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 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.”
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 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, 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.