Approval for this pilot project was received from the Research Ethics Board of the South-East Regional Health Authority.

Patient Population

The target sample size for this pilot project was 30 patients. Eligible patients were those being discharged from the Family Practice & Geriatrics Program or from various internal medicine programs (excluding oncology) to the local home care program. Patients meeting the following criteria were considered for inclusion: expected to be receiving home care services for 3 weeks or longer, not living in facilities where medication assistance was provided by a health care professional, had a family physi­cian who was practising with the regional health authori­ty, had a residential phone line, able to communicate flu­ently in English, and deemed to be at high risk of adverse drug events, by meeting at least one of the following criteria (with the number of patients identified by home care nurses as meeting each criterion specified in parentheses): age 80 years or older (n = 18), using 5 or more medications (n = 28), using high-risk medications such as warfarin (n = 23), having a chronic condition associated with substantial risk of readmission to hospital (e.g., diabetes mellitus or heart failure) (n = 26), having suboptimal medication adherence (n = 8), expected to benefit from medication education (n = 15), having changes to the preadmission medication regimen during the hospital stay (n = 14), and having unresolved medication- related issues upon hospital discharge (n = 0). Overall, individual patients met from 1 to 6 of these criteria (mean 4.4, standard deviation [SD] 1.4).
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Reason for Referral

The home care nurses were responsible for referring patients for clinical pharmacy services. At the time of referral, the nurse was asked to specify one or more of the following reasons for the referral (with the number of patients for each referral reason specified in parentheses): comprehensive review of the medication regimen (n = 6), focused medication review (n = 7), assessment of medication adherence (n = 14), medication monitoring for efficacy and/or toxic effects (n = 2), assessment of a suspected adverse drug event (n = 1), education (n = 17), and other reasons (n = 5). The number of referral reasons for each patient ranged from 1 to 4 (mean 1.7, SD 0.8).

Visit Schedule

Thirty patients were identified for inclusion in the pilot project. The pharmacist (S.M.) completed an initial chart review for each patient, but 3 of the patients were dis­charged from the home care program before the pharmacist made the initial home visit. Therefore, all subsequent analyses are based on the remaining 27 patients. The study protocol stated that each patient would receive a total of 3 visits or consultations with the pharmacist, the first being a home visit conducted as soon as possible after the referral (given that the pharmacist worked 2.5 days per week). The other 2 interactions were to be either home visits or telephone consultations and were to be performed at approximately weekly intervals. A total of 15 patients received 3 home visits. The other 12 patients received either fewer than or more than 3 visits: 2 patients received 1 visit (one of these patients was readmitted to hospital, and the other patient died before receiving additional visits or consultations), 3 patients received 2 visits (2 of these patients were readmitted to hospital, and the third was discharged from the home care program before receiving additional visits or consultations), 5 patients received 4 visits, and 2 patients received 5 visits because of continuing medication-related issues. The types of services provided during these visits varied according to the patient’s needs. After each visit, a patient-specific care plan and implementation strategies were developed.
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Data Collection Patient Care Activities

The pharmacist kept extensive records of all activities associated with providing clinical pharmacy services before, during, and after the home visits or telephone consultations. The following key data were collected: preparation time (i.e., the time required to review the home care chart and the electronic medical record and per­form other preparatory work), travel time, visit duration, and whether the pharmacist completed a medication history, assessment of medication adherence, or patient or caregiver education. Time required for development of the care plan, implementation of the care plan, documentation, contacting the community pharmacist, performing administrative tasks, responding to drug information questions, and performing other mis­cellaneous tasks was also recorded. A timeline of activities performed was plotted, visit by visit, to identify the types of services that patients needed at different stages within the first month or so after discharge from hospital.