Do pharmacists work in silos?

pharmacists in silos: pharmacist in dispensary

Excluding pharmacists when their patients are hospitalised or enter other treatment settings causes nothing but trouble, writes Karalyn Huxhagen

I recently attended the SHPA Summit in Melbourne and presented in the area of Maximising the impact of the pharmacist workforce on RMMR recommendations and outcomes are not considered in the hospital environment when ACF resident transfers to hospital.

The background for my presentation is related to the work that I do. For 30 hours a week I am a community pharmacist at Chemmart Rural View in Mackay and for the rest of the week I work as a consultant pharmacist.

In all of my roles I am dealing with patients who bump in and out of other settings, such as private and public hospitals, aged care facilities, rehabilitation care facilities, prison and domiciliary nursing to name a few.

In my consultant role I perform HMRs for pharmacies and by direct contract with GP surgeries. I have a mix of referral pathways.

When I am performing a HMR/RMMR I collate information from the patient’s community pharmacy, recent hospital admissions and the domiciliary nurses who may be caring for the person in their home.

When patients enter hospital the admission pharmacist will ask the community pharmacy for a recent dispensing history.

When I take these calls in the pharmacy we often have a brief chat about my knowledge of the patient in the community setting: so for example, Michael has been doctor shopping and currently takes 8 x Seroquel 300mg per day according to his mother, even though the mental health team have him on a dose of 3 x 300mg per night.

We discuss pertinent information that may assist to fill in the gaps for the admission process.

When I work in aged care and the resident is transferred to hospital the current medication chart and a brief medical history is sent with the resident. The admitting pharmacist may contact the aged care facility and the admitting GP to try and compile a background for the admission.

What does not happen is that no one makes contact with the pharmacist who has been performing medication reviews on these patients/residents.

When I put this thought to the group at the summit there was a collective sigh of “we have never really thought of that”.

But this would not be hard to do. Each aged facility has a contract with a single pharmacist to perform their medication reviews. In the community there is a defined list of HMR pharmacists performing this work.

As a medication review pharmacist I spend a lot of time looking at areas such as deprescribing, escalation of risk and trying to optimise the patient’s medication.

Depending on where the patient is in their continuum of life pathway, I may have worked with the GP and facility staff to minimise medication to manage the patient as palliative or they could be being managed in a closed environment with minimal medication due to their other risk factors such as falls, failing to eat, failing to swallow.

At times these patients/residents return from hospital and have been placed on many medications that we had previously removed. For example a bedridden non-ambulatory patient in a dementia unit had all of his antipsychotics and Parkinson’s medications removed in the facility and had been eating and drinking better, his behaviour had improved and he was now interacting with the nursing staff.

He was admitted to hospital as he developed pneumonia and needed intensive care. On his return from the hospital he had been put back on the Parkinson’s medication and antipsychotics and a sleeping tablet.

He once again failed to eat, spat his tablets at the nurses and refused to interact with nursing staff and family.

We were back to square one.

No one at the hospital asked the medication review pharmacist, nursing staff or the family why these medications had been removed. There was a silo of care delivered. He may have been hard to manage in his “foreign” environment but maybe we should have had him back in the facility sooner and nursed him in a comfortable environment with his IV antibiotics managed by the RN’s in the facility.

My point is: how do we fix this “silo” thought processing?

There is a lot of discussion currently about pharmacists in General Practice. Some view this as a threat, but I view it as an opportunity.

In my consulting work I would welcome being able to discuss components of the medication review referral with the practice pharmacist. The practice pharmacist will have the innate sense of what I am looking for to inform the review far better.

I would dearly love access to the full patient notes to inform the medication review process but if I cannot have this then the next best step is to liaise with the practice pharmacist who can assist me to perform my role far better.

I am aware that I may lose some of my work to these pharmacists but with the current HMR caps I hope that by working collaboratively with these practices there would be enough work for both of us.

There are so many patients sitting in GP practices who would benefit from a medication review. We have only scratched at the surface of who should be seen.

Having a pharmacist in a GP practice should enable many more patients to be given this service and hopefully have a better health care plan produced.

What are your thoughts? Are we working independently of each other?

Karalyn Huxhagen is a community pharmacist and was 2010 Pharmaceutical Society of Australia Pharmacist of the Year. She has just 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.

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