‘Kindling for conversation’

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New protocols are “shining the spotlight on the importance of medication review at transitions of care,” say pharmacist experts

The Society of Hospital Pharmacists of Australia (SHPA) has unveiled a new framework to support the identification and referral by hospital-based clinicians of high risk patients to Home Medicines Review (HMR), Residential Medication Management Review (RMMR) and Hospital Outreach Medication Review (HOMR) pathways.

Released five months after the HMR and RMMR Program Rules were changed to broaden the referral base beyond General Practitioners and fund up to two follow-up encounters after initial medication review, SHPA’s Hospital-initiated medication reviews (HIMR): Hospital pharmacy practice update brings together the work of hospital, community and accredited pharmacists for more effective medicine management across transitions of care.

SHPA Transitions of Care and Primary Care Chair Deirdre Criddle says the HIMR Practice Update provides practical information enabling hospital-based doctors to harness the April policy changes, which were recommended in the Interim Report of the Royal Commission into Aged Care Quality and Safety.

“Safe transitions of care start in the hospital,” she says.

“With Medication Safety now Australia’s 10th National Health Priority Area, we want to help drive the conversation around pharmacist-led models of care targeting timely post-discharge medication management services for high-risk patients.

“It is important to note these pathways do not replace pathways for services already in place. They are additional or complementary pathways so more people can access medication review, especially when poor resourcing or a lack of time may prevent effective referral.

“We feel the SHPA HIMR Practice Update is the beginning of an overdue conversation between hospital and primary care, to change the culture from discharge to handover and make a real difference for our most vulnerable patients.”

She later told the AJP that when the SHPA Transitions of Care and Primary Care Specialty Practice Group was established three years ago, the Leadership Committee signalled an intent to prioritise pharmacist-led models of care targeting timely post-discharge medication management services for high-risk patients.

“The SHPA HIMR protocols are kindling for conversation between hospital and primary care, and no doubt will require clear communication, collaboration and some iteration among all stakeholders,” she said.

“It presents an opportunity to demonstrate our impact and improve patient care – especially for our most vulnerable patients!

“So, in this, the third year of the third WHO global patient safety challenge to reduce medication-related harm, we now have the opportunity to lead and change the culture from discharge to handover.”

Every year in Australia 250,000 hospital admissions are a result of medication-related problems, costing $1.4 billion, and the transition of care between the hospital and the community remains a known challenge.

SHPA Transitions of Care and Primary Care Leadership Committee member Dr Manya Angley, who provided testimony on inappropriate prescribing and use of antipsychotic medicines to the Disability Royal Commission in September, says the document supports hospitals to integrate new referral pathways into patient care according to their local workforce and community needs.

“This Practice Update provides a long-awaited framework for authentic collaboration between health professions to achieve our common goal – the best outcomes for patients at risk of medication-related harm – and the Leadership Committee acknowledges and thanks the work of experts who have advocated for these interventions over many years,” she said.

“Every sector of our profession now has a responsibility to engage with the HIMR Practice Update, and ensure the protocols effectively address this long-standing gap in care; we encourage Australian hospitals to embrace this complex area.”

She noted that the revised HMR and RMMR program rules were published in April 2020 and included key changes such as broadening of the referral base beyond GPs and funding for up to two follow-ups after initial medication review.

“However, it was evident the revised program rules lacked guidance for hospital doctors to use this opportunity to enhance patient care,” she told the AJP.

“So, the  SHPA TCPC embarked on developing the HIMR protocols, integrating information from the updated program rules and applying it to the hospital setting.

“The HIMR protocols acknowledge that the hospital team (emergency department, ward or outpatient clinic), should endeavour to facilitate referrals for HMRs and RMMRs via the patient’s GP in the first instance.  

“However, when the GP is unavailable or unable to refer for a timely medication review, the HIMR protocols provide a framework for each step of the process for a medication review following a hospital doctor’s referral: screening, gaining consent, flow of information and roles and responsibilities of each clinician.

“We strongly encourage hospitals to embrace and engage with the HIMR protocols and adapt them according to their local context and needs.”

And Katie Phillips, HARP Outreach pharmacist, Melbourne Health and Chair, Victorian Outreach Medication Management Group, Vic, told the AJP that “change is inevitable in healthcare”.

“People are living longer with chronic disease,” she said. “Patients are becoming more complex.

“Bed demand is high. Patients are being discharged from hospital more quickly, and there is a push for the community health sector to manage higher acuity issues and divert hospital admissions.”

She said that for this to be achieved, a safe and informed transition of care is vital.

“Community healthcare doesn’t stop once the patient enters a hospital, and hospital care doesn’t stop once the patient is discharged. We are all responsible for enabling patients to safely transition between the systems.

“There will always be need for hospital outreach pharmacist intervention for the complex cohort of frequent presenters who need more extensive and immediate input.

“These patients need the flexibility and resources of the HOMR model, to not only identify issues but also to problem solve and follow up as part of a multidisciplinary team. 

“But these new SHPA HIMR protocols are shining the spotlight on the importance of medication review at transitions of care, and allow a whole new cohort of rising risk patients the opportunity to receive early intervention which will hopefully reduce the proportion of these patients who will become the frequent presenters of the future.”

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