RMMRs and HMRs ‘inadequate’: SHPA

There should be one full-time integrated pharmacist for every 200 aged care residents, says hospital pharmacy group

Pharmacists should be embedded in aged care homes to provide clinical services, said the Society of Hospital Pharmacist of Australia (SHPA) in its submission to the Royal Commission into Aged Care Quality and Safety this week.

A ratio of one equivalent full-time pharmacist to every 200 aged care residents would provide an appropriate level of medicines management or clinical pharmacy care, the group recommended.

“But this is rarely met – if ever,” it said.

“Most aged care facilities do not have a pharmacist on staff or a pharmacist who is available to spend significant time with patients.

“Pharmacists are contracted primarily for the dispensing of medicines, which can exacerbate poor medicines management, rather than the regular and ongoing clinical review that is needed.”

Research into medication management in aged care facilities indicates that 91% of residents take at least five regular medicines and 65% take more than 10 regular medicines every day.

Meanwhile, discrepancies between doctors’ orders and residents’ medication charts are common and lead to medication administration errors, said SHPA.

A study led by Professor Johanna Westbrook, Director of the Centre for Health Systems and Safety Research at Macquarie University, found residents on average had nearly 10 discrepancies between their record in the general practice and their record at the aged care facility.

The most frequent discrepancy was medication omission (34.9% of discrepancies) where a medication was listed on the facility chart but not on the GP’s record in their practice.

“Thus a GP referring to their records when contacted by a residential aged care facility (which often occurs over the phone) may in fact have incomplete or inaccurate information to inform their decisions,” Professor Westbrook told the Royal Commission.

“Obviously that is mainly a problem when, for example, two drugs might interact with each other, and so you wouldn’t want to prescribe them.”

SHPA said the solution is having integrated or onsite pharmacists to provide access to clinical pharmacy services for aged care residents.

“In contrast to clinical pharmacy service for patients in hospital settings, current clinical pharmacy service provision to aged care residents and home care clients – in the form of federally funded programs such as the Residential Medication Management Review (RMMR) and Home Medicines Review (HMR) – is contractual and provided on an ad-hoc basis at the demand of the aged care service and/or on referral from a GP,” it said.

“The contractual model means it is difficult for pharmacist service providers to detect and address medication-related issues and collaborate with medical practitioners to implement recommendations.

“Its inadequacy in addressing the complex needs of this patient group, who require regular and timely monitoring and review of medicines, is further compounded by arbitrary service limits imposed through the Community Pharmacy Agreement which mean most aged care residents can only access one RMMR every two years rather than being re-assessed whenever medical treatment is revised or their health status changes.

“These limited programs are insufficient to address the disproportionate number of medication complications experienced by frail aged care residents,” said SHPA.

“Many aged care residents or clients do not receive HMR or RMMR, and when they do, it is often not provided at a time when it is most needed (e.g. following a care transition). For example, post-discharge medications reviews are frequently delayed or do not occur, and only one in five home care clients receives an HMR.”

Meanwhile research shows embedded pharmacists can reduce medication-related problems, polypharmacy and adverse drug events, while also being cost-effective, said the group.

Australia’s Chief Medical Officer Professor Brendan Murphy told the Commission in May that embedded pharmacists should be the “highest priority”.

See the SHPA’s full submission here

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  1. Bente Hart

    How would the funding work in rural areas where you got small nursing homes?
    I look after my local MPS nursing home with 26 beds – if 200 beds gives 1 FTE pharmacist for my nursing home would mean 0.13 FTE. Is the idea that the nursing home then gets visited by a pharmacist once every 2 weeks for 1 day? Does not make it attractive to do rural work unless you had other jobs in the area. Is there consideration to provide some rural loading even if the work is done by a local pharmacist who do not have a 200km round trip to get there?

  2. Jenny Gowan

    Remove the cap off 20 HMRs per month per pharmacist ( or organisation) , the 2 year restriction off the RMMRs in ACF, streamline continuum of care between hospital , GP and community with compatible
    electronic data transmission timely discharge – then we may be able to show improved results. Embedding pharmacist in large ACHs in metropolitan areas with adequate funding is a step forward but do not destroy our existing systems for the smaller homes and especially those in the rural settings. We should be building on what we have and assist the dedicated pharmacists who do their very best for low remuneration.

  3. (Mary) Kay Dunkley

    I am not sure if the 1:200 ratio is appropriate, I suggest 1:100 is more appropriate. The challenges in aged care include communication between GPs, specialist consultants, residents, family members, the supply pharmacy, other care providers, nursing staff and patient care assistants. Unless one is diligent in relation to communication the knowledge and expertise of an imbedded pharmacist will not provide much benefit. This all takes time and changes to medication often require considerable negotiation. Many of the residents have multimorbidities but do not have accurate long term health records and so getting to the bottom of a situation is often time consuming – they frequently change GP on admission to aged care. In addition the turnover of residents has increased in recent years as people now enter aged care much later in life and only live for a short while. If pharmacists really are to make a difference we need to ensure that the ratio of pharmacists to residents is such that the work can be undertaken effectively.

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