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Conteúdo (article):

Visita domiciliar como uma ferramenta no cuidado farmacêutico: uma revisão de escopo
Home visit as a tool in pharmaceutical care: A scoping review
Las visitas domiciliarias como herramienta en la atención farmacéutica: una revisión de escopo

Tamires da Silva Montanhas1
https://orcid.org/0000-0002-3953-293
tamiresmontanhas@hotmail.com

Lusnara Edite Teixeira2
https://orcid.org/0000-0002-5459-3740
lusnara2011@hotmail.com

Larissa Torres Fernandes3,5
https://orcid.org/0000-0002-6404-4462
farma.larissatorresfernandes@gmail.com

Sabrina Cerqueira Santos4,5
https://orcid.org/0000-0001-6748-727X
sabrina.cerqueira@ufjf.br

Carina Carvalho Silvestre4,5
https://orcid.org/0000-0002-2162-0810
silvestre.carina@ufjf.br

Larissa de Freitas Bonomo4,5
https://orcid.org/0000-0002-1272-5717
larissafbonomo@gmail.com

1 Specialist in Family Health from the Municipal Health Department of Governador Valadares-MG, Brazil.

2 Pharmacist from the Federal University of Juiz de Fora, Governador Valadares -MG, Brazil.

3 Pharmacist and Master’s student in the Postgraduate Program in Applied Health Sciences at the Federal University of Juiz de Fora, Governador Valadares -MG, Brazil.

4 Department of Pharmacy, Life Sciences Institute, Federal University of Juiz de Fora, Governador Valadares -MG, Brazil.

5 Research Group on Interdisciplinary Studies in Pharmaceutical Care, Federal University of Juiz de Fora, Governador Valadares-MG, Brazil.

RESUMO
As visitas domiciliares (VDs) contribuem para o acesso à saúde, articulação entre os serviços e gestão em saúde. Nas VDs, o farmacêutico pode compreender a subjetividade do paciente, contribuindo para a individualização do plano de cuidado. Objetivou-se fornecer uma concepção ampliada de como as VDs são utilizadas pelos profissionais farmacêuticos para a provisão do cuidado em saúde. Essa revisão de escopo analisou estudos das bases de dados PubMed/MEDLINE, LILACS, Embase, Web of Science, Scopus, CINAHL, e literatura cinzenta. A pergunta norteadora foi “Como as visitas domiciliares são utilizadas pelo profissional farmacêutico para o cuidado em saúde?\'\'. Foram incluídos 116 estudos. Os farmacêuticos prestaram cuidados em saúde por meio de atividades e serviços farmacêuticos, de modo uniprofissional na maioria das vezes, dirigidos principalmente à população idosa. Os principais serviços e atividades realizadas foram direcionados à revisão da farmacoterapia, conciliação de medicamentos, orientações e avaliações, proporcionando altas taxas de implementação de intervenções, e aceitabilidade das recomendações. A atuação dos farmacêuticos nas VDs demonstrou impactos positivos, incluindo a otimização da farmacoterapia, redução de gastos em saúde e melhora da qualidade de vida.
Palavras-chaves: Visita domiciliar, Farmacêutico, Cuidado domiciliar à saúde.

ABSTRACT
Home visits (HVs) contribute to healthcare access, service coordination, and health management. In HVs, pharmacists can comprehend the patient’\'s subjectivity, contributing to the individualizeation of the care plan. The aim of this scoping review was to provide an expanded conception of how HVs are utilized by pharmacists for healthcare provision. This scopingThe review analyzed studies from the PubMed/MEDLINE, LILACS, Embase, Web of Science, Scopus, CINAHL databases, and grey literature. The guiding question was “"How are home visits utilized by pharmacists for healthcare?”" A total of 116 studies were included. Pharmacists provided healthcare through pharmaceutical activities and services, mostly in a uniprofessional manner, primarily directed towards the elderly older adult population. The main services and activities carried outperformed were aimed at medication review, medication reconciliation, guidance and evaluations, providing high rates of intervention implementation and acceptability of recommendations. Pharmacists’\' involvement in HVs demonstrated positive impacts, including optimizedation of pharmacotherapy, reducedtion of healthcare costs, and improvedment of quality of life.
Keywords: Home visit, Pharmacist, Home healthcare.

RESUMEN
Las visitas domiciliarias (VD) contribuyen al acceso a la asistencia sanitaria, a la coordinación entre servicios y a la gestión de la asistencia sanitaria. Durante las visitas domiciliarias, los farmacéuticos pueden comprender la subjetividad del paciente, contribuyendo a la individualización del plan de cuidados. El objetivo fue proporcionar una concepción ampliada de cómo los profesionales farmacéuticos utilizan las VD para proporcionar asistencia sanitaria. Esta revisión de escopo analizó estudios de las bases de datos PubMed/MEDLINE, LILACS, Embase, Web of Science, Scopus, CINAHL y literatura gris. La pregunta guía fue «¿Cómo utilizan los farmacéuticos las visitas domiciliarias para la asistencia sanitaria?». Se incluyeron 116 estudios. Los farmacéuticos proporcionaron asistencia sanitaria a través de actividades y servicios farmacéuticos, de forma no profesional la mayoría de las veces, dirigidos principalmente a la población anciana. Los principales servicios y actividades realizados estaban dirigidos a la revisión farmacoterapéutica, conciliación de la medicación, orientación y evaluaciones, proporcionando altas tasas de implementación de las intervenciones y aceptabilidad de las recomendaciones. El papel de los farmacéuticos en las VD mostró impactos positivos, incluyendo la optimización de la farmacoterapia, la reducción de los costes sanitarios y la mejora de la calidad de vida.
Palabras clave: Visita Domiciliaria, Farmacéutico, Servicios de Atención de Salud a Domicilio.

INTRODUCTION
Home visits (HVs) can make healthcare more accessible, enable coordination between services, serve as a management tool, and improve individuals’ functional capacity1,2,3.
In HVs, pharmacists can understand the patient’s subjective perceptions regarding the disease, pharmacotherapy, and family support network, altogether contributing to individualize care plans2. However, challenges remain in the provision of Clinical Pharmacy Services (CPS), which are related to implementing HVs in the work routine4. Furthermore, gaps in the literature can be identified regarding the impact of pharmacist performance in HVs on healthcare costs, the target population, and the practice model5.
Flanagan and Barns5 addressed this topic in a review of studies published between January 2007 and December 2017 on the outcomes associated with home-based HVs. However, some methodological aspects distinguish the work published by these authors from the scoping review presented herein. This scoping review followed the recommended guidelines for conducting a scoping review. There were no restrictions on publication period or language. The database search was comprehensive in terms of both the databases and the search strategy, and considered the terms in their various combinations.
Given the above, the objective of this scoping review was to provide a broader understanding of how HVs are used by pharmacists to provide healthcare.

METHOD
Study design
This is a scoping review guided by the JBI Manual for Evidence Synthesis6 and conducted according to PRISMA-SCR7. The protocol was registered on the Open Science Framework platform (https://osf.io/d3q4w/).
Research question
The guiding question for this review followed the PCC strategy (Population, Concept, and Context6): “How are HVs used by pharmacists for healthcare?”
The population (P) consisted of original, experimental, observational, or qualitative studies that addressed HVs performed by pharmacists, accompanied or not by other health professionals; the concept (C) was characterized by pharmaceutical HVs; and the context (C) relates to the settings of pharmacist practice where HVs are performed, such as public and private health systems, including community pharmacies, institutions, and others.
Eligibility criteria
Original, experimental, observational, or qualitative studies addressing HVs performed by pharmacists, whether or not accompanied by other healthcare professionals, were included. Reviews, commentaries, brief communications, editorials, and letters to the editor were excluded. There were no restrictions on publication date or language.
Information sources and search strategy
The search strategy used terms related to home visits, pharmacists, and activities performed by pharmacists, standardized by MeSH and DeCS (Supplementary Material). The databases used were: PubMed/MEDLINE, LILACS, Embase, Web of Science, Scopus, and CINAHL, as well as gray literature from the Digital Library of Theses and Dissertations (BDTD) and Open Access Theses and Dissertations (OATD). The search in the databases was conducted on September 18, 2022, and in the gray literature on November 3, 2022.
Study selection
The studies were independently selected by two reviewers, first by analyzing titles and abstracts on the Rayyan® platform (http://rayyan.qcri.org), and then by reading the full text. A third reviewer was contacted in both phases in case of disagreement.
Data collection
The data were collected and organized in a spreadsheet by two reviewers independently, namely: first author and year of publication; country; study design; sample size; target audience; services, activities and interventions performed by the pharmacist; place of activity; professional modality; and outcomes.
Concepts used in the review
Home visits consist of providing healthcare tailored to patients’ needs in the home8,9. CPS are a set of activities organized into a work process. The activities performed by pharmacists are the actions of the work process10. Medication-Related Problems (MRPs) are any events or circumstances involving pharmacotherapy that actually or potentially interfere with desired health outcomes11.
Outcomes have been classified as economic, clinical, and humanistic. Economic outcomes refer to decreased costs or healthcare utilization. Clinical outcomes involve improvements in patient health and reduced use of healthcare services. Humanistic outcomes relate to patient satisfaction and quality of life12. Process indicators are the qualitative and quantitative aspects that measure a pharmaceutical activity or service13.

RESULTS
A total of 2,701 studies were identified, of which 116 met the eligibility criteria and were included in this review. The flowchart of the selection process is described in Figure 1.
Figure 1

The studies were published between 1982 and 2022 and involved 23 countries. The sample size is composed of pharmacists and/or patients, which ranged from six to 22,735 participants, and the most commonly used study design was cross-sectional (n=55). The full characterization of all the included studies is presented in Table 1.
Table 1

Target audience of the studies
The target audience of the studies included individuals receiving HVs or pharmacists who administered them. The individuals receiving HVs were divided into four groups: 1) patients taking three or more medications and/or having chronic conditions. These were described in 77.0% of the studies (n=90)2–5,16–19,21,23–28,30–33,35,38,40–42,44-45,47,48,50,51,53–59,61–66,68–71,73–86,88,89,91–96,98,99,101–104,106–109,112–114,116,118-120,125,127,128. Among these, the chronic conditions were mostly diabetes (n=21; 23.3%)21,23–25,27,28,32,33,41,42,63,66,75,77–79,82,89,112,120,123 and cardiovascular conditions (n=22; 24.4%)2,18,25,27-28,31–33,41,42-48,63,66,68,75,77-78,79,81,82,84,85,108,112,123,125,127; 2) patients who were discharged and/or more likely to have a readmission after discharge were described in 20 studies (22.2%)4,16,18,21,27,35,56,59,60,65,70,71,74,91,94,95,98,106,125,126; 3) older adult patients (no further information) and/or high-risk and complex patients were reported in 11 studies (12.2%)2,28,38,47,54,55,57,62,112,115,122; 4) patients who received visits through referrals from other services and/or health professionals, or who were cited in the study as eligible for HVs were described in 6 studies (6.7%)14,15,23,34,35,90. Furthermore, the pharmacist was present as the target audience in four studies (4.4%)4,67,68,96.
Services and activities performed by pharmacists in HVs
Pharmacists performed various services and activities in the HVs, with the most cited being the medication review (n=56; 48.27%)2,17,20,21,24,25,28,30,32,35,36,39,40,41, 43,44-46,48,49,51-54,56,57,59-62,64,66-69,74-76,78,79,97,99,102-105,107,108,112,113118,119,120,122-124, identification of MRPs (n=40; 34.48%)2,4,14,15,21,34,38,47,49,50,51,52,53,55,60,66,69,70,72,75,77,78,79,81,84,86,89,91,99,103,105,106,108,110,113,117,118,119,121,124; and health guidance (n=38; 16.4%)16,17,19,20,26-29,31,37,39, 48,50,56,57,60,67-69,72,73,77,82,83,91,92,94,95,98,100,102,103,107,118,120,121,126,127. Some studies highlight that pharmacists involved in HVs have undergone training4,5,22,31,32,43,56,64,69,70,73,75,83,90,94,96,98–101,120, monitoring by experienced professionals15,19,122, had a postgraduate degree in pharmaceutical practice or clinical practice57,60,92,95,96,98 and were accredited14,19,23,24,26,32,41,46,47,49,54,56,57,66,90,102.
Professional modality
HVs performed in a uniprofessional manner were identified in 76 studies (65.5%)2,4,5,15,21–30,33,36–39,42,49–51,56,57,61,63,65,67–88,90–93,95,96,98–107,109,114,116,119–121,123,124,127,128. In HVs involving other professionals (n=40; 34.5%)14,16–20,31,32,35,36,40,41,44–48,52–55,58,59,62,64,66,89,94,97,108,110–113,115,117,118,122,125,126, the professionals most cited in the studies were doctors (n=26; 61.9%)14,17,34,35,40,43-44,46–48,52–55,62,64,66,89,94,110–113,115,117,118, followed by nurses (n=16; 38.0%)18–20,36,40,44,45,64,66,108,113,115,118,122,125,126.
Main outcomes of pharmacists’ performance in HVs
Process indicators
Process indicators were presented in 85.3% of the studies (n=99). Patients who received HVs from the pharmacist were referred by other health professionals in 11 studies14,23,34-36,45,49,85,86,90,128. The main reasons for referrals were: review of pharmacotherapy or medication reconciliation for patients with polypharmacy14,34–36,45,86,90; adherence to pharmacotherapy35,45; and pharmacotherapy management14,85.
The main MRPs cited were adherence to pharmacotherapy (n=15; 15.6%)2,14,34,39,44,55,64,69,78–80,85,86,119,127, need for health guidance and/or advice (n=9; 9.4%)14,30,35,64,69,85,113,116,127, drug interactions (n=7; 7.3%)21,34,75,85,97,105,113, duplicate and/or unnecessary medications (n=5; 5.2%)21,55,116–118, dose or frequency (n=4; 4.2%)16,30,39,65, and untreated condition and/or need for additional therapies (n=3; 3.1%)49,64,69. After identifying MRPs, pharmacists were able to issue recommendations to prescribers. The acceptability of the recommendations ranged from 48.0% to 99.0%2,15,34,36,40,43-44,48,62,69,76,77,79,95,105,111,118 and the implementation rate by prescribers ranged from 23.9% to 79.0%34,41,47,50,55,64,76,79,85,93.
Pharmacists intervened directly with the patient and/or family members during the HVs. The acceptance rates of these interventions reached 84.0%34,44,69,71,84,94. The interventions performed by pharmacists during the home visits led to a reduction in the average number of medications used by patients22,92,99,102,117, improved patient knowledge level about drug treatment and the disease24,25,27,33,56,65,102,104,117,121,124,128,130, increased adherence to drug treatment25,26,33,50,64,78,81,88,91,97,127,128,135 and reduced the number of medical consultations38,40,102,111.
Clinical outcomes
Clinical outcomes were presented in 35 studies (30.17%)18,20,22,25,26,28,29,33,35,37,38,40,43,52–54,66,81,85,88,91,92,94,95,98,100,102,114,119–121,127, and involved improvement in laboratory parameters51,81,85,120; improvement in blood pressure levels18,25,33; decrease in Body Mass Index (BMI)25 and abdominal circumference81; reduction in the number of emergency room visits26,35,58, readmissions and their risk28,29,125, hospitalization rate and probability22,35,52,53,102,127, and number of deaths58,94,95,125. Some studies show that pharmacist performance did not influence clinical outcomes20,33,37,66.
Humanistic outcomes
Humanistic outcomes were presented in 25.0%21,24,27,31,37,40,45,48,49,51,54,56,61-62,65,72,74,77,89,92,94,95,98,99,104,109,115,120,121 of the studies (n=29), evidencing high patient satisfaction levels with the HVs21,24,32,48,51,65,74,77,95,99,121 performed by pharmacists, positive influence on knowledge about medications24,27,48,56,61-62,104, benefits in quality of life66,109,120 and in disease control45.
Economic outcomes
Economic outcomes were described in 12.1%15,22,23,54,58,74,87,98-99,102,105,108,112,115 of the studies (n=14), with reductions in health service costs54,105, prescription drugs74,99,108, drug deprescription87, interventions and activities provided by pharmacists15,112.

DISCUSSION
Pharmacists provided healthcare in home visits through activities and services, primarily in a uniprofessional setting. The main services and activities performed were medication review, identification and resolution of MRPs, and health guidance, which resulted in high rates of intervention implementation and acceptance of recommendations.
Home visits are tools in CPS provision which promote autonomy and strengthen the patient-professional bond5,101, optimize medication use, improve health conditions, and provide comprehensive care through interprofessional collaboration. Thus, home visits highlight the contribution of pharmacists to the healthcare process.
The target audience of the studies was predominantly older adult patients, corroborating the findings of Flanagan & Barns5. It is known that the older adult population is more prone to polypharmacy, chronic conditions, and hospitalizations. In this context, the findings demonstrate that this population can benefit from pharmaceutical care received in their homes3,81.
Some studies in this review also indicated positive results in other populations. This demonstrates that HVs, regardless of age group, provide health improvements. However, further studies with populations of different age groups are needed to better understand health outcomes.
Pharmacists’ work in HVs depends on prior professional training. In this sense, undergraduate training can contribute to integrating pharmacists into this practice128. Furthermore, Continuing Health Education policies and partnerships between service and education are essential to qualify and transform health practices, making professionals better prepared to work in this setting129.
Pharmacists can work in a uniprofessional or multiprofessional setting in home visits. Interprofessional collaboration allows pharmacists to reduce administrative burdens by prioritizing clinical activities and services, increasing their credibility with patients, professional satisfaction, and sharing patient information when developing treatment plans62,81.
However, some factors appear to constitute barriers to interprofessional collaboration in home visits, such as lack of and/or low pay4,67,68; time73,97,121; human resources121; implementation of home visits into routine4; complexity of interventions73; and multidisciplinary coordination73. Furthermore, collaboration between physicians and pharmacists is challenging; for it to occur, professionals need to recognize each other’s practices, and the pharmacist must act as a mediator between patients and other team members to improve patients’ health, well-being, and quality of life101,112,118. The outcomes and indicators allowed us to understand the pharmacist’s performance in home visits. The process indicators demonstrated a contribution to the safety and effectiveness of pharmacotherapy; to knowledge about medications and health conditions; to the recovery of the pharmacist’s role in interprofessional practice; and to strengthening the pharmacotherapeutic bond and relationship with the patient, culminating in the promotion of care86 and improved quality of life88.
The positive results of pharmacist interventions can be enhanced by reaching prescribers, culminating in acceptability and implementing recommendations. Furthermore, ongoing strategies are needed to improve communication between professionals20,62 from a longitudinal perspective71.
Clinical outcomes have revealed the importance of pharmacists’ roles in patients’ clinical improvement. HVs result in improvements in behavior and lifestyle habits31 when they are combined with health education strategies, as pharmacists can help patients better understand their conditions through a holistic and comprehensive approach85, encouraging them to seek healthcare81,94,102.
The role of pharmacists in HVs stood out in the humanistic outcomes as more accessible healthcare providers and closer to patients’ needs31. Pharmacists can establish a therapeutic relationship with patients, encouraging them to feel comfortable presenting their problems118 and involve them in decision-making, empowering them to engage in self-care101,116. However, building a relationship of trust and partnership takes time71,116. In this sense, strategies to ensure the sustainability of services must be planned, such as billing infrastructure, designation of the pharmacist as an eligible provider, and payment for services20,118. In other words, adequate financial compensation can be a way to increase loyalty73,116.
Other strategies to optimize and improve the delivery of home healthcare include training and developing pharmacists to provide clinical services62, integrating the service into the workflow, and technological improvements73, which can result in better health outcomes and cost savings in the future62,73,116. Thus, the role of pharmacists in home healthcare reinforces the importance of valuing home care provision62.
The limitations of this review include the lack of access to some studies and in-depth analysis of interprofessional collaboration, patient/family perceptions of pharmacist performance, and protocols used in home healthcare.
Nevertheless, the potential contribution to implementing home healthcare delivered by pharmacists in healthcare settings is highlighted. Furthermore, identifying the main pharmaceutical activities and services can help managers and professionals strengthen the role of pharmacists in home healthcare. Finally, identifying barriers can enable the creation of mechanisms to avoid and/or minimize them, making home health care effective tools.

CONCLUSION
This study reveals the role of pharmacists in home visits through medication review, identification and resolution of MRPs, health guidance, and interprofessional collaboration. The various activities and services provided can achieve satisfactory process, clinical, economic, and humanistic outcomes for managers, healthcare professionals, and patients/users. However, there is a need for studies which address the use of technologies in providing CPS, the impact of cultural and organizational barriers, and the longitudinal assessment of clinical outcomes.

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