Home visit service could reduce medicines-related harm for vulnerable adults

Providing a medicines optimisation service to frail and vulnerable people at home can reduce the risk of medicines-related harm and could prevent hospital admissions, say the authors of a report in Clinical Pharmacist (online, 8 July 2016)^[1]
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The researchers, from the Northern Devon Healthcare NHS Trust, carried out a review of the Exeter Cluster Pharmacy (ECP) service, initiated in 2006, which allows patients to be visited at home by a pharmacist or pharmacy technician.

Sara Dilks, who led the research, says: “Our ECP service focuses on predominantly housebound older adults delivering a sustainable means of reducing medication-related risks through the provision of personalised pharmaceutical care and liaison with their GP and community health and social care services.

“A pharmacy home visit service can optimise a patient’s medication, support them during times of vulnerability and crisis, and enable them to remain at home,” she adds.

Following a six-month retrospective component and a three-month prospective analysis, carried out in 2014, the team found that the service successfully reduced the risk of medicines-related harm. During the prospective portion of the study, the pharmacy team assessed patients using the National Patient Safety Agency risk matrix tool. This showed that 76% of 158 patients were at high or extreme risk of medicines-related harm, which reduced to 21% at final contact.

The team also calculated that 62 hospital admissions were potentially avoided during the retrospective phase and 32 during the prospective phase, equating to 109 prevented admissions per year.

The authors estimate overall annual cost savings of £255,504, taking into account medication costs, hospital admissions and social care costs. Offset against the costs of providing the service each year, using the equivalent of 2.8 full-time staff, savings came to around £100,000.

Dilks says that the idea of a domiciliary pharmacy service isn’t new, but implementation has been slow at both a local and national level. “The evidence from our service review fits the growing national picture, showing that pharmacists in domiciliary settings can save hospital admissions, reduce drug costs and improve patient care at home,” she says.

“It is also an immensely rewarding job role, working with a multidisciplinary health and social care team and making a difference to the lives of many delightful frail and vulnerable older adults in the process.”

The ECP model involves a referral pathway from primary and social care, after which patients are reviewed and prioritised by the pharmacist before being visited at home by either the pharmacist or pharmacy technician.

“During a home visit, information is elicited from the patient and/or their carer, about what they are actually taking. This enables full medicines reconciliation, a level 3 clinical medication review, and identification of any problems with their home medicines management,” says Dilk.

After the visit, proposed medication changes are sent to the GP. The ECP team found that 79% of changes were accepted by GPs during their evaluation, with a further 12% were accepted with modifications.

David Wright, professor of pharmacy practice at the University of East Anglia, says the research shows the need for greater pharmaceutical care in the community. But he questioned whether the need for domiciliary visits reflects a lack of integration of community pharmacists within the primary care team.

“The need for a domiciliary visit of this nature could be considered to represent failure in the care of such patients,” he says. “If community pharmacists were appropriately trained and paid to take a regular, active role in reviewing, monitoring and supporting such patients as part of the primary care team then such visits should not be required.”

Wright also notes that the HOMER trial, a randomised study published in 2005, found no benefit of home-based medication reviews for older patients^[2]
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“We need to identify the best models of care and robustly test them to demonstrate their value to the NHS. Predicting that hospitalisations would be prevented is no longer sufficient. We need to actually demonstrate this with controlled studies.”