[At-home Palliative Care Supported by Interprofessional Work].

In preparation for the advent of a super-aged society in 2025, it is urgent to establish local comprehensive care systems appropriate to the characteristics of the area, so that people can live out their lives as they choose in their own homes. As we move toward a society in which many people are aging and dying at the same time, it is clear that pharmacists will increasingly attend home-care patients during their final days. Our pharmacy had 295 approved home-care patients over the 10 years from 2007 to 2017, of whom 64% (189) had cancer and 36% (106) had other illnesses. Many patient requests were for intravenous nourishment and pain management injections, and the period of home care for 51.7% of end-stage cancer patients was 30 d or less. In this situation, in cases where medical dependence, including at-home palliative care is high, it is essential to begin preparing an environment suited to the patient's personality, medical and nursing needs, and financial situation by asking them how they want to live their lives while they are still in hospital. In order to provide constant at-home palliative care to patients, it is critical for pharmacists to encourage interprofessional relations, including healthcare, nursing care, and welfare. We report the current situation and challenges with respect to interprofessional work and the roles of community pharmacists in a home-care setting.

[Time analysis of pharmacists' home visit duties].

Pharmacists' home visit duties include accepting prescriptions, making inquiries with the attending physician, preparing medication, giving guidance on medication, going on home visits(round trips), and handling insurance claims. In the present study, we measured the time required for each duty and determined work duration per visit. The study took place during September 2013; the sample included 116 subjects and 211 home visits were conducted. Pharmacists' mean work duration per visit was 73 min and 15 s; they spent an average of 36 min and 13 s of this period on round trips involving home visits and providing guidance on medication. Pharmacists are responsible for preparing medication for outpatients; therefore, it can be assumed that they can visit patients at their homes only during the estimated 2-h period after lunch and before the commencement of outpatient service in the evening. Therefore, it is difficult for one pharmacist to visit more than five patients a day. The number of patients that each pharmacist can visit in one week(6 working days)is estimated at 25-30.

[Challenge of providing pharmaceutical products for use in home care].

Due to a rapidly aging society, the exact nature and organization of medical services in Japan are now being reviewed. Consequently, medical services have been divided into three distinct sectors; hospitalization services, outpatient services, and at-home services. In such a situation, the basic function of pharmacies is about to change radically. In this study, I report on the challenge of providing pharmaceutical products for use in home care.

[System for dispensing medicines in home medical care-pharmacy's function as medical care facility-].

The continually increasing pace of the graying of Japan's population has brought us tremendous changes in the function of pharmacy and role of the pharmacist responsible for medical treatment for regional populations. In 1994, the then-Ministry of Health and Welfare suggested a maturity model for dispensing pharmacies, announcing that pharmacies at the 4th level of maturity should participate in the home medical care system. This participation of pharmacies in the home medical care system involved a separation of the prescribing and dispensing of drugs and clinics have been separated, and pharmacy now furnishing medicines. With the separation of prescribing and dispensing, the total number of prescriptions filled by pharmacists exceeds 700 million prescriptions, over 60%of the total number of legal prescriptions, firmly established this system in society. However, problems still remain in regard to the system for dispensing injectable medicines and responding to demand for pediatric prescriptions. This report discusses issues related to the system for furnishing medicines as the home medical care system advances.

[The discharge adjustment of cancer patient with pain - the function of pharmacy and the role of pharmacist].

Cancer is the leading cause of death in Japan. The Cancer Control Act was established in June 2006 to advance a comprehensive and systematic approach to deal with cancer, and efforts are now promoting measures in accordance with local characteristics. We, pharmacies, have seen an increase in the number of patients receiving care at home. During the year from April 2009 to March 2010, 19 out of 24 new home-care patients receiving consultations(approximately 80%)were cancer patients. Excluding 4 cases from that number, opioids were used in 15 cases. In cases not permitting oral administration, a control of acute pain was achieved with the use of suppositories or fentanyl patches. However, there were some cases presented a difficulty in controlling acute pain other than an injection, Hence, an inpatient consultation was performed by other professionals. This paper reports the adjustments involving pharmacies in those 2 cases and problems in dealing with home care treatment along with future topics.

[Functions of pharmacy as medical care provider].

With the 2006 amendment of the Medical Services Law,pharmacy dispensing of prescription drug orders was specified as medical care provider. As a result of specialization in pharmacy going forward, 60% of outpatients now use community pharmacies to fill their prescriptions. Meanwhile, pharmacy has been establishing a procedural system for insurance pharmacy operation. It also is a common practice for a pharmacist to visit home care patient under the physician's direction with the patient's consent. With pharmacy's function has been changing as well as undergoing major changes in the law, a prefectural pharmacy search system was used to carry out a study of home care-based pharmacy functions. In fact, conducting a study over the month of February 2010, we used a questionnaire survey targeting 226 pharmacies in Tokyo and three other prefectures. The questionnaire return rate was 42.6%. The results of the study showed the followings; 59 pharmacies conducted home visits, 59 pharmacies accepted payments covered by insurance, and 24 pharmacies participated with patients in joint discharge guidance. It is clear that pharmacy has broadened their functions from a filling of outpatient prescriptions to home based healthcare services.

[Pharmacies and home-care--today's status quo and problems].

As the trend towards home-care rises, the pharmacy's role in the home-care environment evolves. Now, upon discharge, the pharmacist must confer with the attending physicians and nurses, from the patient's hospital concerning medications which must be prepared for the patient's home-care, since April, 2008. Also, care insurance itself was revised in April, 2009 and patients who are in the terminal phase of their cancer or are receiving home parenteral nutrition can request helpers to visit them up to 8 times per month, like under medical insurance. However, as we look through the current situation, there are still many problems remaining which involve managing home-care and preparing medicines for outpatients, dealing with the dead stock of medicines, and insurance claims. In this issue, we report on the current situation and point out the problems pharmacies are facing with home-care, based on the real world experiences of small pharmacies.

[The role of the pharmacy as a medical facility].

As the separation of dispensary from medical practices has developed over the last 20 years, pharmacies have changed their function accordingly. Pharmacies are now actively participating in medical care, covered by insurance, by preparing medicines for out patients. Also, pharmacists play a integral role in the collaborative approach to health care of home care patients by promoting the proper use of medicines. As pharmacies became the personal pharmacy for local residents, pharmacies which dispense drugs were authorized as medical facilities from 2006. Thus, pharmacies are now facing a new era, in which their role to offer medical products is clear, and that since the collaborative approach by a multidiscipline medical group is now being promoted in local healthcare, the ability to dispense clinical judgment and the capability to cooperate with other professionals from different health care fields is required.

[Pharmacies as healthcare delivering facilities in home care].

Confronted with an aging society, saving costs by efficiently utilizing medical resources has become urgent in Japan. Therefore, due to medical treatment fee constraints, hospitals now have to focus on reducing the length of one's hospital stays resulting in patients who are heavily dependent on medical care being discharged and shifted to home care. Especially for cancer, which is the most common cause of death in Japan, the system of healthcare delivery from inpatient treatment to home palliative treatment has been dramatically improved. Against such a backdrop, this medical supply delivery role of pharmacies was clearly and newly codified into medical law in 2006, thus enabling pharmacies to fulfill their newfound responsibilities as healthcare delivering facilities 24 hours, a day, 365 days a year.

[The role of pharmacies at HPN patient discharge--attending discharge conferences].

After April, 2006, the number of cases of patients with end-stage cancer under home care has steadily increased. Since these patients require both pain control and nutritional management, pharmacists are involved in providing both medication and equipment for a fee. This time, we considered the effect of a pharmacist attending the patient discharge conference for the 10 cases which our pharmacy was involved in from December, 2006 to May, 2008. Such conferences were held in 60% of our cases, and patient conferences with the primary physician in the clinic attended were held twice. Among these, a pharmacist attended four cases. Having a pharmacist attend the conference ensures that the prescription and, medical equipment are checked and that arrangements for insurance payments are made smoothly.

[Pharmacy involvement in home-care services].

Medical care measures of Japan strongly encourage a reduction of medical costs. In such a climate, hospitals encourage inpatients to return home as early as possible, thereby reducing the number of days in their hospital stay to reduce the medical cost. Consequently, the number of patients who receive home-care services has been increasing. Meanwhile, there are many areas that need to be improved for pharmacy to adequately support such advanced home-care services. For example, when a patient switches from inpatient-care to home-care, a pharmacy staff is suddenly asked to provide drugs or to have a home visit to take care the patient. In addition to that, the pharmacy will not receive the medical treatment information of the patient from the hospital. To improve such a case, we report our discussion based on how patient information should be provided to the pharmacy.

[How to supply information to pharmacies during the inpatient transition to home care-information supply booklet required of pharmacies when collaborating on regional medical care].

Recently, medical institutions have been actively trying to reduce the number of inpatients. When inpatients make a transition to home care, the first step is to ensure that they have a homecare doctor, and that a visiting nursing station and pharmacy are available. Next, home care services must be determined once hospital care information has been obtained and the wishes of the patient and their family have been established. However, pharmacies are often only contacted the day or the day before a patient is discharged from the hospital, so they are burdened with a considerable amount of preparation. Based on the information pharmacies need, we therefore created an Information Supply Booklet that medical institutions can hand to pharmacies upon discharge of patients. The entries have been classified according to core and non-core issues for pharmacies. This type of Information Supply Booklet is needed to help patients efficiently adjust to their post-discharge environment. In the future, we would like to revise this booklet into a common national format which would incorporate the views of medical institutions.

[Connecting between hospital, clinical and pharmacy--present and future].

SUBJECT: Along with the promotion of "home medical care", an increasing number of clinics provide home medical care as part of their services or are dedicated to home medical care partly as a result of the reform of the healthcare system. This is considered to be the manifestation of the desire of patients to live their own lives and the intention of the healthcare professionals to satisfy patient needs. We examine what insurance pharmacies should and must do to provide higher-quality services to satisfy such patient needs, this time focusing on the community coordination for the purpose of providing the services which can give sense of security to patients. METHOD: Cases of HPN during the period from July 2002 to June 2003 were subdivided into those in which we were involved before and after the discharge from the hospital and those in which we were involved only after the discharge from the hospital to home medical care and comparatively studied from various perspectives. Existing coordination systems are introduced and discussed to achieve the desirable coordination systems. PRESENT AND FUTURE: In the home guidance service, some patients consult with us on the issues on which they hesitate to consult with doctors or nurses. This suggests that we can contribute to the mental care for patients and their care givers. In order to make the best use of our position, the coordination with hospitals is essential for insurance pharmacies. The degree of contribution to the improvement of QOL or the mitigation of anxiety over inexperienced issues is considered to differ depending on the preparatory period between the cases in which we were involved before and after the discharge from the hospital and those in which we were involved only after the discharge from the hospital to home medical care. The analysis of the differences in the actual cases is considered to be significant to seek for the ideal coordination.

[Connecting between hospital, clinical and pharmacy--present and future].

SUBJECT: Along with the promotion of "home medical care", an increasing number of clinics provide home medical care as part of their services or are dedicated to home medical care partly as a result of the reform of the healthcare system. This is considered to be the manifestation of the desire of patients to live their own lives and the intention of the healthcare professionals to satisfy patient needs. We examine what insurance pharmacies should and must do to provide higher-quality services to satisfy such patient needs, this time focusing on the community coordination for the purpose of providing the services which can give sense of security to patients. METHOD: Cases of HPN during the period from July 2002 to June 2003 were subdivided into those in which we were involved before and after the discharge from the hospital and those in which we were involved only after the discharge from the hospital to home medical care and comparatively studied from various perspectives. Existing coordination systems are introduced and discussed to achieve the desirable coordination systems. PRESENT AND FUTURE: In the home guidance service, some patients consult with us on the issues on which they hesitate to consult with doctors or nurses. This suggests that we can contribute to the mental care for patients and their care givers. In order to make the best use of our position, the coordination with hospitals is essential for insurance pharmacies. The degree of contribution to the improvement of QOL or the mitigation of anxiety over inexperienced issues is considered to differ depending on the preparatory period between the cases in which we were involved before and after the discharge from the hospital and those in which we were involved only after the discharge from the hospital to home medical care. The analysis of the differences in the actual cases is considered to be significant to seek for the ideal coordination.