Patient-pharmacist communication during a post-discharge pharmacist home visit

Patient-pharmacist communication during a post-discharge pharmacist home visit Background With the shifting role of community pharmacists towards patient education and counselling, they are well- positioned to conduct a post-discharge home visit which could prevent or solve drug-related problems. Gaining insight into the communication during these home visits could be valuable for optimizing and consequently improving patient safety at readmission to primary care. Objective To assess patient-pharmacist communication during a post-discharge home visit. Set- ting The homes of patients recently discharged from a single general hospital in the Netherlands. Methods Pharmacists used a semi-structured protocol to guide the consultations and audiorecorded them. Sixty audio-recordings were included for a qualitative analysis in this study with the help of NVivo version 11 software. Main outcome measure (1) Initiator and topics under discussion. (2) Frequency of discussion of topics as per coded in themes and subthemes. Results Issues regarding the administration and use of medication, e.g. regimen and actual drug-taking issues, knowledge gaps regarding their medication and patients’ health were discussed most frequently, followed by medication logistics and medication eec ff tiveness. Patients’ beliefs about their medication and adherence were less frequently discussed. The pharmacist initiated the majority of these topics. Additional non-protocolled topics were scarce and consisted mainly of patient-initiated dissatisfaction regarding the community pharmacy or health insurers. Conclusion Community pharmacists most frequently initiated practical issues, but explored patients’ medication beliefs less adequately. Discussing these beliefs might be easier by increasing patient engage- ment in the consultation and providing training programs for pharmacists. Keywords Community pharmacist · Continuity of care · Home visits · Hospital discharge · Patient-provider communication · Seamless care · The Netherlands · Transitions of care Impacts on practice A home visit protocol enables pharmacists to address known major challenges during the transition from hos- pital to primary care • Addressing patient’s dissatisfaction about health care * Hendrik T. Ensing is important as it facilitates patient participation during rensing@zorggroep-almere.nl consultation and acceptance of pharmacists’ advices Pharmacists should discuss patients’ medication beliefs Research Group Process Innovations in Pharmaceutical Care, Utrecht University of Applied Sciences, Utrecht, and adherence issues more frequently, which might be The Netherlands facilitated by additional pharmacist training and increas- Department of Pharmacoepidemiology and Clinical ing patient engagement Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands Zorggroep Almere, Outpatient Pharmacy “de Brug 24/7”, Hospitaalweg 1, 1315RA Almere, The Netherlands NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands Vol:.(1234567890) 1 3 International Journal of Clinical Pharmacy (2018) 40:712–720 713 Flevoziekenhuis Almere. Patients gave written informed Introduction consent at inclusion and oral consent for audio recording of the consultation at the start of the home visit. All data files The community pharmacist’s role is shifting from traditional were coded by using unique personal identification numbers medication dispensing to patient education and counselling and personal details were removed from the transcripts. [1]. Patient transition from hospital back to their home pro- vides pharmacists with the opportunity to effectuate this role, as this transition is associated with an increased risk of drug- related problems (DRPs). Inadequate patient counselling dur- Method ing the transition is a contributing factor [2, 3]. Pharmacists are well positioned to facilitate the discharge process by per- Study setting forming medication reconciliation, identifying patients with poor health literacy or non-adherence, and providing tailored A qualitative observational study was conducted with audio- discharge counselling [4]. However, to establish continuity of recordings from community pharmacist home visits from care most efficiently and provide adequate patient support, the Home-based Community pharmacist-led Medication discharge procedures should be complemented with adequate management (HomeCoMe) program that were performed post-discharge follow-up [5]. Introducing a post-discharge between November 2013 and December 2014 [12]. The in- community pharmacist home visit can secure continuity of hospital outpatient pharmacy acted as a discharge coordina- care but is not usual care at the moment in the Netherlands. tor and cooperated closely with all community pharmacists. Community pharmacists must adapt their communication It verified patients’ administrative information, reiterated to address the wide variety of patients’ drug-related problems important study information, notified the community phar - during these home visits and achieve patient-centred commu- macists of a pending discharge and transferred all medica- nication. Patient-centred communication is associated with tion-related information to them. increased patients’ satisfaction, better recall of information and The HomeCoMe program consisted of in-hospital phar- improved health outcomes and requires active participation macy interventions and its main component: a post-dis- of both the pharmacist and the patient [6–8]. Patients should charge home visit by the patient’s own community phar- be encouraged to express their needs and concerns regard- macist [12]. Pharmacists used a semi-structured protocol to ing their medication, which pharmacists should address to address patients’ questions and reinforce medication-related support patients in making informed decisions [9]. Little is hospital discharge information. Furthermore, pharmacists known about the topics discussed during a post-discharge aimed to identify and solve pending and emerging post- home visit and most studies investigating patient-pharmacist discharge drug-related problems (DRPs) during the home communication focused primarily on one-way pharmacist visits by (1) performing post-discharge medication recon- information provision, e.g. the extent to which pharmacists ciliation, (2) assessing patients’ medication knowledge, (3) counsel patients, and their communication style, e.g. tone of identifying adherence barriers and (4) determining patients’ voice [10, 11]. Gaining insight in the communication during concerns [12]. Deploying home visits instead of a telephone these home visits could be valuable for optimizing these visits; follow-up is possibly more beneficial due to the personal and consequently to improve patient safety at readmission to touch of face-to-face encounters [13]. Patients might feel primary care. more comfortable at home and are therefore more likely to share their experiences and concerns about their medication Aim of the study and be more receptive to pharmacist’s counselling. Further- more, a home visit may elicit all relevant DRPs since all To assess patient-pharmacist communication during a post- medication is available at home enabling the assessment of discharge home visit by exploring the discussed topics as well specific risk factors, such as inappropriate medication stor - as who—the patient or the pharmacist—initiated a specific age conditions [14]. topic. Study population Ethics approval Patients were eligible if they were discharged from a single general hospital (neurology and pulmonology wards) to their Ethical approval was obtained from the ethics commit- own home, aged 18 years or over, used at least three or more tee of the Radboud University Medical Centre Nijmegen. prescription drugs for chronic use at discharge, had been Local approval was obtained from the scientific commit- hospitalized for at least 48 h and picked up their medication tee of Zorggroep Almere (ZGA, Care Group Almere) and in one of the participating pharmacies. 1 3 714 International Journal of Clinical Pharmacy (2018) 40:712–720 gender, patients’ gender and the presence or absence of an Pharmacist home visit protocol informal caretaker during the home visit. The community pharmacists contacted the patients as soon as possible post-discharge and aimed to visit them within Data coding and analysis 7 days. A semi-structured protocol to guide pharmacists dur- ing the home visits was used (Table 1). Efforts were made Two research-assistants transcribed all 60 recordings ver- to develop a protocol tailored to the individual patient by: (1) assessing patients’ perceptions on their use of medica- batim to ensure consistency. All transcripts were imported into NVivo version 11 software to facilitate analysis. tion in general and specifically for medication started during hospitalization and (2) incorporating open-ended example All transcripts were coded and reviewed by a researcher (HE) and a research assistant (LV). Discrepancies were questions, e.g. for initiating and finalizing the home visit. These efforts aimed to help pharmacists to focus on prob - resolved through discussion and, if necessary, a third researcher (MV) was consulted to reach consensus. A the- lems relevant to the patient [10]. All participating commu- nity pharmacists previously attended accredited courses on matic content analysis was used to examine main themes [15]. First, the three overarching themes based on the performing medication reviews, including patient inter- views. To ensure generalizability, all pharmacists received HomeCoMe protocol were identified: (1) ‘Medication”, (2) “Clinical” and (3) “Other” (Table 2). Next, all subthemes an additional one-day training course on how to perform the home visit and how to tailor their communication to the were coded inductively. After coding of the first five tran- scripts these subthemes were redefined and merged where needs of the individual patient. Besides plenary instructions, the pharmacist practiced with the home visit protocol with possible into a preliminary codebook. Previously coded transcripts were re-coded to match any changes in theme the help of paper patients and role-playing. definitions during this coding procedure. During coding of the remaining transcripts a process of reading and re- Data collection reading, with attention to the identification of new sub- themes, eventually resulted in the final code book with In total, 152 patients received a post-discharge home visit, which was audio-recorded by the community pharmacists. well-defined codes and descriptions (Table  2). Addition- ally, the initiator of each subtheme was coded (pharmacist Incomplete recordings or recordings with very poor sound quality were excluded. This resulted in 122 recordings or patient) as well as an illustrative quote. All data was descriptively analysed by identifying (78.9%) eligible for inclusion of which a random sample of 60 recordings was selected for this study. No new sub- major themes, based on frequency of being mentioned, and the initiator of those themes. themes were identified after 30 recordings, therefore this most likely ensured data saturation. At least one record- ing from 23 of the 26 participating community pharma- cists was included. The recordings from the other three pharmacists were incomplete. To complete data selection a pragmatic approach was used to obtain a selection of recordings that were equally distributed on pharmacists’ Table 1 Main topics to be addressed during the post-discharge home visits Protocol part Aim Introduction To list the topics that the patient wants to discuss, set the patient at ease and clarify the aim of the home visit Clinical issues To obtain an overall impression of patient’s health. This part contains a checklist of possible (drug-related) health issues and example questions to address these issues Beliefs about medication To clarify patient’s beliefs and concerns about medication, their attitude towards taking medication, the (lack of) effect of their medication, experienced side effects and intentional adherence barriers Practical issues To clarify patient’s practical issues with their medication, e.g. difficulties adhering to their daily regimen, with the packaging, with the actual drug taking or unintentional adherence barriers such as forgetfulness or lack of stock Patient’s knowledge To identify patient’s knowledge gaps concerning their medication, e.g. reason for prescribing, medication regimen, duration of use and administration of medication Spare medication To identify and collect possible spare medication Conclusion To conclude the home visit by ensuring the patient has discussed all his topics, summarize and solve identified (drug- related) problems and provide patient with information on the follow-up 1 3 International Journal of Clinical Pharmacy (2018) 40:712–720 715 Table 2 Condensed codebook displaying themes, subthemes and examples Theme Subtheme (example) Medication Medication information (e.g. indication, side effects, mechanism of action) Medication effectiveness (e.g. perceived effect of medication) Non-prescription medication (e.g. over-the-counter medication, vitamins) Beliefs about medication (e.g. needs, concerns, usefulness of medication,) Medication logistics (e.g. repeat prescription issues, stock issues) Medication adherence (e.g. practical or perceptual adherence barriers) Administration and use (e.g. actual drug-taking, medication regimen, multi-dose dispensing system) Clinical Patients’ general health (e.g. existing health issues, worsened symptoms) Hospital admission (e.g. reason for hospitalization, length of stay) Other All themes unrelated to the HomeCoMe protocol (e.g. satisfaction with health care providers, personal information) regimens for medication with an alternating dose schedule Results (e.g. insulin). Pharm5: “We’ll discuss the medication that is discon- General characteristics tinued during hospitalization in just a moment.” Pat10: “Yeah, there are a lot of them!” Pharm5: “That’s right, The 23 pharmacists had a mean of 17.7 ± 8.3  years of let’s discuss them one by one.” working experience in the community pharmacy and per- Pharm19: “All right, let’s see, do you have any ques- formed a mean of 6.5 ± 5.6 home visits. The 60 audio- tions regarding the use of your medication? Pat54: “Well, recordings lasted 28.4 ± 11.4 min on average. I’m familiar with most of them, but I have some questions The mean age of the patients was 65.3 ± 13.5 years and about those two new inhalers.” 51.7% were females. A partner or informal carer was pre- Patients initiated topics in this subtheme to clarify sent during 20 home visits (33.3%). uncertainties concerning their regimen (e.g. questions about medication changes) and to ask for advice. Pat20: Yes, it’s very convenient that you’re here. I was Patient: pharmacist communication discharged from the hospital last Wednesday and there are two medicines I had before which I did not receive at my In total 2450 text fragments were coded (Fig. 1). Approxi- mately three-quarters of the topics discussed during the discharge. Should I still take them?” Potential drug-taking issues were explored more often home visits can be classified within the theme “Medica- tion”, followed by “Clinical” topics. Only a few additional by pharmacists than patients. Pharmacists gathered infor- mation for instance on any discomfort with taking the topics were classified within the “Other” theme (Fig.  1). The five major subthemes, ranked by frequency, and medication, and consequently evaluated the relevance and provided advice or support. accompanying illustrative quotes are described in more detail below, as well as less-discussed subthemes and top- Pharm18: “Could you show me how you use your spacer?” Pat50: “Yes, I have got this blue one. It should ics in the “Other” theme. not whistle, as that indicates that I am inhaling too fast.” If patients initiated drug-taking issues, they shared Administration and use their experiences, or asked for advice to solve drug-taking issues. Administration and use was the largest subtheme (Fig. 1). Pat15: “You’re supposed to dissolve these [amoxicil- The majority of topics within this subtheme concerned lin] in water, but well, I’ve skipped that sometimes. I did patients’ medication regimens which pharmacists initiated it whenever I could though.” Pharm6: “That’s ok, you can more often than patients. Pharmacists identified possible also take them without previously dissolving them.” knowledge gaps and reinforced the information concern- Other less frequently discussed topics concerned pack- ing patients’ discharge medication regimens, explored and aging (e.g. opening blisters), multi-dose dispensing sys- advised on possible regimen improvements, clarified the tems or receiving support (e.g. from partner) in taking duration of use for temporary medication (e.g. pain medi- their medication. cation started at discharge) or determined patients’ daily 1 3 716 International Journal of Clinical Pharmacy (2018) 40:712–720 Non-prescription medication, n = 57 Complaints, personal and study information, Patients’ n = 135 general health, n = 441 Hospital admission, n = 69 Administration and use, n = 904 Medication information, n = 517 Medication logistics, n = 105 Medication effectiveness, n = 106 Medication adherence, n = 55 Beliefs about medication, n = 61 Fig. 1 Distribution of themes (inner circle) and subthemes (outer circle). In total, 2450 text fragments were coded Medication information Topics related to side effects were initiated more often by pharmacists than patients as well. Pharmacists verified The majority of topics within the “Medication information” patients’ knowledge on medication side effects, checked if patients experienced a side effect, acknowledged the exist- subtheme concerned the indications for use. Pharmacists explored this topic more often than patients and informed ence of a side effect or reassured the patient. Pharm23: “You’re using a fairly high dosage of bisaco- patients about the reason for prescribing specific medication. Pharm21: “Can you tell me why you have to take these dyl, do you experience any side effects like stomach ache or nausea? Pat59: “No, not at all.” [diclofenac]?” Pat57: “Sure, I have to take those three times a day. It’s an anti-inflammatory drug and a painkiller as Patients initiated this topic to share information about experienced side effects. well.” If patients initiated this topic they indicated to be una- Pat5: “If I use them, I continuously have to go to the toi- let, I really hate that!” That’s why I skipped a dosage today. ware of the reason for prescribing, mainly in cases of using multiple medications. Thursday I have to take another one and it all will start again.” Pharm2: Okay and did you experience any adverse Pat32: “Is that the one to reduce my cholesterol levels?” Pharm12: “No, these prevent your blood from clotting.” effects from skipping that dosage, for instance shortness of 1 3 International Journal of Clinical Pharmacy (2018) 40:712–720 717 breath or fluid retention in your legs? Pat5: “No not at all, Patients initiated topics within this subtheme to share but my specialist warned me that I should really take them.” their experiences with using medication and whether or Other topics within this subtheme were discussed less not they see a positive effect from it in treating their health frequently and concerned the mechanism of action of the condition. medication and any precautions (e.g. driving precautions). Pat49: “Like I told before, I can sense it coming. So, that provides me with some time to get my inhaler. And it helps Patients’ general health a lot.” Pharm18: “Yeah?” Pat49: “Yes, it helps me getting through it, especially on the warmer days. I really need my Pharmacists initiated topics concerning patients’ general inhaler in the summer.” health more often than patients. They queried patients using a trigger list on possible existing health issues including follow-up (e.g. laboratory tests or GP-visits), inquired for Less‑discussed subthemes worsened or improved symptoms post-discharge or provided life-style advice (e.g. smoking cessation or exercise). The less discussed subthemes were “Hospital admission”, Pharm1: “You were admitted for meningitis, how are you “Medication adherence” and “Beliefs about medication” doing right now?” Pat2: “Reasonably.” Pharm1:”You’re (Fig. 1). Pharmacists dominated the initiation of the sub- not left with any lingering symptoms?” Pat2: “Well yes, I theme “Hospital admission” in which all topics concerning experience some rigorous shaking, especially during physi- patients’ recent admission were discussed, such as the rea- cal exercise.” son for admission and length of stay. Pharmacists used this If patients took initiative, they shared information on question mostly as the opening question for the home visit. experiencing a specific health issue. Pharm17: “Tell me, what was the matter? You were Pat33: “Well, to be honest, the tumour affects my breath- admitted to the hospital and what happened? Why were you ing. I experience shortness of breath, but luckily I’m not in admitted?” Pat47: “Well, I’ve been told that my symptoms pain.” suggested a hernia.” Furthermore, pharmacists asked patients which medica- Medication logistics tion they were using besides the prescribed medication. Pharm14: “Do you use any over-the-counter drugs, Patients participated more actively within this subtheme, ones purchased at the chemist maybe?” Pat35: No, I would however pharmacists initiated topics on medication logistics never do that.” Pharm14: “No supplements either?” Pat35: still more often than patients. Pharmacists verified patients’ “No, all those extra pills, I am not up for that. I think it is medication stock, elucidated and advised on storage condi- unnecessary.” tions and on obtaining repeat prescriptions and collected The subtheme “Medication adherence” was initiated discontinued or expired medication. more often by pharmacists than by patients and involved Pharm8: “Does it sometimes happen that you don’t have pharmacists asking whether patients experienced adherence enough medication left?” Pat22: “No, not at all! My wife problems, for instance due to forgetfulness. and I pay really good attention to having an adequate stock Pharm16: “Do you forget to take your medication at home.” sometimes, a single tablet maybe?” Pat43: “No, never.” Patients initiated these topics mainly to gather informa- Pharm16: “So you are familiar with your daily regimen?” tion or to share their supply inconveniences. Pat43: “Yes, I prepare them all in advance.” Pat24: “Where and how do I get my prescription for those The subtheme patients’ “Beliefs about medication” was pills? Should I contact the specialist or the GP?” initiated as often by pharmacists, e.g. to identify patients’ needs or expectations of their medication, as by patients who Medication effectiveness shared their general attitude towards medication. Further- more, patients expressed specific concerns about using their The last major subtheme was “Medication effectiveness” medication. (Fig. 1). Pharmacists initiated a topic within this subtheme Pharm20: “Let’s see, what do you think about your medi- more often than patients and inquired whether patients expe- cation?” Pat55: “Yes, I do experience the benefits, I mean, rienced a beneficial effect of the medication and provided I have been taking them for a long time already and I’m background information on specific medication, e.g. whether still here!” or not patients could experience an effect at all. Pat12: “Well I’ve had a small hip fracture for which I took Pharm19: “You also have to take tamsulosin, do you these pills. However, I try to minimize my intake because I experience an effect? Pat54: “I don’t know really, I have to worry that with prolonged use my body gets immune for it. take a lot of different drugs, so I can’t tell if it’s beneficial.” And it’s the only painkiller I’m allowed to take!” 1 3 718 International Journal of Clinical Pharmacy (2018) 40:712–720 Other themes as a key factor to improve health outcomes [20]. On the other hand, pharmacists themselves embraced their coun- “Other” themes (Fig. 1) consisted mainly of patients’ dis- selling role by reinforcing hospital discharge information satisfaction with the community pharmacy (e.g. pharmacy and elucidating possible existing or unresolved drug-related services or pharmacy stock), the health insurers (e.g. reim- problems. Furthermore, as pharmacists were in the lead it bursement issues), the hospital (e.g. transfer of information should enable them to monitor the time spent on the home or waiting times) or the general practitioner (e.g. unwanted visit. The lack of dedicated time for pharmaceutical care referral to hospital). was raised as a potential barrier for implementation in eve- Pat13: “You’ve always had a pharmacy delivery service, ryday community pharmacy practice, therefore monitoring but nowadays you’re giving me a hard time.” time could possibly lower that barrier [21]. Other potential Pat6: “And then there is the health insurer who mess barriers for further implementation were the lack of a reim- things up by deciding which medication I receive. Only the bursement fee, the inability of adopting the home visit into cheapest!” the current daily routine of the community pharmacist and Furthermore, patients shared personal information, for inadequate skills in communication and pharmacotherapy instance about their grandchildren or the weather or asked of the community pharmacist [21]. study-related questions. Good communication skills are essential when provid- ing patient-centred care to ensure patients’ understanding of their drug therapy and encourage adherence to their medi- Discussion cation [6, 22]. Pharmacists need to be trained in applying general affective communicative strategies, listening and In this study we showed that administration and use of medi- reflecting, and responding to uttered cues [23]. Combined cation, e.g. regimen and actual drug-taking issues, knowl- with non-specific verbal behaviour techniques, such as social edge gaps regarding medication and patients’ health were talk, these techniques are especially important in address- discussed most frequently, followed by medication logistics ing patient concerns. They not only create a safe and invit- and medication effectiveness. Patients’ beliefs about medi- ing atmosphere between the pharmacist and patient but also cation and adherence were less frequently discussed. The encourage patients to disclose their emotions and concerns pharmacist initiated the majority of these topics. Additional [23–25]. Furthermore, changing the consultation dynamic non-protocolled topics were scarce and consisted mainly of may also help; from a professional “coolness” approach patient-initiated dissatisfaction regarding the community at the beginning of the consultation to becoming warmer pharmacy or health insurers. and avoiding non-verbal cut-offs at the end [ 24]. Incorpo- The most-discussed topics during the home visit consul- rating more open-ended questions and follow-up questions tation are in line with major challenges identified in previ - throughout the home visit could increase the flexibility of ous studies and therefore crucial to address, e.g. patients’ the protocol and might invite patients to express their con- lack of knowledge regarding their medication and medica- cerns [26]. tion regimen [3, 16]. The myriad of medication and clinical It is important to discuss patient experiences, beliefs and topics discussed during the home visits illustrate the rigor adherence issues pro-actively, since not all patients might of the HomeCoMe protocol in identifying post-discharge express these issues themselves. In this study, patients drug-related problems (DRPs). The semi-structured pro- responded mainly with their dissatisfaction regarding tocol resulted in community pharmacists initiating the health care professionals to these questions. Identifying and majority of topics. Pharmacists alternated between open- addressing these complaints is relevant, as it might facilitate ended questions to increase patient engagement and more patient participation and acceptance of pharmacists’ advices structured directive questions to gain information needed [27]. Performing the home visits in the privacy of patients’ to identify possible DRPs. An active patient role is impor- own homes presents a unique opportunity to focus on these tant as it results in greater satisfaction with the care they topics, in contrast to the turbulent and less private environ- receive, a higher commitment to their treatment plans and ment of the community pharmacy [22]. Therefore, to maxi- a better understanding of their treatment, for instance [17, mize the benefit of the pharmacist home visits, pharmacists 18]. However, less-educated patients may find it difficult to should be provided with a more extensive training program ask the most relevant questions concerning their medication focused on how they can explore these topics and which [19]. Furthermore, patients might not clearly express their communication techniques they can use. information needs because they either assume that the phar- An important strength of this study was its large sam- macist has told them everything or because they do not want ple size, most likely ensuring data saturation. As this is to appear ignorant. Therefore, pharmacists need to empower the first study that qualitatively describes the topics dur - patients in fulfilling that active role as it has been identified ing a post-discharge community pharmacist home visit, 1 3 International Journal of Clinical Pharmacy (2018) 40:712–720 719 Conflicts of interest All authors declare that they have no conflicts of the results illustrate the post-discharge consequences for interest. patients at readmission to primary care. Another strength is the substantial number of different pharmacists that Open Access This article is distributed under the terms of the Crea- conducted the home visits. Although they had the same tive Commons Attribution 4.0 International License (http://creat iveco training in advance, they differed in work experience mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- tion, and reproduction in any medium, provided you give appropriate thus minimizing possible biases such as when only a spe- credit to the original author(s) and the source, provide a link to the cific research pharmacist population was included. This Creative Commons license, and indicate if changes were made. increases the internal validity of this study. A limitation of this study is the use of a semi-structured protocol that resulted in pharmacists having less communicative free- References dom during the home visit. Therefore, mapping of the patient-pharmacist communication is possibly hampered 1. Blom L, Krass I. Introduction: the role of pharmacy in as it expected to be substantially defined by the proto- patient education and counseling. 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New York: Holt, Rinehart and Winston; Res Soc Adm Pharm. 2014;10(1):149–55. 1953. p. 98–135. 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Clinical Pharmacy Springer Journals

Patient-pharmacist communication during a post-discharge pharmacist home visit

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Springer International Publishing
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Copyright © 2018 by The Author(s)
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Medicine & Public Health; Internal Medicine; Pharmacy
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2210-7703
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2210-7711
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10.1007/s11096-018-0639-3
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Abstract

Background With the shifting role of community pharmacists towards patient education and counselling, they are well- positioned to conduct a post-discharge home visit which could prevent or solve drug-related problems. Gaining insight into the communication during these home visits could be valuable for optimizing and consequently improving patient safety at readmission to primary care. Objective To assess patient-pharmacist communication during a post-discharge home visit. Set- ting The homes of patients recently discharged from a single general hospital in the Netherlands. Methods Pharmacists used a semi-structured protocol to guide the consultations and audiorecorded them. Sixty audio-recordings were included for a qualitative analysis in this study with the help of NVivo version 11 software. Main outcome measure (1) Initiator and topics under discussion. (2) Frequency of discussion of topics as per coded in themes and subthemes. Results Issues regarding the administration and use of medication, e.g. regimen and actual drug-taking issues, knowledge gaps regarding their medication and patients’ health were discussed most frequently, followed by medication logistics and medication eec ff tiveness. Patients’ beliefs about their medication and adherence were less frequently discussed. The pharmacist initiated the majority of these topics. Additional non-protocolled topics were scarce and consisted mainly of patient-initiated dissatisfaction regarding the community pharmacy or health insurers. Conclusion Community pharmacists most frequently initiated practical issues, but explored patients’ medication beliefs less adequately. Discussing these beliefs might be easier by increasing patient engage- ment in the consultation and providing training programs for pharmacists. Keywords Community pharmacist · Continuity of care · Home visits · Hospital discharge · Patient-provider communication · Seamless care · The Netherlands · Transitions of care Impacts on practice A home visit protocol enables pharmacists to address known major challenges during the transition from hos- pital to primary care • Addressing patient’s dissatisfaction about health care * Hendrik T. Ensing is important as it facilitates patient participation during rensing@zorggroep-almere.nl consultation and acceptance of pharmacists’ advices Pharmacists should discuss patients’ medication beliefs Research Group Process Innovations in Pharmaceutical Care, Utrecht University of Applied Sciences, Utrecht, and adherence issues more frequently, which might be The Netherlands facilitated by additional pharmacist training and increas- Department of Pharmacoepidemiology and Clinical ing patient engagement Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands Zorggroep Almere, Outpatient Pharmacy “de Brug 24/7”, Hospitaalweg 1, 1315RA Almere, The Netherlands NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands Vol:.(1234567890) 1 3 International Journal of Clinical Pharmacy (2018) 40:712–720 713 Flevoziekenhuis Almere. Patients gave written informed Introduction consent at inclusion and oral consent for audio recording of the consultation at the start of the home visit. All data files The community pharmacist’s role is shifting from traditional were coded by using unique personal identification numbers medication dispensing to patient education and counselling and personal details were removed from the transcripts. [1]. Patient transition from hospital back to their home pro- vides pharmacists with the opportunity to effectuate this role, as this transition is associated with an increased risk of drug- related problems (DRPs). Inadequate patient counselling dur- Method ing the transition is a contributing factor [2, 3]. Pharmacists are well positioned to facilitate the discharge process by per- Study setting forming medication reconciliation, identifying patients with poor health literacy or non-adherence, and providing tailored A qualitative observational study was conducted with audio- discharge counselling [4]. However, to establish continuity of recordings from community pharmacist home visits from care most efficiently and provide adequate patient support, the Home-based Community pharmacist-led Medication discharge procedures should be complemented with adequate management (HomeCoMe) program that were performed post-discharge follow-up [5]. Introducing a post-discharge between November 2013 and December 2014 [12]. The in- community pharmacist home visit can secure continuity of hospital outpatient pharmacy acted as a discharge coordina- care but is not usual care at the moment in the Netherlands. tor and cooperated closely with all community pharmacists. Community pharmacists must adapt their communication It verified patients’ administrative information, reiterated to address the wide variety of patients’ drug-related problems important study information, notified the community phar - during these home visits and achieve patient-centred commu- macists of a pending discharge and transferred all medica- nication. Patient-centred communication is associated with tion-related information to them. increased patients’ satisfaction, better recall of information and The HomeCoMe program consisted of in-hospital phar- improved health outcomes and requires active participation macy interventions and its main component: a post-dis- of both the pharmacist and the patient [6–8]. Patients should charge home visit by the patient’s own community phar- be encouraged to express their needs and concerns regard- macist [12]. Pharmacists used a semi-structured protocol to ing their medication, which pharmacists should address to address patients’ questions and reinforce medication-related support patients in making informed decisions [9]. Little is hospital discharge information. Furthermore, pharmacists known about the topics discussed during a post-discharge aimed to identify and solve pending and emerging post- home visit and most studies investigating patient-pharmacist discharge drug-related problems (DRPs) during the home communication focused primarily on one-way pharmacist visits by (1) performing post-discharge medication recon- information provision, e.g. the extent to which pharmacists ciliation, (2) assessing patients’ medication knowledge, (3) counsel patients, and their communication style, e.g. tone of identifying adherence barriers and (4) determining patients’ voice [10, 11]. Gaining insight in the communication during concerns [12]. Deploying home visits instead of a telephone these home visits could be valuable for optimizing these visits; follow-up is possibly more beneficial due to the personal and consequently to improve patient safety at readmission to touch of face-to-face encounters [13]. Patients might feel primary care. more comfortable at home and are therefore more likely to share their experiences and concerns about their medication Aim of the study and be more receptive to pharmacist’s counselling. Further- more, a home visit may elicit all relevant DRPs since all To assess patient-pharmacist communication during a post- medication is available at home enabling the assessment of discharge home visit by exploring the discussed topics as well specific risk factors, such as inappropriate medication stor - as who—the patient or the pharmacist—initiated a specific age conditions [14]. topic. Study population Ethics approval Patients were eligible if they were discharged from a single general hospital (neurology and pulmonology wards) to their Ethical approval was obtained from the ethics commit- own home, aged 18 years or over, used at least three or more tee of the Radboud University Medical Centre Nijmegen. prescription drugs for chronic use at discharge, had been Local approval was obtained from the scientific commit- hospitalized for at least 48 h and picked up their medication tee of Zorggroep Almere (ZGA, Care Group Almere) and in one of the participating pharmacies. 1 3 714 International Journal of Clinical Pharmacy (2018) 40:712–720 gender, patients’ gender and the presence or absence of an Pharmacist home visit protocol informal caretaker during the home visit. The community pharmacists contacted the patients as soon as possible post-discharge and aimed to visit them within Data coding and analysis 7 days. A semi-structured protocol to guide pharmacists dur- ing the home visits was used (Table 1). Efforts were made Two research-assistants transcribed all 60 recordings ver- to develop a protocol tailored to the individual patient by: (1) assessing patients’ perceptions on their use of medica- batim to ensure consistency. All transcripts were imported into NVivo version 11 software to facilitate analysis. tion in general and specifically for medication started during hospitalization and (2) incorporating open-ended example All transcripts were coded and reviewed by a researcher (HE) and a research assistant (LV). Discrepancies were questions, e.g. for initiating and finalizing the home visit. These efforts aimed to help pharmacists to focus on prob - resolved through discussion and, if necessary, a third researcher (MV) was consulted to reach consensus. A the- lems relevant to the patient [10]. All participating commu- nity pharmacists previously attended accredited courses on matic content analysis was used to examine main themes [15]. First, the three overarching themes based on the performing medication reviews, including patient inter- views. To ensure generalizability, all pharmacists received HomeCoMe protocol were identified: (1) ‘Medication”, (2) “Clinical” and (3) “Other” (Table 2). Next, all subthemes an additional one-day training course on how to perform the home visit and how to tailor their communication to the were coded inductively. After coding of the first five tran- scripts these subthemes were redefined and merged where needs of the individual patient. Besides plenary instructions, the pharmacist practiced with the home visit protocol with possible into a preliminary codebook. Previously coded transcripts were re-coded to match any changes in theme the help of paper patients and role-playing. definitions during this coding procedure. During coding of the remaining transcripts a process of reading and re- Data collection reading, with attention to the identification of new sub- themes, eventually resulted in the final code book with In total, 152 patients received a post-discharge home visit, which was audio-recorded by the community pharmacists. well-defined codes and descriptions (Table  2). Addition- ally, the initiator of each subtheme was coded (pharmacist Incomplete recordings or recordings with very poor sound quality were excluded. This resulted in 122 recordings or patient) as well as an illustrative quote. All data was descriptively analysed by identifying (78.9%) eligible for inclusion of which a random sample of 60 recordings was selected for this study. No new sub- major themes, based on frequency of being mentioned, and the initiator of those themes. themes were identified after 30 recordings, therefore this most likely ensured data saturation. At least one record- ing from 23 of the 26 participating community pharma- cists was included. The recordings from the other three pharmacists were incomplete. To complete data selection a pragmatic approach was used to obtain a selection of recordings that were equally distributed on pharmacists’ Table 1 Main topics to be addressed during the post-discharge home visits Protocol part Aim Introduction To list the topics that the patient wants to discuss, set the patient at ease and clarify the aim of the home visit Clinical issues To obtain an overall impression of patient’s health. This part contains a checklist of possible (drug-related) health issues and example questions to address these issues Beliefs about medication To clarify patient’s beliefs and concerns about medication, their attitude towards taking medication, the (lack of) effect of their medication, experienced side effects and intentional adherence barriers Practical issues To clarify patient’s practical issues with their medication, e.g. difficulties adhering to their daily regimen, with the packaging, with the actual drug taking or unintentional adherence barriers such as forgetfulness or lack of stock Patient’s knowledge To identify patient’s knowledge gaps concerning their medication, e.g. reason for prescribing, medication regimen, duration of use and administration of medication Spare medication To identify and collect possible spare medication Conclusion To conclude the home visit by ensuring the patient has discussed all his topics, summarize and solve identified (drug- related) problems and provide patient with information on the follow-up 1 3 International Journal of Clinical Pharmacy (2018) 40:712–720 715 Table 2 Condensed codebook displaying themes, subthemes and examples Theme Subtheme (example) Medication Medication information (e.g. indication, side effects, mechanism of action) Medication effectiveness (e.g. perceived effect of medication) Non-prescription medication (e.g. over-the-counter medication, vitamins) Beliefs about medication (e.g. needs, concerns, usefulness of medication,) Medication logistics (e.g. repeat prescription issues, stock issues) Medication adherence (e.g. practical or perceptual adherence barriers) Administration and use (e.g. actual drug-taking, medication regimen, multi-dose dispensing system) Clinical Patients’ general health (e.g. existing health issues, worsened symptoms) Hospital admission (e.g. reason for hospitalization, length of stay) Other All themes unrelated to the HomeCoMe protocol (e.g. satisfaction with health care providers, personal information) regimens for medication with an alternating dose schedule Results (e.g. insulin). Pharm5: “We’ll discuss the medication that is discon- General characteristics tinued during hospitalization in just a moment.” Pat10: “Yeah, there are a lot of them!” Pharm5: “That’s right, The 23 pharmacists had a mean of 17.7 ± 8.3  years of let’s discuss them one by one.” working experience in the community pharmacy and per- Pharm19: “All right, let’s see, do you have any ques- formed a mean of 6.5 ± 5.6 home visits. The 60 audio- tions regarding the use of your medication? Pat54: “Well, recordings lasted 28.4 ± 11.4 min on average. I’m familiar with most of them, but I have some questions The mean age of the patients was 65.3 ± 13.5 years and about those two new inhalers.” 51.7% were females. A partner or informal carer was pre- Patients initiated topics in this subtheme to clarify sent during 20 home visits (33.3%). uncertainties concerning their regimen (e.g. questions about medication changes) and to ask for advice. Pat20: Yes, it’s very convenient that you’re here. I was Patient: pharmacist communication discharged from the hospital last Wednesday and there are two medicines I had before which I did not receive at my In total 2450 text fragments were coded (Fig. 1). Approxi- mately three-quarters of the topics discussed during the discharge. Should I still take them?” Potential drug-taking issues were explored more often home visits can be classified within the theme “Medica- tion”, followed by “Clinical” topics. Only a few additional by pharmacists than patients. Pharmacists gathered infor- mation for instance on any discomfort with taking the topics were classified within the “Other” theme (Fig.  1). The five major subthemes, ranked by frequency, and medication, and consequently evaluated the relevance and provided advice or support. accompanying illustrative quotes are described in more detail below, as well as less-discussed subthemes and top- Pharm18: “Could you show me how you use your spacer?” Pat50: “Yes, I have got this blue one. It should ics in the “Other” theme. not whistle, as that indicates that I am inhaling too fast.” If patients initiated drug-taking issues, they shared Administration and use their experiences, or asked for advice to solve drug-taking issues. Administration and use was the largest subtheme (Fig. 1). Pat15: “You’re supposed to dissolve these [amoxicil- The majority of topics within this subtheme concerned lin] in water, but well, I’ve skipped that sometimes. I did patients’ medication regimens which pharmacists initiated it whenever I could though.” Pharm6: “That’s ok, you can more often than patients. Pharmacists identified possible also take them without previously dissolving them.” knowledge gaps and reinforced the information concern- Other less frequently discussed topics concerned pack- ing patients’ discharge medication regimens, explored and aging (e.g. opening blisters), multi-dose dispensing sys- advised on possible regimen improvements, clarified the tems or receiving support (e.g. from partner) in taking duration of use for temporary medication (e.g. pain medi- their medication. cation started at discharge) or determined patients’ daily 1 3 716 International Journal of Clinical Pharmacy (2018) 40:712–720 Non-prescription medication, n = 57 Complaints, personal and study information, Patients’ n = 135 general health, n = 441 Hospital admission, n = 69 Administration and use, n = 904 Medication information, n = 517 Medication logistics, n = 105 Medication effectiveness, n = 106 Medication adherence, n = 55 Beliefs about medication, n = 61 Fig. 1 Distribution of themes (inner circle) and subthemes (outer circle). In total, 2450 text fragments were coded Medication information Topics related to side effects were initiated more often by pharmacists than patients as well. Pharmacists verified The majority of topics within the “Medication information” patients’ knowledge on medication side effects, checked if patients experienced a side effect, acknowledged the exist- subtheme concerned the indications for use. Pharmacists explored this topic more often than patients and informed ence of a side effect or reassured the patient. Pharm23: “You’re using a fairly high dosage of bisaco- patients about the reason for prescribing specific medication. Pharm21: “Can you tell me why you have to take these dyl, do you experience any side effects like stomach ache or nausea? Pat59: “No, not at all.” [diclofenac]?” Pat57: “Sure, I have to take those three times a day. It’s an anti-inflammatory drug and a painkiller as Patients initiated this topic to share information about experienced side effects. well.” If patients initiated this topic they indicated to be una- Pat5: “If I use them, I continuously have to go to the toi- let, I really hate that!” That’s why I skipped a dosage today. ware of the reason for prescribing, mainly in cases of using multiple medications. Thursday I have to take another one and it all will start again.” Pharm2: Okay and did you experience any adverse Pat32: “Is that the one to reduce my cholesterol levels?” Pharm12: “No, these prevent your blood from clotting.” effects from skipping that dosage, for instance shortness of 1 3 International Journal of Clinical Pharmacy (2018) 40:712–720 717 breath or fluid retention in your legs? Pat5: “No not at all, Patients initiated topics within this subtheme to share but my specialist warned me that I should really take them.” their experiences with using medication and whether or Other topics within this subtheme were discussed less not they see a positive effect from it in treating their health frequently and concerned the mechanism of action of the condition. medication and any precautions (e.g. driving precautions). Pat49: “Like I told before, I can sense it coming. So, that provides me with some time to get my inhaler. And it helps Patients’ general health a lot.” Pharm18: “Yeah?” Pat49: “Yes, it helps me getting through it, especially on the warmer days. I really need my Pharmacists initiated topics concerning patients’ general inhaler in the summer.” health more often than patients. They queried patients using a trigger list on possible existing health issues including follow-up (e.g. laboratory tests or GP-visits), inquired for Less‑discussed subthemes worsened or improved symptoms post-discharge or provided life-style advice (e.g. smoking cessation or exercise). The less discussed subthemes were “Hospital admission”, Pharm1: “You were admitted for meningitis, how are you “Medication adherence” and “Beliefs about medication” doing right now?” Pat2: “Reasonably.” Pharm1:”You’re (Fig. 1). Pharmacists dominated the initiation of the sub- not left with any lingering symptoms?” Pat2: “Well yes, I theme “Hospital admission” in which all topics concerning experience some rigorous shaking, especially during physi- patients’ recent admission were discussed, such as the rea- cal exercise.” son for admission and length of stay. Pharmacists used this If patients took initiative, they shared information on question mostly as the opening question for the home visit. experiencing a specific health issue. Pharm17: “Tell me, what was the matter? You were Pat33: “Well, to be honest, the tumour affects my breath- admitted to the hospital and what happened? Why were you ing. I experience shortness of breath, but luckily I’m not in admitted?” Pat47: “Well, I’ve been told that my symptoms pain.” suggested a hernia.” Furthermore, pharmacists asked patients which medica- Medication logistics tion they were using besides the prescribed medication. Pharm14: “Do you use any over-the-counter drugs, Patients participated more actively within this subtheme, ones purchased at the chemist maybe?” Pat35: No, I would however pharmacists initiated topics on medication logistics never do that.” Pharm14: “No supplements either?” Pat35: still more often than patients. Pharmacists verified patients’ “No, all those extra pills, I am not up for that. I think it is medication stock, elucidated and advised on storage condi- unnecessary.” tions and on obtaining repeat prescriptions and collected The subtheme “Medication adherence” was initiated discontinued or expired medication. more often by pharmacists than by patients and involved Pharm8: “Does it sometimes happen that you don’t have pharmacists asking whether patients experienced adherence enough medication left?” Pat22: “No, not at all! My wife problems, for instance due to forgetfulness. and I pay really good attention to having an adequate stock Pharm16: “Do you forget to take your medication at home.” sometimes, a single tablet maybe?” Pat43: “No, never.” Patients initiated these topics mainly to gather informa- Pharm16: “So you are familiar with your daily regimen?” tion or to share their supply inconveniences. Pat43: “Yes, I prepare them all in advance.” Pat24: “Where and how do I get my prescription for those The subtheme patients’ “Beliefs about medication” was pills? Should I contact the specialist or the GP?” initiated as often by pharmacists, e.g. to identify patients’ needs or expectations of their medication, as by patients who Medication effectiveness shared their general attitude towards medication. Further- more, patients expressed specific concerns about using their The last major subtheme was “Medication effectiveness” medication. (Fig. 1). Pharmacists initiated a topic within this subtheme Pharm20: “Let’s see, what do you think about your medi- more often than patients and inquired whether patients expe- cation?” Pat55: “Yes, I do experience the benefits, I mean, rienced a beneficial effect of the medication and provided I have been taking them for a long time already and I’m background information on specific medication, e.g. whether still here!” or not patients could experience an effect at all. Pat12: “Well I’ve had a small hip fracture for which I took Pharm19: “You also have to take tamsulosin, do you these pills. However, I try to minimize my intake because I experience an effect? Pat54: “I don’t know really, I have to worry that with prolonged use my body gets immune for it. take a lot of different drugs, so I can’t tell if it’s beneficial.” And it’s the only painkiller I’m allowed to take!” 1 3 718 International Journal of Clinical Pharmacy (2018) 40:712–720 Other themes as a key factor to improve health outcomes [20]. On the other hand, pharmacists themselves embraced their coun- “Other” themes (Fig. 1) consisted mainly of patients’ dis- selling role by reinforcing hospital discharge information satisfaction with the community pharmacy (e.g. pharmacy and elucidating possible existing or unresolved drug-related services or pharmacy stock), the health insurers (e.g. reim- problems. Furthermore, as pharmacists were in the lead it bursement issues), the hospital (e.g. transfer of information should enable them to monitor the time spent on the home or waiting times) or the general practitioner (e.g. unwanted visit. The lack of dedicated time for pharmaceutical care referral to hospital). was raised as a potential barrier for implementation in eve- Pat13: “You’ve always had a pharmacy delivery service, ryday community pharmacy practice, therefore monitoring but nowadays you’re giving me a hard time.” time could possibly lower that barrier [21]. Other potential Pat6: “And then there is the health insurer who mess barriers for further implementation were the lack of a reim- things up by deciding which medication I receive. Only the bursement fee, the inability of adopting the home visit into cheapest!” the current daily routine of the community pharmacist and Furthermore, patients shared personal information, for inadequate skills in communication and pharmacotherapy instance about their grandchildren or the weather or asked of the community pharmacist [21]. study-related questions. Good communication skills are essential when provid- ing patient-centred care to ensure patients’ understanding of their drug therapy and encourage adherence to their medi- Discussion cation [6, 22]. Pharmacists need to be trained in applying general affective communicative strategies, listening and In this study we showed that administration and use of medi- reflecting, and responding to uttered cues [23]. Combined cation, e.g. regimen and actual drug-taking issues, knowl- with non-specific verbal behaviour techniques, such as social edge gaps regarding medication and patients’ health were talk, these techniques are especially important in address- discussed most frequently, followed by medication logistics ing patient concerns. They not only create a safe and invit- and medication effectiveness. Patients’ beliefs about medi- ing atmosphere between the pharmacist and patient but also cation and adherence were less frequently discussed. The encourage patients to disclose their emotions and concerns pharmacist initiated the majority of these topics. Additional [23–25]. Furthermore, changing the consultation dynamic non-protocolled topics were scarce and consisted mainly of may also help; from a professional “coolness” approach patient-initiated dissatisfaction regarding the community at the beginning of the consultation to becoming warmer pharmacy or health insurers. and avoiding non-verbal cut-offs at the end [ 24]. Incorpo- The most-discussed topics during the home visit consul- rating more open-ended questions and follow-up questions tation are in line with major challenges identified in previ - throughout the home visit could increase the flexibility of ous studies and therefore crucial to address, e.g. patients’ the protocol and might invite patients to express their con- lack of knowledge regarding their medication and medica- cerns [26]. tion regimen [3, 16]. The myriad of medication and clinical It is important to discuss patient experiences, beliefs and topics discussed during the home visits illustrate the rigor adherence issues pro-actively, since not all patients might of the HomeCoMe protocol in identifying post-discharge express these issues themselves. In this study, patients drug-related problems (DRPs). The semi-structured pro- responded mainly with their dissatisfaction regarding tocol resulted in community pharmacists initiating the health care professionals to these questions. Identifying and majority of topics. Pharmacists alternated between open- addressing these complaints is relevant, as it might facilitate ended questions to increase patient engagement and more patient participation and acceptance of pharmacists’ advices structured directive questions to gain information needed [27]. Performing the home visits in the privacy of patients’ to identify possible DRPs. An active patient role is impor- own homes presents a unique opportunity to focus on these tant as it results in greater satisfaction with the care they topics, in contrast to the turbulent and less private environ- receive, a higher commitment to their treatment plans and ment of the community pharmacy [22]. Therefore, to maxi- a better understanding of their treatment, for instance [17, mize the benefit of the pharmacist home visits, pharmacists 18]. However, less-educated patients may find it difficult to should be provided with a more extensive training program ask the most relevant questions concerning their medication focused on how they can explore these topics and which [19]. Furthermore, patients might not clearly express their communication techniques they can use. information needs because they either assume that the phar- An important strength of this study was its large sam- macist has told them everything or because they do not want ple size, most likely ensuring data saturation. As this is to appear ignorant. Therefore, pharmacists need to empower the first study that qualitatively describes the topics dur - patients in fulfilling that active role as it has been identified ing a post-discharge community pharmacist home visit, 1 3 International Journal of Clinical Pharmacy (2018) 40:712–720 719 Conflicts of interest All authors declare that they have no conflicts of the results illustrate the post-discharge consequences for interest. patients at readmission to primary care. Another strength is the substantial number of different pharmacists that Open Access This article is distributed under the terms of the Crea- conducted the home visits. Although they had the same tive Commons Attribution 4.0 International License (http://creat iveco training in advance, they differed in work experience mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- tion, and reproduction in any medium, provided you give appropriate thus minimizing possible biases such as when only a spe- credit to the original author(s) and the source, provide a link to the cific research pharmacist population was included. This Creative Commons license, and indicate if changes were made. increases the internal validity of this study. A limitation of this study is the use of a semi-structured protocol that resulted in pharmacists having less communicative free- References dom during the home visit. Therefore, mapping of the patient-pharmacist communication is possibly hampered 1. Blom L, Krass I. Introduction: the role of pharmacy in as it expected to be substantially defined by the proto- patient education and counseling. 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Journal

International Journal of Clinical PharmacySpringer Journals

Published: May 2, 2018

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