To embed or not to embed: the third option

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Is there another way to approach the concept of embedding pharmacists in aged care? We hear from a pharmacist and two doctors who think so

We write in response to the Australian Journal of Pharmacy article “To embed, or not to Embed

Pharmacists are important custodians of medication safety and should be involved in multidisciplinary teams wherever medications are used, and especially in Aged Care where the risk of harm is greatest.

This is not up for debate. And let’s not debate who should be doing it.

What should be debated is why we’re doing this and how we can implement value-based health care. We
define value as care that is needed, desired, justified and prioritised; delivered safely, reliably and
affordably with the desired outcomes and experiences for residents and caregivers.

At the moment the value of clinical pharmacy services in aged care is not demonstrable. Department of Health data shows in 2020, 53% of aged care residents had an RMMR and less than 10% had a follow up review.

Figures are worse for new admissions to aged care with the well-publicised figure of only 21.5% of residents having an RMMR within 90 days of admission despite evidence that this is the period of greatest risk of medication misadventure.

The outcomes of medication reviews have been poorly studied with a reported 70 per cent suffering polypharmacy and overuse of antipsychotics. The experiences of residents in aged care facilities is  disturbing and well documented by the recent Royal Commission into Aged Care Quality and safety.

The government expenditure on RMMRs in 2020 was less than the previous year, suggesting uptake of these services is declining. In addition, on average only 60% of recommendations made by the pharmacist in RMMRs are accepted. Our data suggests that only about 50% of RMMR referrals are accepted by GPs despite follow-up from our office. All this data points to the fact that this service is being underutilised.

Upon examining the barriers within the international and Australian literature, collaboration appears to be the solution.

Imagine multi-disciplinary health care teams (MDT) working together to produce and implement a medication management plan for each resident and monitoring the outcomes of this plan.

Aren’t clinical pharmacists specialising in Aged Care perfectly placed to bring these teams together? These pharmacists are expert and experienced in educating caregivers on medication safety are already embedded in aged care homes.

The solution moving forward has to be getting MDTs together for case conferencing to bring about change, improved outcomes, better quality of life and minimise harm from medication misadventure.

This approach allows all caregivers input to empower residents and their next of kin to make informed decisions in medication optimisation.

The recently released Australian Medical Association (AMA) report “Putting health care back into aged care” supported this concept when it stated:

“annual and as needed medication reviews in collaboration with the person’s usual GP and a pharmacist are essential in ensuring a patient’s medication regime remains suitable for their current circumstances”.

We believe the clinical pharmacists, the resident’s GPs and supply pharmacists need to work more
collaboratively to achieve the goals highlighted by the Royal Commission into Aged Care Quality and
Safety, Royal Australian College of General Practitioners (RACGP) and the AMA.

This, we believe, will bring better outcomes to aged care residents and greater “value” to the system. At Mederev we believe these aged care expert clinically accredited pharmacists are best placed to drive the MDT medication management plans.

The cost of the current RMMR system to the government is approximately $12 million each year. We believe that putting a 0.6 pharmacist for every 200 beds will bring a recurrent annual cost to this system of about $100 million.

Will “embedding” pharmacists into aged care facilities then bring an additional $88 million in “value” to the system? Would busy community pharmacists not specifically trained in aged care residents’ medication needs who also supply those medications be the best people to co-ordinate such a MDT approach and bring value to the system?

Mederev believes that the current system of medication management in aged care, while not being perfect, can be improved and should not be discarded.

The discussion needs to move away from “the who” and moved towards “the why” we need to do this better.

The discussion needs to focus on how “value” can be brought into the system and how to support shared decision-making by caregivers with residents and families on medication management.

Lastly and most importantly we need to improve the outcomes of our precious and vulnerable Australians in our aged care system.

Marea O’Donnell BA MPharm MPS AACP
Dr Stephen Nolan OAM FRACP FCICM MB BS (1st Hons) M.Ed
Dr Jagdeesh Singh Dhaliwal MBChB FRCGP FRACGP MSc DRCOG PGAMedEd

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