACISTS IN HOME CARE
Department of Pharmacy, World University of Bangladesh,
Dhanmondi, Dhaka – 1205, Bangladesh
The term “Home-based care” or simply home care may be defined as a wide array of different types of care provided in the home by a wide range of parties. The continuum of different types of home-based care delivered in the home varies in terms of different dimensions, including acuity, type of care provided, and degree of physician involvement. Home-based care includes both formal and informal personal care services, Medicare skilled home health, physician house calls, and even “hospital-at-home” services. Medication-related issues are basic among home care patients who take numerous medications and have complex medical chronicles and medical issues. The objectives of home social insurance administrations are to assist people with improving capacity and live with more prominent freedom; to advance the customer's ideal dimension of prosperity; and to help the patient to stay at home, maintaining a strategic distance from hospitalization or admission to long-term care foundations. Home care is an arrangement of care given by talented experts to patients in their homes under the bearing of a doctor. Home medicinal services administrations incorporate nursing care; physical, word related, and discourse language treatment; and medical social administrations. Doctors may allude patients for home medicinal services administrations, or the administrations might be asked for by relatives or patients. The scope of home human services benefits a patient can get at home is boundless. Contingent upon the individual patient's circumstance, care can extend from nursing care to specific medical administrations, for example, laboratory workups. Basic analyses among home medicinal services patients incorporate circulatory disease, coronary illness, damage and harming, musculoskeletal and connective tissue disease and respiratory disease.
Reference Id: PHARMATUTOR-ART-2655
Figure 1. Patient Care Transition from Hospital to Home.
Poor transitions of care between settings can affect patient outcomes, even cause harm. Patients and their caregivers may be confused or overwhelmed, and may not understand what to expect, what medications to take, or how to address their needs during transitions. Poorly executed care transitions can lead to adverse events, unnecessary readmissions, reduced quality of life, and unneeded use of resources. “Transitional care is universal. It doesn't matter whether you have a brain injury, or had a hip replacement, a stroke, or a spinal-cord injury. A smooth transition is really important for reducing the number of re-hospitalizations”--Minna Hong, Patient Partner, Peer Support Manager, Shepherd Center (Web Patient-Centered Outcomes Research Institute)
The scope of pharmacy services available in home-care continues to expand. Pharmacists provide a wide range of medications, along with health and convalescent aids, for patients at home. Traditionally community pharmacists have been viewed as providers of prescription and nonprescription medications administered orally. Today pharmacists in community and hospital pharmacies across the country have expanded their services for the homebound patient and provide a variety of sophisticated products and services in the patient's home. Community pharmacists provide home health services including medication reconciliation and teaching. Pharmacists must adapt their communication to address the wide variety of patients’ drug-related problems during these home visits and achieve patient-centered communication. Little is known about the topics discussed during a post-discharge home visit and most studies investigating patient-pharmacist communication focused primarily on one-way pharmacist information provision, e.g. the extent to which pharmacists counsel patients, and their communication style, e.g. tone of voice. Patient-centered communication is associated with increased patients’ satisfaction, better recall of information and improved health outcomes and requires active participation of both the pharmacist and the patient. Patients should be encouraged to express their needs and concerns regarding their medication, which pharmacists should address to support patients in making informed decision. 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. Gaining insight in the communication during these home visits could be valuable for optimizing these visits; and consequently, to improve patient safety at readmission to primary care. A home visit protocol enables pharmacists:
• To address known major challenges during the transition from hospital to primary care
• To address patient’s dissatisfaction about health care is important as it facilitates patient participation during consultation and acceptance of pharmacists’ advices
• To discuss patients’ medication beliefs and adherence issues more frequently, which might be facilitated by additional pharmacist training and increasing patient engagement.
Figure 2. Elements of successful transitional care models. The care plan should include how these needs would be met and by whom. After older persons are discharged from hospital and back at home again, they often have to adjust and cope with possible repercussions due to illness and health problems. Many encounter a variety of problems within the first week back at home, a particularly vulnerable period. The most commonly reported overall adverse event for older persons in several countries is related to medicine treatment, which also causes a considerable number of readmissions. Therefore, competence among involved care professionals has been shown to Moreover, collaboration and multidisciplinary approaches are also highlighted as well as communication among professionals (Rydeman, 2012)
Client Recruitment and Home Visits
Upon admission to the office, any home care customer taking at least nine medications, including over-the-counter and herbal items, is offered a pharmacist home visit. Prior to the home visit, the pharmacist audits the customer's rundown of requested medications and graph notes from other home care clinicians, for example, attendants, word related therapists, and physical therapists. Amid the home visit, the pharmacist examines each drug, including over-the-counter items and herbal enhancements, with the customer and caregiver to evaluate their sign, adequacy, well-being, and consistence, including reasonableness. After the main home visit, the pharmacist contacts the customer's prescriber with any suggestions for upgrading drug therapy. This correspondence is finished by electronic wellbeing record, phone, or fax. Basic proposals incorporate ceasing pointless or copy therapies or changing medicine portions. Follow-up care is composed by the pharmacist and nurse (Shanon et.al., 2013).
Figure 3. Cogwheels of Transition.
Each and every cog must be synchronized and appropriately placed for a seamless, effective and safe care transition. During times of transition, the pharmaceutical care patients receive is often suboptimal and wrought with danger. Home healthcare nurses play a pivotal and important role in providing transitional care to patients by identifying and resolving medication discrepancies. Nurses must partner with pharmacists, physicians, and others involved with care transitions to decrease the likelihood of patients experiencing untoward health consequences associated with medications. (Setter et.al., 2012).
Benefits of the Pharmacy Home Visit Program
Although nurses and therapist, depending on client need and orders, assess all of a client's needs, the pharmacist is able to focus primarily on medications. Through the MOCH program, pharmacists and pharmacy technicians working with their health and social care colleagues and care homes staff, patients and their families, can provide a number of benefits for care homes and their residents including:
• Optimizing medicines (stopping inappropriate or unsafe medicines, and ensuring medicines add value to patient’s health and well-being)
• Patient centered care (shared decision making about which medicines care home residents take and stop)
• Creating better medicines systems for care homes to reduce waste and inefficiency
• Training and supporting care home staff to enhance safer administration of medicines (NHS England).
• Available studies have shown decreased health care utilization, decreased costs to the health system, and improved medication management with pharmacy involvement in home care.
• Beneficial patient outcomes of pharmacy practice in home care settings, such as decreased hospital admissions, decreased emergency department visits, improved quality of life, improved compliance, and decreased adverse events, have been described in many developed countries.
• Positive effects of pharmacy practice in ambulatory care settings, such as decreased benzodiazepine use, improved anxiety scores, improved cardiac outcomes, and improved compliance.
• Most home care pharmacy programs in developed countries provide several services, including comprehensive or targeted medication reviews; education for patients, families, and staff; and provision of drug information (Walus et.al., 2017).
Figure 4. Flow diagram of Refer-to-Pharmacy and Pharmacy Home visit Protocol. Once a referral is accepted, the community pharmacist can then contact the patient to arrange a mutually convenient time for them to visit the pharmacy for their consultation. The pharmacist may then prepare effectively for the consultation as they have a copy of the patient’s discharge letter. The strap line for Refer-to-Pharmacy is “get the best from your medicines and stay healthy at home” which in lay speech means “medicines optimization”. In March 2015 the NICE published Medicines Optimization guidance, which amongst other things states: “a consenting person’s medicines discharge information should be shared with their nominated community pharmacy”. Refer-to-Pharmacy provides the tool to make this possible, and to so routinely for every eligible patient (Gray, 2015).
Common MRPs and Success of Pharmacy Visits at Home
Traditionally, nursing homes have been associated with suboptimal drug therapy and MRPs. In contrast, less is known about drug safety in homecare. Significantly more MRPs were detected among patients receiving home nursing care than patients living in nursing homes. While patients living in nursing homes were often undermedicated, documentation discrepancies were more frequent in home-nursing care. MRP categories leading to changes on the medication lists differed between the settings.
• Untreated conditions: The patient has a medical condition that requires drug therapy but is not receiving a drug for that condition.
• Drug use without indication: The patient is taking a medication for no medically valid condition or reason. For example, a client may be taking proton-pump inhibitor although he or she does not have a history of gastroesophageal reflux disease or peptic ulcers. Conversely, a client with hypertension and diabetes mellitus may not be taking aspirin, although he or she has an indication for it.
• Improper drug selection: The patient’s medical condition is being treated with the wrong drug or a drug that is not the most appropriate for the patient’s special needs.
• Subtherapeutic dosage: The patient has a medical problem that is being treated with too little of the correct medication.
• Overdosage: The patient has a medical problem that is being treated with too much of the correct medication.
• Effectiveness: Effectiveness-related problems occur when a medication dose is too low or when a more effective drug is available. For example, a patient with chronic pain may be taking acetaminophen when an opioid may be more effective.
• ADRs: The patient has a medical condition that is the result of an adverse drug reaction or adverse effect. In the case of older adults, adverse drug reactions contribute to already existing geriatric problems such as falls, urinary incontinence, constipation, and weight loss.
• Safety: When a client is taking a medication with a dose that is too high or is taking a medication that causes an adverse drug reaction, he or she is experiencing a safety medication-related problem. For example, a client may not be able to take amitriptyline for insomnia because anticholinergic side effects are too bothersome.
• Drug interactions: The patient has a medical condition that is the result of a drug interacting negatively with another drug, food, or laboratory test.
• Compliance: The patient has a medical condition that is the result of not receiving a medication due to economic, psychological, sociological, or pharmaceutical reasons. Compliance-related problems describe instances when a client prefers not to take a medication, does not understand how to use a medication, or cannot afford a medication. A client is experiencing a compliance-related problem if he or she does not understand how to use an inhaler or prefers not to take a medication to treat a condition (Shannon et.al., 2013; Walus et.al., 2017; Wolstenholme, 2011).
Figure 5. Pharmacist Advancement of Transitions of Care to Home (PATCH)
service workflow depicting steps to optimize medication safety for high-risk patients. During the pharmacist meeting, a comprehensive medication review, BP and glucose log review, medication reconciliation, and allergy assessment are performed. Additional patient education is provided through verbal discussion and disease state management pamphlets. The pharmacist then discusses all MRPs identified with the PCP immediately after the pharmacist session and a medication plan is formulated. Recommendations are also documented within the EMR in the PCP encounter and are available for the PCP to review prior to the face-to-face visits with the patients. After the PCP visit, patients are provided with a post-visit summary sheet reinforcing educational points from both the pharmacist and PCP sessions as well as an updated medication list. Follow-up visits with the pharmacist are scheduled, if the patient requires additional education and/or management based on the clinical judgment of the PCP or pharmacist (Trang et.al., 2015).
The core of the PATCH service is the ability of pharmacists to provide comprehensive patient-centered care by identifying MRPs and making evidence-based recommendations to providers to optimize medication use. MRPs have been estimated to cost approximately $177.4 billion per year and are estimated to be one of the top 5 causes of death in the elderly population. Identifying, resolving, and preventing MRPs can lead to cost savings as well as improved patient outcomes (Devik et.al., 2018; Trang et.al., 2015). 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. Recognition of the value of the role of the pharmacist has resulted in expansion of clinical services into outpatient settings, including patient homes. For example, the HMR program that was established in Australia in 2001 provides funding for pharmacists to visit patients at home to assess their medication regimens. In Canada, provincial governments are compensating pharmacists for providing medication reviews (MRs) for non-hospitalized patients and also authorizing pharmacists to prescribe (Flanagan, 2018).
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