Should pharmacists be able to initiate reviews?


Changes to HMRs and RMMRs are welcome… although some are not appropriate for the longer term and others do not go far enough, argues pharmacy group

Rural pharmacists have welcomed the interim measures to support delivery of HMRs and RMMRs during COVID-19, says the Rural Pharmacy Network Australia (RPNA).

These changes include remuneration for follow-up consultations, broadening of eligible referrers, the ability to deliver via telehealth, and the option for RACFs to enter into service agreements with multiple RMMR providers.

“These changes will support pharmacists to deliver the vital medication services that patients need. This is especially important in rural areas where patients have reduced access to medical services and higher chronic disease burden,” says RPNA Co-Chair Fredrik Hellqvist.

However he suggests that while some of these measures are not appropriate for the longer term, others do not go far enough to build capacity in rural communities to deliver the medication management services that patients need.

“While the telehealth option is necessary right now, it should be a temporary measure that is suspended at 30th June,” Mr Hellqvist emphasises.

“It is very important that these services are delivered face-to-face, especially the initial consultation. Telehealth may have a place in rural health – and perhaps it may be appropriate under certain circumstances for follow up consultations to be conducted via telehealth – but the patient should always be given the choice of face-to-face service alongside the telehealth option.”

Karalyn Huxhagen, a consultant pharmacist based in Mackay, Queensland, says that the changes are needed and says she plans to utilise telehealth herself.

“In this time of COVID-19 crisis that I welcome the ability to perform medication reviews during telehealth services where appropriate,” Ms Huxhagen told AJP.

“I do plan where necessary to undertake telehealth because since the March lockdown started we’ve had patients who have had refused to have their HMR – not because they don’t want one but because they’ve self-isolated due to their age and medical conditions and do not want anyone in their homes.

“Now the procedure is in place we will now be re-visiting with those patients to see if we can initiate telehealth.”

However she agrees that HMRs are, in general, best performed in person.

“My viewpoint is that the HMR service should where possible be performed in the home, because that is the most appropriate method to determine many issues that are seen by the HMR pharmacist,” says Ms Huxhagen.

“Going forward there may be a role to perform the new services such as the two follow ups as a telehealth service, because the initial HMR would have been performed in the home, but especially for rural areas PhARIA 4-6 the follow-ups may be able to be done in a telehealth format. And I think that’s justifiable.”

Consultant pharmacist Debbie Rigby, from Brisbane, applauded the rapid implementation and acceptance of telehealth services.

“It’s great that HMRs and RMMRs can now be conducted this way so that consumers and medical practitioners are not missing out on these valuable medicines safety programs. I would hope that telehealth services will continue post-COVID especially in rural and remote areas,” she says.

“However telehealth consultations will be challenging to deliver in aged care homes where many people have dementia and there are critical shortages of care staff.

“For HMRs there is a benefit in seeing the patient in their home, and accessing all the medicines they have. I’d like to see telehealth consultations for HMRs and RMMRs continue in rural and remote areas, under specified conditions.”

Meanwhile RPNA further questioned why pharmacists themselves are unable to refer directly for medication reviews.

“As for the broadening of eligible referrers to include other medical practitioners, this is a good first step but it begs the question why pharmacists – as the medicine experts – are not able to identify patients in need and either conduct the reviews themselves (if accredited to do so) or themselves refer the patient to a pharmacist who is appropriately accredited for review,” the group asks.

“At the moment, patients in rural areas are missing out on reviews for a number of reasons. In many cases rural towns are serviced by locums and these GPs are not prioritising medication reviews. Also many patients do not even have access to a GP where they live and their pharmacist is the only health professional who they can easily and regularly speak with. Nobody is in a better position than rural community pharmacists to identify who needs a review.”

RPNA suggests that over-servicing could be controlled by requiring recorded justification for any review undertaken without referral, and by capping the number of reviews a pharmacist can initiate.

“Furthermore, rural pharmacists tend to have good collaborative relationships with their GP colleagues increasing the likelihood that recommendations will be taken up regardless of who initiated the review,” the group says.

Ms Huxhagen emphasises that medication review services should be multidisciplinary in nature.

“Whatever recommendations are made still needs to involve a GP because the prescribing is ultimately performed by the GP,” says Ms Huxhagen.

“I’m not against pharmacists identifying and initiating the HMR service in locations where a GP may not be located in that area, but I would not want it done without GP involvement.

“HMR is a multidisciplinary practice, it involves everybody that prescribes and looks after that patient. Whilst the GP at the moment is [the hub] in the hub and spoke model, because they’re the one that initiates the HMR, truthfully many HMRs are prompted by others – the nurse, the pharmacist, the physio.”

Ms Rigby agreed, calling HMRs and RMMRs “collaborative” services.

“Collaborative medication management reviews are conducted in the context of the patient’s medical and medication history in partnership with the prescriber and the patient,” she told AJP.

“So I don’t think pharmacists should be able to initiate reviews – but can definitely identify people likely to be benefit from one. Collaboration is the key. A follow-up can now occur and be remunerated – this is a really positive step forward and likely to impact on patient outcomes following an initial review.”

PSA told the AJP it was taking the RPNA’s comments into consideration.

“We welcome the RPNA support for these measures and look forward to monitoring and considering future changes to medication review programs as more information comes to light,” said PSA National President, Associate Professor Chris Freeman.

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