The aged care dilemma

hospital pharmacist medication chart

A national residential medication chart is urgently required if we are to begin to fix one pharmacy-relevant aspect of the aged care crisis, says Anthony Tassone   

The recent revelations of alleged mistreatment of residents in aged care facilities have raised a number of complex issues and – as supported by many major stakeholders – these are worthy of a Royal Commission into the sector.

Predictably there have been numerous vocal statements from various peak bodies across the health sector, and such debate and discussion are what is needed to effect change.

Such debates bring a rush of suggestions and proposals that have been motivated by a firm belief of being part of the solution, including suggestions of embedding pharmacists in aged care homes which follow on from the notion that pharmacists should be everywhere that medicines are used.

While pharmacists can play an important role in increasing the quality use of medicines, how achievable is this in the short-to-medium term given the challenges and the alleged resistance by RACFs to have minimum nurse-to-patient ratios?

Sensible solutions are needed and as the Pharmacy Guild’s Executive Director, David Quilty noted in Forefront this week: “Our [the Guild’s] view is that the consumer directed model of community aged care support should fully recognise medication management and support as a core service to enable ageing Australians to live independently in the community.”

An unresolved issue

One of the unresolved and outstanding issues we face is to fix the current situation around National Residential Medication Charts (NRMC).

At present we have an illogical situation where medication charts used by a large number of residential aged care facilities (RACFs) are a legal order for RACF staff to administer medicines but are not necessarily a legal order for the pharmacy to supply medicines to the facility for staff to administer.

Without having legal prescriptions on hand from the prescribing doctor, pharmacies are caught between a rock and a hard place and often are called upon to ensure continuity of supply for patients, with the attendant professional, legal and financial risk.

Unless there is appropriate redress, this shows no signs of improving any time soon with the AMA 2017 Aged Care Survey Report noting: “Respondents were asked of their intentions to visit RACFs over the next two years. Over one third (36%) of respondents who currently undertake RACF visits intend to either visit current patients but not visit new patients, decrease the number of visits, or stop visiting RACFs altogether.”

That is to say, based on these survey results, GPs are not likely to increase the time they spend in RACFs.

A need for action

Something needs to be done, and done now.

Adoption of the National Residential Medication Chart in residential care facilities offers a pragmatic way to improve a bad situation and to make some real differences to the wellbeing of residents in these facilities.

Fundamentally, the whole purpose of a medication chart in a residential aged-care facility is to act a communication tool between doctors, nurses, pharmacists and other health professionals regarding a resident’s medicines along with supporting them as they transition across the care settings, including in and out of the hospital. It is used to direct how and when medicines are to be administered.

At their best, the charts seek to improve medication safety for residents, as well as minimising the administrative burden on prescribers, aged care staff and pharmacists when ordering, administering and supplying medicines.

At their worst, there are risks in the continued use of a chart not compliant with the NRMC. As can be seen from the AMA survey, an increasing number of doctors plan to shun residential aged care facilities, or to reduce their visits to them and number of patients they see.

This can mean prescriptions are not immediately available and a supply without a separate valid prescription does not comply with State legislation.

This puts the pharmacist in an unviable position and facing a conundrum – provide the necessary medicine and potentially be non-compliant with legislation or refuse to provide the medicines and endanger the patient. Not surprisingly, community pharmacists put themselves at risk to ensure the patient’s welfare is the first consideration – albeit often with some disruption as pharmacists seek the proper prescription.

The enormous difficulties experienced by pharmacists to obtain valid PBS prescriptions from prescribers to authorise the ongoing supply of prescribed medications are well known.

Incorrect supply?

Such a predicament was highlighted in a recent newsletter from the Pharmacy Board of Australia (27/9/18) about a recent case before the board. Below is an excerpt from the Board’s newsletter:

Increasingly pharmacies are involved with dispensing medicines to patients in aged-care facilities. In this case, the pharmacy had one owner and employed a number of pharmacists who dispensed medicines regularly to a local aged-care facility. Pharmacists had supplied Schedule 8 medicines based on requests received via facsimile without the prescriber presenting a valid prescription. 

State and territory drugs and poisons legislation sets out the legal requirements for the supply of medicines. On this occasion no attempt was made to ensure that the supply of medicines met these requirements.

Not knowing all of the full particulars of this case, the alarming realities are that pharmacies across Australia are regularly requested to supply prescription medicines, potentially Schedule 8/Controlled medicines based on a standard medication chart order which is an order to administer, but without a valid prescription. 

The dilemma for pharmacists is contemplating the potential consequences of an interruption of medication continuance for patients if the request is not fulfilled. This is not to say that legislation should be ignored or not respected, it is to say that the law simply must change.   

Making it mandatory

If the mandating of NRMC compliant charts cannot happen in the short-term, then State and Territory governments must recognise medication drug charts that are a currently legal order to administer are also allowed as a legal order for the pharmacy to supply.

One initiative which may help address the situation is an Electronic National Residential Medication Chart. At present a trial of these charts is underway (across twelve RACFs in NSW, ACT and South Australia) and this trial is being conducted under a special arrangement that removes many of the exclusions – namely Schedule 8 and Authority required items that currently apply to NRMC and NRMC compliant charts. 

It is anticipated that the electronic NRMC will augment the benefits of the NRMC already demonstrated by the trial carried out by the Australian Commission on Safety and Quality in Health Care, including:

  • safer medication delivery with reduced errors;
  • a consistent approach to medicine prescribing, administration and supply across a variety of settings through standard intuitive design;
  • relevant medicine information captured within a single booklet format supporting a holistic and resident focus; and
  • a reduction in form duplication and administration costs.

In addition, and importantly for the pharmacists, a NRMC compliant chart provides legal surety for the community pharmacy providing the medicines as it constitutes a valid order to supply and administer.

But realistically, these benefits will not be realised without the universal adoption of NRMC compliant charts.

We urge the Government to consider adopting the mandatory use of NRMC compliant charts in RACFs.

The removal of exclusions that currently apply to NRMC compliant charts will also need to be considered if the trial provides evidence that the supply of Schedule 8 and Authority required items can be managed.

Any findings from a Royal Commission into RACFs will take a significant time to surface, potentially years, but much-needed reforms such as mandating NRMC compliant charts are staring us in the face right now and can make a difference for the better in quality and safety for patients. 

Anthony Tassone is President of the Pharmacy Guild of Australia (Victoria)

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