Nature of community pharmacy in home care

To analyze the reason why home care service which community pharmacists provide has not been effectively utilized, a questionnaire on home care services was submitted to 472 home care service users, 215 general practitioners, 10 visiting nurses and 153 home-helpers, and 75 community pharmacists. We were interested in whether or not gaps existed between users' needs, practitioners' demands, and pharmacists' awareness of professional responsibility to pharmacy services. Also, we were interested in whether or not gaps existed in awareness of the importance of cooperation with community pharmacists and influencing factors between practitioners and home-helpers and visiting nurses. The main results were as follows: users and practitioners considered that counseling about home care and welfare services by community pharmacists was important and home visiting was not so important. However, pharmacists considered that home visiting was important and counseling about home care and welfare services was not so important. Therefore, gaps existed between users' needs, practitioners' demands, and pharmacists' awareness of professional responsibility to pharmacy services. Practitioners' awareness of the importance of cooperation with community pharmacists in comparison to that of other professionals was low as well as that of home-helpers, and visiting nurses. However, over 70% of them recognized the necessity of home visiting services by pharmacists. As far as factors influencing the awareness of the importance of cooperation with community pharmacists, practitioners' recognition to home visiting by pharmacists was higher than that of home-helpers and visiting nurses. However, expectations regarding community pharmacists' participation in home care services was higher than that of practitioners.     

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.     

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.     

Pharmacy-based needle exchange (PBNX) schemes in south east England: a survey of service providers

Aims. To describe the activities of service providers with regard to (i) the business operation and policies defining pharmacy-based needle exchange (PBNX) in South East England; (ii) the day-to-day work of PBNX outlets from the provider perspective; and (iii) problems encountered by PBNX providers. Design. (i) Postal self-completion questionnaire to all participating PBNX community pharmacies in South East England; and (ii) postal self-completion questionnaire to needle exchange coordinators. Setting. Community pharmacy needle exchanges. Participants. Pharmacists in charge of needle exchange; and needle exchange coordinators. Findings. Data were collected (i) from 381/440 (86.7%) participating community pharmacists, and (ii) 32/36 (88.9%) of coordinators. The study found that PBNX was reaching injecting drug users (many of whom used PBNX regularly), and providing a wide range of injecting equipment. Although pharmacists reported that problems such as shoplifting occurred relatively frequently, more serious problems such as violence were relatively rare. However, PBNX pharmacists reported needing further training for themselves and their staff. Suggested improvements included better advertising of services and improving returns rates for used injecting equipment. Conclusion. Needle exchange can reasonably be provided by non-specialist health care professionals such as community pharmacists. However, attention should be paid to the educational needs of service providers who also require adequate support.     

Providing drug injectors with easier access to sterile injecting equipment: a description of a pharmacy based scheme

In this short paper we describe the operation of a pharmacy-based scheme operating in Glasgow to provide injecting drug users with sterile injecting equipment. The operation of the scheme is described under a number of headings: its physical location, the policy of selling injecting equipment, the return of previously used equipment, counseling and referral, and, the style of working of pharmacy staff. It is shown that while retail pharmacies may be an important point of contact with injecting drug users it should not be assumed that pharmacy staff already possess the requisite skills for working in this area. There is a need for pharmacists’and their staff to be able to draw upon the experience of colleagues working in this area in order to benefit from a pool of common experience. In addition there is a need to provide staff with access to appropriate back-up and support services.     

Role of pharmacist counseling in preventing adverse drug events after hospitalization

BACKGROUND: Hospitalization and subsequent discharge home often involve discontinuity of care, multiple changes in medication regimens, and inadequate patient education, which can lead to adverse drug events (ADEs) and avoidable health care utilization. Our objectives were to identify drug-related problems during and after hospitalization and to determine the effect of patient counseling and follow-up by pharmacists on preventable ADEs. METHODS: We conducted a randomized trial of 178 patients being discharged home from the general medicine service at a large teaching hospital. Patients in the intervention group received pharmacist counseling at discharge and a follow-up telephone call 3 to 5 days later. Interventions focused on clarifying medication regimens; reviewing indications, directions, and potential side effects of medications; screening for barriers to adherence and early side effects; and providing patient counseling and/or physician feedback when appropriate. The primary outcome was rate of preventable ADEs. RESULTS: Pharmacists observed the following drug-related problems in the intervention group: unexplained discrepancies between patients' preadmission medication regimens and discharge medication orders in 49% of patients, unexplained discrepancies between discharge medication lists and postdischarge regimens in 29% of patients, and medication nonadherence in 23%. Comparing trial outcomes 30 days after discharge, preventable ADEs were detected in 11% of patients in the control group and 1% of patients in the intervention group (P = .01). No differences were found between groups in total ADEs or total health care utilization. CONCLUSIONS: Pharmacist medication review, patient counseling, and telephone follow-up were associated with a lower rate of preventable ADEs 30 days after hospital discharge. Medication discrepancies before and after discharge were common targets of intervention.     

The host‐homes program: an innovative model of respite for carers of people with dementia

Objective: To investigate the operation of an innovative community respite program run by the Brotherhood of St Laurence: the Banksia ‘host‐home’ program, which was designed to provide respite for up to six people with dementia in a care‐worker's home. The program was funded by the Commonwealth Department of Health and Aged Care as part of a funding program for pilot respite care projects. Method: Interviews were conducted with program staff, carers and care‐recipients (older people with dementia). Information from written records such as funding submissions was also used. Results: People using the program were those who experienced barriers utilising centre‐based programs for older people for a range of reasons including advanced dementia, hearing difficulties, difficulties in social interaction or confusion. Carers were very appreciative of the service, and care‐recipients appeared to enjoy the program immensely, citing caring staff, social contact and activities as things they appreciated most. Conclusions: The host‐home program provided an accessible respite option for those unable to use centre‐based services. It enabled more individually tailored activities, greater socialisation and greater attention from staff than possible in centre‐based services. The informal ‘homely’ feel of the program and the fact that relatives obviously enjoyed participating may have made carers feel more comfortable in using a respite service. Since the model creates the potential for cost‐shifting and because of difficulties in supervising staff in their own homes, guidelines and standards appropriate to host‐home programs should be established to ensure quality of care and to protect paid staff and service users.     

The reliability and utility of spirometry performed on people with asthma in community pharmacies

Objective: To investigate the reliability and the utility of spirometry generated by community pharmacists participating in two large asthma intervention trials of 892 people. Methods: The Pharmacy Asthma Care Program (PACP) and the Pharmacy Asthma Management Service (PAMS) involved up to four visits to the pharmacy over 6 months for counseling and goal setting. Pharmacists performed spirometry according to ATS/ERS guidelines to inform management. The proportion of A–E, F quality tests, as per EasyOne? QC grades, were recorded. Lung function results between visits and for participants referred/not referred to their general practitioner on the basis of spirometry were compared. Results: Complete data from 2593 spirometry sessions were recorded, 68.5% of spirometry sessions achieved three acceptable tests with between-test repeatability of 150?ml or less (A or B quality), 96% of spirometry sessions included at least one test that met ATS/ERS acceptability criteria. About 39.1% of participants had FEV₁/FVC values below the lower limit of normal (LNN), indicating a respiratory obstruction. As a result of the service, there was a significant increase in FEV₁ and FEV₁/FVC and asthma control. Lung function values were significantly poorer for participants referred to their general practitioner, compared with those not referred, on the basis of spirometry. Conclusions: Community pharmacists are able to reliably achieve spirometry results meeting ATS/ERS guidelines in people with asthma. Significant improvements in airway obstruction were demonstrated with the pharmacy services. Pharmacists interpreted lung function results to identify airway obstruction for referral, making this a useful technique for review of people with asthma in the community.     

Factors that Affect Older Japanese People’s Reluctance to Use Home Help Care and Adult Day Care Services

The purpose of this study was to examine the factors related to the reluctance of older Japanese people to utilize home help services and day services. Home help services consist of three different types of services (i.e., assisting in bathing and toileting, doing household choirs, such as cooking and laundry, and counseling) and are provided by visiting home helpers at the homes of older people. Day services are services (e.g., providing bathing and meals, monitoring the health status of older people, and counseling) that are provided at day service centers in the community to improve the physical and psychological functioning of older people and to help the burden of caregiving of family members. The data used in the study came from the first wave of the Nihon University Japanese Longitudinal Study of Aging, conducted in November 1999 (and again in March 2000 for those people who had been unable to respond to the initial survey). Face-to-face interviews were conducted with a national probability sample of 6,700 people aged 65 and older. Logistic regression analyses were used to analyze factors that were thought to be related to older people’s reluctance to use services. Approximately, one half of the respondents indicated reluctance to use home help services, and one quarter of the respondents showed reluctance to use day services. Respondents who were female and who lived in urban areas showed a higher probability of feeling reluctant about using both home-help and day services. Also, respondents who had had caregiving experience using these two types of services showed a lower probability of feeling reluctant about using the services. Furthermore, respondents who were older and had income showed a higher probability of feeling reluctant about using day services, whereas those who had had caregiving experience and who participated in social activities showed a lower probability of feeling reluctant about using day services. According to the 1999 survey, there were still many older Japanese people who felt reluctant about using either type of care service. But it is expected that the quality of services under Kaigo Hoken (the mandatory public long-term care social insurance system) will improve further and that older people’s attitudes toward service utilization will change for the better. In the meantime, professional service providers will have to be sensitive to older people’s perceptions about service utilization if they would like to continue to contribute to the improvement process of Kaigo Hoken as a positive force. This study used data from the Nihon University Japanese Longitudinal Study of Aging (NUJLSOA). This survey was conducted by the Nihon University Center for Information Networking as one of their research projects.     

Häusliche Pflegeberatung für Geldleistungsbezieher in der Pflegeversicherung

Beneficiaries from the German long-term care insurance living at home have the option between cash payments and care-in-kind services. For those who opt for cash payments, there is an obligation to receive expert advice and ‘counseling visits’ by a professional nursing service at least twice a year. Although more than 2 million of these ‘counseling visits’ are conducted each year in Germany, hardly anything is known about these visits and whether they are useful for care recipients and their family caregivers. The purpose of this project was to gain insight into the ‘counseling visits’ in order to develop a useful approach for the performance of these visits. Data collection took place in two regions of Nordrhein-Westfalen (North Rhine-Westphalia). Data were collected using a questionnaire on the general performance of the visits, the perception of care recipients and their family members, and from the perspective of the nursing services. Additional qualitative interviews were conducted with family caregivers and nurse managers. Based on the findings, a family-oriented approach for home care counseling was developed and evaluated in 80 home care arrangements. The findings reveal that despite several efforts the usefulness and quality of the counseling visits basically occurs by chance. The family-oriented approach allowed for a better understanding of the home care arrangements and offered a solid ground on which to base recommendations and advice.     

Physician Attitudes Concerning Anticoagulation Services in the Long-Term Care Setting

Objectives: There is little experience in the use of specialized anticoagulation services in the long-term care setting. Even less is known about physician attitudes regarding these services. To examine this issue, we surveyed physicians caring for nursing home residents in a sample of long-term care facilities located in Connecticut. Methods: We surveyed physicians providing care to nursing home residents of a convenience sample of 21 Connecticut nursing homes. (These facilities had participated in a quality assessment and improvement project on preventing strokes in nursing home residents with atrial fibrillation.) Physicians were requested to complete a structured questionnaire about the challenges to managing nursing home residents on warfarin therapy and preferences concerning the use of an anticoagulation service to manage warfarin therapy in this setting. Results: A total of 245 physicians were asked to participate in the survey, and 114 (47%) responded between November 5, 1999 and January 14, 2000. Of the 114 physicians who returned the survey, 91 reported that they currently cared for residents in long-term care facilities and thus completed the questionnaire. The majority of respondents agreed or strongly agreed that an anticoagulation service would reduce the workload on physicians, increase the costs of care for nursing home residents on warfarin, and increase the percent of time that nursing home residents on warfarin are maintained in the target therapeutic range. Most physicians disagreed or strongly disagreed with statements suggesting an anticoagulation service would decrease the costs of care for nursing home residents on warfarin, reduce the liability of the prescribing physician, interfere with their ability to care for patients on warfarin therapy, and reduce the risk of warfarin-related bleeding. Forty-five percent of respondents agreed with a statement that an anticoagulation service would intrude on physician decision-making. Only about half (53%) of the respondents indicated that they would or might utilize an anticoagulation service for managing their long-term care patients on warfarin. Conclusions: Use of a specialized anticoagulation service to manage warfarin therapy is a systems-level approach with the potential to improve the effectiveness and safety of this treatment. Physician skepticism regarding the usefulness of anticoagulation services will only be overcome by subjecting this approach to rigorous evaluation and by assuring physicians of their ongoing involvement in decision-making regarding warfarin therapy in their patients.     

Bridging the Gap in Tobacco Cessation Services: Utilizing Community Pharmacists to Facilitate Transitions of Care in the USA

Interprofessional strategies for promoting tobacco cessation lead to enhanced quit rates among patients; however, current approaches might not effectively support patients with their quit attempts after they are discharged from the hospital. This paper explores opportunities for interprofessional collaboration between health system–based providers and community pharmacists, as one proposed approach to bridging tobacco cessation services during transitions of care. Suggested strategies include (1) increasing other healthcare professionals’ awareness of legislative advances that permit pharmacists to prescribe cessation medications in some states, and (2) encouraging bi-directional communication between health system–based and community-based providers, especially via integrated electronic health records. Community pharmacists can offer a convenient solution to obtain the post-discharge medication and counseling support that patients need to increase their chances of quitting for good. Additional steps are discussed to improve broadscale capacity of this service being provided in community pharmacies.     

Death at Home Following a Targeted Advance-Care Planning Process at Home: The Kitchen Table Discussion

OBJECTIVE: To determine whether home health agency patients' preferences to die at home can be honored following a structured, professionally facilitated advance-care planning (ACP) process provided in the home. DESIGN: A case series of patients who were identified by their home health agency nurses as having a life-limiting illness and then referred for social service assessment, followed for at least 6 months, with median follow-up of 191 days. SETTING: A large, urban, home health agency owned by a not-for-profit integrated healthcare system. PARTICIPANTS: Eighty-four adult patients (median age 75, range 37-94) receiving home care services other than hospice. INTERVENTION: Formally structured social work visits at patients' homes to discuss end-of-life issues, with communication of results to home health nurses and attending physicians. Social workers performed standard psychosocial assessments, obtained patient and family preferences regarding end-of-life care, and provided education about hospice services. MEASUREMENTS: Acceptance of the ACP process, preferences for location of end-of-life care, location of care at the end of life, adequacy of timing of intervention as measured by length of life after ACP, and use of hospice services. RESULTS: Eighty-three of 84 participants (99%) were willing to complete an ACP process in the home setting. Of the 54 patients expressing a clear preference for location of end-of-life care, 46 (82%) wanted this care to be at home. Thirty-nine (46%) of the participants died within 90 days of ACP; 58 (69%) died by the end of the study. Forty-three (75%) of these deaths occurred at home or in a hospice residence. Fifty-one (61%) patients used home, residential, or nursing home-based hospice services during the study. CONCLUSION: In this series of seriously ill home health patients, most preferred to die at home and virtually all were willing to participate in a home-based ACP process. Facilitating ACP among such patients and their families was associated with end-of-life care at home. Use of hospice services was common following ACP in this population.     

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.     

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.     

Drugs and professional interactions: the modern day pharmacist

Pharmacists are not yet fully integrated into the primary health care team and their skills could be better used to help patients with their long term medicines. The government is encouraging the setting up of medicines management services. Community pharmacists are well placed to help patients who have cardiovascular disease or who are at risk of this: they have an opportunity to identify at-risk patients, they can identify under treated patients at the point of dispensing, and they can provide education and advice on lifestyle and diet. They are also involved in smoking cessation services. Practice based pharmacists can improve patient care through medication review clinics.