(1108) Barriers, Facilitators, and Recommended Strategies for Pharmacist-led Medication Management Services for Homebound Older Adults Living with Dementia

Objectives: Providing pharmacist medication management services to homebound older adults with dementia can help improve care coordination and optimize medication adherence. This study aimed to explore pharmacists’ knowledge, attitudes, and recommended strategies to initiate a pharmacist-led medication management service for homebound older adults with dementia and establish collaborative practice between community pharmacies and home health agencies.

Methods: Community pharmacists and pharmacy managers/owners in Alabama were recruited to participate in semi-structured telephone interviews. Rolling recruitment continued from January to June, 2023. Participants were recruited via a faxed study invitation using contact information obtained from the Hayes Directory. Interview questions were informed by the Consolidated Framework for Implementation Research (CFIR), including innovation, outer setting, inner setting, individual, and implementation process domains. Interviews were audio-recorded and transcribed verbatim. Multiple coders conducted rapid content analysis using an Excel template to deductively code transcripts based on CFIR domains. Coding was discussed among the investigators until consensus was reached. Patterns in coding were summarized into over-arching themes describing barriers, facilitators, and recommended strategies to implement a community pharmacist-led medication management service for homebound older adults in collaboration with home health agencies.

Results: Interviews with 12 community pharmacists were completed. Three over-arching themes emerged: 1) need to individualize the service design; 2) barriers and facilitators to service provision; and 3) collaboration strategies. Regarding service design, interviewees expressed that pharmacist medication management services should be individualized and tailored for homebound older adults with memory loss, while simultaneously addressing the needs of family caregivers. This tailoring fell into four domains: service elements, intensity, delivery mode, and frequency. For service elements, pharmacists mentioned a need to individualize the types of services provided, including medication delivery, medication refill synchronization, bubble packing, medication review, medication education, and care coordination. The intensity of services varied depending on the number of medications and changes in older adults’ status, with many interviewees mentioning the need for a comprehensive medication review at the first patient visit or following a care transition, with follow-up medication review visits when a medication is added or changed, and consultations for specific medications when requested by families or home health agencies. For mode of delivery, interviewees thought the medication management service would ideally be delivered in-person at the patient’s home, but thought that video or telephone calls may be feasible with family caregivers or home health providers. For the service frequency, pharmacists mentioned various options ranging from weekly to annually, with some suggesting more frequent weekly visits on service initiation, followed by monthly or quarterly follow-up visits depending on patient complexity. Regarding barriers and facilitators to service provision, pharmacists identified several barriers to providing a medication management service for homebound older adults with dementia. Perceived barriers included lack of a defined reimbursement model and uncertainty surrounding billing procedures, lack of a universal electronic health record, competing tasks and responsibilities in community pharmacies, lack of corporate buy-in, providers lacking awareness of pharmacist roles, and potential patient denial at early stages of dementia. Facilitators included trust and established relationships with communities, patients, nurses, and physicians. Regarding collaboration strategies, pharmacists were open to the idea of contracting with home health agencies. Pharmacists emphasized the need to clearly outline pharmacist responsibilities in collaborative contracts, establish rapport, and demonstrate pharmacist value.

Conclusions: Community pharmacists perceived that homebound older adults with dementia need an individualized medication management service. The service may be individualized in terms of service elements, intensity, delivery mode, and frequency. However, barriers exist in terms of reimbursement, technology, competing responsibilities, and attitudes. Future studies may test collaborative practice models between community pharmacists and home health agencies to help overcome identified barriers.