To embed, or not to embed

The AJP Debate: the case for, and against, having pharmacists embedded within aged care settings or GP clinics 

EMBEDDED PHARMACISTS – The argument for: by Mark Naunton

You might not have given much thought to pharmacists working in general practice or residential aged care facilities (RACFs). I propose that we should extend where pharmacists work, and the premise to my argument? People matter. It is that simple.

In 2019, amidst the Royal Commission into aged care, Health Minister Hunt announced that Medicine Safety and Quality Use of Medicines would become the 10th National Health priority. Drug-induced morbidity has long been a source of global concern. In 1998, we were informed (not for the first time) that about 12% of all admissions to Australian medical wards, and about 20% of all emergency admissions among the elderly, were medicine-related.

This equated to 81,000 medicine-related hospital admissions per year at a cost of $350m annually. About 50% of medicine-related problems (MRPs) were considered preventable. This proportion has not changed over time, so clearly things have not improved—perhaps they have even worsened. There are currently 250,000 medicine-related hospital admissions annually, and a staggering 400,000 additional presentations to emergency departments likely due to MRPs.

Over time we have seen the role of hospital pharmacists expand from dispensing medicines, to being embedded into speciality units like the ICU, medical, and surgical wards. A neonatologist told me a few years ago that she doesn’t start her ward round without a pharmacist being present. Why? Because they enhance the quality of patient care and provide a safety net.

Indeed, some have argued the emergency department (ED) is a key area where elements of the prescribing cascade are initiated. Paraphrasing Chris Alderman—the corticosteroid used in the ED to control the patient’s COPD is the trigger for destabilised BGLs; the antibiotic used to control the UTI facilitates the over-coagulation and major bleed in a patient the following week.

More recently we have seen hospital EDs identified as key areas to improve the quality use of medicines. Gradually, but incompletely, pharmacists are becoming embedded into those areas. We have evidence that pharmacists working in ED improve a range of outcomes including medication safety, optimisation of therapy, timely medication administration, and cost of care. And these activities cannot be successfully performed remotely from the pharmacy department.

The importance of primary care

But we all know that hospitals are not the only source of MRPs. They frequently originate in primary care. Indeed, as stated earlier, MRPs are a major preventable cause for presentation to EDs.

How have we addressed resolving MRPs so far? We have seen expansion of pharmacists’ roles and we now perform home medicines reviews (HMRs), residential medication management reviews (RMMRs) (with follow-up), and more recently MedsChecks conducted in community pharmacies. We have seen efforts, albeit limited, (based on research ~20 years old) to ensure patients at high risk of MRPs associated with hospitalisation have access to pharmacists’ expertise.

But services such as HMRs and MedsChecks are performed in very few patients each year—the proverbial tip of the iceberg. Furthermore, they are often performed in isolation by pharmacists, with minimal interaction with GPs and other health professionals. We need pharmacists to be truly embedded in care teams at the site of care provision. A lack of proximity between care providers increases the risk of inadequate communication systems and practices, which in turn increases the risk of medicine-related adverse outcomes.

There is clear evidence that written communication only between pharmacists and GPs during RMMR service provision is associated with a lower uptake and implementation of pharmacists’ recommendations; whereas interactions that include verbal communication, such as case conferencing and discussion either face-to-face or via the telephone, are associated with higher uptake of pharmacists’ recommendations and, importantly, improved resident outcomes. Unsurprisingly then, MRPs continue to negatively impact patient health at the same rate.

If we liken the general practice/residential aged care facility (RACF) to an ED where some of the MRPs are initiated, then why not also prevent or manage MRPs at the point of origin?

There is growing evidence that having pharmacists working in other settings provides benefits.

Evaluations conducted in Australia have demonstrated the benefit of having pharmacists in general practices and RACFs. Indeed, in the pilot studies, embedded pharmacists have been retained, or in some cases their employment FTE increased, despite the system not being configured to support it. This is telling. Why would you bother to employ someone if you didn’t see it beneficial to you or your patients?

Of course, embedding pharmacists will come at a cost. The cost of not acting, however, may well be greater. Patient care and safety (benefit) should be paramount. There is growing evidence that these models work, but sometimes you can’t wait for all the top-tier evidence to be gathered before acting. The human cost of doing nothing can be significant (as in the COVID-19 pandemic). The UK Government funded pharmacists in general practice with relatively little published evidence at the time. Sometimes, in order to save lives (and money), you need to commit and invest.

Some may argue pharmacists working in general practice or RACFs creates role duplication. However, as above, we have seen little inroad into the resolution of MRPs over time and more multi-faceted interventions are needed. The current system is not managing the tidal wave of MRPs, and it is naïve to think so.

Given that the cost of medication-related hospital admissions to the Australian taxpayer has been well documented, and it now amounts to $1.4bn annually, I think that some investment in the medicines experts who can prevent some of the harm caused by MRPs is well overdue.

Pharmacists have the opportunity to step up and improve the system. We have done enough counting. The status quo is not working. We need pharmacists at every major point where MRPs exist and embedding pharmacists in RACFs and GP practices is a step in the right direction, because people really do matter—it is that simple.

Mark Naunton is Professor of Pharmacy and head of the School of Health Sciences at the University of Canberra.

EMBEDDED PHARMACISTS – The case against: by George Tambassis

Suggestions that non-dispensing pharmacists be embedded in aged care facilities would invariably lead to further fragmentation of care for a very vulnerable cohort of patients.

And to put it bluntly, it is the wrong approach.

Aged care facilities already have long-established relationships with one or more community pharmacies which provide medicines and services for their residents.

Embedding non-dispensing independent pharmacists into these facilities would simply see them provide services which already are adequately met by current arrangements.

Rather than going down the embedding rabbit hole, what we need to be looking at is using the available workforce in community pharmacy, especially in areas with a limited health workforce.

Community pharmacy is an integral part of the primary healthcare system and collaboration between community pharmacy and all healthcare services provides integrated patient-centred care which improves the quality use of medicine—a key to better outcomes in aged care facilities.

The current medicine management system is fragmented and inefficient. This fragmentation of care can negatively affect the quality of service, medicine management, and continuity of care provided to residents. It also can increase the possibility of medicine misadventure, can place the residents’ health at risk, and compromise the quality use of medicines.

At present, most medicine management services such as residential medication management reviews (RMMRs) and Quality Use of Medicines (QUM) services are provided by a small number of providers, resulting in many aged care facilities being serviced by fly-in/fly-out providers rather than by their local community pharmacy, which would be a much more ideal situation.

In addition, suppliers that are not based in the same town as the facility are providing many medicine supply contracts. In these situations, the supplier does not provide urgent medicine support or advice and, as such, the facility commonly relies on the local pharmacy to fill this gap.

Currently, aged care facilities may have arrangements in place with up to four different pharmacy service providers for various functions. Under the current arrangements, many of these services are corporatised and delivered remotely.

The best connection

The key to better and more efficient outcomes is to strengthen the connection between local community pharmacies and the aged care facilities.

For pharmacists to be most effective within an aged care facility at maximum efficiency to the health system, they must maintain and strengthen patients’ relationship with their community pharmacy, and ensure efficient use of limited health funding by not duplicating services already being provided in the local community pharmacies.

Due to the current maldistribution of the pharmacy workforce, particularly in regional, rural, and remote Australia, there is a very real possibility that embedding pharmacists in aged care facilities will exacerbate existing workforce pressures and threaten the future sustainability of the community pharmacy network in these locations.

Moreover, it is an inefficient use of government funds and not cost effective to embed pharmacists and duplicate services that can be provided by community pharmacy in a more timely manner—including access to a pharmacist after hours for urgent needs. Interestingly, hospital discharge seems to usually occur on Friday afternoons, highlighting he importance of seven-day pharmacist availability.

In most areas, embedded, independently contracted or employed pharmacists would not be viable. Community pharmacies in remote or very remote Australia have developed exceptional collaborative models with other local health professionals. They have often cared for these patients for many years and have strong community relationships with family members. They are best suited to provide enhanced models of care and ensure existing relationships are built on and the medication management service is reliable, suitably staffed and consistent with the whole of community care already offered.

The best way to integrate community pharmacy with aged care facilities is through an outreach model of care using local community pharmacists.

With appropriate funding, community pharmacy could provide an individualised, facility-based pharmacy package that could include:

  • seven-day support;
  • a routine, medicine service;
  • access to urgent medicines when it is needed;
  • medicine management system;
  • support for older Australians who want to self-manage their medicines;
  • participation and contribution to relevant case conferencing;
  • provision of medicine reconciliation services to every older Australian;
  • provision of medicine reviews based on clinical need;
  • whole of residential aged care facility clinical audits;
  • participation and contribution to relevant aged care facility committees;
  • assistance to dispose of unwanted medicines; and
  • management of medicines at residential aged care facilities.

Pharmacists are a vital resource in ensuring the safety and quality of services provided to aged care residents, specifically medicine management services. Demonstrably, you cannot separate supply of medicines from Quality Use of Medicines and medicine safety, and the clinical role of the community pharmacist that accompanies supply.

And a major factor in continuing to use community pharmacies to provide medicines and services to aged care facilities is the wide distribution and accessibility of the nation’s 5,800 pharmacies.

In relation to location of community pharmacies and residential aged care facilities:

  • 99% of residential facilities have access to at least one pharmacy within 2.5km radius in metropolitan areas and 93% in regional areas;
  • 78% of residential facilities across Australia have access to at least two community pharmacies and are within 2.5km radius; and
  • 80% of residential facilities have access to three pharmacies within 10km radius.

George Tambassis is the outgoing national president of the Pharmacy Guild of Australia.

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  1. Andrew

    One argument cites facts and figures about the benefit to the community and public health, the other doesn’t and wants more funding for community pharmacies without evidence for outcomes.

    Commercial operations should be at arms length from public health measures.

    • Michael Post

      Agreed. The Guild have presided over a medication misadventure environment that has not improved for decades. Community pharmacy agreements remain committed to fee for product with a sprinkle of ‘ professional setvices’ funding to add a veneer of health intervention.

      • Anthony Tassone

        How exactly is it that the Guild has ‘presided over a medication misadventure environment’ – when it has been the Guild that negotiated through Community Pharmacy Agreements in the first instance any funding for Home Medicine Reviews and Residential Medication Management Reviews?
        When there were was a previous over spends in the Home Medicine Review program that led to the capping of services, rather than allow the service fold – the Guild negotiated the re-allocation of funds from other programs (that were directly delivered from community pharmacies) to HMRs (that were not necessarily delivered by community pharmacy proprietors or employees.
        Rather than a ‘sprinkle of professional services’ in excess of $1 billion of funding towards professional services was negotiated in the sixth and seventh community pharmacy agreements.
        This is all in addition to submissions and advocacy for the Royal Commission into Aged Care with any funding that can be achieved there would be in addition to what is currently available in the Community Pharmacy Agreement.
        Whilst significant, Community Pharmacy Agreements are not the only or exclusive source of remuneration relevant to pharmacists and pharmacies.

        Anthony Tassone
        President, Pharmacy Guild of Australia (Victoria Branch)

        • Michael Post

          Hi Anthony
          The number of medication misadventures per year that has not improved over more than two decades speaks to the failure of the community pharmacy model maintained by Guild Government agreement with almost exclusive funding of Section 90 approvals.
          George Tambassis uses the old ‘ fragmentation of services’ argument that any funding outside Section 90 will collapse the system.
          Section 90 is designed and funded to supply at volume. Consumer education , med reconciliation and sharing of knowledge is poor to non existent in Section 90 – it doesn’t pay to spend time with patients.

          Methods to engage such as HMR and Medscheck are capped at low volume monthly clearly demonstrating patient education is not a priority. How about capping prescription volume per day per pharmacy and having uncapped patient education and medication reconciliation funding if we are serious about health.
          Medication misadventure plus a significant proportion of miserable employee pharmacists are the signal to the profession and Government that the system is broken and that dissociation from Section 90 funding is the solution not the problem. The Guild unfortunately represent the interests of less than 20% of the profession yet control almost all funding- a recipe for the disaster we find ourselves in.

  2. Benjamyn Sung

    Mark Naunton is right. Separate QUM from supply leads to impartiality of services. Geroge Tambassis is wrong in saying that “you cannot separate supply of medicines from Quality Use of Medicines and medicine safety, and the clinical role of the community pharmacist that accompanies supply.” The reason is there is a dual interest in “making money by supply” and “recommendation in the best interest of patients” and these two interests may conflict from time to time.

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