Patient-pharmacist communication during a post-discharge pharmacist home visit
International Journal of Clinical Pharmacy
Patient‑pharmacist communication during a post‑discharge pharmacist home visit
Hendrik T. Ensing 0 1 2 4
Marcia Vervloet 0 1 2 4
Ad A. van Dooren 0 1 2 4
Marcel L. Bouvy 0 1 2 4
Ellen S. Koster 0 1 2 4
0 Zorggroep Almere , Outpatient Pharmacy “de Brug 24/7”, Hospitaalweg 1, 1315RA Almere , The Netherlands
1 Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University , Utrecht , The Netherlands
2 Research Group Process Innovations in Pharmaceutical Care, Utrecht University of Applied Sciences , Utrecht , The Netherlands
3 Hendrik T. Ensing
4 NIVEL, Netherlands Institute for Health Services Research , Utrecht , The Netherlands
Background With the shifting role of community pharmacists towards patient education and counselling, they are wellpositioned to conduct a post-discharge home visit which could prevent or solve drug-related problems. Gaining insight into the communication during these home visits could be valuable for optimizing and consequently improving patient safety at readmission to primary care. Objective To assess patient-pharmacist communication during a post-discharge home visit. Setting The homes of patients recently discharged from a single general hospital in the Netherlands. Methods Pharmacists used a semi-structured protocol to guide the consultations and audiorecorded them. Sixty audio-recordings were included for a qualitative analysis in this study with the help of NVivo version 11 software. Main outcome measure (1) Initiator and topics under discussion. (2) Frequency of discussion of topics as per coded in themes and subthemes. Results Issues regarding the administration and use of medication, e.g. regimen and actual drug-taking issues, knowledge gaps regarding their medication and patients' health were discussed most frequently, followed by medication logistics and medication effectiveness. Patients' beliefs about their 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. Conclusion Community pharmacists most frequently initiated practical issues, but explored patients' medication beliefs less adequately. Discussing these beliefs might be easier by increasing patient engagement in the consultation and providing training programs for pharmacists.
Community pharmacist; Continuity of care; Home visits; Hospital discharge; Patient-provider communication; Seamless care; The Netherlands; Transitions of care
A home visit protocol enables pharmacists to address
known major challenges during the transition from
hospital to primary care
Addressing patient’s dissatisfaction about health care
is important as it facilitates patient participation during
consultation and acceptance of pharmacists’ advices
Pharmacists should discuss patients’ medication beliefs
and adherence issues more frequently, which might be
facilitated by additional pharmacist training and
increasing patient engagement
The community pharmacist’s role is shifting from traditional
medication dispensing to patient education and counselling
]. 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
drugrelated problems (DRPs). Inadequate patient counselling
during the transition is a contributing factor [
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 . However, to establish continuity of
care most efficiently and provide adequate patient support,
discharge procedures should be complemented with adequate
post-discharge follow-up [
]. 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 [
]. Patients should
be encouraged to express their needs and concerns
regarding their medication, which pharmacists should address to
support patients in making informed decisions [
]. 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
]. 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
Aim of the study
To assess patient-pharmacist communication during a
postdischarge home visit by exploring the discussed topics as well
as who—the patient or the pharmacist—initiated a specific
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.
A qualitative observational study was conducted with
audiorecordings from community pharmacist home visits from
the Home-based Community pharmacist-led Medication
management (HomeCoMe) program that were performed
between November 2013 and December 2014 [
inhospital outpatient pharmacy acted as a discharge
coordinator and cooperated closely with all community pharmacists.
It verified patients’ administrative information, reiterated
important study information, notified the community
pharmacists of a pending discharge and transferred all
medication-related information to them.
The HomeCoMe program consisted of in-hospital
pharmacy interventions and its main component: a
post-discharge home visit by the patient’s own community
]. Pharmacists used a semi-structured protocol to
address patients’ questions and reinforce medication-related
hospital discharge information. Furthermore, pharmacists
aimed to identify and solve pending and emerging
postdischarge drug-related problems (DRPs) during the home
visits by (1) performing post-discharge medication
reconciliation, (2) assessing patients’ medication knowledge, (3)
identifying adherence barriers and (4) determining patients’
]. Deploying home visits instead of a telephone
follow-up is possibly more beneficial due to the personal
touch of face-to-face encounters [
]. Patients might feel
more comfortable at home and are therefore more likely to
share their experiences and concerns about their medication
and be more receptive to pharmacist’s counselling.
Furthermore, a home visit may elicit all relevant DRPs since all
medication is available at home enabling the assessment of
specific risk factors, such as inappropriate medication
storage conditions [
Patients were eligible if they were discharged from a single
general hospital (neurology and pulmonology wards) to their
own home, aged 18 years or over, used at least three or more
prescription drugs for chronic use at discharge, had been
hospitalized for at least 48 h and picked up their medication
in one of the participating pharmacies.
Pharmacist home visit protocol
The community pharmacists contacted the patients as soon
as possible post-discharge and aimed to visit them within
7 days. A semi-structured protocol to guide pharmacists
during the home visits was used (Table 1). Efforts were made
to develop a protocol tailored to the individual patient by:
(1) assessing patients’ perceptions on their use of
medication in general and specifically for medication started during
hospitalization and (2) incorporating open-ended example
questions, e.g. for initiating and finalizing the home visit.
These efforts aimed to help pharmacists to focus on
problems relevant to the patient [
]. All participating
community pharmacists previously attended accredited courses on
performing medication reviews, including patient
interviews. To ensure generalizability, all pharmacists received
an additional one-day training course on how to perform
the home visit and how to tailor their communication to the
needs of the individual patient. Besides plenary instructions,
the pharmacist practiced with the home visit protocol with
the help of paper patients and role-playing.
In total, 152 patients received a post-discharge home visit,
which was audio-recorded by the community pharmacists.
Incomplete recordings or recordings with very poor sound
quality were excluded. This resulted in 122 recordings
(78.9%) eligible for inclusion of which a random sample
of 60 recordings was selected for this study. No new
subthemes were identified after 30 recordings, therefore this
most likely ensured data saturation. At least one
recording from 23 of the 26 participating community
pharmacists was included. The recordings from the other three
pharmacists were incomplete. To complete data selection
a pragmatic approach was used to obtain a selection of
recordings that were equally distributed on pharmacists’
gender, patients’ gender and the presence or absence of an
informal caretaker during the home visit.
Data coding and analysis
Two research-assistants transcribed all 60 recordings
verbatim to ensure consistency. All transcripts were imported
into NVivo version 11 software to facilitate analysis.
All transcripts were coded and reviewed by a researcher
(HE) and a research assistant (LV). Discrepancies were
resolved through discussion and, if necessary, a third
researcher (MV) was consulted to reach consensus. A
thematic content analysis was used to examine main themes
]. First, the three overarching themes based on the
HomeCoMe protocol were identified: (1) ‘Medication”, (2)
“Clinical” and (3) “Other” (Table 2). Next, all subthemes
were coded inductively. After coding of the first five
transcripts these subthemes were redefined and merged where
possible into a preliminary codebook. Previously coded
transcripts were re-coded to match any changes in theme
definitions during this coding procedure. During coding
of the remaining transcripts a process of reading and
rereading, with attention to the identification of new
subthemes, eventually resulted in the final code book with
well-defined codes and descriptions (Table 2).
Additionally, the initiator of each subtheme was coded (pharmacist
or patient) as well as an illustrative quote.
All data was descriptively analysed by identifying
major themes, based on frequency of being mentioned,
and the initiator of those themes.
Medication information (e.g. indication, side effects, mechanism of action)
Medication effectiveness (e.g. perceived effect of medication)
Non-prescription medication (e.g. over-the-counter medication, vitamins)
Beliefs about medication (e.g. needs, concerns, usefulness of medication,)
Medication logistics (e.g. repeat prescription issues, stock issues)
Medication adherence (e.g. practical or perceptual adherence barriers)
Administration and use (e.g. actual drug-taking, medication regimen, multi-dose dispensing system)
Patients’ general health (e.g. existing health issues, worsened symptoms)
Hospital admission (e.g. reason for hospitalization, length of stay)
All themes unrelated to the HomeCoMe protocol (e.g. satisfaction with health care providers,
The 23 pharmacists had a mean of 17.7 ± 8.3 years of
working experience in the community pharmacy and
performed a mean of 6.5 ± 5.6 home visits. The 60
audiorecordings lasted 28.4 ± 11.4 min on average.
The mean age of the patients was 65.3 ± 13.5 years and
51.7% were females. A partner or informal carer was
present during 20 home visits (33.3%).
Patient: pharmacist communication
In total 2450 text fragments were coded (Fig. 1).
Approximately three-quarters of the topics discussed during the
home visits can be classified within the theme
“Medication”, followed by “Clinical” topics. Only a few additional
topics were classified within the “Other” theme (Fig. 1).
The five major subthemes, ranked by frequency, and
accompanying illustrative quotes are described in more
detail below, as well as less-discussed subthemes and
topics in the “Other” theme.
Administration and use
Administration and use was the largest subtheme (Fig. 1).
The majority of topics within this subtheme concerned
patients’ medication regimens which pharmacists initiated
more often than patients. Pharmacists identified possible
knowledge gaps and reinforced the information
concerning patients’ discharge medication regimens, explored and
advised on possible regimen improvements, clarified the
duration of use for temporary medication (e.g. pain
medication started at discharge) or determined patients’ daily
regimens for medication with an alternating dose schedule
Pharm5: “We’ll discuss the medication that is
discontinued during hospitalization in just a moment.” Pat10:
“Yeah, there are a lot of them!” Pharm5: “That’s right,
let’s discuss them one by one.”
Pharm19: “All right, let’s see, do you have any
questions regarding the use of your medication? Pat54: “Well,
I’m familiar with most of them, but I have some questions
about those two new inhalers.”
Patients initiated topics in this subtheme to clarify
uncertainties concerning their regimen (e.g. questions
about medication changes) and to ask for advice.
Pat20: Yes, it’s very convenient that you’re here. I was
discharged from the hospital last Wednesday and there are
two medicines I had before which I did not receive at my
discharge. Should I still take them?”
Potential drug-taking issues were explored more often
by pharmacists than patients. Pharmacists gathered
information for instance on any discomfort with taking the
medication, and consequently evaluated the relevance and
provided advice or support.
Pharm18: “Could you show me how you use your
spacer?” Pat50: “Yes, I have got this blue one. It should
not whistle, as that indicates that I am inhaling too fast.”
If patients initiated drug-taking issues, they shared
their experiences, or asked for advice to solve drug-taking
Pat15: “You’re supposed to dissolve these
[amoxicillin] in water, but well, I’ve skipped that sometimes. I did
it whenever I could though.” Pharm6: “That’s ok, you can
also take them without previously dissolving them.”
Other less frequently discussed topics concerned
packaging (e.g. opening blisters), multi-dose dispensing
systems or receiving support (e.g. from partner) in taking
n = 904
n = 135
n = 441
admission, n = 69
n = 517
n = 105
Medication adherence, n = 55
The majority of topics within the “Medication information”
subtheme concerned the indications for use. Pharmacists
explored this topic more often than patients and informed
patients about the reason for prescribing specific medication.
Pharm21: “Can you tell me why you have to take these
[diclofenac]?” Pat57: “Sure, I have to take those three times
a day. It’s an anti-inflammatory drug and a painkiller as
If patients initiated this topic they indicated to be
unaware of the reason for prescribing, mainly in cases of using
Pat32: “Is that the one to reduce my cholesterol levels?”
Pharm12: “No, these prevent your blood from clotting.”
Topics related to side effects were initiated more often
by pharmacists than patients as well. Pharmacists verified
patients’ knowledge on medication side effects, checked if
patients experienced a side effect, acknowledged the
existence of a side effect or reassured the patient.
Pharm23: “You’re using a fairly high dosage of
bisacodyl, do you experience any side effects like stomach ache or
nausea? Pat59: “No, not at all.”
Patients initiated this topic to share information about
experienced side effects.
Pat5: “If I use them, I continuously have to go to the
toilet, I really hate that!” That’s why I skipped a dosage today.
Thursday I have to take another one and it all will start
again.” Pharm2: Okay and did you experience any adverse
effects from skipping that dosage, for instance shortness of
Medication effectiveness, n = 106
Beliefs about medication, n = 61
breath or fluid retention in your legs? Pat5: “No not at all,
but my specialist warned me that I should really take them.”
Other topics within this subtheme were discussed less
frequently and concerned the mechanism of action of the
medication and any precautions (e.g. driving precautions).
Patients’ general health
Pharmacists initiated topics concerning patients’ general
health more often than patients. They queried patients using
a trigger list on possible existing health issues including
follow-up (e.g. laboratory tests or GP-visits), inquired for
worsened or improved symptoms post-discharge or provided
life-style advice (e.g. smoking cessation or exercise).
Pharm1: “You were admitted for meningitis, how are you
doing right now?” Pat2: “Reasonably.” Pharm1:”You’re
not left with any lingering symptoms?” Pat2: “Well yes, I
experience some rigorous shaking, especially during
If patients took initiative, they shared information on
experiencing a specific health issue.
Pat33: “Well, to be honest, the tumour affects my
breathing. I experience shortness of breath, but luckily I’m not in
Patients participated more actively within this subtheme,
however pharmacists initiated topics on medication logistics
still more often than patients. Pharmacists verified patients’
medication stock, elucidated and advised on storage
conditions and on obtaining repeat prescriptions and collected
discontinued or expired medication.
Pharm8: “Does it sometimes happen that you don’t have
enough medication left?” Pat22: “No, not at all! My wife
and I pay really good attention to having an adequate stock
Patients initiated these topics mainly to gather
information or to share their supply inconveniences.
Pat24: “Where and how do I get my prescription for those
pills? Should I contact the specialist or the GP?”
The last major subtheme was “Medication effectiveness”
(Fig. 1). Pharmacists initiated a topic within this subtheme
more often than patients and inquired whether patients
experienced a beneficial effect of the medication and provided
background information on specific medication, e.g. whether
or not patients could experience an effect at all.
Pharm19: “You also have to take tamsulosin, do you
experience an effect? Pat54: “I don’t know really, I have to
take a lot of different drugs, so I can’t tell if it’s beneficial.”
Patients initiated topics within this subtheme to share
their experiences with using medication and whether or
not they see a positive effect from it in treating their health
Pat49: “Like I told before, I can sense it coming. So, that
provides me with some time to get my inhaler. And it helps
a lot.” Pharm18: “Yeah?” Pat49: “Yes, it helps me getting
through it, especially on the warmer days. I really need my
inhaler in the summer.”
The less discussed subthemes were “Hospital admission”,
“Medication adherence” and “Beliefs about medication”
(Fig. 1). Pharmacists dominated the initiation of the
subtheme “Hospital admission” in which all topics concerning
patients’ recent admission were discussed, such as the
reason for admission and length of stay. Pharmacists used this
question mostly as the opening question for the home visit.
Pharm17: “Tell me, what was the matter? You were
admitted to the hospital and what happened? Why were you
admitted?” Pat47: “Well, I’ve been told that my symptoms
suggested a hernia.”
Furthermore, pharmacists asked patients which
medication they were using besides the prescribed medication.
Pharm14: “Do you use any over-the-counter drugs,
ones purchased at the chemist maybe?” Pat35: No, I would
never do that.” Pharm14: “No supplements either?” Pat35:
“No, all those extra pills, I am not up for that. I think it is
The subtheme “Medication adherence” was initiated
more often by pharmacists than by patients and involved
pharmacists asking whether patients experienced adherence
problems, for instance due to forgetfulness.
Pharm16: “Do you forget to take your medication
sometimes, a single tablet maybe?” Pat43: “No, never.”
Pharm16: “So you are familiar with your daily regimen?”
Pat43: “Yes, I prepare them all in advance.”
The subtheme patients’ “Beliefs about medication” was
initiated as often by pharmacists, e.g. to identify patients’
needs or expectations of their medication, as by patients who
shared their general attitude towards medication.
Furthermore, patients expressed specific concerns about using their
Pharm20: “Let’s see, what do you think about your
medication?” Pat55: “Yes, I do experience the benefits, I mean,
I have been taking them for a long time already and I’m
Pat12: “Well I’ve had a small hip fracture for which I took
these pills. However, I try to minimize my intake because I
worry that with prolonged use my body gets immune for it.
And it’s the only painkiller I’m allowed to take!”
“Other” themes (Fig. 1) consisted mainly of patients’
dissatisfaction with the community pharmacy (e.g. pharmacy
services or pharmacy stock), the health insurers (e.g.
reimbursement issues), the hospital (e.g. transfer of information
or waiting times) or the general practitioner (e.g. unwanted
referral to hospital).
Pat13: “You’ve always had a pharmacy delivery service,
but nowadays you’re giving me a hard time.”
Pat6: “And then there is the health insurer who mess
things up by deciding which medication I receive. Only the
Furthermore, patients shared personal information, for
instance about their grandchildren or the weather or asked
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 [
]. 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
openended 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 [
]. However, less-educated patients may find it difficult to
ask the most relevant questions concerning their medication
]. 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 [
]. 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 [
]. 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 [
Good communication skills are essential when
providing patient-centred care to ensure patients’ understanding of
their drug therapy and encourage adherence to their
]. Pharmacists need to be trained in applying
general affective communicative strategies, listening and
reflecting, and responding to uttered cues . 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
]. 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 [
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
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
]. 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 [
]. 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 [
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.
Acknowledgements The authors wish to thank Lieke Verouden (LV),
BPharm, and Yvette Weesie, B.Sc., for transcribing the audio
recordings and their work on the initial coding of themes.
Funding No external funding was received for this study.
Conflicts of interest All authors declare that they have no conflicts of
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