Patient Characteristics

Background information about the patients was col­lected during the first home visit (Table 1). In general, patients were older, had multiple medical conditions, were taking multiple medications, and had been dis­charged from hospital a mean of 11.7 days before the pharmacist’s first home visit. Medical conditions and medication categories were determined from patients’ home care charts, interviews with patients and/or caregivers, community pharmacy records, and the electronic medical records used within the regional health authority. Medical conditions and medication categories that were present in at least one-third of the patients are listed in Table 2. Cardiovascular disease and diabetes mellitus were common, which is consistent with the high prevalence of these diseases in Canada.

Patient Care Activities

Table 1. Characteristics of 27 Home Care Patients Who Received Clinical Pharmacy Services



Characteristic


Mean
± SD (Range)


or
No.


(%)

of
Patients


Age (years)


81.1±7.1


(60-91)


Creatinine clearance (mL/min)


35.0±14.8


(13-71)


No. of medications


11.9±4.0


(7-24)


Days after discharge* (n
=
26)


11.7±5.4


(4-31)


Sex (no.
[%]
of men)


9


(33)


Current smoker (n
= 25)


2


(8)


Influenza vaccination receivedt


16


(59)


Independent medication management


17


(63)



Living arrangements


Alone


14


(52)


With spouse or partner


7


(26)


With a family member


6


(22)



Use of adherence tool


Dosette


6


(22)


Blister packaging


11


(41)


Calendar


2


(7)


SD
=
standard deviation.


*No. of days between hospital
discharge date and date of first home visit by the pharmacist. tIn the
most recent influenza season.

The number of patients receiving successive numbers of visits declined, with 27 patients receiving a first visit, 25 patients receiving a second visit, 22 patients receiving a third visit, 7 patients receiving a fourth visit, and 3 patients receiving a fifth visit. After each visit, a pharmacy care plan was developed for all (100%) of the patients in the study, according to each person’s unique medication- related issues. Medication histories were recorded for all (100%) of the patients at visit 1, and at subsequent visits all patients were asked if there had been any medication changes in the week since the previous visit; however, complete medication histories were recorded for only 12% (3/25) of the patients remaining in the study at visit 2, for none of the patients at visit 3, for 14% (1/7) of the patients at visit 4, and for 33% (1/3) of the patients at visit 5. Adherence was assessed for 70% (19/27) of patients at visit 1, for 44% (11/25) of patients at visits 2, for 41% (9/22) of patients at visit 3, for 29% (2/7) of patients at visit 4, and for none of the 3 patients at visit 5. Finally, patient and/or caregiver education was carried out with all (100%) of the patients at visit 1, 80% (20/25) of patients at visit 2, 68% (15/22) of patients at visit 3, 43% (3/7) of patients at visit 4, and 67% (2/3) of the patients at visit 5. Although the project protocol indicated that visits after the initial visit could be either home visits or telephone consultations, almost all were conducted in the home setting.
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Table 2. Medical Conditions and Medication Categories Among 27 Home Care Patients





Condition or Medication



No.


(%)

of
Patients





Medical condition


Ischemic heart disease


17


(63)


Hypertension


14


(52)


Gastroesophageal reflux
disease, PUD,


gastritis


13


(48)


Dyslipidemia


12


(44)



Diabetes mellitus (type
2)


12


(44)


Insomnia


11


(41)


Anemia


9


(33)


Atrial fibrillation


9


(33)





Medication categories


B-Blocker


17


(63)


Angiotensin-converting
enzyme inhibitor


16


(59)


Vasodilator


15


(56)


Antiplatelet agent


15


(56)


Diuretic


14


(52)


HMG CoA reductase
inhibitor


11


(41)


Oral antidiabetic agent


11


(41)


Oral anticoagulant


11


(41)


Levothyroxine


11


(41)


Acetaminophen


10


(37)


Calcium channel blocker


9


(33)


B2-Agonist


9


(33)



PUD =
peptic ulcer disease,



HMG CoA =
hydroxymethylglutaryl
coenzyme A.

The total amount of time that the pharmacist spent on each patient’s case was also tracked. This value included preparation time before the home visit, travel time, the home visit itself, and any post-visit activities linked to caring for the patient, including development of the care plan and contacting other health care professionals. The average amount of time spent per patient declined significantly from visit 1 (mean 226.7 min, SD 135.9 min) to visit 2 (mean 128.2 min, SD 61.9 min) (pairwise t24 = 3.71, p = 0.001). Although there was a further decline by visit 3 (mean 113.9 min, SD 78.8), it was not statistical­ly significantly different from the time required for visit 2 (pairwise t21 = 0.71, p = 0.49). The complexity of the cases that required follow-up beyond 3 visits explains the large amounts of time spent per patient at visit 4 (mean 102.1 min, SD = 50.0 min) and visit 5 (mean 139.3 min, SD 29.6 min). To better understand the pharmacist’s workload across the weeks after hospital discharge, 3 main activities were chosen for analysis: preparation, visit, and development and implementation of the care plan. The time required for all 3 of these activities decreased somewhat after visit 1 (Figure 1); the decline was most dramatic for pre-visit preparation time, particularly from visit 1 to visit 2.
In terms of scheduling pharmacy services, consider­ably more time was needed for the first home visit after discharge from the hospital, mostly because of the preparation work required. After the first visit, a plateau occurred in terms of time usage. In particular, education continued to be required by a large proportion of the patients who received 2 or more pharmacist visits.
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Figure 1. Mean workload per patient

Figure 1. Mean workload per patient for different activities at successive visits. “Care plan” represents both develop­ment and implementation of the care plan.