HMR ‘follow-ups’: making a difference

medication consultation HMR

After her first HMR, ‘Dorothy’ had her entire medication regime overhauled—was this a good outcome or one that required a further follow-up? Sharon Doolan takes us through what happened

As I approached the familiar home to provide a Home Medicines Review follow-up service for a client, I noted this occasion was unusual: not only was the ‘follow-up’ a new addition to the HMR service, I was armed with hand sanitiser and wearing a mask and gloves.

I have been visiting 93-year-old Dorothy (not her real name) for over a decade. Dorothy has lived alone since 2008. Her home is impeccably presented but given the Covid-19 threat, I requested that we socially distance in the pergola outside without our usual welcoming hug.

I had received the medication management plan from her GP, post HMR, and advised the GP I believed a follow-up with Dorothy would be beneficial to ensure the medication related problems I identified in the initial HMR were resolved.

You might question the need for a HMR, let alone a follow-up, for a lady like Dorothy who has regular GP visits, daily visits from a Veterans’ Affairs Registered Nurse, home care support, a plethora of neighbourhood good Samaritans, and a diligent Community Pharmacy team.

In addition, she has only a handful of medications packed in a DAA, minimal non-packed medicines and she does not stockpile any pharmaceutical items.

It was early May 2020 so this follow-up appointment was more than one month post Dorothy’s initial HMR as per the recently updated HMR Program Rules that were published in April 2020.

Initial HMR

Dorothy’s medical conditions include: Breast cancer – left mastectomy, hypertension, TIA, benign paroxysmal positional vertigo (BPPV), COAD, fracture TIB/FIB Right and Left wrist, early Parkinson’s tremor, osteoporosis, inguinal hernia (L), and atrial fibrillation.

Dorothy, around the time of the first HMR. Used with permission.
Dorothy, around the time of the first HMR. Used with permission.

Dorothy’s current medication list was as follows:

  • Amiodarone 100 mg 1 mane
  • Salbutamol CFC inhaler 2- or 3 puffs four hourly prn
  • Bisoprolol 5 mg half bd
  • Coloxyl with senna  2 bd prn
  • Duloxetine 60mg 1 mane
  • Fosinopril 10mg 1 bd
  • Furosemide 20mg 1 mane
  • Paracetamol 500mg 2 qid prn
  • Pantoprazole 20mg 1 night
  • Tiotropium Respimat inhaler  2.5mcg 2 puffs mane
  • Budesonide/formoterol  turbuhaler (200mcg/6mcg) 1 bd
  • Warfarin 1mg 1.5 (1.5 mg) daily


  • Citalopram – nightmares, diarrhoea
  • Dipyridamole – headaches, malaise


  • Pneumovax (2005 & 2011)
  • Zostavax (2017)
  • Influenza (annually)

Relevant pathology:

Haemoglobin 130 g/L, MCV 102 fL, INR 2.5, Creatinine 147 umol/L, eGFR 27 ml/min/1.73m2, calculated CrCl = 16.5 mL/min (via Cockcroft-Gault equation, actual body weight)

Height – 156cm (2018) & 150cm (2019)

Weight – 59kg (2018) & 49.5kg (2019)

During the HMR I noted significant hypotension and postural hypotension along with her weight loss, all documented by her RN home visits. The GP referral for the initial HMR was to consider these significant changes occurring for the 93 year old.

Both Dorothy and her GP felt an HMR was needed to instigate medication adjustments which Dorothy refers to as ‘life saving’. I firmly believe that my input into Dorothy’s care over the years has played a key role in preventing and managing significant issues for Dorothy.

Blood pressure was most recently measured by the RN as 99/53mmHg and pulse 81bpm (sitting), and BP was 89/45mmHg and pulse 87 bpm (standing)

She reported light-headedness with standing although had attributed these symptoms to her BPPV.

I contacted her GP immediately however he was not available that afternoon. On speaking with another GP in the medical centre, we decided that Dorothy’s antihypertensive medication (fosinopril) should be held until she was reviewed by her GP the following morning.

Dorothy, around the time of the second HMR. Used with permission.
Dorothy, around the time of the second HMR. Used with permission.

I also contacted her community pharmacist to inform them of the situation and be aware of medication pack changes that may occur after Dorothy’s GP appointment the next day.

I prepared the HMR report and sent it to the GP the following day in readiness for the GP’s appointment with Dorothy. I highlighted the absence of a heart failure diagnosis in her medical history in the report.

The medication management plan from the initial HMR showed that the GP agreed with my recommendations, confirmed she had a heart failure diagnosis and agreed a follow-up would be beneficial.

The medication management plan was as follows:

  • Fosinopril 10 mg bd reduced to 5mg nocte with additional monitoring of renal function
  • Duloxetine 60 mg mane dose reduced to 30mg mane in line with her renal impairment,
  • Amiodarone use was reviewed and thyroid function tests ordered,
  • Vitamin D level performed and vitamin D supplement commenced with loading dose (with her history of falls and fractures),
  • COPD inhalers (x3) reviewed due to poor dexterity associated with parkinsonian symptoms and Trelegy Ellipta commenced.

During the HMR process I also noted the following:

  • her PPI dose of pantoprazole 20mg (and her history of weight loss and inguinal hernia),
  • warfarin dosed as 1.5mg daily resulted in a stable INR (I was aware she had been changed from clopidogrel to warfarin through providing her previous HMRs)
  • low dose of furosemide prescribed, her bisoprolol dose was suitable and heart rate steady (no AF determined).

Follow up #1

In anticipation of the follow-up my plan was to:

  • check her weight management and blood pressure,
  • to ensure the changes requested from the GP had been implemented,
  • review her mood with the lower dose of duloxetine,
  • educate and review her management of the new inhaler device,
  • review recent serum pathology.

All very standard follow-up intentions.

However, I found Dorothy’s current medication list was as follows;

  • Salbutamol MDI 2 or 3 q4h prn
  • Bisoprolol 5mg half bd
  • Coloxyl with senna 2 bd prn
  • Vitamin D 1000iu 2 mane
  • Duloxetine 30mg 1 mane
  • Fosinopril 5mg 1 nocte
  • Morphine syrup 1mg/ml 5mL prn
  • Paracetamol 500mg 2 qid prn
  • Trelegy Ellipta inhaler 1 mane

So, what I found during the first follow-up was a complete ‘overhaul’ of her medication regimen, over and above my recommendations. Was this a good outcome or an outcome that required a further follow-up?

Dorothy mentioned the pantoprazole was no longer in her pack. She had purchased Mylanta tablets and was taking a tablet after every meal. Since the pantoprazole had been ceased one month prior, Dorothy found she was unable to swallow food, and her food intake had further reduced.

During one of her medical consultations she was advised to cease Sustagen due to the protein content and her reduced renal function; Dorothy had lost more weight and now was 44.8kg.

Warfarin was no longer in her pack and appeared to have been ceased along with amiodarone and furosemide. Her blood pressure was 104/72mmHg.

Follow-up report #1

There are no perfect answers for Dorothy, just optimal clinical guidance for her current health management.

My follow up letter to the GP included the following; Dorothy would benefit from recommencement of pantoprazole 20mg daily, I suggested the GP review whether antithrombotic therapy should be recommenced (and bloods) and I suggested a dietitian’s involvement to provide recommendations for a suitable dietary supplement.

Would a second follow up be valuable?

My word! This cognisant, humble, yet frail lady is a prime example of a patient likely to benefit from a second follow up.

Consultant pharmacists, don’t doubt yourselves abilities and the part you play in the team for further enhancing the lives of the people for whom we provide this valuable Comprehensive Medication Review service.

Follow up #2

When I arrived at Dorothy’s home for the second follow-up, I learned she had recently been discharged from hospital. She had been admitted to hospital for a week due to shortness of breath, ankle oedema and symptoms associated with atrial fibrillation.

The second follow up occurred three months from the initial HMR and was perfect timing in light of her recent hospital admission.

Warfarin and furosemide had been recommenced since the first follow-up however warfarin was ceased during her hospital admission and her furosemide dose increased. Morphine liquid had also been ceased with digoxin and spironolactone commenced.

Her weight was 46kg, blood pressure 82/56mmHg and heart rate 45 bpm. No postural hypotension observed.

Dorothy had a family member staying with her full time at home and the plan was that this would continue for the short term.

Her current medication list was as follows:

  • Salbutamol MDI 2 or 3 q4h prn
  • Bisoprolol 5mg half bd
  • Coloxyl with senna 2 bd prn
  • Vitamin D 1000iu 1 mane
  • Duloxetine 30mg 1 mane
  • Fosinopril 5mg 1 nocte
  • Paracetamol 500mg 2 qid prn
  • Pantoprazole 20mg 1 nocte
  • Digoxin 62.5mcg 1 mane
  • Spironolactone 25mg half mane
  • Furosemide 40mg 1 mane

Follow-up report #2


Reduce bisoprolol dose to once daily in light of low blood pressure and heart rate. I highlighted the need to increase the diuretic dose to stabilise the HF in the first instance, then cut the bisoprolol night dose.

Monitoring of serum potassium and serum digoxin levels for review.

Her appetite was excellent, no oedema was noted and no symptoms of breathlessness observed.

Courtesy phone call one month after follow-up #2

Although it was not a funded encounter, I felt I had a duty of care to touch base with Dorothy. Dorothy advised me by phone that she had commenced home oxygen and she was using a wheelchair for outings.

She was not experiencing dizziness. She was eating well with a home cooked meal each evening.

Her weight was stable and she was not experiencing pain. Dorothy was spending some weeks on her own however a family member was staying at home with her most of the time.

The dose of her furosemide and bisoprolol had been reduced and digoxin ceased (level was 1.9 nmol/L, R 0.6-1 in heart failure, AF)

Her current medication list was as follows:

  • Bisoprolol 5mg half mane
  • Coloxyl with senna 2 bd prn
  • Vitamin D 1000iu 1 mane
  • Duloxetine 30mg 1 mane
  • Fosinopril 5mg 1 nocte
  • Paracetamol 500mg 2 qid prn
  • Pantoprazole 20mg 1 nocte
  • Spironolactone 25mg half mane
  • Furosemide 20mg 1 mane

Dorothy was grateful for my phone call and assured me that she was content with her quality of life and for the role I had played in optimising it. It is rewarding to note that Dorothy has not experienced a fall this year.

I bumped into Dorothy’s GP at the bakery in our country town and we both agreed that the availability of HMR follow-ups since April 2020 and the ‘cycle of care’ they provide with respect to medication management was a step in the right direction to enhance the care of complex, frail patients like Dorothy.

Sharon has been an Accredited Pharmacist since 1997 and provides Home Medicines Reviews (HMRs) throughout Illawarra, Shoalhaven and the Southern Highlands in NSW. She also provides quality use of medicines (QUM) services and conducts Residential Medication Management Reviews (RMMRs) for several Aged Care Homes. Optimising medication safety is Sharon’s passion – she is Chair of a Clinical Governance committee and enjoys the clinical components and working within a team to overcome the challenges faced by the Aged Care sector. 

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1 Comment

  1. Debbie Rigby

    What a fantastic case report on the benefits of HMRs and follow-ups! Highlights the need for a continuous cycle of care in frail vulnerable older people. Thanks for sharing Sharon.

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