The federal government committed substantial funding to aged care in the recent Budget, but questions have been raised over the efficacy of some of its proposals, says Gerard Stevens
The Federal Government’s response to the Royal Commission into the Safety and Quality of Aged Care was announced in its recent Budget – $17.7bn to be invested in a series of reforms to come into force over five years. This is its complete response with no more funding promised.
It’s a lot of money and it will be gratefully accepted by stakeholders, but it hasn’t pleased everyone. It remains to be seen how much of the new funding will actually add safety and quality to the lives of the elderly.
And what does it mean to pharmacists? For those of us who have always been dedicated to residents of aged care facilities, the extra money in the sector will be welcome and hopefully translate to better health outcomes including improved support for medication management services.
Yet the government response to the Royal Commission provides no extra direct funding towards pharmacy services delivered in residential aged care facilities (RACFs).
Record of achievement
Perhaps this is because there was no criticism of pharmacy in the Royal Commission? Indeed, despite medication management issues being identified as receiving the most complaints within RACFs by the Health Complaints Commissioner, very few arise from within the four walls of pharmacies.
This reality was reinforced in new research undertaken by University of Tasmania Associate Professor Juanita Breen which was presented at the recent National Medicines Symposium and published in the AJP.
From more than 15,000 complaints received in 2019-20, almost 10% had to do with medication. Nearly half of these related to basic medicine administration involving the right resident, medicine, dose, time, route and documentation.
Three categories dominated medication-related complaints: the timing of medication administration (27%); inadequate systems, processes or policies (22%); and chemical restraint (14%). These are all issues that pharmacists have no direct control over.
A/Prof Breen, who consults to the Aged Care Quality and Safety Commission, identified that pain and sedation medication were commonly implicated, with opioids the most frequently mentioned, followed by psychotropics.
She commented that the high number of complaints pointed to a lack of training for aged care staff.
“The reality is it’s the basic things like having pain medication or palliative treatment given on time or getting a trained staff member to give an insulin shot that means more.”
“Staff tell me they receive training infrequently and when they do it’s on topics like anticoagulants or digoxin – while important basic medication management topics need coverage first and foremost.”
The issue of aged care staff training and the role of pharmacy is a vexed one. The Federal Budget provides funding for increased numbers and training over the next five years. But will it be sufficient and what happens after the funding window closes?
It would be unrealistic to expect pharmacy to fill medication management training gaps. Nevertheless, A/Prof Breen makes an important point about ensuring aged care staff are well trained in the basics of medication management and administration, and we do have a role to play.
Filling the gaps
Herein lies an ongoing frustration for those pharmacists who, like me are dedicated to supporting aged care residents. All too often we are expected to fill in gaps without recognition or financial compensation.
Whether it be responding to urgent medication requests at all hours, dispensing without a valid prescription on the expectation and hope that the doctor will eventually get around to sending one (a behaviour that is thankfully abating for those adopting RxMedChart – Webstercare’s electronic version of the National Residential Medication Chart), or being squeezed on service delivery costs by corporate purchasing managers, pharmacy service providers remain unsung heroes of the residential aged care sector.
Yet we deliver critical services whose effectiveness can be measured by the ‘clean sheet’ assessed by the Royal Commission. Imagine the medication mayhem, morbidity and mortality if our stewardship wasn’t so precise and driven by systems that successfully minimise the risk of error.
We have a zero tolerance for any type of error for good reason. The systems we have developed offer numerous ‘failsafes’ designed to catch any errors before medication leaves the pharmacy.
A five-week audit of my pharmacy showed that we packed 574,000 individual doses of medication without even one ‘correction’ required. In this context, ‘correction’ is a soft term where the pharmacist checking packs identifies an anomaly before it is delivered to customers. It’s about never allowing a mistake to get out. Never the wrong medication. Never the wrong dose.
The sense of achievement is palpable and reinforces the pride I have in my profession.
Gatekeepers to clinical data
Pharmacists are clearly the gatekeepers to many of the medication management solutions being sought by the Royal Commission, which emphasised the critical nature of accurate and properly organised data to overcome many of the incidents of sub-standard pharmaceutical care.
Pharmacy-held and curated medication data offers the most accurate and up-to-date analysis of what medications people actually take. It’s why the government is increasingly turning to pharmacies for this data as the ‘source of truth’ in projects such as the Pharmacist Shared Medicines List (PSML) and electronic prescribing which will interact with the My Health Record.
Most pharmacies that service RACFs operate innovative and risk-averse systems and are well-placed to support aged care facilities to navigate this new digital world of data mining and analysis. Innovations such as RxMedChart and the groundwork we’ve done in advancing the PSML for My Health Record, offer facilities with the perfect platform to engage, interact and reap the benefits from operating in the new digital world of aged care.
But it’s not enough to upgrade old systems to new ones. They have to be used to their full effect and that includes harnessing their ability to transform the data they collect into life-saving and patient-empowering knowledge.
Perhaps the biggest impact on community pharmacies, albeit indirectly, from this budget is a significant extension to the number people receiving home care packages – $6.5bn has been allocated to boost home care packages by 80,000 over the next two years. Some medication management services are eligible to be paid through home care packages so this measure is relevant to all pharmacies.
We know that effective medication management is one of the keys to being able to remain largely independent and living at home, so we can expect medication management services tailored to health consumers on home care packages to expand significantly.
Mandated reporting and oversight
For various reasons, far fewer pharmacies provide medication management and QUM services to RACFs. Nevertheless, these can expect to become more involved in supporting facilities to meet more stringent reporting obligations.
The Aged Care Quality and Safety Commission regulates the sector and its role will be reviewed next year. Included in its remit is oversight of the National Aged Care Quality Indicator Program, which has significantly ramped up reporting requirements and the data held by pharmacies will support this process.
Commission funding has been increased by $262.5m over four years and will cover increased resourcing for site visits, and any incident reported under the new mandatory reporting guidelines will trigger a site visit.
Introducing fully paperless prescribing
Another indirect benefit to pharmacies is $46m earmarked to facilitate for the introduction and adoption of an electronic national residential medication chart (NRMC) within RACFs.
The procedures surrounding the funding have not yet been published but are expected soon and will provide an average of about $12,500 per facility to upgrade their systems or adopt new ones that can support fully paperless prescribing. This is an initiative whose success will be dependent in no small part on the relationship between the RACF and their pharmacy service provider.
New quality indicators
Of particular interest are new requirements on medication management – polypharmacy and antipsychotics, and falls and major injury. These join existing quality indicators of pressure injuries, physical restraint and unplanned weight loss, and come into effect from 1 July from when data will need to be collected for a specified date and reported for the quarter ending 30 September.
For the quality indicator medication management – polypharmacy, RACFs must submit data to identify, on a particular reporting date, the number of care recipients:
- whose medication charts and/or administration records were reviewed to assess polypharmacy;
- who were not assessed due to hospitalisation; and
- who were prescribed nine or more medications (not just prescription medicines) following a review of each resident’s medication chart and/or administration records
For the quality indicator medication management – antipsychotics, data must be submitted on the number of care recipients:
- assessed for antipsychotic medication;
- excluded due to hospitalisation;
- who received an antipsychotic; and
- who received an antipsychotic for a medically diagnosed condition of psychosis.
For the falls and major injury quality indicator, RACFs must submit data to identify, on a particular reporting date, the number of care recipients:
- whose records were assessed for falls and major injury;
- excluded due to hospitalisation;
- who experienced a fall (one or more) at the service during the quarter; and
- who experienced a fall resulting in major injury.
Review review red tape
I was particularly pleased with the recommendation by the Royal Commission to extend the Residential Medication Management Review program. The government amended rules for both home medicines reviews (HMRs) and RMMRs in April last year. This was during, and probably influenced by, the Royal Commission.
RMMRs had been capped at one per resident every 24 months, which was clearly inadequate. They, like HMRs, are now capped at three, with two additional follow-up reviews with patients within nine months of the initial review.
But there was no more news on medication reviews in the Budget. The Royal Commission recommended that a review be conducted within three months of entering a facility, yearly thereafter, and at times when there has been a significant change to a person’s medication regimen or health condition.
Most medication incidents occur during transitions of care and when a medication regimen is changed. Entering an aged care facility can sometimes trigger new medications being prescribed and requiring stabilization. The Royal Commission’s recommendation that they be conducted with all new residents within three months of entry would be a sensible additional guideline.
Transition of care from hospitals is also a dangerous time for the elderly because they are discharged from hospital as soon as clinically possible. The enormous variance to the discharge practices employed by hospitals and the information provided to the next point of care, often a RACF, adds to an environment ripe for error.
Hopefully the Government will review the red tape and some of the details that surround the program and can delay the outcome of clinically crucial medication reviews.
Despite the increasing emphasis on improved data use and benchmarking, it is important that we always remember that these data sets represent people – our grandmothers and grandfathers. And let’s not forget that the recommendations also impact the staff who touch, hold, smile, talk to and offer encouragement…those who care for them in lieu of their family. We must be careful not to ‘throw the baby out with the bathwater’.
* Gerard Stevens AM is founder and Managing Director of Webstercare, and a registered and practicing pharmacist.