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What is the role of the pharmacist in home care?
WHAT ISTHE ROLE OF THE PHARMACIST IN HOME CARE? Patrick N. Catania, PhD, RPh
ide range of medications, convalescent aids, for patients aditionally community pharmacists have roviders of prescription and nonprenistered orally. Today pharmacists in community and hospital pharmacies across the country have expanded their services for the omebound patient and provide a variety of sophistiucts and services in the patient’s home. Examples of expanded home services include parenteral nutrition, enteral nutrition, parenteral antibiotics and chemotherapy, pain management, and a wide variety of medical equipment and supplies. The products and services that pharmacists provide to patients are referred to as pharmaceutical care. Home care products and services are provided by pharmacists in association with several health care entities, such as hospitals, managed care organizations, community pharmacies, home health agencies, hospice groups, and specialized home infusion companies.’ To assist pharmacists in defining their areas of responsibility, the American Society of Health-system Pharmacists (ASHP) developed “Guidelines on the Pharmacist’s Role in Home Care.“’ These guidelines refer to the provision of pharmaceutical products and clinical monitoring of patients in the home, especially home infusion therapy and other injectable
OCTOBER
1997, VOL. 2 NO. 5
drug and enteral nutrition therapy, in addition to traditional products and services provided by pharmacists in the community. According to the ASHP guidelines, pharmacists provide or participate in providing the following specific functions: l
Initial
patient
l
Patient
l
Product,
l
Development
l
Patient
l
Effective
assessment
education,
training,
device,
and ancillary
clinical
and counseling supply
of pharmaceutical
selection
care plans
monitoring
communication
with prescribers,
HOME
nurses, and
CARE PROVIDER
229
WHEN other health
care personnel
The guidelines their definition l
l
Direct
also include the following responsibilities of the home care pharmacist’s role:
communication
with the patient
Coordination of drug preparation, and administration
l
Employee
and patient
l
Compliance
l
Documentation
with universal
Reporting
l
Participation
l
Development
of policies
l
Compliance
with licensure
Participation programs
in continuing
l
storage,
to medication
use
precautions
of adverse drug reactions in quality
improvement
activities
and procedures and accreditation education
requirements
and training
Along with the ASHP guidelines, home care pharmacists comply with the accreditation standards of the Joint Commission on Accreditation of Healthcare Organizations and the legally recognized standards of the United States Pharmacopeial Convention (USP).3 Critical responsibilities assigned to pharmacists include drug inventory and security, hazardous waste handling, dispensing, clinical monitoring, tracking and quality control logs, and delivery procedures, as well as actual compounding technique for parenteral products4
HOME
INFUSION
THERAPY
Infusion therapy consists of administering a drug, nutrient solution, or other fluid into the patient through a needle or catheter. Infusion therapy usually is provided intravenously; however, subcutaneous and other administration methods may be used.5 Home infusion therapy has become one of the most important health care alternatives provided by pharmacists because of the technological advances associated with infusion therapy. A heavy reliance on technologically sophisticated parenteral equipment initially led to the use of the phrase high tech home cure to describe home infusion therapy. However high tech as a descriptor of home infusion therapy
230
HOME
CARE PROVIDER
Because of the inherent risk associated with providing drug therapy by parenteral administration in the patient’s home, sophisticated home care pharmacy services are warranted. The home infusion therapy pharmacist provides three major patient care functions: initial patient evaluation; compounding and dispensing drugs, solutions, and nutrients; and ongoing education and clinical monitoring.6
PROVIDING
in the home care record
l
is a misnomer in that technological advances have affected all sectors of home care, not just infusion therapy. Other phrases that have been used to describe home infusion therapy include borne intravenous therapy, borneparenteral therapy, and alternate site intravenous tberapy.5
and caregiver
delivery,
safety related
in
PATIENTS ASK
DRUG INFORMATION
Pharmacists routinely provide drug information to patients, caregivers, and other health care providers. Because home care is a relatively new practice site for the provision of care, pharmacists give careful attention to the unique drug information needs in this setting. Dosing schedules, infusion rates, compatibility and stability concerns, special storage conditions, and adverse outcomes are examples of the kinds of information pharmacists provide.’ Specialized reference books that supplement the credentials of home care pharmacists usually are available in the pharmacy. Drug product selection, drug efficacy, and pharmacoeconomic issues require pharmacists to evaluate drug information. The results of these evaluations serve as the foundation for drug therapy recommendations made by home care pharmacists. In addition to these responsibilities, home care pharmacists provide special education and training sessions for patients, caregivers, and other health care providers to share unique home care drug information in a timely manner. Counseling sessions for patients, in-service lectures for health care providers, and a variety of written materials typically are provided by home care pharmacists.
ASSESSING OUTCOMES OF HOME CARETREATMENT Using a multidisciplinary approach to provide care and treatment of home care patients requires careful service coordination and routine communication among providers. To determine if appropriate outcomes of care and treatment have been achieved, the home care pharmacist works with other health care professionals to provide necessary data and documentation. Routine drug use evaluations and ongoing monitoring help assess outcomes. Analyses of patterns of drug use, rehospitalization as a result of treatment failures, follow-up visits, pharmacoeconomic
OCTOBER
1997, VOL.
2
NO. 5
WHEN
PATIENTS ASK
issues, and treatment comes assessment.’
success rates are included
SEL
in out-
E PHAR
Several factors should be considered when selecting recommending a home care pharmacist, including: l
Types of products
l
Credentials
l
Pharmacy
or
and services available
ment managers,
and drug therapy
consultants.
They have
a commitment to patient care and a concern for positive patient outcomes to ensure quality care in the patient’s home. Home care pharmacists have a strong working knowledge of legal and regulatory issues, accreditation requirements, and financial and reimbursement strategies. Home care pharmacists work closely with other home care practitioners to coordinate care and ensure the continuity of care for patients referred to them.
EFERENCES
Pharmacist
l
location
1. Catania
accessibility
PN. MM,
Health
Markets
2. ASHP
Availability of traditional pharmacy products and services (e.g., prescription and nonprescription medication)
3. Okeke
Degree of trust and confidence the pharmacist*
4. Popovich
CC,
affecting
the patient
has in
to home
Home
health
care.
care
practice.
health
Research; 1993;50:
Barletta pharmacy
In: Catania
PN,
Palo Alto
(CA):
1994.
on the pharmacist’s
Syst Pharm
1997;54: l
editors.
guidelines
Health l
Introduction
Rosner
role in home
care.
Am J
1940.
FP, Gray
VA. USP standards
practice.
Am J Health
and activities
Syst Pharm
1633. M.
Initiatives
aim to integrate
the Joint Commission’s
accreditation
performance process.
measures
Home
Care
into
Provider
1997;2:12.
All pharmacists spend 5 or 6 years in college specializing in drug therapy, especially courses in pharmacology and clinical therapeutics. Some pharmacists have a Doctor of Pharmacy degree (PharmD), a specialty degree in clinical pharmacy practice that requires 6 or 7 years of intensive professional education and clinical training. Although all pharmacists have several years of education, training, and experience, home care pharmacists have additional credentials that prepare them for the unique needs of such patients and caregivers. These credentials include postgraduate training in residency programs and/or completion of specialty courses and clinical rotations in home care.
5. Melikian
DM.
Establishing
a home
infusion
Catania
PN,
Rosner
editors.
Home
Palo Alto [CA]: 6. Catania
PN.
MM,
Health
Home
Markets
health
care:
pharmacy health
Research;
1994.
the new
practice
service.
care
In:
practice.
site. US Pharm
1994;5:3. 7. Catania
PN.
King Guide 8. Catania
PN,
patients.
Rosner
Cont
9. Pharmacists Today
King guide Publications; Care
MM.
to parenterai
admixtures.
Napa
[CA):
1997. Pharmacy
services
for home
health
care
1987;3:20.
top honesty
and
ethics
poll for eighth
time.
Pharmacy
1997;2:8.
Accessibility is an important factor to consider when selecting a home care pharmacist8 This pharmacist should be readily available to teach, give advice, and provide drug information to home care patients and caregivers. Trmely provision of drug therapy as prescribed is imperative. Most home care pharmacists are available on-call 24 hours a day to provide services and consultation when needed. Trust and confidence also are important attributes that should be weighed in selecting a home care pharmacist8 Over the years, the pharmacist has been rated by the public as the most trusted health care professional, according to Gallup polls taken each year since the mid- I 980s.9 Because of this trust, patients usually respond positively to advice and education provided by pharmacists. Home care pharmacists provide pharmaceutical includes roles as clinicians, educators, product
OCTOBER
1997. VOL.
2
NO. 5
care that and equip-
HOME
CARE PROVIDER
23 1
ide range of medications, convalescent aids, for patients aditionally community pharmacists have roviders of prescription and nonprenistered orally. Today pharmacists in community and hospital pharmacies across the country have expanded their services for the omebound patient and provide a variety of sophistiucts and services in the patient’s home. Examples of expanded home services include parenteral nutrition, enteral nutrition, parenteral antibiotics and chemotherapy, pain management, and a wide variety of medical equipment and supplies. The products and services that pharmacists provide to patients are referred to as pharmaceutical care. Home care products and services are provided by pharmacists in association with several health care entities, such as hospitals, managed care organizations, community pharmacies, home health agencies, hospice groups, and specialized home infusion companies.’ To assist pharmacists in defining their areas of responsibility, the American Society of Health-system Pharmacists (ASHP) developed “Guidelines on the Pharmacist’s Role in Home Care.“’ These guidelines refer to the provision of pharmaceutical products and clinical monitoring of patients in the home, especially home infusion therapy and other injectable
OCTOBER
1997, VOL. 2 NO. 5
drug and enteral nutrition therapy, in addition to traditional products and services provided by pharmacists in the community. According to the ASHP guidelines, pharmacists provide or participate in providing the following specific functions: l
Initial
patient
l
Patient
l
Product,
l
Development
l
Patient
l
Effective
assessment
education,
training,
device,
and ancillary
clinical
and counseling supply
of pharmaceutical
selection
care plans
monitoring
communication
with prescribers,
HOME
nurses, and
CARE PROVIDER
229
WHEN other health
care personnel
The guidelines their definition l
l
Direct
also include the following responsibilities of the home care pharmacist’s role:
communication
with the patient
Coordination of drug preparation, and administration
l
Employee
and patient
l
Compliance
l
Documentation
with universal
Reporting
l
Participation
l
Development
of policies
l
Compliance
with licensure
Participation programs
in continuing
l
storage,
to medication
use
precautions
of adverse drug reactions in quality
improvement
activities
and procedures and accreditation education
requirements
and training
Along with the ASHP guidelines, home care pharmacists comply with the accreditation standards of the Joint Commission on Accreditation of Healthcare Organizations and the legally recognized standards of the United States Pharmacopeial Convention (USP).3 Critical responsibilities assigned to pharmacists include drug inventory and security, hazardous waste handling, dispensing, clinical monitoring, tracking and quality control logs, and delivery procedures, as well as actual compounding technique for parenteral products4
HOME
INFUSION
THERAPY
Infusion therapy consists of administering a drug, nutrient solution, or other fluid into the patient through a needle or catheter. Infusion therapy usually is provided intravenously; however, subcutaneous and other administration methods may be used.5 Home infusion therapy has become one of the most important health care alternatives provided by pharmacists because of the technological advances associated with infusion therapy. A heavy reliance on technologically sophisticated parenteral equipment initially led to the use of the phrase high tech home cure to describe home infusion therapy. However high tech as a descriptor of home infusion therapy
230
HOME
CARE PROVIDER
Because of the inherent risk associated with providing drug therapy by parenteral administration in the patient’s home, sophisticated home care pharmacy services are warranted. The home infusion therapy pharmacist provides three major patient care functions: initial patient evaluation; compounding and dispensing drugs, solutions, and nutrients; and ongoing education and clinical monitoring.6
PROVIDING
in the home care record
l
is a misnomer in that technological advances have affected all sectors of home care, not just infusion therapy. Other phrases that have been used to describe home infusion therapy include borne intravenous therapy, borneparenteral therapy, and alternate site intravenous tberapy.5
and caregiver
delivery,
safety related
in
PATIENTS ASK
DRUG INFORMATION
Pharmacists routinely provide drug information to patients, caregivers, and other health care providers. Because home care is a relatively new practice site for the provision of care, pharmacists give careful attention to the unique drug information needs in this setting. Dosing schedules, infusion rates, compatibility and stability concerns, special storage conditions, and adverse outcomes are examples of the kinds of information pharmacists provide.’ Specialized reference books that supplement the credentials of home care pharmacists usually are available in the pharmacy. Drug product selection, drug efficacy, and pharmacoeconomic issues require pharmacists to evaluate drug information. The results of these evaluations serve as the foundation for drug therapy recommendations made by home care pharmacists. In addition to these responsibilities, home care pharmacists provide special education and training sessions for patients, caregivers, and other health care providers to share unique home care drug information in a timely manner. Counseling sessions for patients, in-service lectures for health care providers, and a variety of written materials typically are provided by home care pharmacists.
ASSESSING OUTCOMES OF HOME CARETREATMENT Using a multidisciplinary approach to provide care and treatment of home care patients requires careful service coordination and routine communication among providers. To determine if appropriate outcomes of care and treatment have been achieved, the home care pharmacist works with other health care professionals to provide necessary data and documentation. Routine drug use evaluations and ongoing monitoring help assess outcomes. Analyses of patterns of drug use, rehospitalization as a result of treatment failures, follow-up visits, pharmacoeconomic
OCTOBER
1997, VOL.
2
NO. 5
WHEN
PATIENTS ASK
issues, and treatment comes assessment.’
success rates are included
SEL
in out-
E PHAR
Several factors should be considered when selecting recommending a home care pharmacist, including: l
Types of products
l
Credentials
l
Pharmacy
or
and services available
ment managers,
and drug therapy
consultants.
They have
a commitment to patient care and a concern for positive patient outcomes to ensure quality care in the patient’s home. Home care pharmacists have a strong working knowledge of legal and regulatory issues, accreditation requirements, and financial and reimbursement strategies. Home care pharmacists work closely with other home care practitioners to coordinate care and ensure the continuity of care for patients referred to them.
EFERENCES
Pharmacist
l
location
1. Catania
accessibility
PN. MM,
Health
Markets
2. ASHP
Availability of traditional pharmacy products and services (e.g., prescription and nonprescription medication)
3. Okeke
Degree of trust and confidence the pharmacist*
4. Popovich
CC,
affecting
the patient
has in
to home
Home
health
care.
care
practice.
health
Research; 1993;50:
Barletta pharmacy
In: Catania
PN,
Palo Alto
(CA):
1994.
on the pharmacist’s
Syst Pharm
1997;54: l
editors.
guidelines
Health l
Introduction
Rosner
role in home
care.
Am J
1940.
FP, Gray
VA. USP standards
practice.
Am J Health
and activities
Syst Pharm
1633. M.
Initiatives
aim to integrate
the Joint Commission’s
accreditation
performance process.
measures
Home
Care
into
Provider
1997;2:12.
All pharmacists spend 5 or 6 years in college specializing in drug therapy, especially courses in pharmacology and clinical therapeutics. Some pharmacists have a Doctor of Pharmacy degree (PharmD), a specialty degree in clinical pharmacy practice that requires 6 or 7 years of intensive professional education and clinical training. Although all pharmacists have several years of education, training, and experience, home care pharmacists have additional credentials that prepare them for the unique needs of such patients and caregivers. These credentials include postgraduate training in residency programs and/or completion of specialty courses and clinical rotations in home care.
5. Melikian
DM.
Establishing
a home
infusion
Catania
PN,
Rosner
editors.
Home
Palo Alto [CA]: 6. Catania
PN.
MM,
Health
Home
Markets
health
care:
pharmacy health
Research;
1994.
the new
practice
service.
care
In:
practice.
site. US Pharm
1994;5:3. 7. Catania
PN.
King Guide 8. Catania
PN,
patients.
Rosner
Cont
9. Pharmacists Today
King guide Publications; Care
MM.
to parenterai
admixtures.
Napa
[CA):
1997. Pharmacy
services
for home
health
care
1987;3:20.
top honesty
and
ethics
poll for eighth
time.
Pharmacy
1997;2:8.
Accessibility is an important factor to consider when selecting a home care pharmacist8 This pharmacist should be readily available to teach, give advice, and provide drug information to home care patients and caregivers. Trmely provision of drug therapy as prescribed is imperative. Most home care pharmacists are available on-call 24 hours a day to provide services and consultation when needed. Trust and confidence also are important attributes that should be weighed in selecting a home care pharmacist8 Over the years, the pharmacist has been rated by the public as the most trusted health care professional, according to Gallup polls taken each year since the mid- I 980s.9 Because of this trust, patients usually respond positively to advice and education provided by pharmacists. Home care pharmacists provide pharmaceutical includes roles as clinicians, educators, product
OCTOBER
1997. VOL.
2
NO. 5
care that and equip-
HOME
CARE PROVIDER
23 1