Bandoh
Collaboration Sheet'
Sheet'
Bandohetetal.；al.；Utilization
Utilizationofof'Care'CareManager-Pharmacist
Manager-Pharmacist Collaboration《 Original research 》

Utilization of 'Care Manager-Pharmacist Collaboration Sheet' in Medication
Assessment of Home-Care Patients in Tokai Village
Tsutomu Bandoh1*, Hiromi Nemoto2, Kazuo Uda3, Yumiko Maruyama4, Reiko Maeda3,
Setsuko Maruyama3, Yoshimi Itoh1, Atsushi Koizumi3, Hideki Maeda4,
Motoharu Kutsuwa3, Kouji Oosawa3, Toru Hayakawa5
Medication compliance by home-care patients and the impact of medication on patients’ activities ofdaily life (ADL) and quality of life (QOL) have not been sufficiently assessed. Interprofessional
collaboration has not developed to a sufficient level, particularly the utilization of pharmacists.
The aim of this study was to develop a system in which pharmacists' advice/feedback could be utilized
to identify and resolve issues related to patients' medication and lifestyle early on.
The subjects were sixty-four patients cared for at home (seventeen males and forty-seven females;
average age: 82.1). It was found that twelve of the sixty-four home-care patients were unable to follow
the instructions for use of medication. In addition, thirty of the sixty-four home-care patients had someunused medication in their possession, and twenty-one of the thirty wished to receive assistance from a
pharmacist. Of the twelve patients who could not follow the instructions for use of medication, eightreceived assistance from a pharmacist, and two became able to comply with the instructions afterwards.
According to care managers, thirty-three of the sixty-four home-care patients had some issues related
to medication and/or lifestyle. The pharmacists gave advice/feedback to the care managers in seventeenof the thirty-three cases with issues. In thirteen of the seventeen cases, the care managers were able togain insights from the pharmacist's advice/feedback and included them in the care plan. Furthermore,
six of the twelve care managers expressed their desire for a joint patient visit with a pharmacist, or
participation in the medication support collaboration conference. As a result of pharmacist intervention
in the disposal of unused medication, the number of and amount paid by patients for unused medication
were decreased significantly.
The results suggested that this system was productive as the care managers and the pharmacists wereable to collaborate, thereby identifying and resolving patients' issues related to medication and lifestyle.
Key words; pharmacist, care manager, community health care, home medical care
Received September 26, 2016; Accepted November 25, 2016
Hokkaido Pharmaceutical University School of Pharmacy, Pharmaceutical Community Health Care1, Ibaraki Pharmaceutical
Association2, Japan Home Care Supporting Pharmacist Liaison Meeting3, Tokai Village Welfare Department Nursing and
Welfare Division4, Hokkaido Pharmaceutical University School of Pharmacy, Pharmacotherapy5*Corresponding author:Tsutomu Bandoh, 7-Jo 15-4-1 Maeda, Teine, Sapporo, Hokkaido 006-8590, Japan
Phone +81 11-676-8700
Fax +81 11-676-8666
E mail: bandoh-t7@hokuyakudai.ac.jp

44JapanesejournalofofCommunity
Community Pharmacy
Pharmacy Vol.4,
No.2,
44-55
(2016)
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JournalVol.4,
No.2,●-●(2016)

1． Introduction

In this study, we aimed at developing a system inwhich pharmacists' advice/feedback could be

The demand for medical care for the elderly has

utilized to identify and resolve issues related toseen an upsurge as our society continues to age. Thispatients' medication and lifestyle early on.

entails,inmostcases,

some

form

of
2.

pharmacotherapy for chronic conditions. Faced

Methods

with the rapidly changing environment surrounding
medical care, community pharmacists must step out

1. Project Overview

of their conventional role and play a new and active

A system that enabled close collaboration amongrole in which they put their professional skills to use

pharmacists, care managers, and the Nursing andfor 'well-managed pharmacotherapy.'

Welfare Division, Welfare Department, Tokai

1)

In a report

Village was developed (Fig. 1).

on the promotion of team-based

medical care released by the Ministry of Health,First, patients cared for at home are identified andLabour and Welfare in March 2010, the importance

written consent is obtained after explaining theof active involvement of pharmacists, who areproject to them. A Medication Assessment

considered

medicinal

pharmacotherapy

wasexperts,in

Preliminary Check Sheet is used by care managers

emphasized

as

to

drug

recordpatients'

medication

compliance,

pharmacotherapy has become increasingly complex

medication management, and physical condition.

with the advancement of medical technology.

Afterwards, the care managers report medication-

The report also pointed out that pharmacists had

and lifestyle-related issues that require attention on

not been sufficiently involved in community-baseda Collaboration Sheet. Based on the reported

2, 3)

medical care, of which home care was a part

medication-

. On

and

lifestyle-related

issues,thethe other hand, the report showed that carepharmacists give advice/feedback and collaborate

managers were often asked questions about

with the care managers. The pharmacists holdmedication,

meetings with the care managers as necessary, andincludingquestionsregardingcollect unused medication after the survey.

instructions for use, and issues related to medication
compliance were found.
Given the above circumstances, we believe that the

2. Study Method Using Medication Assessment

establishment of a pharmacist-caremanager

Preliminary Check Sheet and Collaboration Sheetcollaboration system will contribute to 1) increasing

Separately from the Care Plan Form prepared bypharmacists' involvement in community-based

the care manager, a medication assessment sheet ishealth care, 2) increasing care managers’ knowledge

newly prepared to identify issues. The new form isof pharmacotherapy, and 3) improving patients'

called "Medication Assessment Preliminary Checkquality of life (QOL). However, there have been few

Sheet for Care Manager" (Fig. 2-1, 2-2).

reports of any form of pharmacist-care manager
collaboration systems so far.

45

Fig.1 Summary of project

BandohCollaboration Sheet'
Sheet'
Bandohetetal.；al.；Utilization
Utilizationofof'Care'CareManager-Pharmacist
Manager-Pharmacist Collaboration46

JapanesejournalofofCommunity
Community Pharmacy
Pharmacy Vol.4,
No.2,
44-55
(2016)
Japanese
JournalVol.4,
No.2,●-●(2016)

Fig.2-1 Tokai Village Project “Medication assessment preliminary check sheet for caremanager” (No.1)

47

BandohCollaboration Sheet'
Sheet'
Bandohetetal.；al.；Utilization
Utilizationofof'Care'CareManager-Pharmacist
Manager-Pharmacist Collaboration

Fig.2-2 Tokai Village Project “Medication assessment preliminary check sheet for caremanager” (No.2)

48

JapanesejournalofofCommunity
Community Pharmacy
Pharmacy Vol.4,
No.2,
44-55
(2016)
Japanese
JournalVol.4,
No.2,●-●(2016)

The care manager conducts an interview with aand the Collaboration Sheet describing thepatient cared for at home to collect data concerning

collaboration between the pharmacist and the care

the items below, and fills out the Sheet:manager, the identified issues, new understanding

1. Status of medication compliance and unusedon the part of the care manager, etc., and enters the

medication;collected data in an Excel spreadsheet for data

2. Reasons why home-care patient was unable toanalysis. If any unused medication is found, thetake medication;

description and reason for failure to use as well as

3. Presence/absence of medication- and lifestyle-

pharmacist intervention are added to the Excel

related issues as judged by the care manager.

spreadsheet for tallying and analysis. After the

If the home-care patient is deemed to have any

survey is completed, a questionnaire survey is

medication- and/or lifestyle-related issue(s), theconducted for the pharmacists and the care

care manager will write down those issues on the

managers.

Medication Assessment Preliminary Check SheetThis study was approved by the Research Ethics

and send the Sheet by facsimile to the pharmacist in

Committee of Hokkaido Pharmaceutical University

charge. The pharmacist then assesses the contents of

School of Pharmacy (No. 13-03-001).

the Sheet and uses the Collaboration Sheet to give
advice/feedback

for

the

medication-

3. Data and Statistical Analysis

and/or

The data were expressed as mean ± S.D. or mean

lifestyle-related issue(s).
If the home-care patient is found to possess unused± S.E. Statistical analyses of the data were

medication, the care manager and the pharmacist

performed using Wilcoxon’s signed-rank test.

will visit the patient together to dispose of theStatistical significance was accepted at p<0.05.

unused medication (lower part of Fig. 2-2). We
3.

named this sheet describing the collaboration

Results

between the care manager and the pharmacist the'Care Manager-Pharmacist Collaboration Sheet'.

Ten pharmacists from nine pharmacies and

The Nursing and Welfare Division of the Welfare

twelve care managers from seven organizations

Department

participated in the study (Table 1).

of

Tokai

Villagecollects

theMedication Assessment Preliminary Check Sheet
Table 1 List of organizations participating in the study
Organization to which pharmacist is affiliated

Organization to which care manager is affiliatedAIN Pharmacy

Tokai-village regional comprehensive support center

Nemoto Pharmacy

Ai Nemoto Pharmacy care plan center

Nemoto Pharmacy ( in front of Tokai-mura Hospital )Oaks Tokai

Nemoto Pharmacy Group

Tokai-village Council of Social welfere home-care support

North Pharmacy

Home-care support center Sumire

Hitachinaka Pharmacy and others

Sunflower care plan center

AIN Pharmacy Katsuta Store

Care plan Haruka

Tokai Pharmacy
Satsuki Pharmacy

49

BandohCollaboration Sheet'
Sheet'
Bandohetetal.；al.；Utilization
Utilizationofof'Care'CareManager-Pharmacist
Manager-Pharmacist Collaboration

The subjects were sixty-four patients cared for at

Overall, it was found that thirty of the sixty-four

home (seventeen males and forty-seven females).

home-care patients had some unused medication in

The average age was 82.1 ± 6.4; it was 81.7 ± 8.7

their possession, and twenty-one of the thirty

for males and 82.2 ± 5.4 for females. The number ofwished to receive assistance from a pharmacist.

underlying diseases was 3.2 ± 1.6; it was 2.5 ± 1.4

When asked about the reason why they failed to takefor males and 3.3 ± 1.6 for females (Table 2).

their medication, twelve home-care patients who
were unable to follow the instructions for use of

Table 2 Patients’ background
Male

Femalemedicationgave

twentyreasons,

includingdifficulty swallowing (one reason), refusal to be

Total

No. of patients

17 (26.6 %) 47 (73.4 %)Age81.7 ± 8.7

New

8

25

33

reasons), lack of compliance check (three reasons),

Update92231

2.5 ± 1.4

3.3 ± 1.6

3.2 ± 1.6

and others (two reasons) (Fig. 4).

No. of underlying diseases

64

medicated (six reasons), forgetfulness (eight82.2 ± 5.4 82.1 ± 6.4

Mean ± S.D.

It was found that of the sixty-four home-carepatients, forty-seven were taking their medication
as instructed and twelve were not doing so.
Medication compliance was unknown in five of the
sixty-four patients (Fig. 3A). Regarding thequestion of having any unused medication in theirpossession, of the sixty-four patients, nine answered'Yes', thirty-one answered 'No', and three answered'don’t know'. In addition, twenty-one of the sixtyfour patients responded that they would like toreceive assistance from a pharmacist with regard to

Fig. 4 Reasons for failing to take medication

the unused medication in their possession (Fig. 3B).

Of the twelve patients who were unable follow the
instructions for use of medication, eight received
assistance from a pharmacist, and two became able
to comply with the instructions (Fig. 4).
Pharmacist intervention included discontinuationof medication causing adverse effects, creation of a
medication calendar, preparation of single-dose
packets, and request for support from family
members. Medication- and/or lifestyle-related

Fig.3 Questionnaire results of medication status
and unused medicationA) Can you take your medication according to the
instructions for use?
B) Do you have any unused medication in yourpossession?

issues as determined by the care managers were
found in thirty-three of the sixty-four home-carepatients, and thirty-one of the sixty-four patients50

JapanesejournalofofCommunity
Community Pharmacy
Pharmacy Vol.4,
No.2,
44-55
(2016)
Japanese
JournalVol.4,
No.2,●-●(2016)B) Presence or absence of advice/feedback frompharmacist to care manager

were found to have no medication- or lifestylerelated issues by the care managers (Fig. 5A). The
pharmacists gave advice/feedback to the caremanagers in seventeen of the thirty-three patientswith issues (Fig. 5B). In thirteen of the seventeen
cases, the care managers were able to gain insightsfrom the pharmacists’ advice/feedback and included
them in the care plan (Fig. 6A). Moreover, six of thetwelve care managers expressed their desire for a

Fig.6 Presence or absence of care manager’s
insights and their inclusion in care plan,and desire for accompaniment bypharmacist in home-care visitA) Presence or absence of care manager’s insights
and their inclusion in care planjoint patient visit with a pharmacist or participationin the medication support collaboration conference(Fig. 6B).
As a result of pharmacist intervention in theB) Desire for accompaniment by pharmacist in
home-care visit or participation in medical
support collaboration conferences

disposal of unused medication, the amount paid forunused medication by each patient significantly
decreased from 28,818.5 ± 9,183.1 yen to 679.4 ±498.3 yen (Fig. 7). The grand total of the amount
paid for unused medication by the patients in the
study decreased from 432,276.8 yen to 10,191.0 yen,and the reduction rate was 97.6%. Similarly, thenumber of unused medication was reduced
significantly from 6.5 ± 0.9 to 0.7 ± 0.4 as a resultof pharmacist intervention in the disposal of unused

Fig.7 Changes in expenditure for unused
medication (medical expenses) before andafter pharmacist intervention(Mean±S.E. n=15)

medication (Fig. 8).

* : P＜0.05 Wilcoxon’s signed-rank test

Fig.5 Presence or absence of issues as judged bycare manager and of advice andfeedback from pharmacist
A) Presence or absence of issues related to
medication and/or lifestyle as judged bycare
manager

Fig.8 Changes in the number of unused
medication before and after pharmacist
intervention (Mean±S.E. n=15)* : P＜0.05 Wilcoxon’s signed-rank test

51

BandohCollaboration Sheet'
Sheet'
Bandohetetal.；al.；Utilization
Utilizationofof'Care'CareManager-Pharmacist
Manager-Pharmacist Collaboration

The findings of the questionnaire survey forcare managers yielded the following findings: eight

thirteen pharmacists are as follows (Table 3A):

care managers responded 'Yes' and four responded

twelve pharmacists responded 'Yes' and one'No' to the question of whether any new issues were

responded 'No' to the question of whether any

identified on the basis of the pharmacist's

medication-related issues were found throughadvice/feedback, and five care managers responded

collaboration with the care manager, and eleven'Yes' and seven responded 'No' to the question ofpharmacists responded 'Yes' and two responded 'No'

whether collaboration with the pharmacist led toto the question of whether information provided led

resolution of issues. Other survey results indicatedto the adjustment and/or decrease of unusedthat the collaboration between pharmacists and care

medication. The questionnaire survey of the twelve

managers yielded very productive outcomes.

Table 3

Questionnaire results for pharmacist and care manager(%)

A) Questionnaire results for pharmacist
Item
Medication-related issues were found through collaboration with care manager.
Information provided led to adjustment and/or decrease of unused medication.
Collaboration with care manager enabled pharmacist to give more precise advice on medication.
The importance of pharmacist intervention in medication assessment was recognized.
Cases that led to periodic monitoring were identified.
Maintenance and/or improvement of patient’s ADL was observed.
Collaboration with care manager was enhanced through the project.
B) Questionnaire results for care manager
Item
New issues were identified on the basis of pharmacist’s advice/feedback.
Collaboration with pharmacist led to resolution of issues.
Awareness of the importance of medication assessment was enhanced.
Care plan that includes monitored items was available.
Medication-related issues were found through collaboration with pharmacist.
Collaboration with pharmacist was enhanced through the project .

3.

Discussion

Yes
92.3
84.6
100
100
69.2
91.7
100

No
7.7
15.4
0
0
30.8
8.3
0

Yes
66.7
41.7
75.0
33.3
66.7
66.7

No
33.3
58.3
25.0
66.7
33.3
33.3

Therefore, in this study, we developed a system inwhich pharmacists collaborate with care managers

A report1) by a discussion group on the promotion

to identify and resolve medication- and lifestyle-of team-based health care published by the Ministry

related issues of patients.

of Health, Labour and Welfare in 2010 stated the

We found that approximately 19% of the patients

importanceinwere unable follow the instructions for use ofaremedication. This value was consistent with thatconsidered medicinal drug experts. It also reported

reported by Spector, Closson, Wagner, and others4-

that pharmacists had not been utilized sufficiently in

6)community health care, of which home care was a

had unused medication in their possession, and 70%

part2, 3).

of those patients wished to receive assistance fromofpharmacotherapy

activebyinvolvement

pharmacists,

who

52

. In addition, approximately 47% of the patientsJapanesejournalofofCommunity
Community Pharmacy
Pharmacy Vol.4,
No.2,
44-55
(2016)
Japanese
JournalVol.4,
No.2,●-●(2016)

a pharmacist. An understanding of the necessity ofand pharmacists was important. In almost 50% of

medication is crucial to medication compliance by

the cases, the pharmacists offered advice/feedback

patients. Rather than leaving the task of explaining

on the basis of the Medication Assessment

to medical doctors, pharmacists should explain

Preliminary Check Sheet for Care Manager. This

carefully according to the level of knowledge ofsuggested that the pharmacists in Tokai Village had

each patient. As the next step, understanding

a proactive attitude toward community health care.

patient's habits, listening to patient's wishes, andDuring the study, pharmacist intervention in thestreamlining medication regimen will be required.

disposal of unused medication significantly reduced

In any case, the results strongly indicate thatthe number of and amount paid by patients forpharmacists have to support patients' medication

unused medication. In the Asheville Projectcompliance. The reasons why the patients cannot

conducted in the U.S., pharmacist support forcomply with the medication regimen include

patients’ self-management contributed to thedifficulty swallowing, refusal to be medicated, andimprovement of patients’ physiological indices,forgetfulness. All of these issues may be addressed

reducing annual therapy cost per capita by moreby a pharmacist. There were twelve patients whothan 30% over a five-year period. In the said

were unable to take their medication. Eight of themproject8-10), both improvement in therapeutic effectreceived assistance from a pharmacist, including theand reduction in medical care cost were achieved;

creation of a medication calendar, repackaging of

however, prescription drug expenditure was not

medication into single-dose packets, and request for

reduced. In our study, prescription drug expenditure

support from patient’s family. As a result, two

was reduced. This difference may be due to the way

became able to take their medication.

pharmacists assisted patients, as our study has

These findings suggest that patients cared for atconfirmed that pharmacist intervention resulted inhome in the community health care setting desire

the reduction of prescription drug expenditure. It

assistance from a pharmacist, and that pharmacists

has been reported that prescription drug expenditure

can manage patients' medication by contacting them.

could be reduced by reusing unused medication11-13).

Itoh et al.7) reported that the involvement ofThose findings highlighted the urgent need forpharmacists in the inhalation therapy of COPD

specific actions by pharmacists of local pharmacies.

patients contributed to not only the appropriate use

The questionnaire survey of the care managersof medication but also improvement in pulmonary

revealed that almost 70% of the care managers werefunction of the patients. We conclude thatable to identify new issues on the basis ofpharmacists can enhance the therapeutic effects ofadvice/feedback from the pharmacists. In addition,

medication by ensuring patients' medication

75% of the care managers responded that theircompliance.

awareness of the importance of medication

From the perspective of a care manager, it wasassessment had been enhanced. The questionnaire

found that approximately half of the patients had

surveymedication-

approximately 92% of the pharmacists were able toorlifestyle-related

issues.

This

suggested that collaboration between care managers

53

of

the

pharmacists

indicatedthatBandohCollaboration Sheet'
Sheet'
Bandohetetal.；al.；Utilization
Utilizationofof'Care'CareManager-Pharmacist
Manager-Pharmacist Collaboration

5) Closson RG, Kikugawa CA, Noncomplianceobserve maintenance and/or improvement ofpatient's ADL.

Varies with Drug Class, Hospitals, 1975: 49: 89-

Pharmacist intervention in home health care

93.

resulted in improvement of medication-related ADL

6) Wagner EH, Truesdale RA Jr, Warner JT,

and QOL of patients. The close collaboration

Compliance, Treatment Practices and Bloodbetween care managers and pharmacists enabled

Pressure Control: Community and Survey

identification

Findings, J Chronic Dis, 1981: 34: 519-525.

andresolutionofpatients'

medication- and lifestyle-related issues. We believe7) Itoh Y, Bandoh T, Ikemoto Y, Murakami M, Ohno

that the results of this study would contribute

K, Murata Y, Yamaguchi S, Shimamori Y, Hatta

significantly to the enhancement of community-

M, Morita H, Nagamori K, Murakami T,

based health care.

Increased Effectiveness of Inhalation Therapy by
Pharmacist Intervention Among Patients with
Chronic Obstructive Pulmonary Disease, J Pharm

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