‘Community pharmacists may never actually meet the resident.’

Leading pharmacist joins call for colleagues to be integrated in residential aged care facilities – with community pharmacy too separated from the point of care

Pharmacist researcher and PSA’s SA/NT Pharmacist of the Year for 2017, Dr Janet Sluggett, has advocated for the role of embedded pharmacists before the Royal Commission into Aged Care Quality and Safety.

Dr Sluggett is currently the NHMRC early career fellow at Monash University’s Centre for Medicine Use and Safety.

She told the Commission on Friday that “there is an urgent need for a subsidised model of practice which enables pharmacists to be integrated within residential aged care facilities, to provide clinical pharmacy services and support quality use of medicines in residential aged care”.

Non-dispensing pharmacists can undertake a range of activities to improve medicines use in residential aged care, Dr Sluggett said at the Darwin hearing.

Dr Janet Sluggett. Photo: Supplied.
Dr Janet Sluggett. Photo: Supplied.

These include conducting comprehensive medication reviews and routine medication chart checks, advising staff on medicines, collaborative prescribing in conjunction with GPs, administering vaccinations and more.

There is Australian evidence demonstrating this model of practice improves medicines management in residential aged care, she said.

However she conceded that at present it is “extremely rare” for aged care providers to directly employ pharmacists as members of staff to coordinate or deliver clinical medication services.

Her recommendation echoed comments by Australia’s Chief Medical Officer Professor Brendan Murphy, who told the Commission in May that trials embedding pharmacists in residential aged care facilities have shown “very good benefit” for the reduction of antipsychotics and that embedded pharmacists should be the “highest priority”.

Dr Sluggett told the Commission that community pharmacists often don’t have a lot of information about the aged care residents that they’re packing medicines for.

“Community pharmacists often have very limited clinical information provided to them about the residents for whom they are dispensing medications, and may never actually meet the residents for whom they are dispensing medications,” she said.

“This is different to the traditional model of community pharmacy where patients bring in their prescriptions and pharmacists can easily have a face-to-face discussion with a patient of family member picking up a prescription.

nurse giving medicine to senior elderly older woman at hospital nursing home

“Integrating pharmacists within residential aged care facility will improve provision of medicines information at the point of care,” said Dr Sluggett.

She added that physical separation between pharmacies, GPs and residential aged care facilities means that each stakeholder can spend a considerable amount of time communicating between each other.

“Some GPs, community pharmacists and aged care providers have excellent and well-established relationships that can facilitate information sharing, but if not, this can be a barrier.”

However she said community pharmacists can have a bigger role to play if falls risk status was placed up front in DAAs.

“A community pharmacist is dispensing a medicine that could be associated with an increased risk of falls, but the community pharmacist may not have any clinical information or knowledge about that resident,” she said.

“And it would be nice for, you know – a community pharmacist could play a role in flagging this person is being dispensed a medicine that could increase the risk of falls. Perhaps you should consider monitoring this resident a little bit more closely in the next couple of weeks to see if they are at an increased risk of falls.”

Counsel assisting Peter Gray suggested that this would be “a very important measure” considering the devastating impact that falls can have on people in aged care, to which Dr Sluggett agreed.

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  1. -Increase funding/alternative funding for QUM.
    -Expand scope of QUM activities.
    -RMMR reports removed, medication reviews delivered differently.
    -Reimburse set fee per bed numbers.
    -One pharmacist can look after multiple facilities under contractual obligations.

    -New clinical career pathway for community pharmacists.

  2. PeterC

    Surely the issue here is one of economics? I’d just like to ask two things:
    Firstly where is the pharmacy business case for providing QUM services to RACFs, especially smaller facilities? How do you actually make money out of it? The truth is that there is little or no financial incentive for achieving better QUM outcomes.

    Secondly, who finances QUM in RACFs? Where does the money come from, and is it adequate? The short answer seems to be that facilities have to fund it themselves and most choose not to. There’s probably not an RACF in the country that wouldn’t jump at the chance to have a fully funded pharmacist parachuted in to do QUM but most will jump a mile in the other direction as soon as they have to pay for it themselves. And that’s exactly what they do when you ask them to pay

    So the truth is that many RACFs don’t actually want QUM arrangements at their own cost. It explains why many pharmacies are doing QUM for nothing or a pittance – in other words, funding it themselves out of script revenue, which doesn’t create any financial incentive for good QUM outcomes

    Among the (hopefully many) good things that could come out of these inquiries into aged care is more money being made available for pharmacy services – i.e. better financing – and better targeting of incentives towards QUM outcomes. Once the money is on the table we can argue about how to most efficiently spend it. In many cases a sessional service by a local community pharmacy is going to prove to be most economically efficient. Whomever pays.

    • Debbie Rigby

      Just has been discussed with pharmacists in GP surgeries, in some cases (especially in rural areas) the pharmacist working in the aged care facility (and GP surgery) may also work in or own a community pharmacy. The model needs to be flexible to fulfill local needs and workforce. It is likely that it would not be a fulltime position, and therefore on a sessional basis.

    • Fredrik Hellqvist

      Hi Peter,
      An interesting study is PINCER by Avery et al. 2013 (Lancet 2012; 379: 1310–19) that showed positive outcomes when a pharmacist was involved in identifying and giving feedback to GPs regarding prescribing in certain pre-defined circumstances (prescribed a non-selective NSAID if they had a history of peptic ulcer without gastroprotection; a β blocker if they had asthma; ACE inhibitor or loop diuretic without appropriate monitoring). The study identified the ability of pharmacists to reduce the number of medication errors in GP practices with a cost of about £75 per error avoided. However, in the follow up article by Elliott et al. 2014 (PharmacoEconomics (2014) 32:573–590) it was shown that “PINCER produced marginal health gain at slightly reduced overall cost.” This result was further analysed and it was suggested that it may be more cost-effective to target certain errors such as those that individually were shown to be cost-effective rather than looking at everything. These findings would be relevant to the RACF setting. Thus, it would seem that Community Pharmacy is well placed as long as we are supported to do so. Community pharmacy, particularly in rural areas, should be supported and adequately remunerated to provide care across settings. This is a logical and cost-effective approach in smaller communities to make the best use of existing pharmacy resources and strengthen continuity of care, ensuring all members of a patient’s healthcare team are working together.

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