Clinical Pharmacy Services in the Home

Articles on clinical pharmacy services in the home began appearing 3 decades ago but numbers have greatly increased in the last decade. This overview of the English language literature identified 66 reports describing 57 home-based clinical pharmacy programs. Most programs were provided in the context of a time-limited research project. Medication reviews (defined as comprehensive assessment of the appropriateness of the medication regimen) and medication management (defined as assessment and support of medication compliance) were the most common services provided. Primary care, post-hospital discharge, and home healthcare were the typical service contexts, and elderly patients at high risk of medication problems were the primary target population. The early literature predominantly focused on medication management and patient counseling services based in the US; however, since 1991, reports of medication review programs in the UK and Australia have dominated.Barriers to home-based clinical services have been identified at the healthcare system, pharmacy, pharmacist, physician, and patient levels. The most common barriers are lack of (or inadequate) remuneration and the related barriers of community pharmacy or pharmacist time constraints, and the cost and time to attain and maintain pharmacist qualifications. Other important barriers are difficulty in accessing the physician to discuss drug therapy recommendations, and inadequate patient referrals. Additional barriers pertaining to the delivery of the clinical service include inadequate clinical training of community pharmacists, service provision by a pharmacist unknown to the patient, and limited access to patient information for the pharmacist. Patient barriers are lack of awareness, reluctance to accept an intervention from the pharmacist, inaccessibility, and forgetting appointments or refusing the service after initial agreement.The most commonly cited facilitators pertain to the pharmacist-physician relationship; foremost among these is having an established working relationship between the pharmacist and family physician. Others are face-to-face meetings between pharmacist and prescribing physician, and facilitator positions in Divisions of General Practice. A few facilitators of the referral system, pharmacist motivation, and service delivery have also been identified.Evaluative data were provided for 48 programs; 21 programs were evaluated within a randomized controlled trial. Thirteen of these trials found at least one statistically significant difference between groups; however, although important outcomes such as hospitalization and quality of life were often examined, the only parameter that was affected on a consistent basis was medication compliance (four of six trials).The literature on clinical pharmacy services in the home is growing and maturing. While medication review is the most common type of service reported, several other types of clinical services have been explored in this setting. Although evaluation of impact has become more rigorous over time, the overall evidence is limited and many questions remain about optimal practice models and target patient populations. Given the time intensity of home-based services, it is important that more research be conducted to provide firm evidence of value.     

Asthma Friendly Pharmacies: A Model to Improve Communication and Collaboration among Pharmacists,Patients, and Healthcare Providers

Pharmacists, with expertise in optimizing drug therapy outcomes, are valuable components of the healthcare team and are becoming increasingly involved in public health efforts. Pharmacists and pharmacy technicians in diverse community pharmacy settings can implement a variety of asthma interventions when they are brief, supported by appropriate tools, and integrated into the workflow. The Asthma Friendly Pharmacy (AFP) model addresses the challenges of providing patient-focused care in a community pharmacy setting by offering education to pharmacists and pharmacy technicians on asthma-related pharmaceutical care services, such as identifying or resolving medication-related problems; educating patients about asthma and medication-related concepts; improving communication and strengthening relationships between pharmacists, patients, and other healthcare providers; and establishing higher expectations for the pharmacist’s role in patient care and public health efforts. This article describes the feasibility of the model in an urban community pharmacy setting and documents the interventions and communication activities promoted through the AFP model.     

Enhancing Outcomes Research

The emphasis on healthcare in the US is shifting to the ambulatory environment. To date, few studies have evaluated the effects that community pharmacists have on patient care. In an attempt to address this issue, 4 academicians from a college of pharmacy developed a research network of community pharmacists, the Community Pharmacist Research Network (CPR-Net), to study pharmaceutical care outcomes in community pharmacies.CPR-Net practitioners are located throughout the state of Georgia, USA, and offer a variety of dispensing and clinical services. Research interests of these practitioners include pharmaceutical care, health-related quality of life (HR-QOL), pharmacoeconomics and product evaluation. Regarding specific disease states, CPR-Net members are most interested in studying diabetes mellitus, hypertension and asthma.The first project conducted was an assessment of the HR-QOL and adverse effects experienced by patients receiving antidepressant therapy. The pilot project demonstrated that pharmacists could have patients complete the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) questionnaire in the Community pharmacy setting and that community pharmacists could prospectively collect clinical outcomes data.Benefits of this partnership between the Clinical Outcomes Research Group (CORG) and CPR-Net include the opportunity to study pharmaceutical care in real world conditions. Conducting quality research in community pharmacies can be difficult and requires a close relationship between investigators and practitioners. Since most pharmacists practice in a community setting, we need applied research to study the pharmacist’s unique contribution to healthcare.     

Medication management in older persons: what can be achieved in the international community?

As the population ages worldwide, it is important to examine the challenges that are presented in the use of pharmaceutical treatments. This article comments on what is being done in the international community to promote rational use of medications and elimination of medication-related problems. Efforts are underway to identify elders at highest risk and to encourage communication and collaboration between the patient and the health care team, as well as collaboration among disciplines. Solutions to improve medication management are discussed, particularly those presented at a recent conference on Medication Management in Older Patients held under the aegis of the United Nations' International Institute on Ageing (INIA), Malta. These include evidence- based prescribing, interdisciplinary collaboration with increased clinical pharmacist involvement, and implementing programs that increase concordance between patient and health practitioner. Among the conference's conclusions is that more resources need to be allocated for medication management in the home arena.     

Medications Management in Older Persons: What Can Be Achieved in the International Community?

SUMMARY

As the population ages worldwide, it is important to examine the challenges that are presented in the use of pharmaceutical treatments. This article comments on what is being done in the international community to promote rational use of medications and elimination of medication-related problems. Efforts are underway to identify elders at highest risk and to encourage communication and collaboration between the patient and the health care team, as well as collaboration among disciplines. Solutions to improve medication management are discussed, particularly those presented at a recent conference on Medication Management in Older Patients held under the ageis of the United Nations' International Institute on Ageing (INIA), Malta. These include evidence-based prescribing, interdisciplinary collaboration with increased clinical pharmacist involvement, and implementing programs that increase concordance between patient and health practitioner. Among the conference's conclusions is that more resources need to be allocated for medication management in the home arena.     

Consumer perspectives about weight management services in a community pharmacy setting in NSW,Australia

Background Obesity is a public health challenge faced worldwide. Community pharmacists may be well placed to manage Australia’s obesity problem owing to their training, accessibility and trustworthiness. However, determining consumers’ needs is vital to the development of any new services or the evaluation of existing services. Objective To explore Australian consumers’ perspectives regarding weight management services in the community pharmacy setting, including their past experiences and willingness to pay for a specific pharmacy‐based service. Design An online cross‐sectional consumer survey was distributed through a marketing research company. The survey instrument comprised open‐ended and closed questions exploring consumers’ experiences of and preferences for weight management services in pharmacy. It also included an attitudinal measure, the Consumer Attitude to Pharmacy Weight Management Services (CAPWMS) scale. Setting and participants A total of 403 consumers from New South Wales, Australia, completed the survey. Results The majority of respondents had previously not sought a pharmacist’s advice regarding weight management. Those who had previously consulted a pharmacist were more willing to pay for and support pharmacy‐based services in the future. Most consumers considered pharmacists’ motivations to provide advice related to gaining profit from selling a product and expressed concerns about the perceived conflicts of interest. Participants also perceived pharmacists as lacking expertise and time. Conclusion Although Australian consumers were willing to seek pharmacists’ advice about weight management, they perceived several barriers to the provision of weight management services in community pharmacy. If barriers are addressed, community pharmacies could be a viable and accessible setting to manage obesity.     

Expanding the clinical role of community pharmacy: A qualitative ethnographic study of medication reviews in Ontario,Canada

Medication reviews by community pharmacists are an increasingly common strategy to improve medication management for chronic conditions, and are part of wider efforts to make more effective use of community-based health professionals. To identify opportunities to optimize the medication review program in Ontario, Canada, we explored how providers and clients interpret and operationalize medication reviews within everyday community pharmacy practice. We conducted a qualitative ethnographic study at four pharmacies in Ontario, Canada, including non-participant observation of provider and client activities and interactions with specific attention to medication reviews, as well as brief ethnographic interviews with providers and clients, and in-depth, semi-structured interviews with providers. We report on 72 h of field research, observation of 178 routine pharmacist-client interactions and 29 medication reviews, 62 brief ethnographic interviews with providers and clients, and 7 in-depth, semi-structured interviews with providers. We found that medication reviews were variably conducted across the dimensions of duration, provider type, location, and interaction style, and that local contexts and system-wide developments influence their meaning and practice. Medication reviews are exemplary of policy efforts to enhance the role of community pharmacies within health systems and the scope of practice of pharmacists as healthcare professionals. Our study highlights the importance of the local structure of community pharmacy practice and the clinical aspirations of pharmacists in the delivery of medication reviews.     

新医改背景下基层医院临床药师的培养与管理

基层医院配备临床药师是药学服务转变模式的需要,但此项工作开展不甚理想;为此建议：各级领导应对临床药学人才的培养引起重视,采取相应措施防止人才流失;同时药学人员要立足现有岗位学习成才,加快药学知识与临床知识的融合,与临床医师共同做好临床药学服务。     

An Overview of Community Pharmacist Interventions

This article evaluates the cost effectiveness of and patients’ willingness to pay for interventions by community pharmacists in the overall context of pharmaceutical care. The rationale for interventions by pharmacists in patient care is examined from the viewpoint of clinical and economic needs of the healthcare system. The philosophy of the practice of pharmaceutical care is compared with that of disease management. The analysis shows that both clinical and economic deficiencies exist in the current healthcare system that the practice of pharmaceutical care could help to rectify. More importantly, there is congruence in the practice philosophies between pharmaceutical care and disease management, with both being patient centered and outcome focused. Therefore, the practice of pharmaceutical care can be facilitated within the context of disease management.There are many examples showing that interventions by community pharmacists can result in cost savings. However, there are few studies on consumers’ willingness to pay for such services provided; those to date suggest that consumers are willing to pay a modest amount for pharmaceutical care provided by community pharmacists.Barriers for implementing pharmaceutical care by community pharmacists are discussed, and some suggestions of strategies to be adopted for the successful implementation of pharmaceutical care are made. The author is of the view that before full reimbursement for pharmaceutical care is achieved, the successful implementation of pharmaceutical care by community pharmacists will hinge on better utilization of available resources and improvement in communications between pharmacists, patients and other healthcare professionals. Coordinated and systematic efforts would be required to collect information regarding consumers’ willingness to pay in order to assist in negotiating an acceptable level of reimbursement.Finally, in this age of accountability in healthcare, it is necessary for community pharmacists to demonstrate the benefits of their interventions in terms of better outcomes whether they be clinical, economic and humanistic, and that the improvement is achieved at a cost acceptable to the healthcare system. Without the evidence of acceptable cost effectiveness and perceived benefits, any attempt to promote the implementation of pharmaceutical care by community pharmacists, especially in countries where the concept is relatively new, would only be perceived as lobbying for the interest of a particular professional group, and could not be justifiable.     

全程化药学服务在医院住院药房的应用现状分析

全程化药学服务是药师提供的直接的和间接的与药物有关的服务,是药师与临床医生、护士共同协作来完成的服务过程,包括患者的整个治疗过程和预后追踪,药师参与整个用药治疗过程,保证用药合理性,以此来提高患者的生活质量。该文通过对药学服务应用于医院住院药房的现状、局限性进行分析,从而对药师、医院都提出要求,将药学服务渗透到医疗保健行为的各个方面,保证合理用药,减轻患者经济负担,将医疗水平推向新高度。     

门诊西药房药学服务满意度分析与探讨

目的通过调查门诊西药房药学服务满意度情况,并进行分析,从而为提高药学服务质量提供参考。方法采用自制的调查表,调查门诊患者对西药房药学服务的满意度。结果门诊患者对排队等侯取药时间的满意度最低,为93%;其次为西药房药师使用礼貌用语满意度94.6%;再次为西药房药师的服务态度满意度95.8%;再又为西药房药师交待特殊用药的注意事项满意度97%。对满意度各项目进行分析,西药房工作人员超负荷工作是造成满意度偏低的主要原因;其次是药师说话不够婉转,语气生硬,没有使用礼貌用语;再是有些药师缺乏主动服务理念。结论提高患者的满意度,必须在优化取药流程,拓展药师专业技能,开展人性化服务,一切以患者为中心,加强与患者的沟通,规范文明用语礼貌服务,更新服务理念,改善信息系统等方面切实加以解决。     

某院门诊药房工作的现状及完善

目的 探讨提高某院门诊药房药学服务水平和药师工作效率方法.方法 对门诊药房主要存在的问题、影响药学服务水平和药师工作效率的相关因素进行分析.结果 门诊药房应从工作流程各环节全面入手,引导患者正确排队;提高审核处方的效率和质量;明确药品用法和缩短调配时间;学习沟通技巧与艺术及减少药患纠纷;提升药师专业素质:落实奖惩规定从而减少退药.结论 合理利用现代科技,寻求医院其他部门配合,更好地为患者提供优质高效服务.     

'Strong medicine': an analysis of pharmacist consultations in primary care

BACKGROUND: Patients often find it difficult to discuss their medications fully with their prescribing doctor. Little is known about what might be said about medications to another professional within the primary health care team (PHCT). Pharmacists are seeking to extend their role within primary care and are ideally placed to provide independent medication advice. OBJECTIVE: Our aim was to test the feasibility of using primary care pharmacists as medication counsellors, and to analyse the content of their consultations using qualitative methods. METHOD: Some patients were referred by their doctors, some self-referred and others were invited by the pharmacists for medication reviews. Pharmacist-patient consultations took place within GP surgeries and in patients' homes, and were audiotaped, transcribed and analysed qualitatively. The study sample consisted of 25 consultations with three primary care pharmacists conducted over a 3-month period. RESULTS: Referrals from the doctors were slow and there were no referrals from nurses. The pharmacists, who all had clinical backgrounds and were not dispensing pharmacists, experienced few problems with the consultations. Patients were willing to discuss their medications in detail with the pharmacists. A theme emerged regarding the perceived potency of medications, and this seemed to have an effect on the experience of side effects and the perceived efficacy of the medications. CONCLUSIONS: From this small study, it would seem that pharmacist consultations within primary care are a feasible extension of their current role as prescribing budget advisors. The richness of the consultations reflects the acceptability to patients. Feedback of information to other members of the PHCT, given patient consent, would be very useful for a better understanding of the patient's perspective, which in turn would facilitate concordance in the negotiation of the patient's management.     

The Potential and Pitfalls of Medicine Management

Community pharmacists are potentially in a strong position to contribute to improved patient care by providing medicines management services. Several major trials of community pharmacy medicines management (CPMM) have been conducted in Europe, North America, and Australia. Their findings show that some, but not all, of the potential of CPMM is being met, and thus far, evidence of benefit from CPMM is equivocal. There is a need to review the appropriateness of some of the primary outcome measures used in research to date. Key factors in pharmacy practice that impede CPMM include insufficient integration of community pharmacy input into patient pathways through treatment, poorly developed relationships between pharmacists and primary care physicians, lack of access to patient information, inadequate methods for targetting services to patients with identified medication-related problems, and community pharmacists’ willingness (or lack thereof) to provide the service. Recommendations as to how to improve CPMM services so that they deliver their full potential include integrating work practices with medical colleagues, targeting of patients, providing pharmacist access to patients’ medical records, and improving communication with patients.     

军队医院开展临床药学服务的探讨

目的：探讨军队医院临床药师工作开展情况及取得的成果。方法对军队医院临床药师队伍发展现状、参与临床治疗工作的主要内容、对现有工作模式体会以及未来的发展方向进行分析。结果临床药学是医院药学的发展方向;临床药师通过参与临床药学工作,提高药师在医院的整体地位,形成了临床药师治疗团队。结论军队医院临床药师在提高医院合理用药水平、保证医疗质量、缓解医患紧张关系等方面确实发挥着不可替代的作用。     

Pharmacists’ Interprofessional Communication About Medications in Specialty Hospital Settings

Effective communication between pharmacists, doctors, and nurses about patients’ medications is particularly important in specialty hospital settings where high-risk medications are frequently used. This article describes the nature of communication about medications that occurs between pharmacists and other health professionals, including doctors and nurses, in specialty hospital settings. Semistructured interviews with, and participant observations of, pharmacists, nurses, and doctors were conducted in specialty settings of an Australian public, metropolitan teaching hospital. Twenty-one individuals working in the settings of emergency care, oncology care, intensive care, cardiothoracic care, and perioperative care were interviewed. In addition, participant observations of 56 individuals were conducted in emergency care, oncology care, intensive care, and cardiothoracic care. Detailed thematic analysis of the data was performed. Across all of the settings, pharmacy was less visible than medicine and nursing in terms of pharmacists’ work performed, pharmacy documentation and resources, and pharmacists’ physical visibility. Pharmacists, doctors, and nurses largely worked alongside one another rather than with each other. When collaboration occurred, the professional groups engaged in mostly reactive communication to accomplish specific medication tasks that needed completing. Interprofessional differences in attitudes toward medications and medication management communication behaviors were evident. Pharmacists need to engage in more proactive communication in order to reduce the risk of medication errors occurring.