The Importance of In-Home Care Visits

This article was written by Leah K. Wonderful, PharmD, BCGP, in-home clinical geriatric pharmacist for Tabula Rasa HealthCare (TRHC).

For more than a year, TRHC pharmacists have provided in-home medication reconciliation services for members of a health plan. The plan combines Medicare, Medicaid, and Medicare Part D into 1 plan for eligible seniors. The in-home medication reconciliation benefit is offered to members following a hospital discharge.

The in-home visit gives the pharmacist a unique perspective on the medication experience of the member. While in the home, the pharmacist meets with the member and, if applicable, the member’s caregiver. The pharmacist compares discharge information and Part D claims information to the medications present in the home. The pharmacist can assess adherence and discover discrepancies by having the member walk them through when and how they take their medications each day. Medications often forgotten at a physician visit, such as vitamins, herbal supplements, and as-needed medications, are easier for members to remember when they are on the kitchen table in front of them. It is also easy for the pharmacists to spot common medication errors, such as mixing up rescue and maintenance inhalers. Lastly, if the member has had a qualifying fracture, the pharmacists are trained to perform bone mineral density scans in the home and offer education and recommendations on osteoporosis medications.

The TRHC pharmacists use proprietary software to evaluate a member’s medications for potentially inappropriate ones. For example, many multi-drug interactions are due to competitive inhibition of cytochrome P450 enzymes that facilitate drug metabolism. Drugs with a higher affinity for an enzyme can outcompete medications with a lower affinity that are taken at the same time, affecting drug metabolism. These interactions can increase serum concentrations of medications, causing adverse drug events. This can be especially dangerous in the elderly if the medication has sedative or anticholinergic properties. Conversely, these interactions can reduce effectiveness in cases where an active metabolite provides much of the drug effect (certain opioid pain medications, such as clopidogrel).

During the visit, the pharmacist empowers the member to address these concerns with their primary care provider (PCP) by educating the member on their current medication regimen. The pharmacist provides the member with names of formulary alternatives to discuss with their PCP in the event a competitive inhibition interaction is identified. The pharmacist will also recommend changes to administration times to ameliorate an interaction if the PCP prefers to continue the medication. In addition to recommendations for alternatives to medications that can accumulate increasing risk of falls or dryness, the pharmacist may suggest medications that can be discontinued with little risk in order to decrease pill burden or suggest new medications that may improve outcomes based on data in the literature. Again, this is completed in the form of a face-to-face conversation with the member, taking into account the member’s health goals and concerns.

After formulating a plan, the pharmacist will leave behind a medication list organized by time of day (referred to as a “Refrigerator Profile”). The pharmacist will also communicate directly with the member’s PCP to resolve any discrepancies and provide recommendations that mitigate risk from preventable adverse drug events. During the second quarter of 2018, the pharmacists completed 156 in-home visits for members with a mean of 17.8 medications per profile. The pharmacists found on average 2.9 discrepancies per member.

One of the pharmacists recently visited a 68 year-old woman who had been hospitalized for pneumonia. Her daughter was the primary caregiver. Neither the patient nor the caregiver spoke English, yet all of the discharge information given to them was written in English. The discharge medication list outlined four antihypertensive medications, including an angiotensin-converting enzyme inhibitor and an angiotensin receptor blocker. Only 1 of the antihypertensives was present in the home. The discharge summary also included other medications that the family was unfamiliar with, such as gabapentin. The member had 3 inhalers due to a history of chronic obstructive pulmonary disease (COPD) and was using all 3 on an as-needed basis. Additionally, albuterol nebulizer solution had been prescribed, but the family did not have a nebulizer.

In this case, having a pharmacist in the home provided a much different picture than what providers were seeing in a clinic. Educating the family on how to properly use the inhalers and assisting them in obtaining the nebulizer could have been key to preventing an emergency room visit or a readmission for a COPD exacerbation. Reconciling the medication list to reduce confusion gave the family peace of mind and could also reduce medication errors. Having a pharmacist visit the home provides insight that a clinic visit cannot replicate and is a truly valuable service.