**4. Home medication review**

#### **4.1 Introduction**

#### *4.1.1 Importance of medication management at home*

Many patients are hospitalised for chronic conditions such as hypertension, diabetes, asthma, arthritis and cardiovascular diseases, especially geriatrics. As a result, they are given multiple types of medications and polypharmacy is common. There are various drug-related problems (DRPs) that can arise because of polypharmacy such as drug-drug interactions, adverse drug reactions (ADRs), medication errors and drug-food interactions, which may have a detrimental effect on medication adherence [43]. Patients may also forget to take their medications, alter the dose or frequency of their medications or discontinue their medications. Thus, inappropriate medication use among patients is a major health concern, especially among vulnerable patients such as geriatrics [44] and psychiatric patients [45]. ADRs are DRPs that are a major burden to patients, as shown by the fact it is the highest DRP found at admission [4, 5]. Therefore, to address these DRPs at home, home medication review (HMR) was first initiated in Australia [46] and followed by many other countries [45].

#### *4.1.2 Purpose and scope of home medication review*

The purpose of HMR is to assist in identifying, addressing medication-related problems and optimising medication regimens. An accredited pharmacist will conduct the medication review to help people to better understand how to manage their medicines and minimise adverse drug events [47].

#### **4.2 Understanding home medicines review**

#### *4.2.1 Definition and objectives*

HMR is a process designed to ensure that patients take their medicines correctly at home so that medications are used safely and effectively [48]. The term home medication review is also used interchangeably and has the same definition and process as HMR.

#### *4.2.2 Healthcare professionals' roles*

An HMR is intended for the patient's to gain maximum benefit from their medication regimen and prevent medication-related problems through a team approach. This is achieved by conducting a home visit by the healthcare professional team consisting of doctors, nurses and pharmacists and involving the carers.

HMR involves the pharmacist responsibility to assess the patient's adherence to their medications, identify any issues related to the patient's medication regimen and empower the patient and caregiver's knowledge of their disease. They also make recommendations on patients' treatment plans to the responsible health practitioner. This helps to increase the quality use of medicines and decrease adverse events.

Applying HMR to discharged patients is a vital tool to ensure that patients receive proper care and management of their medications during the transition of care. The continuum of quality use of medicines between hospitals and the community needs to be maintained [49]. In the formal process of continuity of care between the hospital and the community, a liaison pharmacist will organise an appointment postdischarge. He/she will contact the community pharmacist to engage an accredited pharmacist to carry out the HMR, as well as to arrange for the report to be sent to the general practitioner and the community pharmacist.

HMR applies to many types of conditions. The three most common types of HMR are HMR Neurology/Stroke, HMR Psychiatry and HMR Geriatrics. However, patients with other chronic conditions may also require the HMR service depending on the assessments made on them.

#### **4.3 The HMR process**

An accredited pharmacist HMR clinical process is categorised into three stages: [50]. Stage 1: Information gathering and review.

The HMR process begins with a referral from the doctor (hospital, GP or CP). The initial assessment will include the reason for referral and the patient's medical and medication history. The pharmacist will conduct a thorough review of the patient's medication including prescription, over-the-counter and complementary medicine.

Stage 2: Pharmacist consultation.

The pharmacist will conduct a face-to-face consultation with the patient and his/ her carer. The medications will be carefully reviewed to identify any potential issues such as drug interactions, duplications, incorrect dosages or medications that are no longer necessary. The pharmacist will assess the person's understanding of their medications, including how and when to take them, any potential side effects and the purpose of each medication.

Stage 3: HMR documentation.

This is the stage whereby the accredited pharmacist collates, generates, prepares the findings and recommends interventions. The complete report will be given to the referring doctor for his consideration to optimise prescribing, enhance patient management and optimise patient's health.

#### **4.4 Benefits and outcomes**

The value of HMR has been shown by two studies related to older adults and underserved groups. Frail and homebound community-dwelling geriatrics were observed to be using a high number of medications and experiencing a significant number of

#### *Delivery of Pharmaceutical Care at Tertiary Level: From Admission to Home Care DOI: http://dx.doi.org/10.5772/intechopen.112503*

DRPs. Recommendations to optimise medication therapy by community pharmacists can be effectively done by HMR [51]. Likewise, underserved communities in Taiwan had many issues with medications, but with pharmacists' home visits, their knowledge of diseases improved and drug-related problems were mitigated, while drug compliance and drug storage methods were improved resulting in less drug wastage [52].

The program *managing your blood pressure* was implemented in a cohort of geriatric African Americans with hypertension to reduce health disparities in blood pressure control. The percentage of patients with controlled BP increased from 46.7% to 49.5%. All other parameters, including knowledge of hypertension, medication adherence and self-monitoring of BP improved significantly from baseline to postintervention [53]. The positive effect of HMR on psychiatric patients was shown by a study in which the impact of a hospital pharmacist-led home medication review programme on 133 patients with schizophrenia. The patients showed significant improvement in medication adherence, knowledge of antipsychotic drugs and quality of life on social and family components [45].

A retrospective review of HMR cases was performed on 224 community-dwelling older people (65 years or older). Most of the pharmacists' recommended actions during the medication review process were consistent with the literature embedded in key Australian information sources. Medication management in older people is complex and challenging as the DRPs identified were 98%. In this vulnerable population, a pharmacist with appropriate training and access to the patient's medical record can assist with improving the quality of medication use [54].

HMR has become an accepted service in many countries as pharmacist-led medicines review has been shown to improve health outcomes [45, 52, 53]. However, there are limited studies that have investigated the cost-effectiveness of HMR by accredited pharmacists. Rosli et al. evaluated the cost-effectiveness of home medication review by community pharmacists and found that it is a cost-effective option that significantly reduced HbA1c levels among T2DM patients, although it was associated with higher mean total costs per participant [55]. This suggests that home medication review programs such as HMR-CP could minimise patients' health-related costs and burdens, thereby enhancing the quality of life and well-being. More economic analyses and costeffectiveness studies are needed to find evidence of the economic benefits of HMR.
