Is embedding non-dispensing pharmacists the ‘wrong’ approach?

Can non-dispensing pharmacists play a crucial role such as prescribing and advising GPs… or should this role be filled by community pharmacists instead

Pharmacist researcher Dr Janet Sluggett, an NHMRC early career fellow at Monash University’s Centre for Medicine Use and Safety, put forward an argument for integrating pharmacists into aged care facilities before the Royal Commission into Aged Care at a Darwin hearing this month.

“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,” she said in her statement to the Commission.

“Integrating pharmacists within residential aged care facilities will improve provision of medicines information at the point of care.

“In my opinion, 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.”

Dr Sluggett said non-dispensing pharmacists can undertake the following activities to create safer medicines use in aged care facilities:

  1. Comprehensive medication reviews and routine medication chart checks.
  2. Education for residents and family members, facility staff and GPs.
  3. Participation in rounds with GPs to advise on medicines use and resolve medicines-related problems.
  4. Assist residential aged care staff and GPs with medicines information queries.
  5. Collaborative prescribing, in conjunction with GPs, to implement agreed deprescribing plans and monitor/adjust doses of medications that require close monitoring (e.g. warfarin) in accordance with monitoring plans agreed with the GP.
  6. Contribute to antimicrobial stewardship activities.
  7. Administer vaccinations to staff and residents.
  8. Contribute to development of local guidelines.
  9. Review medication incidents, and facilitate audit and feedback activities relating to use of high-risk medicines.
  10. Participate in case conferencing.
  11. Undertake assessments of a resident’s ability to self-administer medicines, and provide ongoing support and assessment for residents who are able to self-administer.
  12. Actively participate in relevant committees, such as medication advisory committees, clinical governance and infection control.

However Pharmacy Guild Acting National President Trent Twomey said embedding non-dispensing pharmacists in aged care facilities would be “the wrong approach”.

“There is no funding for such a model, and no likelihood that funding will materialise any time soon. And even if funded, it would still be the wrong approach,” he told AJP.

“The key is to bolster the connection between local community pharmacies and the aged care facilities, so that the pharmacist dispensing the medication is also the pharmacist overseeing the medication management for the patient.

“Community pharmacies that work with residential aged care facilities have long adopted an approach of translating best practice from the community sector into aged care settings,” said Mr Twomey.

He added that it is important to recognise the importance of Residential Medication Management Reviews (RMMRs) and QUM activities undertaken by pharmacists in collaboration with aged care staff.

“There is currently a real risk of these services being corporatised and delivered remotely,” he said.

Dr Sluggett had highlighted in her evidence that the RMMR program is a “valuable service” and has “provided an extremely important mechanism for pharmacists to provide clinical input into medication management for residents”, however there may be considerable variation in the provision of RMMRs in different facilities.

She also said pharmacists should be more involved than they currently are in the RMMR process and there is a need for more funding.

On the Guild’s position, Mr Twomey continued: “Our view is that wherever possible, the delivery of these services should be directly connected to medicines supply by the local pharmacy, and focus on known medication related issues in residential aged care, including overprescribing, the overuse of medication for behavioural issues in patients with dementia, medicine misadventure and errors during transitional care and support for palliative care patients.

“Of course, these services provided by the local community pharmacist also need to be appropriately remunerated, with clear links back to the patients’ general practitioners.”

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  1. Karalyn Huxhagen

    I have to comment as an n=1 as I have been in both situations. I was not directly empoyed by an RACF but have been the QUM and RMMR and dispensing pcist for 5 facilities since the beginning of these programs. I then became the independent contractor for RMMR and QUM services and I liaise with the dispensing phcies-we have an excellent relationship. Being an embedded pcist would give me a greater flexibility and respect within the facility . currently I fight for a desk and compouter access with the visiting GP, physio, aged care nurse consultant, dietitian, podiatrist etc. we try and coordinate our days as we all get the one computer and desk. being on site at the same time as GPs is whimsical in 4 out of 5 facilities as there is no schedule for GP visits. they appear when summoned. one has regular clinic rounds.when I was empolyed by a phcy as the dispensing pcist and RMMR and QUM pcist I rarely got to the ACF as the phcy always found reasons why I was needed on the floor e.g. sickness, dispensing load etc. They never took that role as a serious service that needed me to visit. They felt I could do it all at arms length over a phone. Trent talks about the corporates taking over. Sorry to say that the corporates have already taken over. I lost two ACFs to fly in, fly out services and the ACFs fax charts to an entity far far away. It ticks their accreditation boxes so they are happy with the service. They were not unhappy with my service and I have been wise enough not to push the question of what they were given to employ the corporate as one day I may get that contract back again.

    So whichever way this discussion goes there has to be a great deal of effort by both the community pharmacy and the ACF to treat this role as a professional role with identifed and measured outcomes.

    In this comission review I was asked to give my thoughts on how digital technology can improve the services that we provide. There are a lot of answers to this question but if I am not funded or remunerated for the costs of digitisation than will I incorporate this into my business practice?

    ACFs are like community phcy. They are asked, pushed, forced and legislated into providing a larger scope of services to residents with very little increase in remuneration. we have to work together on this one to make sure it works and the ultimate goal is a healthier happier resident.

    The pilot in Canberra is a good start BUT those facilities are within 30 minutes of home of that pharmacist. Mine are five to six hours drive away, contain a lot of aboriginal and CALD clients witth immense social issues as well as healh issues, serviced by fly in fly out GPs who come once a month. The acute care GP from the hospital picks up the slack. Luckily for him we got him an ipad and some money from the PHN so he can answer from bed for most questions.

    To provide my services I need accomodation, travel expenses, ability to digitally download charts , access to recent blood tests and discharge summaries. Embedding a pcist will be a significnat step forward as at least you will have more automony as to how you practice in the team environment.

  2. Apotheke

    Off course the Pharmacy Guild pushes back because any change to the role of Pharmacists from being Pharmacy owners (Guild members) or the employees of the same is a threat. Pharmacists paid by aged care facilities would not be beholden to a Pharmacy proprietor whose income is dependent on the quantum and frequency of drug supply to a facility. Unbiased professional opinion is obviously unwelcome.

  3. Andrew

    “It won’t work because it won’t work, but if it does work and gets funded, it still won’t work”.

    ACF stuff in pharmacy has always been an effing disaster. Avoiding corporatism in ACF services? Yeah right, here in the real world little operators running on razor thin margins who may or may not exist in six months time are actively cold calling facilities and poaching business, causing a mess, and then when it all goes tits-up the original provider has to come in and hose out all the BS.
    A single point of contact pharmacist associated with each ACF managing and triaging resources would obviously be more effective than the hodgepodge of whatever we call what’s happening now.

  4. Debbie Rigby

    Saying “we’ll do more if we get paid more” does not reassure me that change will happen.

    Pharmacists strongly hold on to the concept of separation of dispensing and prescribing; in my experience medication review should be separate from dispensing to achieve the best patient outcomes.

    ‘Medication reviews’ are done at the point of prescribing and dispensing by doctors and pharmacists respectively. But comprehensive medication reviews #HMRs #RMMRs go beyond assessment of safety, efficacy and appropriateness of one drug at that point in time. They look at the entire medication regimen, in the context of a patient’s clinical status (which has often changed) and their preferences. And they are collaborative with other health professionals and family/careers involved in the care of the patient.

    • Paul Sapardanis

      HMR and RMMR are generally given to the ACR pharmacy provider so it can be rebated back to the ACF. As an owner I have to agree that separating supply and service would provide the best outcomes

  5. mary b

    I dispute Mr Twomey’s assertion that community pharmacists supplying ACF translate best practice to the ACF residents. The simplest example is supplying calcium in the morning and I can offer many other examples of less than best practice – I don’t want to be involved in supply, as an accredited pharmacist I am not competing for your supply income. What I DO want is best practice care for ACF residents and being employed on site is a means to deliver this, in collaboration with the supply pharmacy

  6. Jenny Gowan

    I have been working in this area for many years and find that on the list we are doing all the activities listed except ‘ward rounds, prescribing, and immunisation. We work very closely with the ACF staff, allied health people, geriatricians, GPs and community pharmacy. It can be done. I welcome some additional funding and time to complete the collaborative approach. Our current QUM funding does not provide the time to perform our full role.

    • Was just about to say the same thing.

      Apart from 1. , 3. 5. which relate to the delivery of medication reviews (which I have proposed that the RMMR system needs to change entirely), all activities are already undertaken.

      The viability of embedding a full-time pharmacist into every home is a huge question mark. The homes will definitely not fund it as they are already resourced limited.

      Our current 6CPA funding system could continue to work with minor amendments and/or alternative sources of funds (so not to take from community pharmacy).

      Supply and clinical do not need to compete. Stronger through collaboration. Just learn from the Hospital model.

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