To embed or not to embed: the third option


aged care elderly pharmacy pharmacist medication medicine pills blister pack

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
(19/3/2021).

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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3 Comments

  1. Jarrod McMaugh
    26/05/2021

    This response, while logical, assumes that the placement of a pharmacist into aged care in an embedded manner removes the need for RMMR.

    This is not the case; PSA South Australia Branch has been operating a project where pharmacists are embedded in aged care facilities, and RMMR delivery has not been reduced; collaboration and follow up of recomendations in RMMR have increased, while rapid evaluation of medication changes after a transition of care has impacted positively on medicine-related harms (including readmission to hospital with subsequent transition-of-care medicine issues).

    The original article included a position from George Tambassis that can be summarised as “we don’t want community pharmacist roles in aged care to be reduced by the presence of an embedded pharmacist in the facility.”

    This article takes a position that can be summarised as “we don’t want accredited pharmacist roles in aged care to be reduced by the presence of an embedded pharmacist in the facility”

    Neither of those concerns are warranted, as the embedded pharmacist facilitates the roles that these pharmacists perform, and contribute to effective collaboration and communication between all parties involved in care.

    • Hi Jarrod, thanks and interesting points. Are you implying that the embedded pharmacists from the PSA SA trial were not completing the RMMR themselves, only facilitating them? Are there any further details about the trial? It would be an interesting read to see what activities are undertaken in their time. Lots to learn!

      • Jarrod McMaugh
        26/05/2021

        Correct, and this goes for the PSA run Pharmacists in GP work

        The pharmacists are specifically not undertaking RMMR or HMR (depending on setting) as the purpose of the trials are to demonstrate the financial viability of the roles; there is a risk that the ‘value’ of the role from external decision makers (ie clinic owners, boards or management, etc) is seen as nothing more than being able to deliver HMR/RMMR

        there’s also the issue that a surgery or a facility cannot claim HMR or RMMR payments, so the pharmacist would always need to have their own capacity to claim those fees. Of course they can do that, but this is not our focus.

        The pharmacists embedded in these projects are focused on how they deliver improved outcomes, and how these improved outcomes translate into financial viability for the role (ie does the pharmacist have an impact on outcomes, and does this save time for the GP in a clinic setting so they can see more clients) (does the pharmacist improve outcomes for residents, save time for nursing staff, incentivise the presence of a GP for chart reviews, etc).

        Anyway the role of the pharmacist in those settings shouldn’t be to do HMR or RMMR – we already have pharmacists performing that role. They should facilitate referrals, follow up on recommendations, identify people who need one, as part of their role (which encompasses a lot of other activities)

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