Home Care:

How Does the Pharmacist Fit into the Team?

Home care has been defined as “an array of services that enables clients, incapacitated in whole or in part, to live at home, often with the effect of preventing, delaying or substituting for long-term care or acute care alternatives.” Approximately 545,000 Canadians, (2.5% of the population) receive some type of government supported home care.

When we think about home care most of us think of an elderly person who is living alone and needs supportive services to remain at home but as hospital stays become shorter, patients with acute illnesses increasingly need and are receiving home care services. In Canada, home care is referred to, under the Canada Health Act, as an extended health care service and is currently not considered a medically necessary service under this federal act. As a result home care services are not insured in the same way as hospital and physician services. As the provision of home care services is the jurisdictional responsibility of each province and territory in Canada, this decentralizing of responsibility has resulted in service models which have been developed based on community needs, creating wide variations in service delivery across the country.

Health Canada’s 1999 review of publicly funded home care programs in Canada identified a set of basic services that is common to all of the programs: client assessment, case coordination, case management, nursing services and home support (personal care, homemaking, Meals-on-Wheels and respite services). It also identified other services offered in some programs only. The following professional services were listed: physiotherapy, occupational therapy, respirology, social work, speech therapy and dietician services. Neither pharmaceutical services nor pharmacists were included in this list despite the need for better medication management in acute, chronic and elderly home care recipients.

The report of the Future of Health Care in Canada recommends that the Canada Health Act be revised to include coverage for home care services in the following priority areas: home mental health case management and intervention services, post-acute home care, and palliative home care. Furthermore, the commission recognized the need for better medication management in this sector of the health care system and recommended that this expansion include medication management. The Canadian Pharmacists Association has stated that “Home care does not fall under the auspices of the Canada Health Act; however, since it is being used to replace hospital-based care, Canadians deserve to have equivalent care available in their home”.

Medication Problems in the Home Care Sector

A decade ago patients remained in hospital longer after both acute illnesses and surgery and there was less of a need for home care services in this sector. Technological and drug advances, shorter hospital stays, and a growing ageing population, have led to services traditionally managed in hospitals and long term care settings to be managed at home. Home health care spending in Canada, has increased from 1.2% in the 1980’s to 3.3% (3.1 billion) in the 2000’s. As hospital beds disappear and patients are released ‘quicker and sicker’, reliance on home care grows. While in hospital, the patients have access to a wide variety of services, including clinical pharmacy services. These services are available to very few of the growing number of patients who are now receiving home care. Today, more drugs are being consumed within the home care sector. These drugs now include technically complex or potentially toxic medications that were previously used only in hospitals.

More than 80% of seniors receiving home support services take medications and most of these take four or more different prescriptions daily. In one study 97% of patients were taking at least one medication at the time of admission to a home care agency. In addition, most of these patients also take between one and three non-prescription drugs daily.

The large number of medications consumed by patients receiving home care is inevitably associated with a high frequency of medication problems and potential medication problems. Meredith et al examined the frequency of potential medication errors in the home care environment in a cross-sectional survey of 6,718 study participants over the age of 65 years from two of the largest home healthcare agencies in the United States. Nearly one-third of the home health patients had evidence of a possible medication problem or was taking a medication that would be considered inappropriate for this age group. A further 19% of these elderly home care recipients had a possible medication error as assessed using the Home Health Criteria, a specially designed set of criteria developed by an expert panel for use in the home healthcare setting, 17% using the Beers Criteria, and 30% using either. As the number of medications taken increases the possibility of medication errors increases.

When one also considers the multiple drug regimens and functional disabilities of many longterm, home care patients, it is clear that people receiving home care are more likely to require medication management support. Research has shown that medication management for the community-dwelling senior citizen is poor. This is largely due to a system that does not integrate the pharmacist to ensure close scrutiny of medication regimens.

Home Care Pharmacy – the History

Home care pharmacy has been described as the “provision of specialized, complex pharmaceutical products and clinical assessment and monitoring to patients in their homes” . Activities related to home care pharmacy can include home infusion therapy, parenteral and enteral nutrition, hospice pharmaceutical services, educating the home care nurse and other caregivers about medications, clarification of procedures for specific problems, provision of additional clinical consultation for complex patients and, if necessary, discussion of problems with physicians.

In both Canada and the United States pharmacy services in publicly funded programmes have consisted mainly of supplying and monitoring infusion therapy. Home care pharmacy has struggled in recent years to be seen as more than the provision of infusion therapy with which it has traditionally been identified. The American Society of Hospital Pharmacists (ASHP) has defined home care pharmacy as the “provision of pharmaceutical products and clinical monitoring to patients in the home, including but not limited to home infusion therapy and other injectable therapy and enteral nutrition therapy.” The ASHP Guidelines Minimum Standard for Home Care Pharmacies also suggest that a home care pharmacy is one that provides primarily home infusion products. This narrow definition of home care pharmacy may have contributed to the exclusion of pharmacists from the list of health professionals that the American Health Care Financing Administering (HCFA) regulations allow to perform drug regimen reviews for home care recipients.

The background paper on the role of the pharmacist in home care, prepared in 2001 for the Canadian Pharmacists Association, concluded that the role of the pharmacist in home care in Canada has also been largely limited to the provision of infusion therapy. Other organizations have recognized a broader role for pharmacists in home care. The Canadian Society of Hospital Pharmacists’ (CSHP) position statement on the pharmacist’s role in home health care lists distributive, clinical, consultative, advisory and educational functions. Pharmacist’s services fall under professional care (geriatric assessment and consulting) in the set of core services that should be included within home and community care as defined by Canadian Association for Community Care/Canadian Home Care Association (CACC/ CHCA). Pharmacists also have potential roles in case management (needs assessment), caregiver support (respite and advice), palliative care, necessary medical supplies and equipment, and access to subsidized prescription drugs.

Medication Management in Home Care – the Present

The number of community pharmacies in Canada which provide home care services is small. MacKeigan et al identified clinical home care practices using key informant and snowball sampling and were able to locate 31 pharmacies across Canada who were providing home care, representing 0.5% of pharmacies in Canada. Home care services provided by these pharmacists included: compliance support, patient education, medication regimen review, monitoring for efficacy and adverse effects of new medications, and education and drug information provision to other home care providers. Most referrals (48%) for these services came from other health care professionals. Reimbursement was the largest and most commonly cited barrier to providing home care pharmacy services.

The Canadian Pharmacists Association surveyed a random sample of Canadian community pharmacists in the summer of 2003 (CPhA, unpublished, 2003). A small proportion of the respondents (14%) said they had some affiliation or connection with a home care agency although in most cases these were informal. The services which were provided by the pharmacists to the agency with whom they were affiliated included: filling prescriptions, compliance packaging, prefilling syringes, provide inservices to home care nurses.

Community pharmacies in Canada have also been providing a number of services which are substitutes for services provided by hospital or long-term care facilities. Most of the community pharmacies surveyed said they provided compliance (blister) packaging (88%) and 86% said they provided reviews of current medications and usage. Fewer than half said they did patient assessments (40%) and only 14% said they did home medication counseling, education and training. For the most part, these pharmacy services are unrecognized and are not reimbursed. Only 17% of the pharmacists surveyed said they received reimbursement for these services and in most cases this reimbursement came from the patient followed by third-party payers. As in the study by MacKeigan et al reimbursement was identified as a major barrier to more extensive provision of home care services by community pharmacists.

Although lack of payment is perceived as a major barrier, programs providing payment for these services are still uncommon and where they exist are not used to their full extent. In Quebec RAMQ covers two pharmacist intervention services: refusal to fill and pharmaceutical opinion. The number of claims for such interventions lags behind expectations, despite payment having been available for 20 years. Issues raised included 1) lack of personal financial gain arising from billing, 2) lack of time to give or bill services, 3) fear of the physician’s negative reaction when sent an opinion, 4) having intervened or given opinions without billing for these services, and 5) desire for a simplification of the methods for billing, including the possibility of billing for verbal opinions without the mandatory letter to the physician.

Medication Management in Home Care – the future

There are a number of successful models of home care pharmacist services. In Australia, the government pays the pharmacist to provide home visits (Commonwealth Department of Health and Aged Care 2001). A similar programme exists in New Zealand where the government pays pharmacists to conduct intensive medications reviews. Neither country requires enrolment in a home care program for the medication review. In both countries, the key to the success of the home care pharmacist has been the multidisciplinary approach in which pharmacist-physician communication and involvement of other health care professionals is mandated by the programme.

The Albany College of Pharmacy and the Visiting Nurse Association of Albany (USA) have collaborated to develop a clinical pharmacy practice within a home care provision agency. The pharmacist in this programme provides drug information to other health care professionals, develops programmes targeting specific drug problems, has instituted longterm- care and pain management initiatives, adverse drug reaction reporting, and is involved in policy development. As part of the long-term-care initiative pharmacists make home visits during which they conduct a pharmacotherapeutic assessment and make recommendations. The pharmacist interventions have had a positive impact on patient care and have illustrated the many opportunities for a pharmacist, within a home care agency, to improve patient care.

Research in home care pharmacy has also been conducted in the United Kingdom. In one study of home visits by community pharmacist volunteers in the UK, 37% of physician interventions suggested by the pharmacist and 50% of community pharmacist interventions were acted upon. In another UK study of the impact of providing home care pharmacy service interventions, an independent clinical panel determined that of the 85 implemented recommendations (97%), five prevented hospital admissions, 22 prevented the likelihood of harm or side effects and 31 improved the efficacy of the patient’s medication regime. In Canada nurse/pharmacist teams conducting home visits have demonstrated positive results both in cost savings and in improved patient outcomes.

In the hospital environment, a pharmacist would be routinely involved in the selection and monitoring of the drugs used to treat these patients. Despite the growing body of evidence for the effectiveness of home care pharmacy, home care services have evolved without the inclusion of pharmacy services. This has resulted in two levels of care: one for Canadians in an institutional setting and one for those receiving home care.

Moving the Present into the Future

When used effectively, the pharmacist can improve Canadians’ health by being involved in the use of drugs, which are the most frequently used medical intervention. Pharmacists are well qualified to be the drug experts in the health care system because they have a minimum of five years’ university education devoted to drugs and their use. A growing number of pharmacists have an additional two-year Doctor of Pharmacy degree. Pharmacists are licensed and must meet and maintain rigorous standards through national and provincial examination processes. Despite these qualifications and increasing evidence of pharmacist’s value as a member of Canada’s health care team, the knowledge and skills of pharmacists are underutilized.

It is clear that current home care programs could be improved by the involvement of a pharmacist and that the pharmacist has been overlooked in the development of home care. According to Commissioner Romanow:

“...pharmacists can play an increasingly important role as part of the primary health care team, working with patients to ensure they are using medications appropriately and providing information to both physicians and patients, monitor patients’ use of drugs and provide better information and communication on prescription drugs.”

To reach this goal of integrating pharmacist services into Canadian home care services a number of steps must be taken. Pharmacists must work with government to clearly define the services to be included and paid for in home care. Indicators for quality care for home care services, including pharmacy services, must be developed and implemented. Reimbursement methods for pharmacy home care services need to be identified and developed. Both Governments and health care providers must work towards the provision of a seamless health care so that all care providers have access to the same information in order improve the provision and consistency of care in the home care and other environments such as hospitals. Canadian pharmacy practice researchers and pharmacists associations are now actively involved in taking these steps.