I

Provision of a domiciliary service by community pharmacists . JULIA SCHNEIDER and NICHOLAS BARBER

The potential benefits of home visits by community pharmacists to housebound people with medication diffkulties were examined. Sixteen community pharmacist volunteers made initial home visits to 39 patients referred by 14 general practitioners. The medication in their possession was noted, and information about the medication recorded from the medication container label, a patient medication record provided by the referring sugery and the patients’ own knowledge. In 35 cases there were discrepancies between the medicines in the patient’s possession, those they were currently taking and those listed on the patient medication record. Non-adherence, medication hoarding and adverse drug reactions were found. After each visit a summary was sent to the patient’s G P and dispensing pharmacist. GP intervention was requested for 25 patients and dispensing pharmacist intervention for 17. Follow-up visits to 18 patients one month later showed that 37 per cent of suggested GP interventions and 50 per cent of suggested dispensing pharmacist interventions had been acted on. Feedback was received from the visiting pharmacists during a meeting and from the GPs and dispensing pharmacists by interview. The service was valued by the patients and endorsed by the GPs and all the community pharmacists involved, indicating that community pharmacists have a potential role to play in enhancing the care of specific housebound patients through domiciliary visits.

ONE of the key objectives in the 1989 Govern- ment White Paper “Caring for people”’ was “to promote the development of . . . domiciliary ser- vices to enable people to live in their own homes, wherever feasible and sensible.” The need for home services was also recognised in the 1992 Department of Health and pharmaceutical pro- fession joint working party report: which stated that “arrangements should be introduced to pro- vide domiciliary pharmaceutical services for pa- tients who are unable to use the pharmacy in person.”

This article describes a pilot study which aimed to identify and quantify the problems associated with drug use by housebound people in the community, while exploring the contributions that community pharmacists can make to improve drug use by the housebound through the imple- mentation of a domiciliary service.

Method

The work was carried out in the London borough of Barnet, in conjunction with Barnet family health services authority (FHSA) and North West Thames regional health authority (RHA). A steering group of nine multidisciplinary members was set up in March, 1993, to administer the study. The group comprised the FHSA phar- maceutical adviser, primary care manager and director of professional support services, the chairman and secretary of the local pharmaceuti- cal committee, the North West Thames regional pharmacy services development manager, a gen-

eral medical practitioner, a pharmacy practice lecturer and a practice research pharmacist (JS).

All the general practices (approximately 90) and community pharmacists (approximately 90) in contract with the FHSA were invited to partici- pate in the study. The general practitioners in the practices were asked to refer for a domiciliary visit any housebound patients who were having some difficulty with their medication due to a medical, physical or psychological condition. The community pharmacists were asked to make the visits. Each referred patient was allocated to one of the participating community pharmacists. This was not necessarily their regular dispensing phar- macist.

Structured visit reports were developed as the instruments of data collection. They had been reviewed in the validation phase, during seven home visits. An evening training event held for the participating pharmacists covered the perceived role of the pharmacist in providing a domiciliary service, training in communication skills, dealing with potential problems during a visit and how to complete the reports.

The referred patients were informed about the visit in a letter from their GPs. They were then telephoned by their visiting pharmacists to agree a convenient date. All the initial visits were conducted in June, 1993. During each visit, the community pharmacist constructed a patient pro- file, discussed with the patient a number of drug related issues including adherence, hoarding and adverse drug events, and completed a drug chart for all the prescribed medication in the patient’s

Clinical Pharmacy Unit, Northwick Park & St Mark’s NHS Trust, Watford Road, Harrow, Middlesex, England HA1 3UJ Julia Schneider, BSc, MRPharmS, research and development pharmacist

Centre for Pharmacy Practice, School of Pharmacy, University of London Nicholas Barber, PhD, MRPharmS, professor ofthe practice of pharmacy

At the time of this study, Ms Schneider was a postgraduate pharmacist at the Centre for Pharmacy Practice, School of Pharmacy, University of London

Correspondence to: Me Schneider

Int J Pharm Prmt L9%;4:19-24

MARCH 19%. THE INTERNATIONAL JOURNAL OF PHARMACY PRACTICE . 19

possession. Drug name, form, strength, dose and frequency were recorded for each item, using the medication container label, the patient’s medica- tion record as provided by the referring GP and the patient’s own knowledge. This information was entered on the initial visit report.

Following each visit, a summary was completed indicating the nature of any problems discussed, action taken and advice given by the visiting pharmacist. When appropriate, an intervention by the patient’s GP and/or dispensing pharmacist (identified from the container labels) could be requested, in which case they were sent the summary for action.

In general, patients who were given advice by the visiting pharmacist about their medication and/or for whom interventions were requested received a follow-up visit approximately one month after the initial visit. However, if a patient did not want a follow-up visit or was too confused to benefit from a second visit, they were not followed up.

Feedback on the study was received from the participating pharmacists during a meeting with the steering group and from the GPs and the patients’ community pharmacists by interview. The interviews were tape recorded to facilitate transcription, then coded and analysed.

Results

Fourteen GPs, from seven surgeries, referred 49 patients to the pilot study. Of these, 39 received a visit, six being unavailable at the time of the study and four refusing a visit. Sixteen community pharmacists participated, each visit- ing between one and three patients. Nineteen community pharmacists were identified as the patients’ regular dispensing pharmacists. Two patients were visited by their dispensing pharma- cist.

The average initial visit length was 56 minutes (range 30 minutes to 1 hour 45 minutes). Thirty- three patients were over 70 years old, the major- ity lived alone and half were affected by a physical disability such as poor vision or arthritis.

At the receipt of their last prescription, 16 (41 per cent) patients had seen their GP- 13 at home and three at the surgery; 23 (59 per cent) patients had, therefore, received a repeat prescription without seeing their GP. Thirty-five patients relied on someone to deliver their medication, one third using their community pharmacist. Four- teen patients received help with their medication at home - eight from lay carers, four from a district nurse and two from their community pharmacist.

The patients had in their possession an average of eight (range two to 16) prescribed medicines. They were currently taking an average of six (range one to 13) and they had an average of five (range two to 13) listed on their surgery medica- tion records. In 35 (90 per cent) cases there was one or more discrepancy between the number of medicines in their possession, those currently being taken and those on the medication record.

Panel 1: Definitions

Non-adherence: A patient was said to be non-adherent if he or she omitted one or more prescribed medicines or administered one or more dis- continued medicines

Inaccurate medication record: A patient’s medication record was termed inaccurate if one or more prescribed medi- cines were missing from the record or if one or more discontinued medicines were still listed

Hoarding: A patient was said to be hoarding if he or she stored one or more discontinued prescribed medicines or an excess quantity (ie, a greater quantity than would have been obtained on the current prescription) of one or more currently prescribed medicines

The discrepancies were attributed to three fac tors: non-adherence, an inaccurate medicatioi record and hoarding. These terms are defined ii Panel 1.

Non-adherence alone was judged to be thc reason for the discrepancies in three cases, inac curate records alone the reason in six cases anc hoarding alone the reason in three. In 15 cases, i combination of two of these factors was judged tc account for the discrepancies (for six patiFnts ii was a combination of non-adherence and inaccu. rate records and for nine a combination oi hoarding and inaccurate records). In eight cases all three factors were judged to be responsible. 11 total, 72 incidences of medication hoarding wert found, involving 60 different medications.

Patients were asked whether they managed tc take all their medicines according to the instruc. tions given to them by their doctor and/or on tht container label. Twenty-five (64 per cent) stated that they “always” followed the instructions; 14 (36 per cent) stated that they “sometimes” did, Forgetfulness, confusion, poor understanding ol dosage instructions and side effects were the maim reasons cited for not always being able to follow the instructions.

Patients had an average of two (range one ta eight) purchased medicines, the majority of these being taken on an “as required” basis.

Sixteen (41 per cent) patients reported an adverse drug reaction. The majority of these were gastrointestinal effects: nausea, constipation, di- arrhoea and upset stomach, caused by non- steroidal anti-inflammatory drugs, opioid analge- sics and iron. Incontinence from diuretics and drowsiness from benzodiazepines were also re- ported.

Eleven potential drug interactions were identi- fied by the community pharmacists for nine (23 per cent) patients. These included three reports of potential paracetamol toxicity (where the pa-

20 THE INTERNATIONAL JOURNAL OF PHARMACY PRACTICE, MARCH 1996

Table 1: Categories and frequencies of requests for general practitioner intervention (25 patients) Category of intervention Number of requests Confirmation of therapy, eg: 12

Should patient be taking Zantac 150mg tablets? Could GP confirm the dose of temazepam patient should be taking? Should patient be taking co-dydramol and diclofenac, or has the diclofenac been replaced by the co-dydramol?

Could GP review patient’s antidepressant therapy What medication should patient be taking in response to allergic reaction? Could GP review patient’s analgesic medication: not taking the Temgesic tablets; takes eight co-proxamol daily but finds they cause drowsiness so also buys paracetamol

Review of therapy, eg: 9

Review of symptomb), eg: Patient breathless after a short walk Patient has itchy scalp and suffering hair loss

5

Alteration of medication due to adverse effects or potential interactions, eg: 4 Prochlorperazine tablets making patient feel more nauseous. Buccal cinnarizine may be a helpful alternative Patient taking temazepam and lorazepam at night and waking drowsy. Can medication be altered to prevent this?

Patient taking lndocid 25mg capsules three times daily and still experiencing severe knee pain

Could this PMR be amended? Discontinued items are still listed; one item needs to be added

Addition of medication for a poorly controlled condition, eg:

Update of patient medication record, eg:

3

3

Provision of additional advice, eg: Advice from the prescriber on how patient should take medications may help with adherence

2

Review of repeat prescribing procedure, eg: 2 Patient has excessive quantities of medication in stock, including over 150 temazepam lOmg capsules and an additional four months’ supply of propranolol 160rng capsules. She says she has not seen GP for over six months. Can this situation be rectified?

1. A blood test to measure this patient’s potassium levels may be in order, due to potential hypokalaemia with bumetanide and prednisolone and the resulting risk of digoxin toxicity

2. Could GP write dosage instructions for all prescription items, otherwise they are labelled “As directed,” but the patient does not remember how to take them

3. Could GP prescribe Frumil for this patient and not co-amilofruse, because the different generics she receives confuse her?

4. Could the patient’s in-dwelling catheter be changed to one that can be replaced every four to five weeks because she finds that the current one is blocking after about four weeks of use?

5. Could the patient receive a visit from a dietitian? She is diabetic and has no knowledge about how to manage her diet

Miscellaneous requests: 5

Total number of interventions reauested 45

tient was taking two products each containing paracetamol) and three reports of potential ulcer exacerbation (where a patient taking an H,- receptor antagonist for the treatment of an ulcer was concurrently taking an NSAID.

Twenty-one (54 per cent) patients had one or more medication problems which could have led to non-adherence and administration errors. These included difficulty reading container labels, problems opening child-resistant closures, having multiple containers of the same medication and mixing or transferring medication.

Advice was given by the community pharma- cists to 32 (82 per cent) patients on a variety of topics including disposal, administration, adher- ence and diet. In the initial visit summaries, the visiting pharmacists requested G P intervention for 25 (64 per cent) patients, with an average of two (range one to five) interventions per patient, and requested dispensing pharmacist interven- tion for 17 (44 per cent). The categories and frequencies of the interventions requested, to- gether with examples, are reported in Tables 1 and 2.

Twelve community pharmacists made 18 follow-up visits, the average visit length being 37

minutes (range 10 minutes to one hour). Patients understanding of and compliance with the advice given by the community pharmacist at the initia visit was checked at follow-up and found to be good; a few forgetful and confused patient needed previously given advice to be reinforced A number of patients still had problems wit1 understanding dosage instructions, adherence adverse drug effects, reading labels and openinj child-resistant closures. Of the 27 G P interven tions requested for the patients who were followec up, 10 (37 per cent) had been acted on at follov up, as had six of the 12 dispensing pharmacis interventions requested.

Feedback The visiting pharmacists perceivec that the domiciliary service had been of benefit tc the patients, the GPs and themselves, a point the! highlighted at their meeting. They reported com, ments the patients had made at the end of thc initial visits and at the follow-up visits, anc improvements in patient medication managemen that they had noted at follow-up (Table 3).

With regard to the future provision of thc service, concern was expressed about the need foi further training that would be necessary in ordei

21

Table 2: Categories and frequencies of requests for community pharmacist intervention (17 patients) Category of intervention Container related requests, eg: 10

Number of requests:

Provide non-child-resistant closures for all containers Dispense medicines in large containers for easy handling A monitored dosage system would be of benefit to the patient

Labelling related requests, eg: Provide large print labels Ensure all labels have clear dosage instructions Label all containers and original packs

Accept returned medication for disposal If possible keep all patient’s medication in stock, so that there are no items owing Confirm the dosage of temazepam by checking the patient’s medication record Patient would benefit from a prescription collectionhedication delivery service

Medication related requests, eg:

7

5

Advice for community pharmacist to give to patientkarer, eg: 5 Patient is blind and would benefit from advice when any new medicines are dispensed Advice is needed about medication disposal Advice on the action of the drugs would help patient’s adherence Patient would benefit from advice on inhaler techniquehe of Volumatic

Total number of interventions requested 27

to carry out the visits with maximum benefit, the length of time taken up by visits, the lack of remuneration and the necessity for patients to be visited by their own dispensing pharmacist. It was emphasised that the success of a community pharmacy domiciliary service was dependent on the referring GPs acting on the interventions requested by the visiting pharmacist whenever applicable.

Nineteen community pharmacists were identi- fied as the regular dispensing pharmacist for one or more of 37 of the 39 patients who were visited (for two patients a dispensing pharmacist could not be identified); 18 of these were interviewed. Sixteen (data missing for one) felt that making domiciliary visits was a suitable role for communi- ty pharmacists, although they expressed reserva- tions similar to those of the visiting pharmacists.

Fifteen were positive about the visits being beneficial to the patients. Thirteen (data missing for three) felt that the visit summaries would have been useful to the patients’ GPs, and 12 (data missing for five) felt that the GP intervention requests had been appropriate.

Seven of the 11 dispensing pharmacists (data missing for four) who had been requested to make an intervention thought that they had been ap- propriate and they had acted on ’ them where possible. Seventeen dispensing pharmacists felt that a domiciliary service would have a positive effect on their relationship with the GPs of those patients they visited.

Ten of the referring GPs were interviewed, representing six of the seven surgeries that had participated in the study. Five of these six surger- ies had computerised patient medicine records, covering 32 of the 39 patients visited. The GPs named patient and personal benefits as a result of the service: “the more professional input, the better for the patient;” “community pharmacists are the medication experts and can pick up on points we may miss;” “the feedback was valuable and raised my awareness of patients’ problems.”

All the GPs felt that the visit summaries had

been useful, and they considered that none of th interventions requested were inappropriate in th context of the community pharmacists’ limitec knowledge about the patients. However, they fel that not all the interventions required action taking into account the patients’ whole clinica picture. A number of interventions were going ti be acted on at the next patient visit or at the issu, of the next prescription so had not been complet ed before the follow-up visit.

All the GPs expressed a general willingness ti accept clinical suggestions made by the visitin community pharmacists, although three empha sised that the final prescribing decisions should bs left to the doctors. Eight felt that the schems would improve relations between themselves ant their local community pharmacists; two felt tha relations were already good.

Discussion

Housebound patients with suspected medica tion difficulties were referred to this pilot stud: by their GPs. The community pharmaciits wht visited them at home unearthed a range o

Table 3: Benefits of domiciliary service perceived by the participating pharmacists Benefits to the patient:

and dose regimen

medicines

Received a full explanation of their medication, including administration

Understanding of adverse drug effects improved Appreciated how to store their medicines and dispose of unwanted or expired

Adherence improved Confidence improved

Made aware of specific patients’ problems Feedback they received was valuable for patient assessment It was helpful to have another health care professional visiting patients at

Benefits to the general practitioner:

home Benefits to the visiting pharmacists:

Greater understanding of patients’ medication problems Visits helped to improve professional role satisfaction Visits helDed to raise the profile of the Dharmacist in the community

22 THE IITER>ATIO\AL J O L RXAI. OF P H A R W A C I PRACTICE, M A R C H 1996

problems contributing to suboptimal drug thera- py. These included non-adherence, hoarding, adverse drug events, drug interactions, inability to read labels, difficulty opening containers, the presence of multiple containers of the same medi- cation and the removal of medication from its original containers. Although our sample cannot be generalised to the population at large, these problems have been well documented in previous studies”1° and our findings are comparable with them.

Approximately eight per cent of the total number of general practices and 20 per cent of the community pharmacists in contract with Barnet FHSA took pant in this pilot domiciliary pharma- ceutical service. The low participation rates can possibly be explained by the fact that such services are not established practice and the uptake of new initiatives is known to follow a broadly similar pattern led by a few innovators.”

Some other studies of domiciliary pharmacy services have differed from our work in a number of ways. In a study by Fairbrother et a1,12 patients referred by three GPs had to be over 65 years of age and taking at least three oral medicines regularly. The patients were interviewed once and the questionnaire was designed to provide infor- mation on factors influencing adherence, such as patient knowledge of the names and uses of their medicines, labelling and packaging and efficacy of treatment.

In another study,13 emphasis was placed on the ability of community pharmacists to improve drug regimen adherence by patients with medication problems. Patients were identified for a visit using a number of referral sources, ie, pharmacy held patient medication records, district nurses, the pharmacy department of the local district general hospital and GPs.

The discrepancies between the medicines that the patients in our study were holding, those they were taking and those their GPs thought they were taking were interesting. The surgery medica- tion records of 29 patients were inaccurate, although the majority (32 out of 39) of all the patients’ records were computerised, which could lead to the expectation of a high level of accuracy, 4 similar rate of inaccuracy has been noted for paper medication record systems. 1 4 7 1 5 Reasons +en by the GPs to explain their inaccurate records were poor communication with hospitals, record updating by receptionists, the use of ocums, the time taken to amend records because If the computer system, insufficient computer :erminals and home visits.

Home visits were a factor because paper notes ind prescription details from the visit had to be ransferred onto the computer system later, at the iurgery. Visits, therefore, introduced an extra step into the computerised record keeping process uhich may not have always been carried out bllowing every home visit. If this finding is ;eneralisable, it has important implications for uture schemes involving the transfer of informa- ion between surgeries and community pharma- :ists. It also questions the use of GP records for

other studies, for example, pharmacovigilance and pharmacoepidemiology .

Hoarding was generally of discontinued medi- cation. Six patients had an excess quantity of current medication, possibly reflecting patient non-adherence or extra repeat prescriptions.

In the patients’ homes, the community pharma- cists did what they could to improve drug therapy while reducing potential risks, through advice and action, and the follow-up visits highlighted good patient compliance with the advice given. Therapeutic problems were referred back to the GPs and, although the suggested interventions were considered appropriate, under half the GP interventions and only half of the dispensing pharmacist interventions had been acted on by the time the follow-up visits were conducted. The GPs did say, however, that they intended to act on a number of interventions at the next patient consultation or at the issue of the next prescrip- tion.

This highlights two points. First, the follow-up visits were possibly too close to the initial visits to allow for all the appropriate interventions to have been acted on. Secondly, the GPs did not seem to consider the majority of the interventions to be urgent; they were content to act on them at a future time.

Despite the fact that the GPs referred patients for a domiciliary visit and expressed a general willingness to accept clinical suggestions made by the community pharmacists, there may have been a certain lack of acceptance of the new role in practice.

Studies16J7 of the attitudes of GPs towards a variety of extended roles for the community pharmacist have shown less acceptance of phar- macist involvement in clinical areas of practice than in non-clinical areas. The low number of interventions acted on by the GPs is at odds with the situation in hospitals, where the daily contact between pharmacists and doctors, as well as pharmacist access to patients and their notes, leads to high compliance rates with suggested prescription changes. 1820

In this study, patients were not visited by their own dispensing pharmacist, but all the partici- pants felt this was essential and would probably improve the number of dispensing pharmacist interventions acted on at follow-up.

Many community pharmacists would require further clinical training to carry out this role. The community pharmacist needs to be integrated into the primary health care team, and a feasible approach could be to work with district nurses in a domiciliary care programme. The district nurse is often the first person a GP will contact if a patient is having problems at home.

The service piloted in this study has since been expanded.*l This will provide the opportunity to carry out more work on aspects of pharmacy home visits, including the criteria for patient selection, assessment of the service provided, the economics of the service, the effect on GP and community pharmacist relations and the benefits to patients.

MARCH 1996, THE INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 23

ACKNOWLEDGMENTS: The authors wish tp thank the funders of this project: the Royal Phar- maceutical Society of Great Britain, through the Sir Hugh Linstead Fellowship (1992-93) and the Galen Award (1993-94), and North West Thames regional health authority. We would also like to thank Barnet family health services authority, all the steering group members and the community pharmacists and general practitioners involved.

References

1. Caring for people: Community care in the next decade and beyond. Cmnd 849. London: HM Stationery Office, 1989. 2. Pharmaceutical care: The future for community pharmacy. Report of the joint working party on the future role of the community pharmaceutical services. London: published by the Royal Pharmaceutical Society on behalf of the Department of Health and the pharmaceutical profession, 1992. 3. Stewart RB, Caranasos GJ. Medication compliance in the elderly. Med Clin North Am

4. Forbes AJ, Rees JA, Ross AJ. Using home helps to identify people needing pharmaceutical advice. Pharm J 1989;242:R18-20. 5. Tully M. Iatrogenic disease in the elderly patient. Hosp Pharm Pract 1993;3:138-41. 6. Cartwright A. Medicine taking by people aged 65 or more. Br Med B d 1W0;46( 1):63-76. 7. Hammarlund ER, Ostrom JR, Kethley AJ. The effects of drug counselling and other educational strategies on drug utilisation of the elderly. Mt?d Care 1985;23(2):165-70. 8. Murray M, Darnell J, Weinberger M, Martz B. Factors contributing to medication non-compliance in elderly public housing tenants. Drug ZnteU Clin Pharm 1986;20: 16-52.

1989;73(6):1551-61. 1

.

9. Law R, Chalmers C. Medicines and elderly people: a general practice survey. Br Med J

10. Kiernan PJ, Isaacs JB. Use of drugs by the elderly. J R Soc Med 1981;74:196-200. 11. Stocking B. Promoting change in clinical care. Qual Health Care 1992;1:56-60. 12. Fairbrother J, Mottram DR, Williamson PM. The doctor-pharmacist interface, a preliminary evaluation of domiciliary visits by a community pharmacist. J Soc Admin Pharm 1993;10:85-91. 13. Roberts DK. A domiciliary clinical pharmacy service. J R Soc Health 1987;5:172-7. 14. Price D, Cooke J, Singleton S, Feely M. Doctors’ unawareness of the drugs their patients are taking: a major cause of over-prescribing? Br Med J 1986;292:99-100. 15. Hulka BS, Kupper LL, Cassel JC, Efird RL, Burrdette JA. Medication use and misuse: physician-patient discrepancies. J Chron Dis

16. Spencer JA, Edwards C. Pharmacy beyond the dispensary; general practitioners’ views. Br Med J

17. Nathan A, Sutters CA. The community pharmacist’s extended role. GPs’ and pharmacists’ attitudes towards collaboration. J Soc Admin Pharm 1993; 10: 70-84. 18. Cotter S, McKee M, Barber N. Hospital pharmacists’ participation in audit in the United Kingdom. Qual Health Care 1993;2:228-31. 19. Batty R, Barber N. Ward pharmacy: a foundation for prescribing audit? lbid 1992;1:5-9. 20. Hawkey CJ, Hodgson S, Norman A, Daneshmend TK, Garner ST. Effect of reactive pharmacy intervention on quality of hospital prescribing. Br Med J 1990;300:986-90. 21. Anonymous. Barnet and Brent pharmacists win over E100,000 for development projects. Pharm J 1995;254:75. I

19.76; 1 :565-8.

1975 ;28: 7-2 1.

1992;304: 1670-2.

24 THE INTERNATIONAL JOURNAL OF PHARMACY PRACTICE, MARCH 19%