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Current perspectives on pharmacist home visits:

do we keep reinventing the wheel?

This article was published in the following Dove Press journal:

Integrated Pharmacy Research and Practice

Priti S Flanagan 1,2 Abstract: The scope of clinical pharmacy services available in outpatient settings, including
Andrea Barns 1 home care, continues to expand. This review sought to identify the evidence to support phar-
macist provision of clinical pharmacy services in a home care setting. Seventy-five reports were
1
Pharmacy Community Programs,
Lower Mainland Pharmacy Services, identified in the literature that provided evaluation and description of clinical pharmacy home
Langley, BC, Canada; 2Faculty of visit services available around the world. Based on results from randomized controlled trials,
Pharmaceutical Sciences, University
of British Columbia, Vancouver, BC,
pharmacist home visit interventions can improve patient medication adherence and knowledge,
Canada but have little impact on health care resource utilization. Other literature reported benefits of a
pharmacist home visit service such as patient satisfaction, improved medication appropriateness,
increased persistence with warfarin therapy, and increased medication discrepancy resolution.
Current perspectives to consider in establishing or evaluating clinical pharmacy services offered
in a home care setting include: staff competency, ideal target patient population, staff safety, use
of technology, collaborative relationships with other health care providers, activities performed
Video abstract during a home visit, and pharmacist autonomy.
Keywords: clinical pharmacy, home care, home visit, medication review, pharmacist

Introduction
Over the past several decades, the scope of clinical pharmacy services has expanded
both in terms of skills and areas in which services are offered. Traditionally, the
availability of clinical pharmacy services has been in the purview of hospitals where
increased clinical pharmacy services has been associated with reduced length of stay
and mortality.1 Recognition of the value of the role of the pharmacist has resulted
in expansion of clinical services into outpatient settings, including patient homes.
Point your SmartPhone at the code above. If you have a For example, the Home Medicines Review (HMR) program that was established in
QR code reader the video abstract will appear. Or use:
http://youtu.be/1GqaKjewScQ Australia in 2001 provides funding for pharmacists to visit patients at home to assess
their medication regimens.2 In Canada, provincial governments are compensating
pharmacists for providing medication reviews (MRs) for non-hospitalized patients3
and also authorizing pharmacists to prescribe.4
While there is evidence to suggest that pharmacist prescribing activities can
improve patient outcomes in outpatient settings,5–7 the evidence to support the ben-
Correspondence: Priti S Flanagan
Lower Mainland Pharmacy Services, 2nd efit of MRs in outpatient settings is equivocal. Holland et al conducted a systematic
Floor, 8521 198A Street, Langley, review and meta-analysis to evaluate the impact of pharmacist-led MR in older adults
BC V2Y ØA1, Canada
Tel +1 604 455 1328 (ext 741403)
and reported that there was no effect on reducing mortality or hospital admissions,
Email [email protected] but that the intervention may reduce the number of prescribed drugs and improve

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Flanagan and Barns Dovepress

drug knowledge and adherence.8 More recently, an evalua- human subjects. Additionally, the gray literature and refer-
tion of the MR service available in the province of British ence lists of articles found were searched for additional
Columbia, Canada, reported that there had been little impact records. One hundred and fifty-six unique records were found,
on prescription drug use in the province as a result of this of which 54 were excluded as they were conference abstracts
program.9 In contrast, a systematic review and meta-analysis or the full article access was not possible. In addition, a fur-
that evaluated medication reconciliation programs at hospital ther 27 were excluded as they did not describe pharmacists
transitions and included pre- and post-discharge pharmacist doing HVs in a unique study published in 2007 or onward,
visits reported significantly reduced adverse drug event leaving 75 articles that were included in this review.
(ADE)-related hospital revisits attributable to the interven- Different programs and authors use different terminology
tions, which included pharmacist home visits (HVs).10 A to refer to similar concepts. We will be referring to medication
recent randomized-controlled trial (RCT) determined that reconciliation (MRec) as the act of comparing all medication
an extended intervention that included both a pharmacist- lists in order to reconcile and create a master list of what the
led pre-hospital discharge MR and post-discharge follow-up patient should be taking. MR refers to the act of compiling
significantly reduced readmissions within 30 or 180 days a list of medications the patient is taking and assessing the
compared with usual care; however, the MR alone did not.11 appropriateness of each medication and the regimen as a
These studies were not focused solely on clinical phar- whole. MRec may be included in the process of MR. We
macy services in home care and so applicability to this setting will refer to medication, therapy, or drug-related problems
is limited. A review of clinical pharmacy services offered in as drug-related problems (DRPs).
the home concluded that more rigorous evaluation is needed
to support the value of these services and highlighted that Evaluation of pharmacist home visit
questions remain about optimal practice models and target initiatives
patient populations.12 In our health authority, home care Pharmacist HV initiatives in 11 countries were found
clinical pharmacy services have matured to the point where described in the literature: Australia, Brazil, Canada, Japan,
they are an established component of home care in locations Jordan, the Netherlands, New Zealand, Singapore, Thailand,
where they are available, with ongoing requests for more. The the UK, and the USA.
maturation of these services has seen the pharmacist involved
in increasingly more aspects of home care services, beyond Randomized-controlled trials
what was initially supported by evidence.13 Determining best The nine RCTs and two cost-effectiveness analyses of phar-
practices for clinical pharmacy services offered in the home, macist HV initiatives are outlined in Table 1.14–25 In general,
as well as other settings, is important to guide practice that the programs included those older than 60 years and who were
will ensure maximum patient benefit. Furthermore, changes expected to be at increased risk of medication misadventure.
in technology, patient and provider experience, safety, and Five studied patients being discharged from hospital14,16,18,19,22
expectations for pharmacy services are possible influencers and four recruited from outpatient settings.15,20,23,24 Souter
of how services are delivered or valued. et al recruited from both an inpatient and outpatient setting.25
The purpose of this review is to identify outcomes associ- Additional eligibility criteria used to define the target study
ated with clinical pharmacy services provided in the home, as population included number of medications (≥2 to ≥5); func-
well as to describe current perspectives of practice described tional decline, frailty, or disease-specific (CHF/stroke). Six
in the literature. of the studies described the qualifications of the pharmacists
conducting the intervention, indicating training or experience
Literature search beyond an entry to practice degree.14–16,18,19,23
Two separate literature searches were undertaken to identify Two studies reported reduced health care utilization
articles published for the time period from January 2007 to attributable to the pharmacist HV intervention: reduced pre-
December 2017. This time frame was chosen to follow up on scribed medications15 and reduced non-heart failure hospital
a previous review published in 2008.12 Using the key terms days.22 The cost-effectiveness analyses of the Anticipatory
“Pharmacist” and “home visit”, EMBASE, Medline, OVID, and Preventative Team Care (APTcare) trial and the HOMER
CINAHL, Biomedical Reference Collection, EBMR, and trial (published in 2005) did not support cost-effectiveness
Google Scholar were searched. The search was limited to of the pharmacist HVs.16,17,21 The HOMER trial interven-
the citations published in the English language and involved tion group experienced significantly increased emergency

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 Table 1 Randomized controlled trials (RCTs) of pharmacist home visit services
Study details Patient characteristics Mean/ Patient Pharmacist characteristics Intervention Evaluation Outcomes
median age numbers and period
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gender
Holland et al14 Age >18 years 76.9 149/144 Postgraduate qualification or RX provided copy of 6 months ↔ emergency hospital
2007 UK Discharge home after an recent CE in therapeutics discharge letter admissions
emergency hospitalization for 36.5% Female 7 hours training in HF HV × 2 (within 2 and 8 ↔ mortality
HeartMed HF 4 hours communication training weeks of discharge)
≥ 2 medications on discharge (1/2 group) Med Review
17 pharmacists HF Education
PCP
Adherence
Lenaghan et al15 Age >80 years 84.3 68/66 Postgraduate qualification RX received current 6 months ↔ non-elective hospital
2007 UK ≥4 medications Experience with home-based medication and medical admissions

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≥1 medication risk factor 65.6% Female medication review history ↔ care home admissions
POLYMED Registered with GP practice 1 pharmacist Med Review ↔ mortality
Education ↓ medications prescribed
PCP ↔ quality of life
Adherence
Remove meds
Pacini et al16 Age >80 years 85.4 415/414 Postgraduate qualification HV × 2 within 2 months of 6 months Low probability the
2007 UK Discharge home from hospital or discharge intervention was cost-
Cost- ≥2 medications 62.4% Female Recent CE in therapeutics Med Review effective
effectiveness 2-day training course on Education
analysis of prescribing in the elderly Remove meds
HOMER17 22 pharmacists PCP
Adherence (CommRX)
Triller and Age ≥21 years 79.7 77/77 Doctor of Pharmacy degree HV within 1 week, plus 6 months ↔ all-cause hospitalization
Hamilton18 Diagnosis of HF Residency in home care 7–10 and 18–21 days later ↔ HF hospitalization
2007 USA Referred from hospital for 72% Female 20+ years of clinical experience Med Review (HF and ↔ all-cause mortality
home care nursing 1 pharmacist non-HF)
Education
Vuong et al19 Age ≥55 years 71.8 152/164 Bachelor of Pharmacy HV within 5 days of 8–12 weeks ↑ self-perceived medication
2008 Australia Discharge home from hospital Postgraduate diploma in clinical discharge understanding
Hospital admit for medication 47.4% Female pharmacy Med Review ↑ medication knowledge
misadventure/misuse 2 pharmacists Adherence score
≥3 medications Remove meds ↑ self-reported adherence
Medication regimen change
during hospitalization
Newly trained on use of

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appliance
(Continued)

143
Pharmacist home visits review
 Table 1 (Continued)

144
Study details Patient characteristics Mean/ Patient Pharmacist characteristics Intervention Evaluation Outcomes
median age numbers and period
gender
Required medication monitoring
Flanagan and Barns

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with 7 days of discharge
Dexterity, vision, hearing, or
other impairment that may
impact medication taking
Chronic condition
Language difficulties
Imminent loss of independence,

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housebound, or living alone
Hogg et al20 Age ≥50 years 71.3 64/56 1 pharmacist Anticipatory and 12–18 months ↑ quality of care (QOC)
2009 Canada On GP practice roster Preventive Team Care for chronic disease
Gray et al 201021 Risk of functional decline, 57.5% Female (APTCare) management
Cost- physical deterioration, or Addition of RX and 3 NP ↑ QOC for disease
effectiveness emergency services to practice prevention
analysis Good candidate for additional Med Review Not cost-effective
medical resources PCP
Barker et al22 ≥4 medications 72.5 64/56 Hospital based pharmacists HV within 96 hours of 6 months ↔ mortality
2011 Australia Meets Framingham criteria for discharge, at 1 and 6 ↔ hospitalizations
HF 54% Female months ↑ all-cause and HF hospital
Hospital stay >48 hours Adherence days
Education ↓ non-HF hospital days
Remove meds ↔ Quality of life
CommRX
Elliott et al23 ≥2 medications 84 40/40 ≥5 years clinical pharmacy HV within 28 days of 6 weeks up to ↑ HV within 28 days of
2012 Australia Referred to Aged Care experience including subacute referral 20 weeks referral (100% vs 35%)
Assessment Team (ACAT) 63.8% Female aged care and hospital outreach Med Review ↑ medication regimen
medication management Discuss with geriatrician changes
Not accredited to conduct HMR PCP ↑ use of adherence aid
3 pharmacists Remove meds ↑ reported easier to
manage medications

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 Basheti et al24 Age >18 years 60.6 48/49 1 pharmacist Med review (HV or clinic) 3 months ↑ DRP resolution
2016 Jordan Outpatient clinic roster for all patients ↓ DRP
At least one of: 70% Female Intervention received: ↑ medication adherence
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≥5 medications Education ↔ quality of life

≥12 doses/day PCP
Discharge from hospital (within
4 weeks)
Medication regimen changes in
previous 3 months
Symptoms suggestive of ADR
Subtherapeutic response to
medication
Souter et al25 Stroke diagnosis 73 18/17 Med review in hospital or 6 months 5.8 DRPs/patient
2017 Scotland Discharged home from hospital clinic 19/23 recommendations

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or attends outpatient neurology 40% Female Education accepted by GP
clinic HV at 1,3 and 6 months
after hospital discharge or
clinic visit
PCP
CommRX
Abbreviations: Adherence, adherence assessment and/or aids provided; ADR, adverse drug reaction; CE, continuing education; CommRX, communicate with community pharmacy; DRP, drug-related problem; GP, general practitioner;
HF, heart failure; HMR, Home Medicines Review; HV, home visit; MD, medical doctor; Med Review, assessment of medication regimen for the purpose of identifying and resolving drug-related problems; RX, pharmacist; NP, nurse
practitioner; PCP, contact primary care physician to resolve DRPs; Remove meds, removal of discontinued or expired medications.

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Pharmacist home visits review
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readmissions.17 APTcare, a multidisciplinary collaboration accredited pharmacists are funded to provide home-based
focused on patients with chronic disease, despite providing MR services for community-based patients at risk of
increased quality of care was not cost-effective, this may medication misadventure.2 In addition to conducting a
have been reflective of it being in the implementation stage, comprehensive MR, pharmacists provide patients with
rather than established.16,17 education, assess and aid in adherence and removal of old
The clinical outcomes reported from these RCTs indi- medications. A report documenting findings and recom-
cated that these programs can improve medication under- mendations must be sent to the patient’s physician and
standing, knowledge, and adherence and result in increased community pharmacy.
resolution of DRPs. No benefit on quality of life was reported. Most of the other studies were evaluations of pharmacists
While not all of the RCTs evaluated economic outcomes, conducting an HV intervention similar to the HMR,29,40
it is hard to explain the limited impact of the pharmacist inter- except that not all reported pharmacists removed expired or
ventions on health care costs. The interventions ­undertaken discontinued medications.26,35,38,40,42 Some authors described
in these trails all appeared to involve pharmacists conducting a MRec intervention rather than a MR.27,28,41
MR for the purpose of identifying DRPs with subsequent The outcomes evaluated and reported in these studies
communication to a physician. What is unclear is the depth are outlined in Table 3. In contrast to the RCT data, more of
of the medication regimen assessment, for example, were the these studies reported reduced health care costs. The excep-
recommendations in line with evidence to support reducing tion to this was Hanna et al, who reported an overall increase
morbidity and mortality? Also, the acceptance of recom- in hospital admissions; however, when they broke the study
mendations made by the pharmacist was not always reported. population down by age, there was a benefit of reduced hos-
Moreover, the extent of access the pharmacists had to medical pitalizations among those aged 51–65 years.38 Improvements
and laboratory information was sometimes limited and may in clinical and humanistic outcomes were also reported in
not have allowed for a comprehensive MR.14–16,19 Matura- these studies. The difference in impact of the pharmacist
tion of clinical pharmacy services may have occurred over interventions on health care costs reported in these studies,
the course of years these studies were undertaken, and later compared with the RCTs, may be attributable to study design.
studies appeared to involve pharmacists doing more detailed The patients and settings were similar, as well as the extent
reviews with greater prescriber collaboration,24,25 but did not of pharmacist training, to those described in the RCTs. The
evaluate economic outcomes. The most recent trial to evaluate evaluation time periods in the RCTs were at least 6 months
economic outcomes was conducted by Barker et al; however, or longer, whereas these studies reported economic benefits
the usual care group received an extensive intervention which over 30 days 36,40and at 6 months.35,42
may have limited the impact of the study intervention.22
Other activities performed by the pharmacists included Program reports
removing expired or discontinued medications,15,16,18,22,23 Table 4 outlines the 23 articles describing evaluations of
education,14–16,18,22,24,25 and adherence assessment.14–16,18,20,22 clinical pharmacy home care services in which no com-
While these activities alone or together may be of benefit parison group was used.43–65 The post-hospital discharge
to patients, unless the medication regimen is optimized to patient population was the most represented in these arti-
ensure maximal efficacy and minimal harm, they might not cles.44,46,48,52–54,59,60,63,64 Other authors describe programs estab-
be enough to significantly improve patient outcomes. lished in community settings43,47,49,56,58,61,65and clinics.45,50,55,57,62
Other patient characteristics included being elderly, presence
Comparison studies of a chronic disease, or number of medications.
The 17 studies using a comparison design for evaluation of The majority of these articles describe a program in which
a pharmacist HV intervention are outlined in Table 2.26–42 a HV was conducted to undertake a MR.43–-50,52–-65 The HVs
The majority of these studies evaluated the pharmacist HV were typically conducted by a pharmacist, with some authors
intervention in a population of those recently discharged describing the use of pharmacy technicians,63,64 pharmacy stu-
(acute care or skilled nursing facility). 27–31,33,34,36–38,40,41,42 Some dents,50 pharmacy residents/students accompanying a nurse
specified patients from a primary care setting,35,39 while two practitioner57 or a pharmacy resident, or a pharmacist.59 Onda
studies sourced patients from administrative claims data.26,32 et al do not specifically describe an intervention; however, a
The largest proportion of studies were evaluations of pharmacist-conducted MR is assumed.58These authors sent
the HMR in Australia.26,30,31–34 Through the HMR program, a survey to pharmacists who conducted HVs, the purpose of

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 Table 2 Comparison studies of pharmacist home visit services
Study Study intervention population Pharmacist HV intervention Comparison strategy Comparison Evaluation
Characteristics Age % Female Number number period
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Roughead et al26 Veterans or war widows 81.6 30 273 HMR Matched controls 20:1 5444 1 year post
2009 Australia Age ≥65 years from administrative
Dispensed beta-blocker for claims
heart failure
Hugtenburg et al27 Registered at 1 of 37 study 69.7 51.2 336 HV within 1 week of discharge Delivery of medication 379 6–9 months
2009 The Netherlands pharmacies MRec at discharge, usual care
Discharged home from hospital Medication overview for patient according to Dutch
≥5 prescribed medications and GP Pharmacy Standard
Education
Check of home supplies
Synchronized medication

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dispensing
Setter et al28 Age ≥50 years 74.9 57 110 Medication discrepancies Eligible patients assigned 110 8 weeks
2009 USA Discharged from hospital to identified and documented (all to a geographically
home care patients). separate nursing team
≥1 selected diagnosis Intervention received:
MRec facilitated
Flanagan et al29 Age ≥65 years 80 60.2 836 Medication Management Before and after 836 1 year
2010 Canada ≥6 medications Program (MMP)
Discharge home HV within 1 week of discharge
Med Review
Education
PCP
Adherence
Remove meds
Castelino et al30 Age ≥65 years 76.1 55 372 HMR Before and after 372 n/a
2010 Australia Referred for HMR
Castelino et al3 Criteria examples: 75.3 55 270 HMR Before and after 270 n/a
2010 Australia ≥5 medications
>12 doses/day
Significant medication changes
in previous 3 months
Medicine with narrow
therapeutic index
Discharged from an institution
within previous 4 weeks
Roughead et al32 Veterans or war widows 81.6 36 816 HMR Matched controls 20:1 16,320 >1 year

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2011 Australia Age ≥65 years from administrative
Warfarin use claims
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147
Pharmacist home visits review
 Table 2 (Continued)

148
Study Study intervention population Pharmacist HV intervention Comparison strategy Comparison Evaluation
Characteristics Age % Female Number number period
Stafford et al33 Age >18 years 67.7 38 129 HMR Usual care 139 90 days
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2011 Australia Discharged from hospital 2–3 HVs within2–8 days of

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Warfarin discharge
Stafford et al34 Age >18 years 67.7 40 129 HMR Usual care 139 90 days
2012 Australia Discharged from hospital 2–3 HVs within 8–10 days of
Warfarin discharge
Pharmacists had completed post-
discharge service (PDS) training

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Desborough et al35 Age >65 years n/a n/a 117 Med Review Before and after 92 6 months
2012 UK On GP roster PCP Cost-consequence (16 lost to follow-
Living at home Adherence analysis up,
Difficulty managing medications 9 died)
Reidt et al36 Discharged from acute care 60 67 153 HV within 1 week of home care Matched controls 1:1–3 380 30 days
2014 USA Referred for home care nursing admission
≥9 medications Med Review
MRec
PCP
Kogut et al37 Discharged from hospital n/a 46.7 (entire 20 HV within 14 days of discharge Those who declined the 10 ≥30 days
2014 USA Age ≥50 years cohort) Med Review ePHR system
Chronic medical condition Demonstration of an electronic
personal health record (ePHR)
system
Hanna et al38 Patients discharged from 72.1 51 398 HOMR (Hospital Outreach Eligible patients who 118 12 months
2016 Australia hospital at high risk of Medication Review) service declined the service
medication misadventure, provided by a Health Authority
eg, history of non-adherence, pharmacist
chronic disease, language/ Med Review
cultural barriers, ≥4 PCP
medications/day
Hamano et al39 Age ≥65 years 84.7 59.3 182 Consults for patients about Patients who did not 248 Cross sectional
2015 Japan Prescribed medications by one effects of drugs and monitor receive a pharmacist 8 months
of five primary care clinics adherence HV
Received HV by MD
Reidt et al40 Discharged home from skilled 70.8 57 87 Pre-discharge Med Review Usual care of 189 30 days
2016 USA nursing facility Education geriatrician and nurse
Adherence practitioner
HV (or by phone) one week Group assignment
after discharge depending upon
discharge day

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Dovepress Pharmacist home visits review

Table 3 Outcomes reported from non-randomized comparison

Abbreviations: Adherence, adherence assessment and/or aids provided; GP, general practitioner; HMR, Home Medicines Review; HV, home visit; IV, intravenous; MD, medical doctor; Med Review, assessment of medication regimen
for the purpose of identifying and resolving drug-related problems; MRec, medication reconciliation; RX, pharmacist; PCP, contact primary care physician to resolve DRPs; Remove meds, removal of discontinued or expired medications;
studies

6 months
Economic ↓ Emergency department visits36,40,42
30 days

↓ Hospitalization26,29,32a,35,42
↑ Hospitalization38
↑ Medication costs39b
↓ Hospital and medication costs35
Clinical ↓ Drug Burden Index (DBI)30
↑ Medication appropriateness31
↑ Medication discrepancy resolution28
402
89

↑ Oral anticoagulation knowledge (OAK)34c

Those who declined the

↓ Major and minor hemorrhagic events33

intervention or did not
respond to phone call
Care coordinator HV

↑ Warfarin persistence33
↑ Medication adherence35
↑ DRP identification36
Humanistic ↑ Satisfaction27,37d,41d
Notes: aFor the time period 2–6 months after RX intervention. No difference for
<2 months, 6–12 months; ↑hospitalization >12 months. bSignificantly higher costs
of potentially inappropriate medications (PIMs) compared to those who received a
home visit from a nurse and no pharmacist home visit. cSignificantly higher than usual
Home Based Medication Review

care at 8 days post-intervention, but not at 90 days. dFor intervention group only.
Care coordinator and RX HV

Abbreviations: DRP, drug-related problem; RX, pharmacist.

which was to determine the prevalence of ADEs and poten-

Med Review

tially inappropriate medication use among the population.

Education

Education
(HBMR):

The impact of the HV programs described in these

MRec

PCP

PCP

reports were mainly related to identification of DRPs, rec-

ommendations made, or medication changes that occurred
as a result of the pharmacist’s actions.44–50,53,55,62–65 A variety
of other impacts were also reported: satisfaction,43,44,48,52,54,60
156

99

time reduction for other disciplines,45 ADE identification,47,58

perceptions of program,51 experience,61 adherence,56,59 clini-
cal parameters,55,56 and knowledge.48,56,60,61 Three programs
reported economic outcomes including reduced readmission
43.6

50.5

rate52,59 and cost-avoidance.63

National surveys
78.4

73.6

Five nationwide surveys evaluating pharmacist HV services

≥2 unplanned admissions within
Discharged from acute care or

were identified.66–70 An evaluation of general practitioner (GP)

Medicare advantage enrollees

Discharge from acute care

engagement in HMR in Australia received 376 (33%) respon-

skilled nursing facility

dents, of which 180 had participated in HMR.66 The authors

previous 3 months

reported that of those who had participated in the HMR, over

>5 medications
Age ≥60 years

half did not provide written feedback on the HMR report to

the pharmacist or discuss it with the pharmacist. Further,
only 10.6% provided the pharmacists with patient informa-
tion such as recent laboratory results and 6.7% accepted
the pharmacist’s recommendations, yet over half agreed or
Shcherbakov and

2017 Singapore

strongly agreed that the HMR benefits their patients.

n/a, not available.
Cheen et al42

A Canadian survey received 17 responses from pharma-

2016 USA
Tereso41

cists who provided HVs.67 Services provided include: medi-

cation reconciliation, adherence assessment, education for

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Table 4 Program evaluations of clinical pharmacy home visit services

Study Patient characteristics Service description Evaluation details
Moultry and Isolated, elderly needing assistance HV 15–60 minutes 30-item survey completed by 18/30
Poon43 managing medications Med Review 96% felt knowledgeable about medications
2008 USA Referred by community agency MRec after HV
N=30 recipients over 1 year Education emergency preparedness 73% felt HV would reduce visits to MD
Disaster proof medication storage 94% satisfied/somewhat satisfied
Remove meds 100% would recommend program to others
Documentation: action plan with
DRPs to take to MD
Referral to other services as needed
MacAulay et al44 Discharged from hospital to home care HV on average 11.7 days after hospital 98 DRPs: 3.6 DRPs/patient
2008 Canada and one of the following: discharge ↓ DRPs from visit #1 to visit #2
Age ≥ 80 years Follow-up HV or by telephone 116 recommendations: 4.3
≥ 5 medications Med Review recommendations/patient
Use of high risk medication Adherence Recommendation significance
Chronic condition Education 17% very significant
Suboptimal adherence PCP 71% significant
Benefit from medication education 11% somewhat significant
Medication changes during hospitalization Satisfaction survey (n=16)
Unresolved DRPs at discharge Overall satisfaction 9.9/10
N=27 Importance of HV 9.8/10
Average age=81.1 years Usefulness of HV 9.5/10
67% Female
Stell et al45 Outpatient Disease Management Unit Med Review 20 medication recommendations
2008 Australia Referrals to RX from unit coordinator PCP 17 medication issues identified for further
for those who may benefit from RX clinician review
review N=34 MD responses
eg, patients taking multiple medications Perceived medication list more accurate
they organized themselves, new patients, when completed by RX
available patients ↓ Time for other clinicians to obtain
N=24 patients received HV medication list
Average age =79 years 5.4 minutes/patient not seen by RX vs 1.8
42% Female minutes/ patient seen by RX
Flanagan et al46 Age ≥65 years Medication Management Program (MMP) 259 DRPs: median 2 DRPs/patient
2010 Canada ≥6 Medications HV within 1 week of discharge 135 Medication discrepancies: median 1
Discharge home Med Review discrepancy/patient
N=110 Education
Average age =84 years Adherence
56% Female PCP
Remove meds
Eichenberger Medication history available at 76 HVs by students 7.4 DRPs/patient identified vs 3.6 DRPs/
et al47 community pharmacy (n=79 pharmacies) Med Review patient if HV not conducted
2011 Switzerland with fifth year pharmacy master student Adherence Experience of an ADE
interns Recommendations summarized for 19 (86.4%) of transplant patients
N=54 Diabetic and age ≥60 years supervising RX who could decide on 26 (48.1%) of diabetes patients
Average age =71.4 years intervention
37% Female
N=22 Transplant patient and age ≥18
years
Average age =52.6 years
50% Female
Hussainy et al48 Patients referred to palliative care HMR N=422
2011 Australia (medication screening by pharmacist) Ensuring medication access N=52 HV
Patients discharged home from hospital: Team member education average 54.4 minutes
hospital visit prior to discharge and HV n=113 DRP interventions
7–10 days thereafter or HV if from a n=120 recommendations
different hospital
(Continued)

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Dovepress Pharmacist home visits review

Table 4 (Continued)
Study Patient characteristics Service description Evaluation details
Consult and collaboration with team Survey n=20/32 (63%) response
Liaison with other health providers 100% role was helpful
(continuity of care) 90% improved medication knowledge
Implementation through education 60% changed practice
of symptom management protocol 95% more likely to discuss medication
(education) issues with the pharmacist
Castelino et al49 Age ≥ 65 years HMR 1110 DRPs: Average 4.9 DRPs/patient
2011 Australia HMR conducted by seven accredited 1114 recommendations to GP
pharmacists 964 recommendations required evidence
N=224 support; 94% evidence based
Average age =74.6 years
53% Female
Willis et al50 Age ≥65 years Undergraduate pharmacy students 57 (48%) patients had a change in therapy
2011 USA Registered at primary care performing HV, n=75
N=118 Activities: 102 (86%) prescribed a falls risk medication
Best possible medication history
Falls risk evaluation
Blood pressure check
Reviewed by pharmacist afterwards
White and Chinese and Vietnamese immigrants No RX HV or intervention Two focus groups to assess perceptions of
Klinner51 eligible for, but who have not received HMR among immigrants
2012 Australia HMR Had not heard of HMR, but welcomed it
N=17 (6 Chinese, 11 Vietnamese) Concern that HMR would upset MD or lack
of cooperation
Concerns and confusion about medicines
RX role is medicine supply
GP role is medication decisions
Neither GP nor RX helpful in responding to
detailed medication questions
Difference between ethnicities in trust for
MD
Language barrier for accessing medication
information
Novak et al52 Medicare patients recently discharged Pharmacist Care Manager (PCM) 30% reduction in readmissions
2012 USA from acute or subacute care HV 2–3 hours followed by at least PCM job satisfaction
High risk for readmission, eg, multiple weekly telephone calls
chronic conditions, multiple medications, Med Review
multiple hospitalizations in the previous MRec
12 months Adherence
Education
Assessment of falls risk, cognition,
mental health, nutrition and caregiver
needs
PCP
Kwint et al53 Age ≥65 years HV conducted by trained community DRPs
2012 The ≥5 oral medications pharmacists 1565 (10/patient) DRPs based on pre-visit
Netherlands Discharge from hospital Med Review adjusted and completed review
Use one of 10 community pharmacies by two independent reviewers 415 DRPs identified through HV
N=155 pharmacists. Reviewer pharmacists 905 (58%) DRPs resulted in a
Median age =76 years prioritized DRPs and sent back to recommendation
54% Female pharmacists to discuss with MD within 264/905 (29%) recommendations
4 weeks implemented
DRPs identified during HV more likely to
have a higher priority and recommendations
implemented
(Continued)

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Table 4 (Continued)
Study Patient characteristics Service description Evaluation details
Flanagan et al54 Age ≥65 years Medication Management Program Satisfaction survey (telephone)
2013 Canada ≥6 medications (MMP) High level of satisfaction
Discharge from hospital HV within 1 week of discharge Pharmacists easy to understand
103/175 (58.9%) respondents Med Review Appreciation for resources pharmacist
Average age = 79.1 years Education provided
54.4% Female Adherence Recommendations to have more pharmacist
Remove meds home visits and offer phone visits
PCP
Martins et al55 Patients with hypertension referred for 6 HV × 1 hour/HV, average 30 days 142 DRPs (mean=10.1/patient) identified
2013 Brazil pharmaceutical care between visits 66/135 (48.8%) pharmaceutical interventions
Age 30–74 years Med Review implemented:
Plus 2 of the following: Blood pressure measurement – pharmacological intervention to optimize
Blood pressure ≥140×90 mmHg Cardiovascular risk assessment treatment: n=27
Using ≥3 medications Adherence – preventive pharmacological intervention:
Regimen changed ≥ twice in previous PCP n=23
year – non-pharmacological intervention: n=16
Comorbidity Cardiovascular risk
Non-compliance ↓ n=3 patients
N=14 ↑ n=1 patient
Average age = 61.6 years ↔ n=9
85.7% Female
Moultry et al56 African-American patients Managing Your blood pressure (MY At 6 months
2015 USA Age ≥65 years BP) program ↓ SBP (mean 140 vs 137 mmHg)
≥1 anti-hypertensive 2 HV with RX, 1 hour each at baseline ↔ DBP
Living independently and 6 months 90% using home BP machine
N=306 Biweekly telephone calls by pharmacy ↓ nonadherence
Average age = 74 years student ↑ hypertension knowledge
83% Female Med Review
Medication record and action plan
PCP
Poon et al57 Home-Base Primary Care Drug Regimen Review (DRR) initially 53 DRR and 56 HV
2015 USA Veterans’ Affairs and quarterly via chart review by a 133 recommendations→93(70%) accepted
Patients likely to benefit from a HV pharmacist 44(33%) from DRR→27 accepted
N=49 Addition of HV by pharmacy residents 89(67%) from HV→66 accepted
Average age =81 years and students (accompanying nurse ↑DRPs identified and recommendations
12% Female practitioners) accepted with HV vs DRR
Onda et al58 Age ≥65 years Survey to pharmacists who did HVs 2053 (48.4%) prescribed a PIM
2015 Japan Had received a pharmacist HV to identify prevalence of adverse drug 165/2053 (8%) suspected PIM-induced ADE
N=4243 events (ADEs) and PIM (potentially Top 5 PIMs: H2 blockers, short-acting
Average age =82.7 years inappropriate medication) benzodiazepines, chronic stimulant laxative
73% Female use, long-acting benzodiazepine, digoxin
Top 5 medications associated with ADEs:
anticholinergic antihistamines, ultra-long-
acting benzodiazepines, sulpiride, short-
acting benzodiazepines, digoxin
Kalista et al59 Recently discharged from hospital to HV by pharmacist/pharmacy resident At 28 days:
2015 USA Visiting Nurse Service (VNS) with a within 1 week of VNS admission and ↑ Adherence
primary diagnosis of heart failure two telephone calls (at weeks 1 and 4) 2 patients readmitted vs 38% readmission
N=10 Med Review rate for VNS heart failure patients
Average age =81.3 years Adherence 1 patient died
60% Female Education
Hanna et al60 Patients discharged from hospital at high HOMR (Hospital Outreach N=217 (45%) patient questionnaire
2015 Australia risk of medication misadventure Medication Review) service provided response
N=487 by a Health Authority pharmacist HV worthwhile
Average age =72.8 years Med Review ↑ Medication knowledge and understanding
50.3% Female Adherence of how medications helped medical
Education conditions
PCP
(Continued)

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Table 4 (Continued)
Study Patient characteristics Service description Evaluation details
↑ Confidence and ↓ confusion about
medications
Pharmacist was helpful and suggestions
would help them take medications properly
N=105/487 (21.6%) MD questionnaire
response
96% (n=101) agreed with recommendations
92% would adopt some or all of
recommendations
81% (n=85) review provided greater
understanding of patients’ medication
management abilities
Ahn et al61 Patients who had received HMR HMR Semi-structured interviews
2015 Australia N=15 Participants had limited understanding of
HMR
Benefits: ↑ knowledge, holistic review,
medication improvement, ↑ health seeking
behavior, strengthened self-management,
encouraged others to have HMR
Difficulties: limited information and
engagement from pharmacist; delays in
process; limited GP follow-up and support
for program
Reidt et al62 Ambulatory care clinic patients Home-based Medication Therapy 62% referrals from internal medicine clinic
2016 USA Transportation barriers to clinic Management (MTM) 51% referrals from MD
attendance HV 30–60 minutes Top referral reasons: 17% each
Unwilling to bring medications to clinic Med Review Nonadherence
Concerns about environmental factors Education Transportation barriers
affecting medication use Adherence Medication reconciliation with public health
N=53 patients (74 HV) PCP nurse
55% age ≥65 years Median 3 DRPs/patient
57% Female 40% compliance related
Bailey et al63 2016 ≥2 Chronic conditions Pre-hospital discharge: 1264 DRPs: Average 3.4 DRPs/patient
Surbhi et al64 ≥2 Hospitalizations or 1 hospitalization Med Review 642 DRPs resolved
2016 USA and ≥2 emergency department visits in Education 50.8% of pharmacist recommendations
previous 6 months Medication list accepted
Target condition driving diagnosis for SafeMed: Pharmacy technician Estimated cost-avoidance =US$370,681
index hospitalization conducted post-discharge HV, within Cost-avoidance/DRP identified =US$293.30
Medicaid/Medicare enrollee 72 hours, and follow-up by telephone
Age ≥18 years calls
≥6 medications or 1 high-risk medication Assist with MRec and Med Review
N=374 Reinforce Education
Pharmacist: resolve DRPs through
targeted MTM via telephone or clinic
visit
Walus et al65 Patient referrals sourced from: HV or telephone appointment with 271 DRPs identified: average 2.1/referral
2017 Canada Home care intakes pharmacist 250 recommendations
Patients waiting in acute care for home N=40 comprehensive Med Review 36/81 (44%) accepted by prescriber
care service N=95 targeted Med Review or 37/43
Direct referrals education 36/40 pharmacist
N=122 (135 referrals) Documentation and communication in 19/36 patient
Average age =71 years chart, phone calls, fax. Average of 1.5 clinical pharmacy key
63.1% Female performance indicators (cpKPIs) identified/
referral: DRP resolution, education,
development of pharmaceutical care plan
Abbreviations: Adherence, adherence assessment and/or aids provided; DRP, drug-related problem; GP, general practitioner; HV, home visit; MD, medical doctor; Med
Review, assessment of medication regimen for the purpose of identifying and resolving drug-related problems; MRec, medication Reconciliation; RX, pharmacist; PCP, contact
primary care physician to resolve DRPs; Remove meds, removal of discontinued or expired medications; HMR, Home Medicines Review; ADE, adverse drug event.

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patients/caregivers and health professionals, chronic disease or pharmacy technicians who would be providing the
monitoring, and assessing acute health concerns. None of the service. 14–16,33,35,41,42,50,51,53 In other reports, background
programs was government funded, and three of the pharma- education or experience of the pharmacists was mentio
cists reported charging a private home care agency for their ned.14–16,18,19,22,23,38,42,45,60,72,73 No comparison was done at the
services. Facilitators for HVs identified in the survey were level of qualifications, experience, or training to outcomes.
referrals from physicians and support from management. The In our health authority, the pharmacists working in a home
barriers cited by respondents were insufficient remuneration care setting as part of the Medication Management Program
and lack of time for completing visits. (MMP) must have completed an Accredited Canadian Phar-
A similar survey undertaken among British pharmacists macy Residency or equivalent in order to be hired. They
received 247 respondents (81.5% response rate). 68 The receive orientation on conducting HVs and documentation
authors reported that 74% of respondents had specific but thereafter.
undefined training, and 81% of the services were funded Use of pharmacy students, residents, and pharmacy
through Primary Care Trusts. HV services operational beyond technicians highlights the use of resources to both provide
a year were those that included social services, GPs, and com- learning opportunities and also extend the scope of clinical
munity nurses in the service protocol of operations and those pharmacy services.
that received more of their referrals from GPs (90% vs 50%). Competency of personnel to provide the service influ-
Patient preference for medication therapy management ences the extent to which DRPs and issues preventing patients
was evaluated in Thailand.69 Based on the 265 respondents, from achieving optimal health can be identified and resolved.
the authors reported that patients valued this service and It includes clinical knowledge about disease states and drug
preferred pharmacist visits to occur in the pharmacy rather therapy and the ability to communicate to extract and provide
than their home and that the preferred visit length was 20 information.
minutes rather than 1 hour.
In the Netherlands, an evaluation of implementing a HV Patients
service to patients after hospital discharge was undertaken The most commonly studied patient population was
using a focus group (22 pharmacists) to identify barriers and patients who had recently been discharged from hos-
facilitators, followed by a survey (20 pharmacist respondents) pital. 14,16,18,19,22,24,25,27–29,33,34,37,38,41,42,44,46,48,52,54,59,60,62,63,74–76
to score the relevance and feasibility of items identified Heart failure was the most commonly mentioned
during the focus groups.70 The pharmacists included in this ­diagnosis.14,16,18,22,26,59,74,77 While HVs can be more convenient,
evaluation conducted on average 5.4 HVs/year. The authors not all patients may want or need a HV MR.69 Furthermore,
reported that both the need for reimbursement and the they may have preferences for how long it should take.69 Sev-
readiness of community pharmacy to adapt daily routines to eral authors commented on the length of time spent at a HV,
implement such a service as two barriers to implementation. ranging from 15 minutes to 2 hours.14,19,29,37,38,43,47,48,55,56,59,74,78
In addition to HV time, travel time must be considered and
Current perspectives these together can prevent HVs from being a broadly available
In addition to the aforementioned reports, 18 articles describ- service and highlight the need to restrict the service to those
ing clinical pharmacy services in a home care setting were for whom it is necessary.
identified in the literature.71–88 In these reports, the pharmacist Several authors reported an increased identification of
HV intervention was not evaluated. The following section DRPs as a result of a HV compared with medication list
highlights some current perspectives based on these articles, review47 or chart review53,57 and that the DRPs identified
together with those articles previously described that provided during a HV may be more likely to result in a medication
an evaluation of clinical pharmacy HV services. change.24,28,64 Patients included in these studies were those
who might be expected to have many medications: diabetes,47
Competency transplant,47 older patients,57 and older patients discharged
Training and qualifications for pharmacists, pharmacy from hospital.53 Poon et al identified veterans who were likely
residents and students, and pharmacy technicians involved to benefit from a HV service; however, they do not further
in HV programs varied. The HMR program in Australia articulate this criteria.57 Age was often a consideration in the
requires pharmacists to be accredited.2 In some initiatives articles included in this review and may impact the outcome;
training was provided to pharmacists, pharmacy students, although this was reported by Hanna et al, the numbers in

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each age group were too small to make conclusions about those whose drug interactions were assessed using clinical
the impact of age.38 Vuong et al described inclusion criteria judgment and a drug information resource.82 This RCT was
indicative of frailty in their study that selected individuals not an evaluation of a pharmacist HV service; some HVs
beyond age, number of medications, and discharge from were provided, but illustrates a resource that could be used
hospital.19 Frailty may be a criteria to use in deciding for to enhance MR services provided in the home.
whom outpatient clinical pharmacy services be delivered, Besides the ePHR system, all the technology described
including HVs, as medications can impact both physical and was for use by pharmacists prior to and/or after a HV, and
cognitive functioning.89 the need for Internet connectivity in patient homes was not
discussed. The ePHR system would necessitate patient access
Safety to the Internet. Pharmacist access to the Internet at patient
Safety for pharmacists conducting HVs was discussed in homes is an important aspect to consider in expanding the
five articles.36,60,76,79,80 Safety strategies reported include: use of technology for HV clinical pharmacy services.
conducting HVs in pairs;76 texting to inform of arrival and
departure times76 calling patients not previously met prior Collaboration
to arrival;80 and wearing a uniform or badge.80 Pre-screening The majority of HV programs described in the literature
of patients with a safety risk assessment was described, with involved pharmacists providing the service and connecting
those patients believed to be a safety risk to staff ineligible with other health care professionals, such as physicians in
for a HV.60 Similarly, in our health authority, a pre-visit tele- order to communicate the findings from their assessment
phone risk assessment screen is conducted, with follow-up and make suggestions for changes. The reported physi-
items to be assessed during the HV. Depending upon the cian acceptance of recommendations varied from 18% to
risk identified and whether or not it can be mitigated for the 95%.14,18,23,24,28,29,42,44,65 The extent to which communication
HV, either staff do not conduct the HV or conduct it with a with prescribers occurred or the suggestions for change that
security personnel. were implemented was not always detailed. Furthermore,
As patients for whom HVs are provided are typically pharmacist and physician collaboration may not happen,
more frail, staff safety may be overlooked in HV initiatives. even if it was the expectation of a program.66 Authors of an
However, the safety of the neighborhood, the residence, the evaluation of pharmacist recommendation implementation
presence of pets and other inhabitants, as well as patient/ and the extent of collaboration between pharmacists and
caregiver/cohabitant illness and recreational drug use must GPs reported on average 50% (range ­17%–86%) of phar-
also be considered. macist recommendations were implemented in the 12 RCTs
included in the review.90 Implementation rate was higher
Technology with increased presence of elements reflective of collabora-
Ten articles discussed the use of technology to aid in phar- tion, such as pharmacist with clinical experience; patient’s
macist HVs. 27,36,37,40,50,62,74,76,81,83 The majority described regular pharmacist providing the intervention; sharing of
using an electronic medical record (EMR) as a way for the medical records; patient interview by a pharmacist; referral
pharmacist to get information about the patient’s medi- by GP; case conference; formulation of an action plan; and
cal conditions and/or communicate with the primary care follow-up on actions.
provider.27,36,40,50,62,74,76,81 Access to medical records, whether As many of the programs described and evaluated in this
EMR or not, is essential to aid a pharmacist to better assess review were new initiatives, the time needed for relation-
a medication regimen.12 The use of an electronic personal ship building for collaborative practice with other health
health record (ePHR) that allows patients or caregivers to care professionals may not have been sufficient to be able
maintain medical information and a medication list and to effect changes to patients’ medications and consequently
exchange this information with health professionals was health outcomes. Strategies to leverage existing relation-
reported to result in identification of DRPs in significantly ships or create the opportunity for relationship building
more patients during a HV compared to patients who did described in the studies include involving community
not use the ePHR.37 Use of a clinical information system to pharmacists in providing HV programs,27,47,53,67 inserting a
assess patient genomics and support a pharmacist’s assess- pharmacist as part of a multidisciplinary team,23,42,48,77,81,82
ment of drug interactions among home care clients resulted or adding the HV component to an existing clinical phar-
in significantly reduced re-hospitalizations compared to macy service.57

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The extent of collaboration can also depend upon the setting relied on prescriber acceptance of their recommendations.
from which HV services are offered. Settings identified in the For example, unlike hospital settings where anticoagulation
HV literature include: dispensing p­ harmacy,24,44,53,58,69,71,76,77,78,84 protocols have been established to allow pharmacists to dose
home care,28,29,36,46,54,59,65,81,83 chronic disease management or adjust warfarin, HMR pharmacists discussed warfarin dosing
specialty service,23,25,43,45,48,54,62,75,79,82 institutional transition changes with a physician.73 Prescribing authority for phar-
service,22,37,38,40,42,44,63,64,73,74 health care agency,41,52,57,70,72 and macists is likely to impact this. Matthies describes his role
primary care.15,20,24,35,39,50,55 Pharmacists working in health conducting HVs to patients discharged from an emergency
authority or multidisciplinary teams may have more oppor- department and his ability to initiate or alter patients’ medica-
tunity to establish collaborative relationships; however, col- tions.88 His collaboration with a primary care physician and
laborative partnerships can also be established in community health authority position allows him access to both EMRs, as
settings. A downside of HV services being offered from a well as a collaborative working environment. Collaborative
community pharmacy can be limited time to conduct HVs working relationships with other health care professionals
and lack of funding.65,66,68 and access to information necessary to properly assess drug
Several authors described pharmacists providing HV therapy should not be considered less important if pharma-
services with other health care providers: paramedics,74 cists have prescribing authority.
nurses,28,42 social workers,84 multidisciplinary teams,36,48,68,77,81
and with a nurse practitioner and primary care physician.21,40,85 Limitations
Co-visiting patients with other health care providers is not It is likely that there are more home care clinical pharmacy
only an opportunity to strengthen the team relationships but services occurring than have been reported in the literature
can enhance collaboration at the point of patient care through and identified for this review. Surveys done in Canada and
the opportunity for complementary skill sets. For example, the UK illustrate the breadth of services available in these
a pharmacist working in a palliative care team reportedly jurisdictions; however, individual reports of all services
increased medication-related knowledge of team members included in the surveys were not found. Furthermore, it is
and patients.48 likely that not all publications were found as the two sepa-
Another important aspect of relationship and collabora- rate literature searches conducted had only 22 citations in
tion is referral. Receiving referrals from a physician may not common.11,14,15,22,26,27,29,32,39–42,50,59,60,66,67,73,75–78 In addition, one
only impact the longevity of a HV program,68 but also may evaluation of the MMP, that exists in our health authority,
result in more collaboration for making medication changes failed to show up in either search.46 No comparison to inpa-
through case conferences.15,53,71 However, receiving referrals tient clinical pharmacy literature was conducted to evaluate
for a pharmacist HV intervention may not occur, despite whether elements that contributed to positive outcomes in the
being recommended.23 inpatient setting can or do exist in the HV clinical pharmacy
services literature.
HV activities
MR and MRec were the two most commonly reported Conclusion
HV activities, with education, adherence assessment, and Pharmacist HV services are available in many countries
removal of medications no longer used occurring often. throughout the world. Unlike literature from inpatient set-
Other activities reported less frequently were: pharma- tings, the outcomes reported are equivocal, particularly
cist performing physical assessments;36,50 chronic disease related to the impact of a pharmacist HV intervention on
monitoring;20,25,50,55,56,67 education for lifestyle changes;87 subsequent health care costs. Mirroring the conclusions of a
falls assessment;50,52and assessment of cognition,52 mental previous review of clinical pharmacy services in the home,
health,52nutrition,52 and caregiver needs.52 A HV is an ideal further refinement of how pharmacist HV services should
opportunity to assess many aspects of a patient’s health sta- exist is needed, including the patient population ideally
tus, balancing that with what is the best use of a pharmacist served by a HV and a practice model that best contributes
during the HVs needs to be considered. to collaborative practice.12 Other important elements to
consider in both establishing and evaluating a HV program,
Autonomy and which may be applicable to other settings in which clini-
The impact of pharmacists being able to enact their medica- cal pharmacy services are offered, were identified. These
tion recommendations was not reported; rather pharmacists include: staff competency, use of technology, staff safety,

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Dovepress Pharmacist home visits review

activities to be performed during a clinical pharmacy inter- 17. Holland R, Lenaghan E, Harvey I, et al. Does home based medication
review keep older people out of hospital? The HOMER randomised
vention (eg, HV), and pharmacist autonomy. Consideration controlled trial. BMJ. 2005;330(7486):293.
of these elements could help to generate further substantia- 18. Triller DM, Hamilton RA. Effect of pharmaceutical care services on
tion of the role of pharmacists providing clinical services outcomes for home care patients with heart failure. Am J Health Syst
Pharm. 2007;64(21):2244–2249.
in a home care setting. 19. Vuong T, Marriott J, Kong D, Siderov J. Implementation of a community
liaison pharmacy service: a randomised controlled trial. Int J Pharm
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20. Hogg W, Lemelin J, Dahrouge S, et al. Randomized controlled trial of
The authors report no conflicts of interest in this work. anticipatory and preventive multidisciplinary team care: for complex
patients in a community-based primary care setting. Can Fam Physi-
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