Proximity and partnerships : embedding pharmacists in Australian aged care homes to improve quality use of medicines

Abstract

Background Australia’s population is ageing, and the population entering residential aged care homes (RACH) are increasingly complex, frail, multimorbid, cognitively impaired, and have high levels of care dependency. RACH residents are at high risk of medication-related harm which result in adverse outcomes including avoidable hospital admission. Preventing medicationrelated harm in the high-risk RACH population is an important public health issue. The primary pharmacist-led medication review role in Australian RACH is the consultancy-based biennial residential medication management review (RMMR) service. This research was undertaken to explore whether Australian pharmacy practice can be diversified to reduce the risk of harm associated with medication use in RACH, by evaluating current pharmacy practice and exploring the feasibility of a residential care pharmacist (RCP) model. Methods Three individual studies were conducted to address the objectives of this thesis. The first study was a systematic review of the literature to narratively synthesise the current evidence reporting outcomes associated with pharmacist-led medication reviews in RACH residents with dementia. The second study was a cross-sectional survey design to obtain qualitative and quantitative data informing perspectives of Australian pharmacists, general practitioners (GPs) and nurses on the suitability and delivery of RMMRs for residents with dementia. The third study was a pilot non-randomised controlled study to explore RCP feasibility through stakeholder acceptability, demand and limited-efficacy testing. A part-time pharmacist was embedded into a RACH located in the Australian Capital Territory for six months in 2017. A similar RACH under the same organisation was used as the control site and received usual services. Data were obtained from RCP activities records, resident health records, incident reports, observation of staff practice, communication records, surveys and semi-structured interviews. Quantitative data underwent parametric and non-parametric analyses, depending on distribution. Qualitative data underwent inductive thematic analysis. Results In Study 1, five observational studies and one randomised controlled trial were identified from 3387 evaluated references during the systematic review. Pharmacist-led medication reviews, which involve multi-disciplinary collaboration may reduce polypharmacy and inappropriate psychotropic medication use. Study 2 surveys exploring stakeholder perspectives on the RMMR service for RACH residents with dementia were completed by 15 GPs, 15 pharmacists and 13 nurses. Participants were more likely to use written forms of communication than verbal communication (p<0.01). If there was limited verbal communication between stakeholders RMMRs were perceived to have minimal benefit. Preventing medication-related problems and supporting deprescribing were viewed as positive outcomes associated with RMMRs. Insufficient remuneration was the primary barrier to effective face-to-face collaboration and delivery of individualised resident care. Collectively these findings suggest that pharmacist expertise is regarded as value-adding to resident care, provided there is adequate support for multi-disciplinary collaboration and communication. In Study 3, the RCP documented 335.3 hours performing 284 activities. Activities were either clinical interventions conducted at the individual-level or system-level interventions to improve medication safety. Residents and staff valued, and were satisfied with, pharmacist expertise. The ease of access to this expertise enabled shared problem solving, enhancing responsiveness to resident needs. At the intervention site there were significant improvements compared to baseline in: the incidence of inappropriate dosage form modification (22% pre vs 0% post, p<0.01); the frequency of allergy documentation (77% pre vs 100% post, p<0.01); mean monthly medication incident reporting (13.3 ± 7.4 pre vs 25.7 ± 10.8 post, p<0.05); mean time spent on medication rounds per resident (4.8 minutes ± 1.1 pre vs 3.2 minutes ± 1.7 post, p<0.05); employee influenza vaccination rates (46.5% in 2016 vs 69.2% in 2017, p<0.01); and the proportion of residents at the study site requiring hospital admission (28% pre vs 12% post, p<0.01). There were no differences in outcomes observed at the control site. Conclusion The existing model of pharmacist-led medication review in Australia is inadequately remunerated to support routine pharmacist collaboration with other members of the multidisciplinary RACH team caring for residents with dementia. It is feasible to embed pharmacists into existing RACH care teams and this is an effective strategy for improving health service indicators. This research provides information on clinical and operational processes and outcomes to direct future larger scale investigations into the quality use of medications in RACH and economic implications for the Australian health care system.

Date of Award	2020
Original language	English
Supervisor	Mark NAUNTON (Supervisor) & Sam KOSARI (Supervisor)