Recommended: an expert pharmacist presence

elderly couple silhouette made from pills

The Final Report into the aged care sector makes several recommendations about the involvement of pharmacists, including medication management reviews

The Final Report of the Royal Commission into Aged Care Quality and Safety was tabled in Parliament on Monday, recommending “fundamental reform” of the entire aged care system.

In their Report, titled Care, Dignity and Respect, Royal Commissioners Tony Pagone QC and Lynelle Briggs AO write that, “The extent of substandard care in Australia’s aged care system reflects both poor quality on the part of some aged care providers and fundamental systemic flaws with the way the Australian aged care system is designed and governed”.

“People receiving aged care deserve better. The Australian community is entitled to expect better.”

Instead of focusing on the needs of older people, the existing system has focused on the requirements of aged care providers, they write.

The Royal Commission investigation was announced by Prime Minister Scott Morrison in 2018, as Four Corners prepared to air a two-part series titled “Who Cares?”

The series identified a number of significant problems with the treatment of aged care residents, particularly the overuse of antipsychotic medicines.

Now, the Commissioners have made 148 recommendations, including the establishment of a new Aged Care Act to enshrine rights and provide a universal entitlement for high quality and safe care based on assessed need.

These include a recommendation “to provide comprehensive medication management reviews by pharmacists to prevent harmful medicine interactions, overuse of medication or chemical restraint via inappropriate use of antipsychotics”.

“In aged care, medication management reviews are critical to reduce chemical restraints and other inappropriate use of medications,” the report states.

“People living in residential aged care are entitled to only one Residential Medication Management Review every 24 months, unless there are significant changes to their medical condition or medication regimen.

“We recommend that the Australian Government should improve access to medication management reviews for people receiving aged care by funding pharmacists to undertake reviews on a person’s entry to residential care and annually thereafter, or more often if there has been a significant change to the person’s condition or medication regimen.

“Residential Medication Management Reviews should also be available to people who receive respite care or transition care in a residential aged care facility.

“The Interim Report identified widespread use of chemical restraints in the purported ‘care’ of many older people in residential aged care.

“In its response, the Australian Government announced changes intended to address problems with medication management. These measures are commendable, but they do not go far enough to address a problem that has persisted for decades.

“The Australian Government should introduce stricter requirements for prescribing antipsychotic medicines for people in residential aged care. Under the Pharmaceutical Benefits Scheme Schedule, risperidone is only subsidised for the treatment of autism in children when under the supervision of a paediatrician or psychiatrist.

“We recommend a similar practice should apply to residential aged care: only a psychiatrist or a geriatrician should be able to initiate treatment with antipsychotic medicines for people in residential aged care.

“This will ensure that every person in residential aged care is reviewed by a specialist before antipsychotic medicines are begun.”

Governments should introduce multidisciplinary outreach services for all aged care residents, the report says, which would include pharmacists as well as nurse practitioners and allied health workers.

Another recommendation is that providers have arrangements with allied health professionals, including employing – or otherwise retaining – at least one pharmacist, as well as mental health practitioners, oral health practitioners, podiatrists and more.

This would utilise a “blended funding model” including “a capped base payment per resident designed to cover about half of the costs of establishing ongoing engagement of allied health professionals,” and “an activity based payment for each item of direct care provided”.

Pharmacy reacts

The Society of Hospital Pharmacists of Australia welcomed the recommendations supporting the inclusion of pharmacists in aged care settings.

SHPA Chief Executive Kristin Michaels said the supported presence of a pharmacist in the residential aged care setting will help ensure the safe, quality care of this vulnerable cohort.

“Research released by the Office of the Royal Commission into Aged Care Quality and Safety this month found that between 2014 and 2019, hospital admissions from aged care residents increased by 20%, while emergency department (ED) admissions increased by 27%; more than one-third of all aged care residents present to EDs at least once a year,” she said.

“The evidence makes clear that investment in embedding a dedicated Geriatric Medicine Pharmacist as part of minimum allied health care, supported by capped-base payments per resident and activity-based payments for the direct care provided, will be a strong step toward reduced medicines misuse and medication-related hospitalisations and injuries among older Australians.

“We have called for this expert pharmacist presence for some time and look forward to partnering with government to ensure safe and effective implementation.”

Ms Michaels also welcomed the decision to allow and fund pharmacists to conduct medication reviews on entry to residential care from 1 January 2022 and annually thereafter.

“SHPA strongly supports enhanced Residential Medication Management Review service delivery, given that publicly available data indicates in 2018-19, only 30% of Australia’s 243,000 aged care residents were able to access a RMMR service.

“Dedicated pharmacist presence will ensure the optimal efficacy of RMMRs for aged care residents, and we welcome the amendment of the eligibility criteria to include people in residential respite and transition care.

“The crucial role of pharmacy in aged care is undeniable, with Australian research indicating 91% of aged care residents take at least five regular medicines, and 65% take more than 10, every day.

“SHPA will continue to advocate for investment in embedding clinical pharmacy services for aged care residents – including 1:200 pharmacist-to-resident ratios – so pharmacists can identify and manage medication-related issues before they lead to avoidable harm and admission to hospital,” she said.

“When present in the right place at the right time, pharmacists can identify deprescribing opportunities and foster high quality clinical handover as patients move between care settings, which is vital for their wellbeing and quality of life.”

The PSA also welcomed the final report.

“Inappropriate chemical restraint, and polypharmacy leading to sedation, falls and avoidable hospitalisations are some of the biggest problems in aged care. Pharmacists are the key to solving these problems,” said president Christopher Freeman.

Access the Final Report here.

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