This study qualitatively analyzed the current situation of home healthcare from the perspective of care managers involved in home healthcare in medically underpopulated areas and evaluated the actual situation and problems faced by pharmacists in home healthcare and the required roles of pharmacists. In considering the direction of home healthcare as a concrete example of community healthcare, the quantity, quality and issues of required services will differ greatly depending on whether the target is a large city or a depopulated area. The home healthcare in large cities with large populations and sufficient medical resources has become well known as a system in which patients have a visiting pharmacist and can receive healthcare comparable to that provided in hospitals. In depopulated areas with small populations and limited medical resources, however, it is not always possible to achieve the same results as in large cities, even if by successful example of such areas is followed. In depopulated areas such as mountain villages and remote islands, the population is generally ageing and demands for medical and long-term care services are increasing, but due to a lack of personnel and resources, systems such as health and medical welfare services have not been developed [13].

Our study also reveals that underpopulated areas have limited medical and human resources. Serious problems such as financial burden on providers and the withdrawal of providers due to a decrease in the number of patients implementing home healthcare were also found. Additionally, many older adults are forced to live alone or with older caregivers, leading to reduced relationships with their families. And it was also clear that pharmacists’ visits were less frequent, as it was not easy for pharmacists to visit in the remote, underpopulated areas. This clearly shows that the characteristics of depopulated areas are widely influential (Fig. 1). A previous study reported the specific characteristics of drug treatment in patients undergoing home healthcare: visits to multiple hospitals, risk of increased leftover drugs, drug interactions and self-judged overdose, patients’ distrust of drugs, anxiety about taking drugs, awe or reticence towards physicians, and difficulty disclosing leftover drugs [14,15,16]. These characteristics appear to be similar to those of patients receiving home care in medically underpopulated areas.

Collaboration between physicians and pharmacists has been reported to be promoted in outpatient settings, and the information provided by pharmacists helps physicians make better decisions to review prescriptions, leading to more appropriate drug treatment [17]. Some cases have been reported in which pharmacists’ involvement in drug treatment and adverse drug reaction measurements was effective in multidisciplinary collaboration in the introduction of home care rehabilitation [18]. In addition, other professions expect pharmacists to demonstrate their expertise and provide consultation on the use of medical narcotics in home palliative care [19]. Therefore, pharmacists in home healthcare in medically underpopulated areas should also work with attending physicians to optimize drug treatment, including the adjustment of leftover drugs and erroneous patient medication use. Moreover, it is important for pharmacists to actively participate in pre-discharge conferences to demonstrate the need and usefulness of pharmacists in collaboration with physicians [20]. Therefore, visiting pharmacists should utilize their expertise to create a bridge of communication with physicians by checking the patient’s oral medication status and proposing a reduction in medication. Furthermore, the role of the visiting pharmacist is considered important because of the acceptance of explanations by the pharmacist for patients receiving home care [21]. Previous studies have also shown that it is important to ensure that care managers are aware of the benefits of pharmacist home visits and that care managers give users and their families a good explanation of the need for such visits [22]. To achieve this, it is considered necessary for pharmacists to actively participate in discharge conferences and service manager meetings, to communicate with care managers on a regular basis, and for pharmacists to actively conduct awareness-raising activities for care managers. It was also reported that care managers had requests for pharmacists to strengthen collaboration with physicians and to provide information on home visit management guidance [23]. In the present study, as in previous studies, there is a desire for pharmacists to visit patients at home, suggesting that there is a need to strengthen collaboration with physicians and care managers. However, a new problem related to in-hospital prescribing was identified in this study, which differs from other regions where in-hospital prescribing is rare, as there are no pharmacies in the area covered by this study and most outpatient prescriptions are in-hospital. This is assumed to be due to the typical problem of no-pharmacy towns and villages, where there is no contact point for pharmacist involvement in prescribing problems, resulting in more requests for response.

Our study examined several problems related to the management of patients’ medication at home by pharmacists involved in home care in medically underpopulated areas. Previous studies have reported that 40–60% of patients with heart failure receiving home care are nonadherent [24]. Medication discontinuation triggers exacerbation of symptoms, and adherence to medication is the key to heart failure treatment, which is relevant not only in depopulated areas but also in home healthcare in urban areas. Focusing on the differences from areas with pharmacies, in the depopulated areas studied in this study, most outpatient prescriptions are in-hospital prescriptions, and out-of-hospital prescriptions are rare. This exposes a typical prescribing problem in pharmacy-free areas, where there is no contact point for pharmacists to get involved, resulting in more requests for pharmacy pharmacists to respond. As a result, they also face the problem of insecurity in managing patient compliance with medication. Medication compliance tends to decline in home healthcare because of the difficulty in establishing a support system to ensure medication compliance among healthcare professionals [16, 25]. Therefore, it is important to explore each problem individually, while perceiving the entire living environment of each patient.

Visiting pharmacists are required to check patients’ medication status through frequent visits. Unfortunately, our study revealed that the number of visits by pharmacists in medically underserved areas was so low, such as less than once a week, that pharmacists did not provide adequate medication management. In Japan, visiting nurses, caregivers, and care managers implement medication management. More than 50% of visiting nurses involved in home care felt burdened by medication management [26]. Therefore, it was thought that the intervention of visiting pharmacists in medication management was highly significant and required. Particularly in depopulated areas, the roles required for pharmacists include managing medication and adjusting leftover drugs for older adults with dementia and those living alone, collaborating with other professionals, acting as a bridge to physicians, checking medication status through frequent visits, and adhering to oral medication instructions.

It may also be important to provide careful guidance and support for medication, including resolving questions related to specialist knowledge of medicines that cannot be addressed by other professionals. In addition, there are common aspects of the current situation regarding home healthcare, although they may differ in degree regarding the lack of manpower in pharmacies and the professionalism of pharmacy pharmacists who are not mature [27]. However, in a small community such as the one in this study, the problem of care managers’ lack of understanding of pharmacist services may be resolved, since it is possible to provide adequate information to other professions, including care managers. Similarly, the differences in response to home health care services by pharmacists, frequently reported in other studies, are unlikely to have occurred in this study because this study was conducted in a pharmacy-free area and there were fewer pharmacies and pharmacists involved. The Ministry of Health, Labour and Welfare in Japan is promoting the establishment of a comprehensive community care system by 2025 with the aim of preserving the older adult’s dignity and supporting independent living so that they can continue to live their own lives in their own familiar neighborhoods as long as possible. It is based on local autonomy and initiative, and needs to be developed in accordance with local characteristics [28]. For this purpose, our results indicate that collaboration with public authorities such as the government is necessary.

This study has some limitations. Owing to interviews with care managers in certain regions, the findings might not necessarily apply to other regions. Second, even if qualitative research is generally conducted carefully, it could not be denied that the results may contain bias due to the researcher’s subjectivity and values. Third, the results of our study, which were derived from qualitative research based on current problems and the local environment, may not directly lead to generalizable findings that require a high degree of objectivity and logic, although our results may provide suggestions for solving real-world problems. Fourth, although all of the subjects in this study had caregiver background, there may be differences in the participants’ perceptions of pharmacists and the way of collaboration with pharmacists depending on their backgrounds [4]. Particularly if the care managers have a medical background, their knowledge of the medical field and understanding of the pharmacist’s competence may facilitate effective use of the pharmacist’s expertise. Fifth, this study reviewed only the perspective of care managers and did not examine the perspectives of home nurses, visiting physicians and pharmacists who are particularly involved in home healthcare, which may need to be considered in the future. Sixth, conclusions based on involvement with a small number of pharmacies may compromise objectivity.In the future, we believe that these weaknesses could be compensated for through the development of research, including a questionnaire based on the categories and concepts extracted by our study and through a series of quantitative survey studies, making it possible to propose statistically credible and real-world solutions to the factors promoting home care by pharmacists in medically underpopulated areas. At the same time, the study only worked with pharmacists in just one care-providing facility, so facility specificity cannot be ruled out. Future studies in similar locations with fewer pharmacists need to be verified to see if similar results can be obtained.