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.