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

The community pharmacist’s role is shifting from traditional medication dispensing to patient education and counselling [1]. Patient transition from hospital back to their home provides 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 during the transition is a contributing factor [2, 3]. Pharmacists are well positioned to facilitate the discharge process by performing medication reconciliation, identifying patients with poor health literacy or non-adherence, and providing tailored discharge counselling [4]. However, to establish continuity of care most efficiently and provide adequate patient support, discharge procedures should be complemented with adequate post-discharge follow-up [5]. Introducing a post-discharge community pharmacist home visit can secure continuity of care but is not usual care at the moment in the Netherlands.

Community pharmacists must adapt their communication to address the wide variety of patients’ drug-related problems during these home visits and achieve patient-centred communication. Patient-centred communication is associated with increased patients’ satisfaction, better recall of information and improved health outcomes and requires active participation of both the pharmacist and the patient [6‐8]. Patients should be encouraged to express their needs and concerns regarding their medication, which pharmacists should address to support patients in making informed decisions [9]. Little is known about the topics discussed during a post-discharge home visit and most studies investigating patient-pharmacist communication focused primarily on one-way pharmacist information provision, e.g. the extent to which pharmacists counsel patients, and their communication style, e.g. tone of voice [10, 11]. Gaining insight in the communication during these home visits could be valuable for optimizing these visits; and consequently to improve patient safety at readmission to primary care.

To assess patient-pharmacist communication during a post-discharge home visit by exploring the discussed topics as well as who—the patient or the pharmacist—initiated a specific topic.

Ethical approval was obtained from the ethics committee of the Radboud University Medical Centre Nijmegen. Local approval was obtained from the scientific committee of Zorggroep Almere (ZGA, Care Group Almere) and Flevoziekenhuis Almere. Patients gave written informed consent at inclusion and oral consent for audio recording of the consultation at the start of the home visit. All data files were coded by using unique personal identification numbers and personal details were removed from the transcripts.

In this study we showed that administration and use of medication, e.g. regimen and actual drug-taking issues, knowledge gaps regarding medication and patients’ health were discussed most frequently, followed by medication logistics and medication effectiveness. Patients’ beliefs about 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.

The most-discussed topics during the home visit consultation are in line with major challenges identified in previous studies and therefore crucial to address, e.g. patients’ lack of knowledge regarding their medication and medication regimen [3, 16]. The myriad of medication and clinical topics discussed during the home visits illustrate the rigor of the HomeCoMe protocol in identifying post-discharge drug-related problems (DRPs). The semi-structured protocol resulted in community pharmacists initiating the majority of topics. Pharmacists alternated between open-ended questions to increase patient engagement and more structured directive questions to gain information needed to identify possible DRPs. An active patient role is important as it results in greater satisfaction with the care they receive, a higher commitment to their treatment plans and a better understanding of their treatment, for instance [17, 18]. However, less-educated patients may find it difficult to ask the most relevant questions concerning their medication [19]. Furthermore, patients might not clearly express their information needs because they either assume that the pharmacist has told them everything or because they do not want to appear ignorant. Therefore, pharmacists need to empower patients in fulfilling that active role as it has been identified as a key factor to improve health outcomes [20]. On the other hand, pharmacists themselves embraced their counselling role by reinforcing hospital discharge information and elucidating possible existing or unresolved drug-related problems. Furthermore, as pharmacists were in the lead it should enable them to monitor the time spent on the home visit. The lack of dedicated time for pharmaceutical care was raised as a potential barrier for implementation in everyday community pharmacy practice, therefore monitoring time could possibly lower that barrier [21]. Other potential barriers for further implementation were the lack of a reimbursement fee, the inability of adopting the home visit into the current daily routine of the community pharmacist and inadequate skills in communication and pharmacotherapy of the community pharmacist [21].

Good communication skills are essential when providing patient-centred care to ensure patients’ understanding of their drug therapy and encourage adherence to their medication [6, 22]. Pharmacists need to be trained in applying general affective communicative strategies, listening and reflecting, and responding to uttered cues [23]. Combined with non-specific verbal behaviour techniques, such as social talk, these techniques are especially important in addressing patient concerns. They not only create a safe and inviting atmosphere between the pharmacist and patient but also encourage patients to disclose their emotions and concerns [23‐25]. Furthermore, changing the consultation dynamic may also help; from a professional “coolness” approach at the beginning of the consultation to becoming warmer and avoiding non-verbal cut-offs at the end [24]. Incorporating more open-ended questions and follow-up questions throughout the home visit could increase the flexibility of the protocol and might invite patients to express their concerns [26].

It is important to discuss patient experiences, beliefs and adherence issues pro-actively, since not all patients might express these issues themselves. In this study, patients responded mainly with their dissatisfaction regarding health care professionals to these questions. Identifying and addressing these complaints is relevant, as it might facilitate patient participation and acceptance of pharmacists’ advices [27]. Performing the home visits in the privacy of patients’ own homes presents a unique opportunity to focus on these topics, in contrast to the turbulent and less private environment of the community pharmacy [22]. Therefore, to maximize the benefit of the pharmacist home visits, pharmacists should be provided with a more extensive training program focused on how they can explore these topics and which communication techniques they can use.

An important strength of this study was its large sample size, most likely ensuring data saturation. As this is the first study that qualitatively describes the topics during a post-discharge community pharmacist home visit, the results illustrate the post-discharge consequences for patients at readmission to primary care. Another strength is the substantial number of different pharmacists that conducted the home visits. Although they had the same training in advance, they differed in work experience thus minimizing possible biases such as when only a specific research pharmacist population was included. This 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 freedom during the home visit. Therefore, mapping of the patient-pharmacist communication is possibly hampered as it expected to be substantially defined by the protocol. Furthermore, it resulted in pharmacists dominating the conversation. However, pharmacists provided room for patients to initiate those topics relevant to them in the introduction and concluding parts of the home visit. As patients mainly responded with dissatisfaction towards their health care providers, it is important to incorporate these topics within the protocol. Another possible limitation of this study was the use of audio recordings. This might have caused a behavioural change (Hawthorne effect) as the pharmacist and patient were aware that they were being recorded [28].

Community pharmacists most frequently initiated practical issues regarding the administration and use of medication, followed by knowledge gaps regarding medication and patients’ health. Although included as a separate part of the protocol, pharmacists less frequently discussed patients’ medication and health beliefs. Additionally, patients initiated topics related to dissatisfaction with received care, which is important to address as it might facilitate patient participation and acceptance of pharmacists’ advices. Providing training programs for pharmacists to improve pharmacists’ communication skills in adopting general affective communicative strategies and non-specific verbal behaviour techniques during the consultations might improve pharmacist-patient interaction. These follow-up home visits provide an opportunity for community pharmacists to collaborate with patients to reinforce hospital discharge information in a safe environment for patients.