INvestigation of the impact of a Pharmacist in a Hospital At Home Care Team (IN PHACT)

Abstract

Background:

In November 2020, Island Health, with the support of the British Columbia Ministry of Health, introduced the Hospital at Home (HaH) care model at Victoria General Hospital in Victoria, British Columbia. Given the acuity of the patients anticipated to receive care through this model, questions arose regarding how the delivery of clinical pharmacy services on which inpatients rely on could be included. With limited supporting evidence for the inclusion of a clinical pharmacist, Island Health launched the HaH program with 2 clinical pharmacists who provide services 7 days a week during daytime hours. The aim of this study is to assess the impact of the HaH pharmacist on patient care, from the perspective of the pharmacists serving in this role, patients, caregivers and program stakeholders.

Methods:

This prospective, observational mixed-methods study was conducted from December 2021 to March 2022. Data collection involved the HaH pharmacist documenting daily clinical activities and resolving drug therapy problems, patients and caregivers completing a 4-question postdischarge phone survey and program stakeholders completing a 9-question online survey and an optional 7-question interview.

Results and Interpretation:

It was found that one of the most significant roles the pharmacist plays is in identifying indications for medication therapy and making recommendations to initiate therapy where there is an absence. There was high congruence between patient, caregiver and stakeholder perceptions that the HaH pharmacist positively affects patient care within the Island Health model.

Conclusion:

This study provides support for the integration of a dedicated clinical pharmacist in the HaH care model.

Introduction

Hospital at Home (HaH) is an innovative model of acute care that was incorporated into Island Health in Victoria, British Columbia, in November 2020. The combination of in-person and virtual supports allows patients to receive safe and effective care from acute care health care providers. Despite being at home, patients who live within a defined catchment radius are “admitted” to the hospital and remain under the care of a hospital-based team. The program functions as additional medicine wards of Victoria General Hospital (VGH) and Royal Jubilee Hospital (RJH) in Victoria. The team is composed of physicians, clinical pharmacists, acute care nurses, clinical nurse leaders, registered dietitians, occupational therapists and rehabilitation assistants. The clinical pharmacists provide services 7 days a week during daytime hours and work onsite at VGH and RJH.

Knowledge into Practice.

• There are limited published studies discussing the role that clinical pharmacy has in a Hospital at Home (HaH) model of care.

• This study aims to evaluate the impact of the clinical pharmacist on patient care within the HaH model in British Columbia, using quantitative and qualitative metrics.

• One of the most significant roles the HaH pharmacist plays is in identifying indications for medication therapy and making recommendations to initiate therapy where there is an absence.

• Patients, caregivers and stakeholders believe that the HaH pharmacist positively affects patient care within the Island Health model.

• This study provides support for the integration of a dedicated clinical pharmacist in the HaH care model.

When the Health Authority was discussing implementing HaH, the pharmacy department was identified as a major stakeholder, given the target patient population and the requirement to provide medication therapy outside the hospital. Distribution of hospital-supplied medications to patients in their homes brought with it obvious challenges. However, given the acuity of the patients anticipated to receive care through this model, there were questions about the equivalent delivery of clinical pharmacy services upon which brick-and-mortar hospital-admitted patients and care teams rely on.

A review of the literature was conducted and published by the primary author prior to conducting this research, focusing on the use of clinical pharmacy within HaH teams around the world. ¹ The review identified only 3 published studies discussing the role of clinical pharmacists in a HaH model of care.^2-4 This study aims to evaluate the impact of the clinical pharmacist on patient care within the HaH model in British Columbia using quantitative and qualitative metrics.

This study had 3 objectives:

1. To assess the impact of the HaH clinical pharmacist on patient care, as documented by the clinical pharmacist.

2. To assess the patients’ and caregivers’ perceptions of the HaH clinical pharmacist’s impact on patient care.

3. To assess the program stakeholders’ perception of the HaH clinical pharmacist’s impact on patient care. Stakeholders included personnel directly involved with the HaH program, such as registered nurses, physicians, program leaders, rehabilitation assistants and registered dietitians.

Mise En Pratique Des Connaissances.

• Peu d’études ont été publiées sur le rôle de la pharmacie clinique dans un modèle de soins d’HAD.

• Cette étude vise à évaluer l’incidence du pharmacien clinicien sur les soins aux patients dans le cadre du modèle d’HAD en Colombie-Britannique, à l’aide de mesures quantitatives et qualitatives.

• L’un des rôles les plus importants du pharmacien en HAD est d’identifier les indications du traitement médicamenteux et de faire des recommandations pour amorcer le traitement en cas d’absence.

• Les patients, les aidants et les parties prenantes estiment que le pharmacien en HAD a une incidence positive sur les soins aux patients dans le cadre du modèle Island Health.

• Cette étude soutient l’intégration d’un pharmacien clinique spécialisé dans le modèle de soins de l’HAD.

Methods

This prospective, observational mixed-methods study was conducted from December 2021 to March 2022 at Victoria General Hospital, a tertiary hospital in Victoria, British Columbia. During the study period, the clinical pharmacists carried out their daily clinical activities on site at VGH, providing usual care to patients admitted at VGH and RJH, the second tertiary hospital in Victoria.

The eligibility criteria for admission into Hospital at Home includes being at least 19 years of age; not from assisted living or long-term care; living within the geographic catchment area; safe home environment; requiring hospital-level care for a known, reversible condition; clinically stable; adequate activities of daily living and instrumental activities of daily living support; low fall risk; expected length of stay less than 14 days; unlikely to require multiple in-hospital tests, treatments or consultations; intravenous access obtained; no pain crisis; no acute stroke; no unstable psychiatric disorder; consenting to abstain from substance abuse; and consent from both patient and caregiver.

All consenting patients and caregivers were asked to complete a postdischarge phone survey, and all consenting Hospital at Home stakeholders were asked to complete an online survey and an optional interview focusing on the clinical impact of the clinical pharmacist.

Ethics and institutional approval were obtained from Island Health and the University of British Columbia. Data collection consisted of 3 parts:

• Over a 14-week period, the HaH clinical pharmacist documented the daily activities they completed using clinical pharmacy key performance indicators and the drug therapy problems (DTPs) they identified and resolved. These study data were collected and managed using REDCap version 12.0.27 (Vanderbilt University) electronic data capture tools hosted by Island Health. REDCap is a secure, web-based software platform designed to support data capture for research studies, providing 1) an intuitive interface for validated data capture; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for data integration and interoperability with external sources.^5,6

• Over a 17-week period, 4 survey questions were added to a postdischarge survey conducted with all consenting patients and caregivers. A 4-point Likert scale was used to assess the patients’ and caregivers’ level of agreement towards statements regarding the HaH pharmacist’s clinical activities. This survey was completed over the phone approximately 10 to 14 days after the patient was discharged from the program.

• Over a 12-week period, a 9-question online survey was sent to all HaH stakeholders who currently or previously worked for the program. A 4-point Likert scale was used to assess the stakeholders’ level of satisfaction with the HaH pharmacist’s clinical activities. These study data were collected and managed using REDCap electronic data capture tools hosted by Island Health. An optional 7-question virtual interview was offered to survey respondents. All interviews were conducted over Zoom version 5.11.2 (Zoom Video Communications) and were audio recorded and then transcribed using Microsoft Word Online (Microsoft 365). The primary author verified the accuracy of all transcriptions prior to thematic coding. Transcripts were independently coded by all authors prior to identifying the main themes.

Data collection occurred 1 year after the HaH program launched. Some data points were collected and reported based on hospital site, because at the time this research was being conducted, the HaH pharmacist was based at VGH and provided care to patients at VGH and RJH.

Results

Sixty-one percent of the 123 patients admitted to the program during the study period were 70 years of age or older. Seventeen percent of the patients were between the age of 50 and 59, and 17% were between the age of 60 and 69. Seventy-eight patients were admitted from VGH, and 45 were admitted from RJH.

Pharmacist activity during admission

The HaH pharmacist participated in almost all the daily interprofessional patient care rounds for each patient and facilitated most of the admission medication reconciliations (Table 1). The pharmacist contacted community pharmacies on 46 occasions, and 63% of the time they were clarifying home medications or discharge prescriptions. The pharmacist spoke to 110 patients during their admission, and medication education was provided to 54 patients during their admission. The pharmacist identified an overall average of 3 DTPs per day.

Table 1.

Percentage of admission and discharge activities in which the HaH pharmacist participated

Admission activities	VGH	RJH
Percentage of individual patient care rounds in which the HaH pharmacist participated	96% (559/585)	98% (410/419)
Percentage of patients who received documented admission medication reconciliation, as well as resolution of identified discrepancies, facilitated by the HaH pharmacist	96% (75/78)	76% (34/45)
Discharge activities	VGH	RJH
Percentage of patients who received documented discharge medication reconciliation facilitated by the HaH pharmacist	80% (53/66)	45% (20/44)
Percentage of patients who received medication education by a pharmacist at discharge	70% (46/66)	48% (21/44)
Percentage of patients who received a medication calendar from the HaH pharmacist in preparation for discharge	26% (17/66)	7% (3/44)

HaH, Hospital at Home; RJH, Royal Jubilee Hospital; VGH, Victoria General Hospital.

The most common DTP that the HaH pharmacist identified was patients requiring additional therapy (Figure 1). This occurred 94 times out of the 264 identified DTPs. For the patients who required additional therapy, the most common related medication categories were cardiovascular medications (20%), antimicrobials (18%) and antithrombotics (16%). One in every 5 instances where the pharmacist identified the need for additional therapy was classified as having major clinical significance (defined as requiring an intervention to prevent a moderate to major, or reversible, detrimental effect, or an adjustment of therapy based on accepted evidence-based guidelines).

Figure 1.

Type and number of drug therapy problems identified and documented by the HaH pharmacist over a 90-day period

Pharmacist activity in preparation for discharge

The HaH pharmacist facilitated most of the discharge medication reconciliations at VGH but fewer than half of those at RJH (Table 1). Medication education was provided to 70% of the patients discharged from VGH but only 48% of those from RJH. Approximately one-quarter of the patients at VGH received a medication calendar, whereas only 7% from RJH received one.

Patient and caregiver perceptions

All 27 patient and caregiver survey respondents agreed or strongly agreed that they received quality care from the HaH pharmacist; the pharmacist took a personal interest in them; the pharmacist was available when they needed them; they had trust and confidence in the pharmacist; they were confident the pharmacist knew enough about their health problems and that the pharmacist is a critical member of the HaH health care team (Table 2).

Table 2.

Percentage of patient and caregiver survey respondents who agreed or strongly agreed with the statements regarding the Hospital at Home (HaH) pharmacist’s clinical activities

Patient and caregiver survey respondents who agreed or strongly agreed that. . .	%
they received quality care from the pharmacist	100% (27/27)
the pharmacist took a personal interest in them	100% (27/27)
the pharmacist was available when they needed them	100% (27/27)
they had trust and confidence in the pharmacist	100% (27/27)
they were confident the pharmacist knew enough about their health problems	100% (27/27)
Pharmacists are critical members of the HaH health care team	100% (27/27)

Stakeholder perceptions

More than 90% of the 25 stakeholder survey respondents were completely satisfied by the HaH pharmacist’s ability to educate patients and caregivers about the safe and appropriate use of medications; of their availability for consultation; of their ability to liaise with other health care professionals; and of their ability to provide advice to patients about their medications and/or health conditions (Table 3). The stakeholders who responded to the survey included 13 registered nurses, 7 physicians, 3 clinical nurse leaders, 1 rehabilitation assistant and 1 program director.

Table 3.

Percentage of stakeholder survey respondents who were completely satisfied with the HaH pharmacist’s clinical activities

Stakeholder survey respondents who were completely satisfied that the HaH clinical pharmacist. . .	%
educates patients and caregivers about the safe and appropriate use of medications	92% (23/25)
monitors and reports patient’s response to drug therapy	76% (19/25)
is available for consultation	96% (24/25)
liaises with other health care professionals delivering patient care to facilitate positive health outcomes	96% (24/25)
provides advice to patients about their medications and/or health conditions	92% (23/25)
reviews therapies and makes necessary changes to help promote positive health outcomes	88% (22/25)

From 8 stakeholder interviews, 4 positive themes and 1 negative theme were found to demonstrate the impact of the HaH pharmacist. They are outlined in Table 4 with supporting quotes. The stakeholders who were interviewed included 3 registered nurses, 3 physicians, 1 clinical nurse leader and 1 program director.

Table 4.

Themes with supporting quotes from stakeholder interviews that demonstrate the impact of the Hospital at Home (HaH) pharmacist on patient care

Positive themes	n
Ensuring that medication prescribing is up-to-date, evidence-based and safe “Just this morning in our structured team rounds, medications were discussed for a particular scenario and the doctor didn't quite know what to do. The pharmacist made suggestions and the doctor was like ‘oh, right! OK yeah, we could do that.’” “I’ve had . . . recent suggestions in terms of heart failure management, where I may have suggested something, but in fact it’s probably more appropriate to prescribe something different or to do things differently so I always appreciate the advice I’ve received [from the pharmacist].”	6/8 interviews
Collaborating with others to proactively address all logistical issues involving medications “Long story short, it was our pharmacist who was able to help collaborate and pull the right people together and get the answers and figure out what the solution was so that [issue] doesn’t happen again.” “Everything from patient education to communicating with the pharmacy, submitting the prescription, following up with the pharmacy to make sure that the medication is dispensed appropriately. I would say [the pharmacists] facilitate a safer transition.”	6/8 interviews
Ensuring that medical and medication histories are accurate and comprehensive “Our pharmacists take the time to make [best possible medication history] accurately reflect [how a patient is taking their medications] so in future encounters, as inpatients, their medications are ordered the way they’re familiar with taking them at home.” “The pharmacists actually lighten my workload. For instance, getting information from the patient in terms of their medical history or their medication history or, for instance, which pharmacy they use and how they like their medications dispensed or administered.”	5/8 interviews
Ensuring all patients and/or caregivers are educated about medications “They also talk to every patient before discharge. They make medication calendars for them. They set up the transition from hospital at home to the community better than I’ve seen set up in patients being discharged [from the wards] to the community and they’re also there to answer questions from patients after they’ve been discharged.” “[The pharmacist does the] teaching and learning component that I don’t always have time to go do and nor do I have the knowledge necessarily to go all the way into that type of detail.”	5/8 interviews
Negative theme
Inconsistent coverage and challenges with a single-site pharmacist coverage model affecting the quality of care “When we don’t have one of our regular pharmacists and we have someone filling in who’s not there a lot, we do see a change in the quality of care and that’s understandable, but I wouldn’t say it’s negative. It’s just not quite as awesome as when it’s one of our regular pharmacists.” “When the other pharmacists fill in, it’s just not equivalent and I’m not sure why that is, maybe because there isn’t just one dedicated pharmacist.”	5/8 interviews

Discussion

The HaH pharmacist actively participates in activities during admission, including patient care rounds, medication reconciliation and medication education, as well as activities in preparation for discharge, including discharge medication reconciliation, medication education and medication calendars. Patients, caregivers and stakeholders resoundingly agree that the HaH pharmacist is a critical member of the HaH health care team.

Quantitative analysis

One of the most significant roles the HaH pharmacist plays is in identifying indications for medication therapy and making recommendations to initiate therapy where there is an absence. This was demonstrated through the number and type of DTPs the pharmacist identified (Figure 1). Of 264 DTPs, 36% were for instances where the pharmacist made a recommendation to initiate therapy for patients who were missing therapy. This is similar to results published by Belaiche et al. ⁷ in their observational study assessing the rates and types of drug-related problems prevented and resolved by the clinical pharmacist in a Home-Base Hospital unit in France. Those investigators reported that 24% of the identified DTPs pertained to untreated conditions requiring additional therapy. Of the patients who were missing therapy in our study, the most common related medication categories were cardiovascular, antimicrobials and antithrombotics, which is unsurprising due to the wide use of these medications for common medical conditions. In addition to identifying the medication involved in the DTP, the pharmacist classified each DTP based on its clinical significance, which ranged from no clinical significance to extreme clinical significance. When additional therapy was warranted, it was classified as having major clinical significance in 1 of every 5 instances. These findings underscore not only the quantity of DTPs the HaH pharmacist is able to identify but also the magnitude of meaningful impact to patient care in the HaH care model.

Qualitative analysis

There was high congruence between patient, caregiver and stakeholder perceptions that the HaH pharmacist positively affects patient care within the Island Health model. All patients and caregivers resoundingly agreed that the pharmacist provides quality care, is trustworthy and knowledgeable, is available when needed and is an important member of the HaH team (Table 2). It was significant to see that within a relatively short period of time after implementation, most stakeholders were completely satisfied with the clinical activities of the pharmacist, with more than 90% completely satisfied by the pharmacist’s ability to educate patients and caregivers, be available for consultation, liaise with others and provide advice to patients (Table 3). The one statement with notably less stakeholder satisfaction (while still greater than 75%) related to the pharmacist’s monitoring and reporting of patients’ responses to drug therapy, which highlights a potential area for improvement. The care team may benefit from more communication from the pharmacist on patients’ responses to drug therapy and the parameters that are being monitored to ensure medication efficacy and safety.

The quantitative and qualitative data draw focus to the importance of a consistent staffing model with respect to a dedicated pharmacist assigned to a specific HaH site to optimize care delivery. More than 50% of the stakeholders identified challenges with inconsistent coverage and a single-site pharmacist providing coverage to 2 sites. Additionally, the percentage of admission and discharge activities in which the HaH pharmacist participated was almost always lower at the site the pharmacist did not work from. This difference may be affected by the pharmacist’s inability to participate in conversations and discussions that happen outside of structured team rounds, as the pharmacist attends RJH structured team rounds by online video conferencing or by telephone; however, if the RJH team wants to speak with the pharmacist throughout the day, they need to call or text them. In contrast, since the pharmacist works onsite at VGH, they can listen to the conversations going on in the office and contribute when it is beneficial. It is evident that the care team relies on the pharmacist’s role to function properly.

A limitation of this study was the short data collection period, as this was a pharmacy residency project and had to be completed within 1 year. A second limitation is this study did not have a comparative analysis of the outcomes before and after integration of the HaH pharmacist or the interventions provided by clinical pharmacy for brick-and-mortar hospital-admitted patients. Additionally, there are inherent biases associated with the study design. These include recall bias that may have influenced the patient, caregiver and stakeholder survey and interview results. Performance bias may have also influenced the clinical activities that the pharmacists completed because they were aware of the study’s intent.

This prospective, observational mixed-methods study provides support for the integration of a dedicated clinical pharmacist in the HaH care model. This has been established and recognized by patient, caregivers and stakeholders within the first year of the program. To further support the inclusion of a clinical pharmacist in new HaH programs, a health economic analysis of the impact of the clinical pharmacist would be a beneficial next step.