Pilot Study on the Role of Board Certified Pharmacists in Palliative Pharmacy to Enhance Pharmacist Participation in Pre-Discharge Conferences for Home-Based Palliative Care in Japan

Abstract

Background:

Ensuring a smooth transition from hospital cancer care to home palliative care remains a key challenge, while pharmacist involvement in pre-discharge conferences has traditionally been limited in Japan. We investigated whether coordination by the Board Certified Pharmacist in Palliative Pharmacy (BCPPP) could enhance the extent and quality of pharmacist participation.

Methods:

In this retrospective descriptive observational study, we examined pre-discharge conferences for patients with advanced cancer, pharmacist participation rates and level of involvement from hospital and community pharmacies, methods of medical narcotics administration, and the rates of short-term readmission from January 2018 to December 2024. The BCPPP-led coordination initiative was initiated in 2022, which comprises of identification of the patients requiring home palliative care, arranging the pre-discharge conferences, support for opioid pharmacotherapy, coaching ward pharmacists, and ensuring the continuity of pharmacotherapy after discharge. Outcomes were compared between periods before (2018–2021) and after the start of interventions by a certified pharmacist (2022–2024).

Results:

A total of 110 pre-discharge conferences were conducted. The certified pharmacist in palliative pharmacy coordinated collaboration with medical social workers. Pharmacist participation in pre-discharge conferences significantly increased after the intervention (hospital: 9.3% vs. 80.0% [p < 0.01], community pharmacies: 5.3% vs. 54.3% [p < 0.01]). The proportion of pharmacist recommendations focused on discharge planning increased from 35.7% to 73.3% (p < 0.05). The two- and four-week readmission rates did not differ significantly before and after the intervention (two-week: 13.2% vs. 3.0%; four-week: 17.6% vs. 18.2%).

Conclusions:

Coordination by a certified pharmacist in palliative pharmacy increased pharmacist participation inside and outside the hospital and promoted more proactive involvement in palliative care during pre-discharge planning. Although short-term readmission rates did not significantly change, strengthened collaboration between hospital and community pharmacies may contribute to improved continuity of palliative care during the transition to home.

Keywords

home palliative care Board Certified Pharmacist in Palliative Pharmacy pre-discharge conference opioids community pharmacy hospital-pharmacy collaborations

Background

Medical care in Japan is shifting from a “hospital-complete model” to a “community-complete model,” in which care is provided through collaboration among multiple professionals in the area of residence. According to vital statistics, it is necessary to establish a system for patients to return home based on population and aging trends, as well as estimates of the demand for care and possible future diseases. To ensure an uneventful discharge, there is a need for enhanced services, cooperation, and collaboration among various fields of medicine, insurance, welfare, and long-term care in the community.

To construct a seamless regional collaboration for cancer patients, the Nagoya Memorial Hospital established the Higashi-Nagoya Home Healthcare Roundtable with the participation of pharmacists in 2014 and developed communication tools for cooperation in palliative medicine¹ that can be shared by multiple professionals since 2015. At the same time collaboration between community and hospital pharmacies was initiated in 2014 at our institute,² mainly for patients receiving chemotherapy, and has been implemented in a bidirectional manner. Through hospital-pharmacy collaboration, outpatients with cancer attending Nagoya Memorial Hospital receive coordinated pharmacy care and monitoring for chemotherapy- and opioid-related side effects without needing to find a pharmacy or seek out this information themselves. This collaboration does not extend to hospital discharge, which is recognized as a major issue by hospital and community-based pharmacists. At discharge, medical social workers (MSWs) usually play a central role in coordinating discharge planning according to the wishes of patients and their families and serve as moderators on the day of the patients’ transition to home care.^3–6 The Japanese Society of Pharmaceutical Palliative Care and Sciences launched the Board Certified Pharmacist in Palliative Pharmacy (BCPPP) program in 2010 to foster pharmacists with advanced expertise in palliative pharmacotherapy, opioid management, and interdisciplinary palliative care.⁷ Certification requires clinical experience in palliative care, continuing professional education, case-based assessment, and formal competency evaluation. Despite increasing demand for home-based palliative care in Japan, structured pharmacist involvement in transitions from hospital to home remains limited. In Nagoya Memorial Hospital, challenges related to opioid management, symptom control, and communication between hospital and community pharmacies during discharge planning had frequently been recognized in clinical practice. Aiming at addressing these issues, a BCPPP-led coordination initiative was introduced in 2022 to facilitate pharmacist participation in pre-discharge conferences and strengthen pharmacist involvement in home-transition support. Several surveys were conducted to examine the rates of pharmacists’ participation in pre-discharge conferences.^8–10 The above rates were extremely low, and this issue has been highlighted nationwide. Therefore, the present retrospective descriptive study aimed to evaluate whether coordination led by the BCPPP could increase pharmacist participation and active involvement in pre-discharge conferences for patients with cancer requiring home-based palliative care.^11,12

Methods

Study design and setting

The single-center retrospective descriptive observational study was conducted aiming at investigating whether BCPPP-led coordination could enhance the extent and quality of pharmacist participation in pre-discharge conferences for home-based palliative care. This initiative was introduced in 2022 at Nagoya Memorial Hospital. Our institute, a regional medical care support hospital in Japan, has 416 beds equipped with an emergency room and intensive care units (six beds), approximately 50 hospitalized patients with cancer, an average length of hospital stay of approximately 11.3 days, and 25 pharmacists, including two BCPPPs. The target population of this study consisted of patients with cancer who required home-based palliative care and underwent pre-discharge conferences during the study period. We retrospectively examined electronic medical records and pre-discharge conference records to assess the number of conferences held for patients with cancer, patient age, disease name, participation rates and level of involvement from hospital and community pharmacies, methods of medical narcotics administration, and the rates of short-term readmission from January 1st, 2018, to December 31st, 2024. Outcomes were then compared between before and after the start of interventions by the BCPPP (2018–2021 vs. 2022–2024). All patients included in this study were subsequently discharged and received palliative care at home.

BCPPP initiatives

The interventions conducted by the BCPPP in the current study consisted of five structured components: (1)

identification of the patients with cancer requiring home palliative care support.

(2)

coordination of pre-discharge conferences in collaboration with medical social workers.

(3)

support for opioid pharmacotherapy, including recommendations regarding opioid selection, dosage adjustment, dosage form modification, and preparation for home administration.

(4)

coaching ward pharmacists and clarifying their expected roles before participation in pre-discharge conferences.

(5)

transfer of medication-related information to community pharmacists to ensure the continuity of pharmacotherapy after discharge.

These interventions were routinely implemented as part of discharge planning, with additional individualized support provided according to patient-specific needs.

Pharmacist involvement classification

The type and definition of pharmacist involvement were categorized as informational contributions or assessment-based clinical recommendations across five symptom-management domains; pain management, continuous infusion/patient-controlled analgesia (PCA) management, polypharmacy management and medical adherence, psychological support, and the management of other symptoms (Table 2).

Statistical analysis

Data were analyzed using descriptive statistics. The ratios of the two groups before and after the initiatives were compared using Fisher’s exact test. The averages of the two groups were compared using the Mann–Whitney U test. All statistical analyses were performed using EZR software (Saitama Medical Center, Jichi Medical University, Saitama, Japan).¹³ All p-values were two-sided, and p-values of 0.05 or less were considered statistically significant.

Ethics approval and consent to participate

This study was approved by the Ethical Review Board of Nagoya Memorial Hospital (approval number: 2025-06) and conducted in compliance with the “Ethical Guidelines for Medical and Health Research Involving Human Subjects.” Information regarding the study was disclosed on the hospital’s website, and informed consent was obtained using the opt-out method.

Results

During this period, 110 pre-discharge conferences were held for patients with advanced cancer at Nagoya Memorial Hospital. Hospital pharmacists participated in 35 cases (31.8%), and community pharmacists participated in 23 cases (20.9%).

Patient characteristics at the pre-discharge conference

The characteristics of patients with advanced cancer at the pre-discharge conference are shown in Table 1. A total of 75 pre-discharge conferences were held before the initiative (2018–2021) and 35 after the start of the BCPPP intervention (2022–2024). The sex ratio was 44 males (58.7%) and 31 females (41.3%) during the former period and 16 males (45.7%) and 19 females (54.3%) during the latter period, with no significant difference observed. During 2018–2021, colorectal cancer was the most common tumor, followed by stomach cancer, while hematopoietic and urological cancers occurred at similar frequencies. In contrast, during 2022–2024, hematopoietic cancers became the most common, followed by colorectal cancer, with pancreatic and lung cancers observed at comparable rates. Before the initiative by the BCPPP (2018–2021), there were 30 cases (40.0%) of prescribed opioids; oral oxycodone was the most common in 15 cases (20.0%), followed by fentanyl patches in 8 cases (10.6%), and no continuous infusion (CI) of medical narcotics. During the period of 2022–2024, 21 (60.0%) patients received opioids, with fentanyl patches being the most common (n = 9, 25.7%), followed by both oral and CI of oxycodone (n = 4, 11.4%).

Table 1.

Characteristics of Patients with Cancer Who Were Consulted at the Pre-Discharge Conference

Characteristic	2018–2021 (n = 75)	2022–2024 (n = 35)
Gender
Male	44 (58.7%)	16 (45.7%)
Female	31 (41.3%)	19 (54.3%)
Age
Average	75.5	76.9
Median (min–max)	77 (42–92)	77.5 (54–93)
Tumor
Colorectal	21 (28.0%)	7 (20.0%)
Stomach	15 (20.0%)	2 (5.7%)
Hematopoietic	7 (9.3%)	8 (22.8%)
Liver	6 (8.0%)	0
Urologic	7 (9.3%)	2 (5.7%)
Pancreatic	6 (8.0%)	4 (11.4%)
Lung	6 (8.0%)	4 (11.4%)
Gynecological	3 (4.0%)	3 (8.6%)
Sarcomas	2 (2.7%)	0
Breast	0	1 (2.9%)
Unknown primary	0	3 (8.6%)
Others	2 (2.7%)	1 (2.9%)
Opioids
Oxycodone (oral)	15 (20.0%)	4 (11.4%)
Hydromorphone (oral)	0	2 (5.7%)
Tapentadol (oral)	2 (2.7%)	0
Methadone (oral)	3 (4.0%)	0
Morphine (oral)	2 (2.7%)	0
Fentanyl (patch)	8 (10.6%)	9 (25.7%)
Oxycodone (continuous infusion)	0	5 (14.3%)
Fentanyl (continuous infusion)	0	1 (2.9%)
None	45 (60.0%)	14 (40.0%)
Pharmacist participation
Hospital	7 (9.3%)	28 (80.0%)
Community pharmacy	4 (5.3%)	19 (54.3%)

Participation rates of pharmacists in pre-discharge conferences

Figure 1 shows the participation rates of hospital and community pharmacists in pre-discharge conferences from 2018 to 2024. None of the hospital pharmacists attended pre-discharge conferences until 2020. Their participation increased to 7 out of 20 conferences held in our institute (35.0%) in 2021, 8 out of 12 (66.7%) in 2022, 8 out of 10 (80%) in 2023, and 12 out of 13 (92.3%) in 2024. On the other hand, the participation rate of community pharmacists remained at approximately 5% each year until 2021. After our institute started the initiative led by the BCPPP, community pharmacists attended 2 cases out of 12 (16.7%) in 2022, 8 out of 10 (80%) in 2023, and 9 out of 13 (69.2%) in 2024. Figure 2 shows the participation rates of hospital and community pharmacists in pre-discharge conferences between 2018–2021 and 2022–2024. The participation rates of each group of pharmacists significantly increased after the initiative led by the BCPPP (hospital pharmacists: 9.3% vs. 80.0%, p < 0.01; community pharmacists: 5.3% vs. 54.3%, p < 0.01).

Opioid dosage forms before and after the start of the initiative led by the BCPPP

Figure 3 shows the comparison of opioids dosage forms between the periods of 2018–2021 and 2022–2024. There were no cases in which opioids were administered in CI during the former period, whereas there were six cases (17.1%) during the latter period. There was no significant difference in the ratio of opioids prescribed orally and in patch form between the periods 2018–2021 and 2022–2024 (oral: 29.3% vs. 17.1%, p = 0.24; patch: 10.7% vs. 25.7%, p = 0.052).

Pharmacist involvement in symptom management and discharge planning

Table 2 summarizes the categories of pharmacist involvement in symptom management and discharge planning assessed during the study period, and the detailed breakdown of each category is presented in Table 3. Until 2020, pharmacist involvement was largely limited to information provision, and proactive recommendations related to discharge planning were difficult to implement. From 2021 onward, the frequency of pharmacist recommendations gradually increased.

Table 2.

Type and Definition of Pharmacist Involvement in Symptom Management and Discharge Planning

Category	Domain	Informational contributions	Assessment-based clinical recommendations
a	Pain management	Sharing pain/opioid-related information without explicit therapeutic proposal	Recommendations based on assessment, including opioid adjustment or switching
b	Continuous infusion/PCA management	Information regarding infusion devices or current settings	Recommendations for PCA initiation or optimization
c	Polypharmacy/Adherence	Information regarding medication burden or adherence	Recommendations for regimen optimization or deprescribing
d	Psychological support	Information sharing regarding psychological distress	Recommendations supporting symptom management
e	Management of other symptoms	Information regarding nausea, bowel, sleep, etc	Recommendations to optimize symptom control

Informational contributions were defined as pharmacist involvement without explicit therapeutic proposals. Assessment-based clinical recommendations were defined as assessment-driven proposals intended to influence discharge pharmacotherapy.

PCA, patient-controlled analgesia.

Table 3.

Number of Times Pharmacist Involved in Providing Information or Discharge Planning from 2018 to 2024

Year	Informational contributions					Assessment-based clinical recommendations
Year	a	b	c	d	e	a	b	c	d	e
2018	1				1
2019	2
2020	1
2021	2			2		1		2		2
2022	1				2	2	2			1
2023	1		1		2	2	1	1		1
2024				1		2	3	5		2

a: Pain management.

b: Continuous infusion/PCA management.

c: Polypharmacy/adherence.

d: Psychological support.

e: Management of other symptoms regarding nausea, bowel, sleep, etc.

PCA, patient-controlled analgesia.

After the initiation of coordination led by the BCPPP in 2022, pharmacist involvement shifted from the simple provision of drug information to active recommendations for discharge planning. Consequently, the proportion of pharmacist recommendations focused on discharge planning significantly increased from 35.7% to 73.3% (p < 0.05; Fig. 4).

Short-term readmission rates

The rates of short-term readmission were determined during the period from January 2018 to December 2024. The two- and four-week readmission rates did not differ significantly before and after the intervention by the BCPPP (two-week: 13.2% vs. 3.0%; four-week: 17.6% vs. 18.2%).

Discussion

The present retrospective observational study implicated that coordination led by the BCPPP should contribute to a marked increase in pharmacist participation in pre-discharge conferences, involving both hospital and community pharmacists. Importantly, this quantitative improvement in attendance was associated with a shift in the nature of pharmacist contributions, from passive information provision to proactive engagement in discharge planning. The primary findings of the present study were related to care processes and enhanced participation of both hospital and community pharmacists rather than direct patient-centered clinical outcomes.

Previous nationwide surveys revealed that the rates of pharmacist participation in pre-discharge conferences were consistently low in Japan.^8–10 In our hospital, community pharmacists are not routinely engaged in hospital discharge planning, which may result in the limited participation of pharmacists during the process of transitions to home care. A nationwide investigation conducted by the Japanese Ministry of Health, Labour and Welfare revealed that the most common reason provided by community pharmacists for not participating in pre-discharge conferences was “because I was not approached by the medical institution”(87.2%).⁸ The second was that they “did not have time” or that they “would coordinate with the hospital in other ways than the pre-discharge conference” (5% and 3%, respectively). Shiraishi et al. described that 83.6% of community pharmacists had never participated in pre-discharge conferences, with “no coordination with the hospital” and “no contact,” being the reasons for nonparticipation in 51.2% and 35.2%, whereas 16.4% had participated.⁹ These previous studies highlighted barriers to participation of community pharmacists in pre-discharge conferences; however, they did not either provide or implicate the measures how to eliminate such barriers and then actively transform the roles of pharmacists. We suggested that BCPPP-led coordination should remove the barriers the community pharmacists often felt and alter the quality of the functional role of pharmacists.

Community pharmacists have emphasized the importance of obtaining patient information during hospitalization to support the care after discharge in continuity.¹⁴ Pre-discharge conferences offer a valuable opportunity to share information regarding anticipated symptom progression, medication plans, and the goals of home-based palliative care with patients and their families. Participation of both hospital and community pharmacists is important for facilitating information exchange regarding medication management and symptom control during the transition to home care. The BCPPP may play a central role in facilitating communication by providing guidance, role clarification, and professional support to hospital pharmacists. The specialized training and clinical experience required for BCPPP certification may also facilitate more proactive pharmacist engagement in symptom-oriented discharge planning. The BCPPP-led initiative extended beyond arranging conferences and included facilitating participation of ward pharmacists through the coordination of their workload and role clarification. In addition, direct pharmacist-to-pharmacist communication with community pharmacies enabled exploration of feasible medication strategies for home care and fostered collaborative relationships that may not have been achieved through administrative coordination alone. Before the initiative of BCPPP, the role of pharmacists was largely limited to simple provision of information related to drugs, often dependent on requests from MSWs. In contrast, the introduction of BCPPP-led coordination increased the rates of pharmacists’ participation and induced direct communication between community and hospital pharmacists. It consequently occurred that pharmacists provided recommendations related to opioid selection, dosage forms, and preparation for home administration, reflecting a more integrated role in discharge planning. As for hospital pharmacists, their involvement facilitated more effective collaboration with community pharmacists, particularly in discussions regarding opioid dosage forms and administration devices required for home palliative care. Such discussions during pre-discharge conferences are very important for aligning pharmacotherapy with the practical constraints of home settings. In this context, the availability of PCA enables the CI of opioids and may expand feasible options for managing refractory pain at home.^15,16 These alterations required structured preparation, role clarification, and professional support in advance to pre-discharge conference, which might motivate the attendance to engage in the clinical support of the patients with intractable cancer. However, we did not perform structured symptom screening such as pain, nausea, dyspnea, psychological distress, and sleep disturbances during care transitions. No evaluation of spiritual/religious concerns, ethical and legal aspects of care, and patient- and family-reported quality perceptions was given in the current study. Considering the indicator set of hospice and palliative care quality proposed in the United States of America,¹⁷ the clinical efficacy of the BCPPP-led interventions for the above indicator sets are the future subjects.

Despite these improvements in care processes, the rates of short-term readmission did not differ significantly before and after the intervention by the BCPPP. This is due probable to the differences in characteristics between process-related outcomes and clinical endpoints. Outcomes of patients receiving palliative care are influenced by various factors, including disease trajectory, symptom burden, social circumstances, and the availability of home care resources. Some patients with advanced cancer suffer from rapid clinical deterioration, which may necessitate readmission regardless of the quality of discharge planning. Therefore, the lack of a significant reduction in readmission rates should not be interpreted as evidence against the value of pharmacist involvement but rather as a limitation of readmission rates as a sole outcome measure in this population.

This study has several limitations. First, it was conducted at a single institution, which may limit the generalizability of the findings. Second, in some cases, pre-discharge conferences could not be held due to rapid progression of basic diseases, even when preparations for home palliative care were underway. Finally, although pharmacist participation and opioid administration routes changed after the BCPPP initiative, the direct impact of these changes on patient-centered outcomes¹⁷ was not comprehensively evaluated in the present analysis. Further multicenter studies are warranted to clarify whether BCPPP-led coordination can improve clinical outcomes and quality of home-based palliative care.

Conclusions

The coordinating role of the BCPPP contributed to an increase in the participation of pharmacists, both hospital and community pharmacists, in pre-discharge conferences. Furthermore, BCPPP-led education and structured support facilitated a shift in hospital pharmacists’ roles from passive information provision to proactive involvement in discharge planning for home-based palliative care. These findings suggest that BCPPP-led coordination should strengthen hospital–community pharmacy collaboration and support a more integrated transition from hospital care to home palliative care.

Authors’ Contributions

M.K. had full access to all data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. M.K., K.I., and S.K. contributed to the study design and conceptualization. M.K., N.K., A.A., S.H., and R.H. collected the data. M.K. and K.I. were involved in data analysis and interpretation. M.K., E.K., C.T., N.Y., and Y.T. organized pre-discharge conferences and were involved in the interpretation of the findings. M.K. and S.Y. performed the statistical analysis. M.K. and K.I. drafted and revised the article. S.Y. and S.K. supervised the study. All authors critically reviewed and revised the article and approved the final version for submission.

Footnotes

Acknowledgments

The authors thank Honyaku Center Inc. for English language editing.

Consent for Publication

Participants provided consent for publication by responding to a questionnaire.

Availability of Data and Materials

All study data that support the findings of this study are available from the corresponding author, M.K., upon reasonable request.

Author Disclosure Statement

The authors declare that they have no competing interests.

Funding Information

No funding was received for this article.

Abbreviations Used

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