Working together: Aged care pharmacists

(L-R): Richard Thorpe (pharmacist), Tamara MacLeod (nurse practitioner), Nicole McDerby (pharmacist), Mark Naunton (pharmacist), Paresh Dawda (GP) and Sam Kosari (pharmacist) at Goodwin Aged Care in Ainslie, ACT. Credit: Megan Haggan/AJP

What is it like working in a multi-disciplinary aged care team? AJP speaks with four different pharmacists making a difference on the ground

Richard Thorpe

Credit: Goodwin

Richard is Australia’s first ever full-time in-house (or ‘embedded’) pharmacist, hired to be part of the multi-disciplinary health team at the Goodwin residential aged care facilities in Ainslie, ACT.

“It’s a unique position created by Goodwin and wasn’t a job that any other pharmacist in Australia was doing,” he told AJP.

“Traditionally, pharmacists would visit facilities to do medication reviews and they may not return to any specific facility for two to three months.

“That basically means they’re working as a contractor and don’t get the chance to build up relationships with facilities’ staff and the residents as I am doing at Goodwin. So this is a massive step forward for pharmacists working in age care,” he says.

“Medication-related issues are front and centre for a lot of our elderly residents. To have someone on site who can be their advocate and help insure quality use of medicines in an age care environment, I think, is critical.”

Richard says a large part of his role is working directly with residents.

When new residents move in to Goodwin, he will often sit with them and their families to review their medications.

“It’s a great opportunity for everyone to take stock and identify any potential issues that may have gone unchecked,” he says.

“I then work with care staff to ensure the medications are administered correctly. It not only ensures medications are managed appropriately, but it also really helps to ease the resident’s transition into Goodwin.”

He says there may be some misconceptions regarding the role of the pharmacist in aged care.

“My role is not to dispense the tablets and the medicines – we have a supply pharmacy who does that. And my role is not to administer the medicines to the residents – we have carers and registered nurses who do that,” says Richard.

Richard is also regularly involved in clinical meetings, case conferences and presentations with residents, their families and GPs.

“I love the way that I have the ability to follow through with Goodwin residents and see recommendations come to reality and see the impact that has on the resident’s wellbeing,” he says.

He also administered staff flu vaccinations, which resulted in a staff vaccination rate far exceeding the industry average and mitigating the effects of Canberra’s severe 2019 flu season on Goodwin residents.

Goodwin told AJP that it is seeing huge value in Richard’s role.

“Goodwin is seeing improvements and time reductions in medication rounds, allowing carers to spend more time with residents to provide other forms of support,” says Goodwin CEO Sue Levy.

“It’s been wonderful to see benefits – not just in the wellbeing of our residents, but also for staff, families, and external consulting medical professionals.

“The care staff feel more supported. They receive more training and education which allows them to be more confident in their role, and they always know they have a professional to consult if they have any questions or uncertainties.”

Credit: Prestantia Health

Nicole McDerby

Nicole has experience in various pharmacist roles including community pharmacy, hospital pharmacy, research and academia.

However for close to nine months she has been working as a clinical pharmacist in a multi-disciplinary team for Prestantia Health in Manuka, ACT.

“In that time, I have worked closely with the GP, nurse practitioners and enrolled nurses who are also part of that team,” she says.

“I also rely on effective relationships with the care and nursing staff at the numerous aged care homes across Canberra that we provide our services to, in order to perform my role in resident care.”

Her role is to provide clinical medication review, with a large emphasis on optimising chronic pain management and rationalising medicines use in the context of palliative care goals.

“Looking at ways to optimise medicines is a large part of this,” she says.

“However I also provide education on non-pharmacological pain management strategies for both aged care staff and individual residents to try and minimise reliance on opioids to provide pain relief.

“We monitor resident opioid usage, pain scores and participation in non-pharmacological strategies such as physiotherapy, group exercise classes, massage and heat packs to try and find a plan that works best for each resident and their level of cognitive and occupational function.”

Nicole says successful approaches to pain management require a team-based approach to care.

“Within Prestantia Health we routinely collaborate and discuss resident care strategies, discuss options with residents and their family members through case conferencing, and including staff providing care on a day-to-day basis in these processes.”

Mark Naunton

Mark says he has been fascinated by aged care ever since he was exposed to it as a child, when his grandparents moved into an aged care facility.

“My grandfather had terrible emphysema and required care,” he tells AJP.

“I remember being intrigued by the medicines, and nursing staff administering medicines to the residents.”

Later in life he found himself working in a pharmacy that supplied medicines to a large residential aged care facility.

“I remember the large number of issues I was identifying but not always able to effectively resolve from the pharmacy, and there were no RMMRs being done at that time,” says Mark.

“I arranged informal case conferences and lots of phone calls with GPs and nurses to try to address some of the issues I was seeing.

“For example, there were residents who were being supplied chloramphenicol eye drops for months on end which didn’t seem clinically indicated or good practice. We still see this occasionally,” he says.

As Head of Pharmacy at the University of Canberra, Mark introduced placements for pharmacy students several years ago, with a focus on geriatrics.

This is an important part of our curriculum because many of the issues we see with medicines occur in the elderly, who are the largest consumers of medicines in primary care.

“Having students on placement is great as they have the opportunity to identify actual and potential problems and then have the opportunity to resolve real-world problems.

“Not that long ago a student identified a resident who had been on high-dose prednisolone for a respiratory complaint for several months when it was only intended to be used for three days.

“It was good to be able to feedback to the student months later that the resident had been slowly weaned off that medication.”

He shares another story of the positive impact of pharmacists on quality of life in elderly people.

“I was in a home early this year at the request of a resident to review his medicines, as they were concerned about the cost of his medicines,” says Mark.

“We were able to discuss and then in collaboration with his GP and nursing staff reduce his medicines from 18 to 14 medicines, as well as reduce the dose of several of his remaining 14 medicines,” he says.

“One of his medicines was a costing him over $100 a month. When I visited him a few months later he was a much brighter and happier, not just because we reduced his medicines—including some which were sedating—but because he was less stressed about the cost of his medicines, which was causing some family conflict.

“I thoroughly enjoy working in aged care and collaborating with nurses and GPs to address the needs of residents from a medication perspective.”

Sam Kosari

Sam, who provides aged care services as a consultant pharmacist, says the role is extremely useful for the sector.

He is currently leading two research projects to expand the role of pharmacists in the primary care and aged care facilities.

“[Pharmacists] work collaboratively and are identifying patients with clinical needs that may be met with best use of the composite skills the pharmacist and the GP bring,” he says.

“A particular focus for us is in the management of patients with chronic pain.”

This involves pharmacists undertaking a review of medications and side effects, and reviewing multiple sources of information to gain an assessment of the level of pain control and what other non-pharmacological methods are being used.

Pharmacists also undertake a reconciliation of the medicines to ensure the medication listed at the nursing home reconcile with the GP list.

“This translates into suggestions which are passed onto the GP in the form of a draft care plan. The GP reviews the care plan in the context of the patients overall goals of care, amends and finalises the care plan.

“The implementation of the care plan, particularly if there are changes to medication, is undertaken either by the GP or the nurse practitioner,” says Sam.

Interdisciplinary collaboration between health professionals is known to enhance the quality of care,  improve patients’ health outcomes and reduce medication errors, he explains.

“However in residential aged care facilities, lack of accessibility to on-site pharmacists and doctors in a timely way, can affect medication safety. GPs, pharmacists and nursing staff are the key health professionals involved in the prescribing, supply and administration of medicines.”

Pharmacists can have a key role in managing medication-related issues in aged care settings; they can liaise with GPs, nurses and the supplier pharmacy to coordinate the medication-related activities to improve medication safety.

This includes co-ordinating the transition of care, medication reconciliation following a locum/GP-resident visit, regular medication reviews and clinical audits on specific medications or conditions.

“It is common to observe in aged care facilities that some short-term medications likely prescribed by locum GPs, are left on the prescribing chart and being continuously supplied, while the regular GP is not aware of this until the next time they attend the facility.

“This scenario creates an opportunity for pharmacist to identify these and similar cases through ongoing chart review and audits, take action in a timely manner and contributing to the overall co-ordination of medication management in collaboration with GPs and nurses in aged care facilities,” says Sam.

This article was compiled with the kind help of Mark Naunton, Head of the School of Health Sciences and Head of Pharmacy at the University of Canberra.

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  1. Debbie Rigby

    For me, this is the best news story for 2019. Even if you are not involved with RMMRs, it demonstrates significant progress with pharmacists working to their full scope of practice in a collaborative way. It’s about building relationships to provide patient care, based on trust and respect for our knowledge and skills.

    This is what I think aged care and RMMRs/QUM services need to be as routine care. The Royal Commission in Aged Care had highlighted many problems and embedded aged care pharmacists are part of the solution.

    The announcements yesterday for follow-up HMRs and RMMRs based on clinical need by the accredited pharmacist, referrals by hospital and medical practitioners, and escalated QUM services is a really positive step.

    • I agree that pharmacists need to be actively available to the staff so that their expertise can be better utilized. This can be achieved in many ways without the need of an “in-house” pharmacist, a proposal in which I am struggling to envision how this would be applied to ALL RACFs.

      Current contractual agreements with facilities are an effective way to ensure that all facilities receive an accepted standard of service. What does need to change, are the rules and expectations that define these accepted standards of service.

      1) Deliver RMMR efficiently (in-house reviews, case conferencing etc.)

      2) Enhanced and strictly defined QUM and clinical pharmacy programs (AMS, case conferencing, psychotropic surveillance, chart checks, education programs, etc. )

      3) Increased funding to support enhanced QUM/RMMR activities

      There are plenty of RMMR/QUM providers already providing “enhanced” QUM services to facilities but there are also plenty that are not. Those that are not will definitely need to focus on expanding their services to facilitate the demands of the sector or risk being left behind.

      There is no need to re-invent the wheel. Just refine and streamline the process.

      • Debbie Rigby

        Changes to HMRs and RMMRs were announced yesterday. I think these enhancements are a very positive improvement.

        – Introduction of up to two follow up services for the HMR and RMMR Programs undertaken on the basis of clinical need.
        – Referral pathways for HMR and RMMR expanded to allow for any medical practitioner to initiate a service; this includes general practitioners, specialists and hospital doctors.
        – Service providers to load outcomes of the initial service and any follow up service(s) for the HMR and RMMR programs into the patient’s My Health Record (if there is one) or provide these documents to the patient and their healthcare team, including the referring doctor, the patient, the carer, the aged care facility and the community pharmacy (each if identified/applicable).
        – The follow-up HMR and RMMRs services to be preferably undertaken by the same accredited pharmacist who undertook the initial HMR or RMMR, however provisions put in place for an alternative accredited pharmacist or a registered pharmacist to undertake the follow-up in consultation with the referring medical practitioner and the pharmacist providing the initial review.
        – For the Quality Use of Medicines Program, service providers to escalate the level of activities they are providing with an associated doubling of funding, which may include undertaking additional activities and following up on previous activities to ensure uptake and/or implementation has been effected.

        • That’s great. Is there a link to read more?

        • Big Pharma

          Yes interesting isn’t it……

          Such is the importance of HMR services that expanded referral pathways have been introduced (something that blind Freddy could have recognised 10 years ago). The elephant in the room remains….how can a program be expanded if preferred providers can’t be accessed? Once touted as the future of pharmacy, an accredited pharmacist still isn’t a fulltime role and remains a hobby at best with an arbitrary cap of LESS THAN 1 PATIENT PER DAY! No other health profession has this restriction. Rural HMR services have been decimated.

          The importance of HMRs has been recognised! The referral pathway has been expanded! If the cap is not AT LEAST doubled these changes are of little relevance.

          • Jarrod McMaugh

            Firstly, the caps don’t need to be increased. They need to be abolished and replaced with audits.

            Second, many (if not most) professions (not practitioners) are funded for “less than one” patient per day.

            Some health professionals never see a funded patient, and all of their services are provided privately.

            The difference is, if a patient was referred for HMR and advised that their service would be privately billed, they’d pass on having the service.

            HMR is important, but it isn’t supposed to provide a pharmacist with a ‘complete career’ by being 100% funded…. in fact a pharmacist who focused their practice exclusively on HMR and DMMR would probably become less and less capable of providing high quality HMR over time due to de-skilling in other important areas of practice.

          • Big Pharma

            Absolutely caps need to be abolished. Absolutely there needs to be audits. An easy solution from day dot was the introduction on an audit. I wont hold my breath on cap abolition whilst these programs are included within the CPA (which they shouldn’t be). Not too difficult nor costly to audit providers operating above certain numbers (just like they do with Medicare item numbers).

            Patients have paid privately for HMRs in the past. I recognise this is not the norm. In my experience HMRs represent a huge cost saving to the government by decreasing PBS expenditure and reducing hospital admissions. Anecdotally I save the government, federal and state, a fortune each year. Deprescribing alone would have paid for my service several times over. This number was exponentially greater when I flew into high risk rurally isolated areas (at my own cost) to assist these communities-precap. So, whilst we have the PBS and public hospitals, indeed these programs should be federally funded.

            Disagree the quality of a review would diminish without operating in other areas of practice. In fact quite the opposite, especially with referrals now being expanded to specialists and their preferred providers. Clinical pharmacy is indeed a specialised area of the profession. In fact, from my own observations, the standard quality of a HMR has plummeted since the cap introduction as preferred providers are unable to be accessed (again anecdotal). The feedback I have received from several GP friends and colleagues is that many have stopped referring for HMRs in their areas due to the poor quality of the reports or the substantial delay in accessing an experienced provider. I have seen lists of names with “who not to refer to” come via a patients community pharmacy. This is indeed disappointing and there is only one way to combat the trend.

          • Jarrod McMaugh

            “Clinical pharmacy is indeed a specialised area of the profession”
            Clinical pharmacy is any practice of pharmacy where you interact with a health care consumer

            The purpose of working in other areas – as per my previous commemt – has multiple points to it – one is the opposite of clinical practice… that is, more exposure to other health care providers & multiplicity of practice techniques, insights, experience, etc. The most capable HMR providers that I have personally worked with have all had (or continue to have) diverse areas of practice.

            There is also the practical application of clinical knowledge that some HMR providers don’t have experience with – the ability to contextualise a potential medicine issue & give it the weight (or not) that it deserves.

            For instance, triple whammy in an elderly frail person… lets fix that. Same combination in a fitter 40 year old (who it turns out is using NSAIDs rarely as PRN, and who’s diuretic is at a dose for vasodilatation that is unlikely to significantly alter glomerular perfusion) is probably a footnote on the HMR report instead of the feature.

            Too narrow a focus of a persons career can lead to as many problems as the broad scope of practice that leads to deskilling among many of our colleagues. Practice should be varied in a way that brings experience & wisdowm without diluting effectiveness

          • Michael Post

            I agree Jarrod. I would hate to see pharmacists that are specialised in medication review solely focus on this work.
            It’s like professional athletes right? The best golfers hardly ever play golf . Pro golfers play hockey as Happy Gilmore demonstrated .
            The best obstetricians I know spend most of their time treating skin cancer.
            Your post rings very true to me.

          • Jarrod McMaugh

            I’m sorry Michael, did you misunderstand my opinion that an HMR pharmacist benefits from experience in areas of other pharmacy work to mean that an HMR pharmacist should never do HMRs?

            I’ve yet to meet a pharmacist who only wants to do HMR and RMMR work, or who doesn’t benefit from working in other areas of pharmacy

          • Big Pharma

            Spot on! The more THRs an interventional Cardiologist does the better prepared he/she will be for the next PCI

          • Debbie Rigby

            Agree the caps to HMRs should also be changed or removed. I would be comfortable with a cap of 20 per week. In my experience it is difficult to conduct more than 4 per day including travel and writing the report + discussions with the GP and community pharmacist.
            I haven’t seen the details yet, so hopeful there will be additional changes there.

          • Big Pharma

            Absolutely agree. It is not possible to provide a quality review and written report, travel and liaise with others involved in the patient’s care for more than 4 patients per day. I think 3 patients could be done comfortably and to a high quality.

      • Amandarose

        I have recently been contracted directly by a an aged care facility provider as an in-house pharmacist just 1 day a week.
        The role is to do reviews when people come in or when staff have issues. There is also a big push to reduce the use of anti-psychotics since the royal commission.
        The job involves liaising with the RMMR providers and pharmacies. So far I have only been doing this job for a few months and I can see the benefit f the role but I am finding it emotionally draining due to what I consider terrible treatment of a couple of patients. I was losing sleep over it to be honest. But change takes time and persistence and patience.
        I was offered a full-time role but I don’t want the stress to be honest. Not yet anyway.
        The culture is changing slowly in aged care with some great leadership in the particular chain so I will keep at it for now.

  2. Andrew Kelly

    Interesting that none of these people describe in their “multi disciplinary teams” the pharmacy that is actually tasked with supplying medications to these residents. Is their opinion not required or not deemed worthy? Any previous interactions they have had with doctors, nurses, etc not deemed significant?

    • Jarrod McMaugh

      PSA is currently facilitating a trial of pharmacists in RACF for the CSAPHN.

      One of th critical parts of this program is coordination with the local pharmacy, as well as the supply pharmacy (rural RACFs often have supply from a pharmacy hundreds of kilometers away)

      Is it deemed worthy? Yes… far more the worthy, it is essential.

      • Paul Sapardanis

        Why do RACF use supply pharmacies many kilometres away when they have a capable local pharmacy able to provide the same service?

        • Jarrod McMaugh

          you would need to ask the facilities in question – its not uncommon….

          2 most common reasons I’ve seen are:
          1) Supply pharmacy tendered at the lowest rate
          2) RACF has a head office that contracted 1 supply pharmacy for multiple RACF sites

          • Paul Sapardanis

            I wonder if medicare has ever considered auditing these contracts to see if they are in breach. Money/goods/services going back to the RACF???

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