Inquiry into the ideal function of the pharmacy in home care*

Background: The aim of this study is to analyze why home‐care services provided by pharmacists have not been effectively utilized. Method: Questionnaires were submitted to home‐care service users, physicians, visiting nurses and home‐helpers and pharmacy directors. We studied whether gaps existed between users’ needs, physicians’ expectations of pharmacy services and pharmacists’ awareness of the importance of pharmacy services. We also investigated whether a failure to recognize the importance of cooperation with pharmacists in home‐care provision existed among physicians and nurses/home‐helpers. Results: Users and physicians expect pharmacists to be more involved in counseling about home care and welfare services than home‐visiting services. Pharmacists recognize home visiting services as being of greater importance than counseling about home care and welfare services. The results indicated that gaps existed between users’ needs, the physicians’ expectations and pharmacists’ awareness of the importance of pharmacy services. In terms of cooperation with pharmacists, study results implied that: (i) nurses/home‐helpers’ awareness of pharmacists’ home‐visiting service is lower than that of physicians; (ii) physicians’ expectations regarding pharmacists’ participation in home care services is lower than that of nurses/home‐helpers; (iii) over 70% of both groups recognize the necessity of pharmacists’ home‐visiting service. Conclusions: Pharmacists need to get more involved in counseling users about home care and welfare. Also, there should be a special focus on heightening nurses/home‐helpers’ awareness of pharmacists’ home‐visiting service and on raising physicians’ expectations for pharmacists’ participation in home care services to develop home‐care related pharmacy services in Japan.     

A patient-centered pharmacy services model of HIV patient care in community pharmacy settings: a theoretical and empirical framework

Reflecting trends in health care delivery, pharmacy practice has shifted from a drug-specific to a patient-centered model of care, aimed at improving the quality of patient care and reducing health care costs. In this article, we outline a theoretical model of patient-centered pharmacy services (PCPS), based on in-depth, qualitative interviews with a purposive sample of 28 pharmacists providing care to HIV-infected patients in specialty, semispecialty, and nonspecialty pharmacy settings. Data analysis was an interactive process informed by pharmacists' interviews and a review of the general literature on patient centered care, including Medication Therapy Management (MTM) services. Our main finding was that the current models of pharmacy services, including MTM, do not capture the range of pharmacy services in excess of mandated drug dispensing services. In this article, we propose a theoretical PCPS model that reflects the actual services pharmacists provide. The model includes five elements: (1) addressing patients as whole, contextualized persons; (2) customizing interventions to unique patient circumstances; (3) empowering patients to take responsibility for their own health care; (4) collaborating with clinical and nonclinical providers to address patient needs; and (5) developing sustained relationships with patients. The overarching goal of PCPS is to empower patients' to take responsibility for their own health care and self-manage their HIV-infection. Our findings provide the foundation for future studies regarding how widespread these practices are in diverse community settings, the validity of the proposed PCPS model, the potential for standardizing pharmacist practices, and the feasibility of a PCPS framework to reimburse pharmacists services.     

Pharmacists' Awareness and Attitude Toward Blood Pressure Measurement at Home and in the Pharmacy in Japan

The aim of this study is to investigate the status of Japanese pharmacists' awareness and attitude toward blood pressure (BP) measurement at home (HBP) and in the pharmacy. Of the 708 community pharmacists and the 117 hospital pharmacists, more than 90% of pharmacists answered that HBP was equally important to or more important than clinic BP, 71.9% (community) and 48.7% (hospital) recommended HBP measurement to the hypertensive patients, and about 15% correctly recognized the reference values of HBP hypertension. Among community pharmacists, 54.0% answered that BP-measuring devices were available in their pharmacy. More aggressive promotion of HBP measurement among pharmacists is warranted.     

Team‐Based Interprofessional Competency Training for Dementia Screening and Management

As many as 50% of people satisfying diagnostic criteria for dementia are undiagnosed. A team‐based training program for dementia screening and management was developed targeting four professions (medicine, nursing, pharmacy, social work) whose scope of practice involves dementia care. An interprofessional group of 10 faculty members was trained to facilitate four interactive competency stations on dementia screening, differential diagnoses, dementia management and team care planning, and screening for and managing caregiver stress. Registrants were organized into teams of five members, with at least one member of each profession per team. The teams rotated through all stations, completing assigned tasks through interprofessional collaboration. A total of 117 professionals (51 physicians, 11 nurses, 20 pharmacists, 24 social workers, 11 others) successfully completed the program. Change scores showed significant improvements in overall competence in dementia assessment and intervention (very low = 1; very high = 5; average change 1.12, P < .001), awareness of importance of dementia screening (average change 0.85, P < .001), and confidence in managing medication (average change 0.86, P < .001). Eighty‐seven participants (82.9%) reported feeling confident or very confident using the dementia toolkit at their home institution. In a survey administered 3 months after the session, 48 respondents reported that they had changed their approach to administering the Mini‐Cog test (78%), differential diagnosis (49%), assessment of caregiver stress (74%), and accessing community support and services (69%). In conclusion, team‐based interprofessional competency training is a team teaching model that can be used to enhance competency in dementia screening and management in medical, nursing, pharmacy, and social work practitioners.     

General practitioners' knowledge, confidence and attitudes in the diagnosis and management of dementia

OBJECTIVE: To measure general practitioners' knowledge of, confidence with and attitudes to the diagnosis and management of dementia in primary care. SETTING: 20 general practices of varying size and prior research experience in Central Scotland, and 16 similarly varied practices in north London. Participants: 127 general practitioners who had volunteered to join a randomised controlled trial of educational interventions about dementia diagnosis and management. METHODS: Self-completion questionnaires covering knowledge, confidence and attitudes were retrieved from practitioners prior to the educational interventions. RESULTS: General practitioners' knowledge of dementia diagnosis and management is good, but poor awareness of its epidemiology leads to an over-estimate of caseload. Knowledge of local diagnostic and support services is less good, and one third of general practitioners expressed limited confidence in their diagnostic skills, whilst two-thirds lacked confidence in management of behaviour and other problems in dementia. The main difficulties identified by general practitioners were talking with patients about the diagnosis, responding to behaviour problems and coordinating support services. General practitioners perceived lack of time and lack of social services support as the major obstacles to good quality care more often than they identified their own unfamiliarity with current management or with local resources. Attitudes to the disclosure of the diagnosis, and to the potential for improving the quality of life of patients and carers varied, but a third of general practitioners believed that dementia care is within a specialist's domain, not that of general practice. More experienced and male general practitioners were more pessimistic about dementia care, as were general practitioners with lower knowledge about dementia. Those reporting greater difficulty with dementia diagnosis and management and those with lower knowledge scores were also less likely to express attitudes endorsing open communication with patient and carer. CONCLUSION: Educational support for general practitioners should concentrate on epidemiological knowledge, disclosure of the diagnosis and management of behaviour problems in dementia. The availability and profile of support services, particularly social care, need to be enhanced, if earlier diagnosis is to be pursued as a policy objective in primary care.     

Practical use of informal services and cooperation with psychologists under the long-term care insurance

Home care of patients is mainly performed by visiting nurses. To adequately perform the care, many type of knowledge are needed. Especially psychological approaches can minimize the pain to the patients and their family and shortening its duration and raising the efficacy of the treatment. Cooperation with clinical psychologists can be effective. We present three cases who were difficult to help by nurses alone Thus, Nurses provided in cooperation with the psychologists. First case was a 27-year-old man with cerebral palsy. Second case was a 55-year-old man with lung cancer, terminal stage. Third case was a 60-year-old man with amyotrophic lateral sclepsis. Through these different cases, we recognized the difficulties of medical care at home and also the importance of cooperation with psychologist. With the aging of society, the amount and type of home care needed will increase. Under long term insurance, the various type of knowledge, especially, psychological approaches is important. At the same time, training and education in this field for visiting nurses is required.     

Day‐care service use is a risk factor for long‐term care placement in community‐dwelling dependent elderly

Aims: To identify predictors of long‐term care placement and to examine the effect of day‐care service use on long‐term care placement over a 36‐month follow‐up period among community‐dwelling dependent elderly. Methods: This study was a prospective cohort analysis of 1739 community‐dwelling elderly and 1442 caregivers registered in the Nagoya Longitudinal Study for Frail Elderly. Data included the clients' demographic characteristics, basic activities of daily living, comorbidities, and use of home care services, including the day‐care, visiting nurse, and home‐help services, as well as caregivers' demographic characteristics and care burden. Analysis of long‐term care placement over 36 month was conducted using Kaplan–Meier curves and multivariate Cox proportional hazards models. Results: Among the 1739 participants, 217 were institutionalized at long‐term care facilities during the 36‐month follow‐up. Multivariate Cox regression models, adjusted for potential confounders, showed that day‐care service use was significantly associated with an elevated risk for long‐term care placement within the 36‐month follow‐up period. Participants using a day‐care service two or more times/week had significantly higher relative hazard ratios than participants not using such a service. Conclusion: The results highlight the need for effective measures to reduce the long‐term care placement of day‐care service users. Policy makers and practitioners must consider implementing multidimensional support programs to reduce the caregivers' willingness to consider long‐term care placement. Geriatr Gerontol Int 2012; 12: 322–329.     

Relationship of the community in National Center for Geriatrics and Gerontology

Acute hospital has to have a good community relationship because of looking for a services and settings after discharge for elderly patients. In particular, physicians should have good relations with other physicians, visiting nurses, and care managers, because elderly patients had to go to facilities or nursing homes instead of their own homes. We must obtain information concerning care services and build networks between hospitals and the community in order to provide good services. To enable this we established a good discharge support team. We also have to educate the staff and care managers to take good care of patients. A comprehensive geriatrics and team approach is important for geriatric medicine in the community through care conference. So geriatricians must take part in care conferences and take a leadership role in networks for people with care needs. Finally our national center for geriatrics and gerontology has to take a role of the future achievement in geriatric field and provide information related research and clinical activity for the elderly.     

Präventive Hausbesuche durch eine speziell fortgebildete Pflegefachkraft bei 60-jährigen und älteren Personen in Hamburg

There is increasing interest in home visits by phycisians, nurses or occupational therapists which offer health promotion or preventive care to older people. However, the practical performance of home visits, the targeting, and the effectiveness are ambigious. The collaboration in the EU-study 'disability prevention' gave the opportunity to recruit non-selected people 60 years and older from 14 general practitioners' patient lists in Hamburg. The study participants were offered different programs of health promotion, i. e., group sessions at the geriatric center and preventive home visits. The home visits were made by a nurse who received special training, and a curriculum was established. Seventy-seven elderly persons were visited because they were not able to attend the group sessions at the geriatric center due to self-reported problems in mobility. The investigations revealed combined risks for development of functional decline and dependency in the majority of these community dwelling elderly persons. These findings were unknown to the general practitioners. For example, the risk of falling as recorded by assessment was elevated in more than half of the persons visited. Screening and assessment are useful for planing measures of health promotion and prevention. There are still questions open to discussion. The targeting, practicability, and prerequisites in structure of service provision are considered with regard to the present study's results and an upto date literature review.     

Referring TB suspects from private pharmacies to the National Tuberculosis Programme: experiences from two districts in Ho Chi Minh City, Vietnam.

SETTING: Ho Chi Minh City, Vietnam. OBJECTIVE: To describe pharmacists' attitudes towards referring TB suspects to the National Tuberculosis Programme (NTP) and to evaluate the feasibility of a new referral system. METHODS: 1) Questionnaire survey of 150 private pharmacies; 2) qualitative interviews with 16 pharmacists; 3) monitoring the use of new referral forms for 21 months. RESULTS: Use of a simple referral form was thought to be manageable by 72% of the pharmacists. Pharmacists identified a number of different types of risks associated with referral of TB suspects to the NTP; clients could turn to another pharmacy (61% of respondents); criticise the pharmacist if it appears that they do not have TB (42%); or remain untreated because they are not able to visit the NTP (41%). Fifty-eight (39%) of eligible pharmacies referred at least one client. At least 373 suspects were referred, 149 were tested and 10 had TB. CONCLUSIONS: It is feasible to let pharmacies refer TB suspects. For there to be a significant impact on case detection, it is important to acknowledge a number of concerns expressed by pharmacists and attempt to change both clients' and providers' expectations with regard to the pharmacists' role.     

Effects on health care use and associated cost of a home visiting program for older people with poor health status: a randomized clinical trial in the Netherlands

BACKGROUND: Home visiting programs have been developed to improve the functional abilities of older people and subsequently to reduce the use of institutional care services. The results of trials have been inconsistent and their cost-effectiveness uncertain. Home visits for a high-risk population rather than the general population seems a promising approach. We therefore studied the effects of a home visiting program for older people with poor health. This article describes the effects on health care use and associated cost. METHODS: We conducted a randomized clinical trial among 330 community-dwelling citizens, aged 70-84 years, in the Netherlands. Participants in the intervention group (n = 160) received eight home visits by a trained home nurse over an 18-month period; a multidimensional geriatric assessment of problems was included. The main outcomes are: admissions to hospital, nursing home, and home for older persons; contacts with medical specialists, general practitioners, and paramedics; and hours of home care help. The data on health care use were mostly obtained from computerized databases of various medical administration offices; the follow-up period was 24 months. RESULTS: Inpatient and outpatient health care use was similar for both groups, with the exception of a higher distribution of aids and in-home modifications in favor of the intervention group. No differences were found between the intervention and control group in health care cost. CONCLUSION: The home visiting program did not appear to have any effect on the health care use of older people with poor health and had a low chance of being cost-effective. We conclude that these visits are probably not beneficial for such persons within the health care setting in the Netherlands or comparable settings in other Western countries.     

Care and nursing in remodeling long term care insurance

Long term care insurance was changed in 2006. The main purpose of remodeling is to support preventive care and to develop community comprehensive care center and community based services. Community based services are composed by group homes, night care services, small multi-function complex care services, day care services for dementia, satellite nursing homes. Preventive care in long term care insurance is composed of muscle training, oral care and improvement of nutrition. Visiting nurse services can provide day care at nurse stations. These arrangements are strongly expected to support care workers and visiting nurses. An assessment for dementia, Center version was developed by the Tokyo Center for Dementia Care Training and Research. It is intended to lead to person-centered care for elderly people with dementia. An act to prevent abuse of the elderly has been started in 2005. This was established to protect the property of the elderly, even if they might have cognitive dysfunction. A support doctor system has been started to educate primary care doctors and to make early diagnosis for dementia. These changes are expected to provide better care for old people.     

Caring for the person receiving ventilatory support at home: care givers' needs and involvement.

Little is known of the needs of family members who provide home care to persons receiving ventilatory support (VS). In a structured interview of 44 care givers of 29 persons receiving VS, finances, provisions for emergencies, information, family relationships, and continuity of care were ranked as the most important needs. Needs for support services were ranked highest in importance to the care givers of persons receiving continuous VS, care givers who did not live in, and children of persons receiving VS. Parents of persons receiving VS ranked educational needs and attention to other family members of highest importance. Handling emergencies was most important to less experienced care givers, whereas financial and respite needs were more important to experienced and full-time care givers. Findings suggest the need for early participation of community health care professionals in care giver preparation, negotiations with third-party payers, 24-hour support services, information networks, and long-term, comprehensive coverage of services.     

Effects of a late-life suicide risk--assessment training on multidisciplinary healthcare providers

Older adults are among the highest at risk for completing suicide, and they are more likely to seek mental health services from providers outside of traditional mental health care, but providers across the spectrum of care have limited training in suicide risk assessment and management and particularly lack training in suicide prevention for older adults. An educational program was developed to increase awareness and improve suicide risk assessment and management training for a range of healthcare providers who may see older adults in their care settings. One hundred thirty-two participants from two Veterans Affairs Medical Centers participated in a 6.5-hour-long workshop in the assessment and management of suicide risk in older adults. Participants were asked to complete pre- and postworkshop case notes and report on subjective changes in knowledge, attitudes, and confidence in assessment and managing suicide risk in older adults. Participants included social workers, nurses, physicians, psychologists, and occupational therapists from a variety of care settings, including outpatient and inpatient medical, outpatient and inpatient mental health, specialty clinics, home, and community. After the workshop, participants demonstrated improvement in the overall quality of case notes (P = .001), greater ability to recognize important conceptual suicide risk categories (P = .003), and reported heightened awareness of the importance of late-life suicide. The results suggest that educational training may have beneficial effect on the ability of multidisciplinary care providers to identify and manage suicide risk in elderly adults.     

Clinical pharmacists and inpatient medical care: a systematic review

BACKGROUND: The role of clinical pharmacists in the care of hospitalized patients has evolved over time, with increased emphasis on collaborative care and patient interaction. The purpose of this review was to evaluate the published literature on the effects of interventions by clinical pharmacists on processes and outcomes of care in hospitalized adults. METHODS: Peer-reviewed, English-language articles were identified from January 1, 1985, through April 30, 2005. Three independent assessors evaluated 343 citations. Inpatient pharmacist interventions were selected if they included a control group and objective patient-specific health outcomes; type of intervention, study design, and outcomes such as adverse drug events, medication appropriateness, and resource use were abstracted. RESULTS: Thirty-six studies met inclusion criteria, including 10 evaluating pharmacists' participation on rounds, 11 medication reconciliation studies, and 15 on drug-specific pharmacist services. Adverse drug events, adverse drug reactions, or medication errors were reduced in 7 of 12 trials that included these outcomes. Medication adherence, knowledge, and appropriateness improved in 7 of 11 studies, while there was shortened hospital length of stay in 9 of 17 trials. No intervention led to worse clinical outcomes and only 1 reported higher health care use. Improvements in both inpatient and outpatient outcome measurements were observed. CONCLUSIONS: The addition of clinical pharmacist services in the care of inpatients generally resulted in improved care, with no evidence of harm. Interacting with the health care team on patient rounds, interviewing patients, reconciling medications, and providing patient discharge counseling and follow-up all resulted in improved outcomes. Future studies should include multiple sites, larger sample sizes, reproducible interventions, and identification of patient-specific factors that lead to improved outcomes.     

Content and Outcomes of Dutch Nurse Clinics for Children with Asthma

Dutch specialist asthma nurses run extramural and transmural nurse clinics for children with asthma. Extramural clinics are run under the responsibility and in the premises of a home care organization. Transmural clinics are run in an outpatient clinic in close collaboration and joint responsibility between home care organizations and hospitals.

Effects of and differences between these clinics were determined by using a quasi-experimental design. Visiting a nurse clinic appears to result in a reduced information need and reduced use of health care services. Parents of asthmatic children visiting transmural nurse clinics appeared to have a lower information need than those attending extramural nurse clinics.