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sagepub.com/journals-permissionsDOI: 10.1177/17151635231200233
Implementation of the pharmacist role in Hospital at Home (HaH) was largely based on re-creating the services provided to hospital inpatients; however, we understood that there may be important differences in the clinical services that pharmacists needed to provide in order to optimize care in HaH that may be overlooked without formal investigation.
La mise en œuvre du rôle de pharmacien dans le cadre de l’hospitalisation à domicile (HAD) a été largement basée en recréant les services fournis aux patients hospitalisés; nous avons compris, cependant, qu’il pouvait y avoir des différences importantes dans les services cliniques que les pharmaciens devaient fournir pour optimiser les soins dans le cadre de l’HAD, des différences qui pourraient être négligées en l’absence d’une enquête formelle.
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 mixedmethods 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. Can Pharm J (Ott) 2023;156:324-330.
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.
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-andmortar 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:
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:
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.
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. Seventyeight patients were admitted from VGH, and 45 were admitted from RJH.
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.
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 adjust ment of therapy based on accepted evidence-based guidelines).
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).
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.
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.
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 brickand-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.
From Victoria General Hospital (Patrick, Harder) and Island Health Authority (Spina), Victoria, BC; the Faculty of Pharmaceutical Sciences (Patrick, Harder, Spina), University of British Columbia; and University of Victoria, Health Information Sciences (Spina), Victoria, BC. Contact morganpatrickrph@gmail.com
Acknowledgments: The authors would like to thank Dawn Pollon for assisting with ethics approval, Rounak Haddadi for assisting in the patient and caregiver survey, the HaH clinical pharmacists for documenting their daily activities, the patients and caregivers for responding to the survey and the stakeholders for responding to the survey and volunteering to be interviewed.
Author contributions: M. Patrick designed the project, collected the data, analyzed the data, drafted the initial manuscript, revised the manuscript and approved the final manuscript. C. Harder supervised the project and reviewed, revised and approved the final manuscript. S. Spina supervised the project and reviewed, revised and approved the final manuscript.
Disclosure of funding: No financial support was received.
Disclosure of potential conflicts of interests: No potential or known conflicts exist for any of the authors.
ORCID iD Morgan E. Patrick https://orcid.org/0000-0002-7622-4241
