Just 3 years out of university, in 2019 Maria Berbecaru MPS made history by implementing Australia’s first integrated community pharmacy-delivered medicine supply and on-site clinical service model at an RACF.
What was your response to the announcement that every government-funded aged care facility will receive funding to engage an on-site pharmacist?
The government’s announcement it would be providing funding towards embedding pharmacists within RACFs brings me great joy and excitement to see this area of practice gain the attention it has and have this unique position become widely adopted across the country. There has been a lot of hard work invested over previous years by researchers, namely the Pharmaceutical Society of Australia, many accredited pharmacists and various other individuals to shine light on this very important (but neglected) area of practice and the importance of pharmacists within the aged care setting.
The allocated government funding should be viewed as a collective win for the pharmacy profession, RACFs and residents, as well as Australia’s health system overall. Embedding pharmacists within healthcare teams will be both a short-term and long-term solution to reduce the burden on Australia’s strained healthcare system.
Why are on-site pharmacists important in aged care?
Our vulnerable older population in residential aged care facilities are at significantly higher risk of medication harms than other members of our society. RACF residents are commonly on more medications, have multiple comorbid conditions, are frail and commonly have limited face-to-face interaction with pharmacists. Medication harms are also more likely to occur during transition of care for example, into and out of hospital.
I believe by having an integrated medication supply and embedded residential clinical pharmacist service allows pharmacists to identify medication-related problems and intervene in real time as well as, closely monitor outcomes of implemented medication recommendations. Additionally, it enables pharmacists to swiftly attend to medication changes that have occurred and ensure change is communicated to all relevant members involved in the resident’s care (including hospital discharge patients) ultimately, reducing medication-related harm and enhancing residents’ quality of life.
What would you like to see included in the new model?
I believe for this new embedded aged care pharmacist model to be successful long-term, there needs to be input from various individuals within the pharmacy profession experienced in aged care (e.g. accredited pharmacists, community pharmacy owners, pharmacy advocacy bodies, aged care pharmacists) assisting the ‘decision makers’ on how the funding should be implemented and establishing the role.
A collaborative partnership between the accredited pharmacist and community pharmacy servicing the RACF would be ideal with the accredited pharmacist driving this new model as they would be the one mainly responsible for medication management on-site.
Whilst funding and its allocation are important, there also needs to be a strong and well-equipped pharmacist workforce to ensure this new model’s longevity and securing any future ongoing government financial support. It is crucial embedded aged care pharmacists undergo training and development for this newly established role to ensure they deliver the services confidently, appropriately and to a high standard. Implementation of online and face-to-face training would be worthwhile. Additionally, as this unique workforce grows, the development of an ‘embedded aged care pharmacists group’ would provide an invaluable opportunity for individuals to share their experiences, learn, support each other and grow the role further.
How will on-site pharmacists improve medicine safety?
Embedded aged care pharmacists will be uniquely positioned to interact with a wide range of individuals (directly and indirectly) involved in the residents’ care and influence overall medication management.
Communication with nursing staff during daily ward rounds allows pharmacists the opportunity to identify medication-related problems and intervene in real time, as well as discussing the crushability of oral medicines, residents of concern (e.g. changing behaviours, increasing pain episodes), attend to medication changes that may have occurred and ensure change is communicated to all relevant members involved in residents’ care. Assisting visiting GPs with resident rounds and becoming involved at point of prescribing (e.g. answering medication-related clinical queries, providing advice on drug selection, dosages and prescription writing). Additionally, discussing RMMRs and psychotropic reviews conducted and sharing medication knowledge.
Furthermore, the embedded pharmacist can closely monitor outcomes of implemented medication recommendations and act swiftly if any concerns arise. Attending family conferences to support GPs and answer medication concerns residents/family members may have and using the opportunity to educate them as needed. Supporting clinical care/facility managers in reviewing medication management policies/procedures (i.e. implementing new or updating existing ones), active involvement in multidisciplinary meetings, implementing functioning imprest system.
Additionally, delivering educational sessions to nursing and care staff surrounding psychotropic, antimicrobial use. At an organisational level, assist with implementation of medication packing and electronic medication management systems, undertaking clinical activities as requested (e.g. observing nursing staff administer S8 medications), active involvement in MAC/clinical governance meetings.
What are the most important medicine safety issues pharmacists in aged care should address?
There is an abundance of work embedded aged care pharmacists can undertake at their selected RACF, however, the needs of each facility will vary. A good starting point for pharmacists to focus on would be medication reviews or activities relating to the National Aged Care Mandatory Quality Indicator Program. Currently, the National Aged Care Mandatory Quality Indicator Program only places emphasis on poly-pharmacy and anti-psychotic reporting as part of medication management. As we know, there are many other drug classes that may be considered potentially dangerous or inappropriate in the elderly population which are not recorded, for example benzodiazepines, opioids, anti-depressants and antimicrobials.
Embedded aged care pharmacists can play a key role in ensuring these agents are prescribed, monitored and deprescribed appropriately by undertaking audits, regular specific reviews on a 3-monthly basis and being involved in the facility’s Antimicrobial Stewardship program.
Whilst ‘medication safety’ primarily relates to more clinical aspects, I believe there should be more emphasis placed on the logistics of medicines delivery as well. For example, when a GP makes a change to a resident’s medication there needs to be clear processes implemented and executed within a timely manner to ensure the change is communicated to all relevant members involved in the residents’ care and physical changes to the medication pack are undertaken (at RACF and community pharmacy).
Additionally, ensuring certain medications that are more difficult to obtain (e.g. midodrine, revlimid) are organised with supplying pharmacy/local hospital and delivered on time, ready to be administered on due date. Again, embedded aged care pharmacists will be well-placed to directly assist with logistical operations through communication with nursing staff during daily ward rounds and contacting relevant personnel in community pharmacy/hospital.
What would you look for in an aged care pharmacist?
While the embedded aged care pharmacist role is stimulating and satisfying, it can also be challenging some days. Aged care pharmacists are likely to be the only medication expert or resource available onsite and largely responsible for all aspects (e.g. logistical and clinical) surrounding medication management. Given the relative unpredictability of the role and various individuals working within or visiting the RACF, the ‘ideal’ aged care pharmacist will need to be approachable, adaptable, patient, resourceful, clinically sound, independent, a team player and have familiarity with community pharmacy systems.
How will we know medicine use is safer?
I believe documentation and monitoring will be key to identifying whether medicine use is safer in RACFs where there are embedded aged care pharmacists practising. For example, conducting a ‘facility drug-usage audit’ at the commencement of pharmacists’ employment on select drug classes (such as anti-psychotics, benzodiazepines, opioids and antibiotics) and then on a quarterly basis would provide trends to assess the impact on medication safety.
Additionally, self-recording drug-related problems embedded aged care pharmacists encounter on a daily basis and how they intervened would also be beneficial to illustrate their involvement and influence on medicines use. Furthermore, creating a survey for nursing staff to complete and provide their perspective on the pharmacists’ involvement towards medication safety would be helpful.