Karalyn Huxhagen unpicks the ways in which pharmacists should be utilised in residential aged care… with appropriate remuneration

The recent announcement of the Royal Commission into Aged Care facilities is a timely opportunity to put our best case forward as to how we can be part of the solution to the issues being experienced within this sector.

Government is currently ‘throwing’ band aid money, and while that is of short term use, pharmacy needs to become an embedded partner in aged care.

We are a peripheral contributor to services. There are many amazing pharmacists providing advanced aged care practice in Australia and there is many examples of projects and research that can be utilised to strengthen our submissions.

I have been working in aged care for my whole career – supply, quality use of medicine, audits, drug utilisation evaluations, medication advisory committees, education, competency assessments, projects – I think the only areas I have not touched are laundry and catering.

I did have one wonderful Scottish GP who performed a full audit of a facility as he felt the residents he cared for were having their cholesterol levels raised by the way the food was cooked. It was a thorough investigation with the poor DON having to prove that the vegetables and meats were cooked in an appropriate manner.

There are so many areas of aged care that are continual problems for both the facility and pharmacy and we need to provide solutions rather than problems.

So how can we help? Where do we start with our list of suggestions to improve provision of aged care? How will our suggestions be funded? Is there a role for embedded pharmacists providing clinical services to aged care facilities?

What is on your list?

Clinical handover

When a resident goes to hospital or comes home from hospital who does the clinical handover to and from the hospital pharmacist? Who ensures that the medication chart has a ‘reason for prescribing’ noted in the medication chart?

Clinical handover is important both ways. Aged care facilities document absolutely everything about a resident – toileting, bowels, food intake, falls, anxiety levels and so much more.

Does this information travel with them to hospital? Rarely. Is there a clinical handover to discuss the reason for referring the resident to the hospital, the leading up issues and the probable causes? Does the hospital pharmacist ring  the QUM/RMMR pharmacist and have a chat about the resident? Once again, rarely.

My biggest issue is that I actively work with the resident, their family and the facility to deprescribe and minimise the medication load and when the resident returns from hospital so much of that work has been undone by well-meaning medical staff.

Does the resident need their cholesterol managed by medication at 88 years of age? Maybe if they are still piloting a plane or managing a mining company but it is a rare need.

Clinical handover differs from discharge summaries. Discharge summaries are a bland , standard document that has been filled in by a junior house officer who may/may not have really touched the resident.  As we have moved to the e-form discharge summaries I find them very non-useful as the JHO has just clicked on the most appropriate response and pressed send. There is no discussion or comment.

So how does a pharmacist working in an aged care facility make this process more efficient and optimise the ongoing care of the resident?

A pharmacist located within an aged care facility could be the person who ensures that the transfer of information about the prescribed medications and reason for prescribing is transferred accurately.

The pharmacist is the person who should be the guardian of the medication chart. If the resident is discharged post MI/CABG  it is important that there is a decision made as to when to review post CABG medications. These medicines may not need to stay in place till the end of their life.

The current project that I am part of is a collaborative project that enables the nursing staff to speak to a senior medical officer about a deteriorating resident before they are sent to hospital. The aim is to minimise the number of transfers to hospital and to manage the residents in their place of residence. Some of the preliminary findings are areas to consider as issues for the Royal Commission.

Lack of training and learning for GPs placed into situations of managing residential age acre patients.

There is no ‘College of Aged Care Trainers’ . Learning is done on the run and maybe on their rotations in general practice. How to upskill and support busy GPs is an ongoing issue

Lack of competency of aged care workers.

The ongoing workforce issues in aged care has resulted in a swing to using endorsed or adjunct nursing personnel that do not have the experience level of registered nurses.

While these health providers deliver appropriate care their level of competency in areas such as clinical evaluation and medication management varies considerably. In our research we have also identified a significant issue with the level of competency and skill set of overseas trained nursing staff.

To upskill these nurses places a large impost on the aged care facilities resources.

Residents are being treated in silos.

The GP is given their resident’s issues to deal with when they go to the ACF, rarely is there a case conference of team meeting about the resident.

For example I currently have a patient with an extremely low sodium count who has had many ambulance rides as she becomes confused and very muddled. On every discharge from the hospital her low sodium count is noted as a problem but no recommendations are made to fix the issue.

The GP is told by the discharge registrar that they ceased the Mirtazapine as it would be the cause. This could be so but this resident takes a quarter of a 15mg Mirtazapine at night.

For such a low dose to affect sodium is a long shot in a dark hole in my opinion. The sodium has not improved since the Mirtazapine was ceased.

On closer investigation it was discovered (by the pharmacist) that the food intake for this resident is boiled vegetables mashed with boiled chicken. There is nil salt added nor any condiments.

This lady eats no snacks or anything else apart from this bland diet. She has four cups of tea a day and no other water intake. There is no soda water or any other beverage. She will not allow salt as her old GP told her it would raise her blood pressure.

This resident would have benefited so much from a case conference to discuss all of the issues and dispel her fears.

Pain is not considered as a contributor to other medical issues.

Pain management in aged care is an area that really flies under the radar for many residents. Aged care facilities do maintain very good pain charts but are they missing situations where pain could be the contributor to other problem?

 The GP in a very quick visit or via fax is informed that Resident X is not sleeping well, restless and disruptive. Without a comprehensive review of the resident the GP may not realise that the background to the deterioration in the resident may be related to pain.

This is not any one  person’s fault, but it is a scenario that a pharmacist working within the facility team can connect the dots for. For example, on closer examination of this resident the pharmacist may identify an increasing need for aperients as the resident’s bowels have become sluggish.

The increase in irritability, lack of tolerance to others and poor sleeping requires a comprehensive assessment before prescribing of a BZD or Quetiapine.

Constipation can lead to pain issues through the complex network of lower back to pelvic nerve systems. The discomfort alone is enough to  increase irritability. A pharmacist in the facility can connect the dots for these complex residents and be a clinical set of eyes and ears for the busy GP’s who are often working only with a snapshot in time of the resident’s health issues.

These are just a few examples of how a pharmacist embedded in aged care practice can support the health care team as well as improving the health of the residents. Pharmacists have a diversity of clinical knowledge as they are taught to be generalists but can hone their skills to practice in specific areas such as aged care.

We bring a wealth of knowledge and skills to the team that can enhance aged care practice but I refuse to sign off on any advancements that do not provide appropriate remuneration for our role.

For way too long we have provided outstanding services to aged care for a pittance or no remuneration at all. It is time to be acknowledged, utilised and remunerated as we should be. If any group within pharmacy steps up and offers to provide these advanced practices for nil remuneration than we are doomed.

If you work or touch aged care in any capacity I implore you to think long and hard about how your pharmacy practice could provide solutions to improve aged care in Australia.

Send your ideas to PSA, PGA, your local member and the facilities you service. Do not say you will provide these services for pittance. Put forward the solutions to the problems and let the arbitrators discuss the financial planning.

Karalyn Huxhagen is a community pharmacist and was 2010 Pharmaceutical Society of Australia Pharmacist of the Year. She has been named winner of the 2015 PSA Award for Quality Use of Medicines in Pain Management and is group facilitator of the Mackay Pain Support Group.