El volumen de los depósitos es de 4312 m 3 , considerándose algo insuficiente

MedRec in home care starts and ends with the client and according to Safer Healthcare Now (2010) it comprises four basic steps: identifying the client; creating the BPMH and identifying discrepancies; resolving and communicating discrepancies; and closing the MedRec loop. The optimal time to complete the BPMH is during the first visit of the home care clinician. The admitting clinicians must be well-trained for conducting a systematic process for obtaining the medication history from all sources possible. The admitting clinician is responsible for verifying clients’ medications with the primary care provider to account for those they have previously taken at home and any new medications added during a recent hospital stay. MedRec is an effective means to reduce medication errors and improve medication safety (Bruning, Selder 2011). During the process of obtaining the medication history of the client, the clinician identifies discrepancies and either resolves them with the client or family members or communicates the identified discrepancies to the responsible physician or pharmacist. The last step of the MedRec is pivotal, since in this step the reconciled medications must be verified by the patient or family members to ensure they have understood the changes appropriately (Safer Healthcare Now campaign 2010). Although MedRec has been recognized as an effective resolution for the problem of the communication of the medication information and prevention of the medication discrepancies, a number of hindrances have also been identified for the performance of this process. Bruning and Selder (2011) revealed three major factors hampering the accurate formation of the home care medication list; firstly, referral documents lack a clear list of the medications being taken before hospital admission and those specified at the hospital discharge. Secondly, interpretation and decipher the meaning of terms by the clinicians because of the typographical errors, problems in faxed or copied documents, and etc. Finally, the use of the prohibited abbreviations and instructions in the patient’s medication information lists (Bruning, Selder 2011). These practices are discouraged because they allow for error of interpretation.

3.2.6. Challenges

Like in other health care settings, while conducting MedRec in home care a number of challenges would be encountered, most of which are relevant to the unique environment in the home of the

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patients. As mentioned earlier, homes are places designed for living and not for providing healthcare services. Accessibility to health care professionals is much lower, and most of the tasks are carried out by the patient or the family members and caregivers who are not usually trained for provision of such services and administration of the medications. As Lang et al. (2006) emphasize, the traditional institutional patient safety perspective does not fit the home environment and that the complexity of the issues in home setting should be viewed from “different sets of glasses.” In this regard, Audette et al. (2002) studied the classification of the drug-related problems in the home care setting, and concluded that the traditional classification schemas may not be efficient and practical in the home environment and is unable to illuminate the problem correctly and resolve that (Audette et al. 2002). Therefore, client autonomy, active physical and emotional role of the family members and caregivers, knowledge deficit of the patient and family members, uncontrolled environment, intermittent access to health care professionals, inadequate preparation of the patients to participate in their post-institutional care (Coleman et al. 2005), and etc. are only a number of factors that cause the complex nature of the home care environment. Safer Healthcare Now (2010) has indicated a number of challenges for implementation of the MedRec by the home care staff agencies: work load issues and change fatigue; closing the MedRec process loop; multiple providers, specialists, physicians, pharmacists involved in the client’s care; the most responsible physician/nurse practitioner is not always easily identified; clinician engagement; and communication from one care setting to the next (Safer Healthcare Now campaign 2010). Another critical factor is the lack of data concerning the costs and consequences of such services in home care settings, which has caused limited ability of the home care managers to undertake evidence- based decisions; home care health professional and providers are limited in their ability to practice evidence-based care; and provincial and federal policy makers are limited in their ability to develop evidence-based health policy (Coyte et al. 2000).

3.3. MedsCheck

In Ontario Government profoundly believes in the role of pharmacists as part of an integrated team that provides an enhanced level of care for patients. The Transparent Drug System for Patients Act (TDSPA) passed in the Ontario Legislature in June 2006 included a landmark decision to recognize the valuable role of pharmacists by compensating them for providing professional services to Ontarians. MedsCheck as the first of these initiatives was launched by the Ministry of Health and Long-Term Care (MOHLTC), collaboratively with the Ontario Pharmacy Council (OPC) and the Ontario Pharmacists’ Association (OPA) beginning April 1st, 2007. On July 17, 2007 the program was expanded to include all Ontarians, and on November 30, 2007 the MedsCheck Follow-Up was introduced to accommodate patients who require another MedsCheck during the annual time- frame. (Ontario Ministry of Health and Long-Term Care 2010)

3.3.1. Definition

According to MOHLTC (2008) patients who are residents of Ontario, hold a valid Ontario Health Card, and are taking a minimum of three prescription medications for a chronic condition are eligible for this service. The service is intended to promote better patient health outcomes. MedsCheck annual service is a one-on-one interaction of the community pharmacist with a patient, in order to review their medications, identify and resolve any medication-related issues, educate patients about their medications and their possible side-effects, and ensure that medications are

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taken as prescribed. In another word, MedsCheck is a service provided to maximize patient compliance to the medication therapy (ibid). Patients are advised to bring their medications containers and vials and all the OTC medications they are taking to the MedsCheck review. It is pivotal to ensure that the conversation with the patient is conducted in a private area away from others, and patients should feel comfortable during the MedsCheck service, since the pharmacists will collect personal, life-style and health information from the patients (ibid).

The results of any MedsCheck, including a comprehensive medication list (Appendix D.2) and recommended action, will be shared with the patient/caregiver and, when appropriate, with their physician and/or primary healthcare provider. It is important to ensure that if the patient’s medication list is to be sent to the family physician or any other healthcare providers, be ensured to explain clearly why the report is sent to them. For example, it should be indicated whether the list is for information and record purposes only, or if it is needed that the physician addresses a specific concern. (ibid)

MedsCheck Follow-Up is referred to any additional MedsCheck reviews conducted within the one- year time-frame for patients. MedsCheck follow-ups are conducted based on the annual MedsCheck at the same pharmacy that the annual MedsCheck was provided. Otherwise, the pharmacist must take every effort to obtain the annual MedsCheck review from the originating pharmacy or the patient (ibid). MedsCheck follow-up is carried out if a patient is discharged from hospital, a pharmacist decided it is necessary, a physician or registered nurse requested for it, and a planned hospital admission is available. Therefore, the MedsCheck program is an optimal resource for accurate and up-to-date medication information at the transition of care from community to institution (Leung et al. 2010).

3.3.2. Reimbursement

Pharmacists are reimbursed for the MedsCheck service they are providing for their patients. They are paid $60 for each annual MedsCheck (which was initially $50 and was increased recently), $25 for MedsCheck follow-ups, $150 for each consultation with homebound patients, and $75 for reviewing medications for patients with diabetes (Lynas 2011). A full list of reimbursement fees are illustrated in Appendix D.1.

3.3.3. Advantages

There is a myriad of benefits identified for running the MedsCheck program. From the patients’ perspective, MedsCheck has enabled them to better understand their medication regimens, their adherence to their medication regimens has been improved, which has resulted in higher satisfaction for them. In addition to provision of a most up-to-date medication list for the patients, MedsCheck has increased patients’ familiarity with their medications, and has enhanced their participation in their own care processes (ibid).

From pharmacists’ point of view, it has improved the relation between patient and pharmacist to a great scale, has valued the pharmacists’ job through reimbursement, and consequently has increased their job satisfaction. MedsCheck has provided the opportunity to the pharmacists to better educate their patients, and obtaining a more accurate profile about their patients. A study about the initial experience of the pharmacists in Ontario reveals that the majority of pharmacists

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felt that an important benefit of providing this service was the personal satisfaction they felt (Dolovich et al. 2008). Despite the challenges, all found the experience to be very fulfilling.

From Physicians and nurses’ standpoint MedsCheck has the potential to decrease the effort needed at the admission and discharge processes of healthcare settings. MedsCheck has facilitated the MedRec by providing the most recent updated medication list, which can enormously save time from soliciting such information from different sources. Moreover, it has improved the communication between the different settings as well. While it is not possible to simply substitute a pre-admission clinic BPMH with MedsCheck, it is believed that if MedsCheck could be arranged for all eligible patients prior to pre-planned admissions for inpatient surgery, MedRec could be performed on admission and at discharge for a greater number of patients. This is because a major current workload for hospital pharmacists is to create BPMH for MedRec on admission (Leung et al. 2010).

3.3.4. Challenges

Regarding the implementation of the MedsCheck, healthcare professionals are facing a number of challenges, which should be overcome in order to obtain more number of reviews. Firstly, the patients’ unfamiliarity with the program has resulted in less interest by them to receive such a service and makes patient recruitment a time consuming process for the pharmacists (ibid). Pharmacists have to allocate more time for explaining the benefits of the MedsCheck to their patients, and convince them that the service is free for them and is paid for by the government. Secondly, conduct of the MedsCheck demands changes to the workflow and the staffing of the pharmacies. The most significant change identified is the pharmacist overlap coverage which highlights the need for an additional pharmacist to carry out dispensary while MedsCheck is being conducted for another patient (Dolovich et al. 2008). Moreover, conducting reviews outside of regular pharmacy shifts, setting appointments for reviews, changing pharmacist schedules to accommodate reviews, cleaning up a room to be used for the reviews and training technicians to prioritize prescriptions and minimize interruptions while a pharmacist is conducting a MedsCheck are other changes need to be applied.

Thirdly, time constraint is the most prominent challenge for the pharmacists to overcome (Leung et al. 2010). The interview with the patient takes about 30 minutes, depending on the number of medications, patient’s familiarity with his or her medications, and the number of discrepancies being identified during the review. Also, pre and post-discussion activities such as the time involved preparing for the discussion (i.e., printing, reviewing and cleaning up the patient profile) and for documentation and follow-up (i.e., with the patient’s physician) also significantly adds to the time commitment (Dolovich et al. 2008).

Forth, the quality of the MedsCheck reports varies in different settings. MOHLTC has allowed the pharmacies to adapt the MedsCheck template to meet their preferences, but from the MedRec point of view it is important that the report includes accurate and up-to-date information about the name, dose, route and frequency of all drugs, including over-the-counter (OTC) medications. Usually, inclusion of the OTC drugs highly varies from different pharmacies.

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Fifth, insufficient reimbursement is another challenge for the pharmacies. The amount of compensation provided is not enough to cover the cost of hiring an overlap pharmacist. Also, it is said that “there is not enough funding to support all other activities we [pharmacists] do, many of them mandated by the legislation” (Lynas 2011). Other barriers to the process identified as potential poly-pharmacy, frequent interruptions during reviews, forgetting to offer the service, documentation requirements and the lack of a private room, and patient inability to visit the pharmacy for a face-to-face appointment (Leung et al. 2010).

3.3.5. Facilitators

It is pivotal to take action in order to overcome the barriers to the MedsCheck process, and increase the provision of the service with such benefits as mentioned before. There are a number of tasks that could be done in order to increase the patients’ awareness about the MedsCheck service and its benefits, and as a result mitigate the challenge of patient recruitment. Activities such as providing an information pamphlet about the MedsCheck service into the documents distributed to patients prior to admission and after discharge from hospital (ibid). Television and radio advertisements are also valuable recruitment tools. Pre-established good relationships with patients also allow pharmacists to introduce and explain the value of the service more effectively (Dolovich et al. 2008). Regarding the workflow and staffing issues, it has been suggested to schedule MedsCheck reviews by appointment during the slower times, reduce documentation, and maximizing the use of technicians. Pharmacist overlap is a key facilitator, being indicated in one study (ibid). Also, availability of a private room, access to computer and internet during the interview are other factors that assist the carry out of the MedsCheck reviews. Although there is no requirement for the pharmacists to provide a copy of the MedsCheck review to the family physicians (Tracy 2008), increasing the physicians’ awareness (Pojskic 2011) of the program is another key facilitator in motivating the patients to receive MedsCheck more often. It would be worthwhile to submit the MedsCheck report to the patients’ family physicians, when is thought to be necessary by pharmacists. It should be noted that bombarding physicians’ offices with unrequested MedsCheck documentation (Steven 2008) will degrade the value of such reports and discourage physicians from asking such information from their patients. However, providing such information for physicians takes time and effort by the pharmacists which should be considered for more effective compensation (ibid). Advantages, challenges, and facilitators for MedsCheck are summarized in table 2 below.

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Table 2 - Advantages, challenges and facilitators for MedsCheck initiative