The aged care on-site pharmacist initiative is set to build on pioneering efforts over at least 5 years and revolutionise the way pharmacists look after older Australians. 

The shocking medicine and abuse problems laid bare by the Royal Commission into Aged Care Quality and Safety¹ have yet to be rectified.

Recommendations relating to pharmacists working on site in residential aged care facilities (RACFs) were aimed at correcting widespread use of chemical restraint, lack of consent and polypharmacy leading to sedation, falls and avoidable hospitalisations.² It is expected to take years to eradicate such practices with a host of adequate systems and regulations to prevent their return, now including the aged care on-site pharmacist initiative.

‘The program must meet the recommendations from the royal commission to facilitate quality use of medicines through the work of pharmacists,’ says PSA National President Dr Fei Sim FPS.

‘We need to maximise pharmacist time on ground in RACFs to undertake systems, governance, operational and clinical duties. ‘Studies have found that medication management reviews undertaken by pharmacists in RACFs contribute significantly to patient safety and having pharmacists on site reduces pressure on aged care staff. This is what we must strive for – to improve the lives of those living in residential aged care,’ says Dr Sim.

All details of how pharmacists will work on site in aged care have yet to be hammered out following the sudden Government announcement in April, without consultation with the profession, that the $350 million program would be run by ‘community pharmacy outreach’. ³

What, exactly, such outreach entails, and whether the previously stipulated and ‘inadequate’ ratio of one pharmacist to 250 residents will remain, is also not yet clear, says Dr Sim. ‘PSA recommends flexibility in the administration of the program, to ensure residents of as many RACFs as possible can benefit from pharmacist intervention to enable safe and effective use of medicines,’ she says.

With the start date delayed twice already from 1 January 2023, to 1 July 2023, a continued lack of implementation detail may push the date back into 2024.

The Australian Pharmacy Council announced late last month it expects to finalise Performance Outcomes to complement its already-developed accreditation standards by August 2023.

What is clear is that pioneering work by accredited pharmacists including Richard Thorpe MPS in the ACT, Neil Petrie MPS in Victoria, and pharmacists who participated in the PSA-facilitated Pharmacists in Residential Aged Care project funded by the Country SA PHN4 and the Pharmacists in Residential Aged Care Facilities (PiRACF)⁵ trial in the ACT, has paved the way for a new career path for which credentialled training is now available from PSA.⁶

What is coming

While the program was initially expected to be delivered through RACFs, the government will instead provide $350 million to ‘fund community pharmacies to employ pharmacists to work on-site in residential aged care homes in a clinical role’.⁷ The model does not include funding for medicine deliveries or packing. And it is not compulsory for an RACF to have an on-site pharmacist.

‘For those pharmacies that opt not to take advantage of this new investment, there will continue to be funding for aged care residents to receive pharmacist support under existing pharmacy programs funded through the Seventh Community Pharmacy Agreement, including residential medication management review services for individual residents,’ David Laffan, Assistant Secretary, Pharmacy Branch at the Department of Health and Aged Care told attendees at the Consultant Pharmacists’ Conference, CPC23 in May.

With details of how the program will run yet to be determined, it heralds a new way of approaching medicine safety in aged care, with accredited pharmacists moving beyond conducting residential medication management reviews (RMMRs) to working as part of an interdisciplinary healthcare team. Program aims include:

• Increasing understanding of resident needs
• Improving medicine use and safety
• Allowing for continuity in medicine management 
• Providing easy access to pharmacy advice for staff and residents and 
• Integrating on-site pharmacists with the healthcare team.²

It follows a long-term campaign by PSA to expand the role of pharmacists in RACFs to improve patient safety and address the recommendations set out by the royal commission, particularly recommendation 38, which states residential aged care should include allied health.²

The PSA’s Victorian President, consultant pharmacist and Adjunct Associate Professor Amy Page FPS (she/her), focuses on medicine safety and the quality use of medicines in older people in her role as a senior research fellow at the University of Western Australia. She says pharmacists can make a significant difference in RACFs on an individual and facility-wide level.

While polypharmacy is a recognised issue, Adj A/Prof Page says under-prescribing is another problem pharmacists can help address. ‘One of our recent studies⁸ found that … there are a lot of people who aren’t using enough medicines.

‘We found that 4% of people in residential aged care who had activities of daily living curtailed by pain or discomfort were charted for neither regular nor PRN analgesia,’ she says. ‘So, identifying symptoms that could be managed with medicine is also something that an on-site pharmacist could pick up on, particularly when it comes to pain and things that have a big impact on someone’s quality of life.’

A new age

A team of researchers, including Adj A/Prof Page, recently surveyed pharmacists 9 about their level of interest in working on site in RACFs.

‘Theoretically, a lot of pharmacists were very interested,’ she says, ‘but they wanted to see what the model would look like and what would be involved.’

Pharmacists have also been eager to upskill their clinical knowledge before taking on a role. The PSA23 conference in Sydney this month included an ‘aged care deep dive’ dedicated session covering everything from anti-microbial stewardship to better alternatives to chemical restraint.

As a new career path with only a handful of pharmacists currently working on site across Australia, peer support is also very important.

Dr Kenneth Lee FPS (he/him), Senior Lecturer at the University of Western Australia, consultant and GP pharmacist is set to launch a Pharmacists in Aged Care Community of Practice later this month, for those interested in the sector. 

‘There’s a lot to learn’ says Dr Kate Wang MPS (she/her), lecturer at RMIT and research pharmacist at Alfred Health, who joins Dr Lee, along with several academic colleagues from around the country in the development of this Community of Practice. ‘The community of practice will be a safe environment for pharmacists to bounce ideas off each other, ask questions and learn from each other,’ she says.

Setting the standard 

The Federal Government has engaged the Australian Pharmacy Council (APC) to develop accreditation standards for the training programs that will credential pharmacists to work in RACFs and conduct medication management reviews.¹⁰

Sarah Gillespie FPS recently joined PSA as Accreditation Training Manager following the closure of the Australian Association of Consultant Pharmacy (AACP), where she was Clinical Services Manager (see AP May 2023). The PSA will continue to advocate for accredited pharmacists in RACFs, she says. ‘The PSA is the natural home for accredited pharmacists and offers an accreditation program in addition to support and ongoing training for accredited pharmacists and those looking to become accredited. In a submission to the government, PSA recommended that the minimum qualification for an aged care on-site pharmacist who conducts RMMRs should be to hold current pharmacist accreditation to deliver medication management reviews and be connected with a community of practice, including mentoring,’ Ms Gillespie says.

As the APC continues developing its standards, AACP Medicine Review Numbers will remain valid until 30 June 2024, to ensure accredited pharmacists can continue to provide services.¹¹ It is expected, Ms Gillespie says, that to work on site in aged care, current accredited pharmacists will transition to ‘credentialed pharmacists’, with an anticipated bridging module or additional CPD required.

‘Vital’ on-site support 

Amelia Wood MPS has been an on-site pharmacist at the 52-bed Longridge Aged Care in Naracoorte in rural South Australia for almost 4 years.

What began as 10 hours a week as part of a trial, coordinated by PSA and the Country SA Primary Health Network, is now a permanent 2-day a week role. She says seeing the improvements her recommendations can make in the lives of residents is incredibly rewarding.

‘I had a resident recently who was put on antipsychotics to stop her wandering. I gave it a 6-week trial and then recommended ceasing. The GP reduced the dose, and then another 6 weeks later I was able to convince him to cease altogether. The resident is now only on paracetamol and doing well. I don’t think that would’ve happened without continuity of care,’ she says. ‘I also do some RMMRs for another aged care facility and it’s hard not knowing whether they’ve made the changes I recommended or if the RMMR has had any impact at all.’

Ms Wood works closely with the RACF’s Clinical Nurse Manager, Emmanuel Geri (he/him) who says Ms Wood provides ‘vital support’ on appropriate medication use. 

She has also helped the RACF transition to digital medication charts and registered it as a vaccination site.

‘Having an on-site pharmacist is a great resource that should be available to all residential care facilities,’ Mr Geri says. ‘On-site pharmacists can provide clinical expertise readily to residents, their family members and staff … It has also had a positive impact on polypharmacy, by providing recommendations to GPs to change or reduce residents’ medications.’

Aged care nurse Shelley Wiggins says an on-site pharmacist makes a difference ‘every day’ at her RACF in Tasmania, for the staff as well as the residents.

‘I’ve learnt so much from having our pharmacist work side by side with us,’ she says. ‘If we have any medication-related queries, they’re resolved a lot quicker through having someone there. I’ve had residents who have developed swallowing difficulties, and the pharmacist is able to review their medications and let us know what’s safe to crush. It’s educating us as well.’

The RACF currently employs a pharmacist for 3 hours a day, Monday to Friday, and Ms Wiggins hopes the hours are extended in future – and that on-site services are a given across the country.

Geriatrician and clinical pharmacologist at Royal Perth Hospital Professor Christopher Etherton-Beer (he/him) studies how to improve medicine outcomes in older people. Prescribers, he says, ‘really value’ the work of on-site pharmacists where they are available.

‘Health care is best delivered by multi- and interdisciplinary teams working together,’ he says. ‘I have never met a doctor who isn’t grateful for work by other healthcare professionals that improves care for their patients and makes their life easier.

‘Ensuring that medication reviews are done by a pharmacist who knows the patient well, and can work in a team with the patient or their advocate and GPs or other prescribers, is very important.’

Looking ahead 

When the pharmacy co-owned by Lauren Haworth MPS (she/her) in rural Victoria took on the RMMR, Quality Use of Medicines and service contracts for a small RACF, she knew she needed to upskill, despite already being accredited.

‘I had never worked in an aged care facility before, so we got a friend of mine, whose job is conducting RMMRs in Tasmania, to come over and I shadowed him,’ she says. ‘He helped me get my head around it, because there are different goals for people in RACFs compared to HMRs.’

As a community pharmacy owner, Ms Haworth says she already faces a lot of business uncertainty following the 60-day dispensing announcement and is eager to learn exactly how the aged care on-site pharmacist initiative will be delivered. Despite the unknowns, she is excited about the program, believing more pharmacist involvement in RACFs can only be positive.

‘Rather than just sticking a bandaid on a problem, pharmacists will probably attempt to get to the bottom of things e.g. if a resident is using oxycodone (Endone) every night, let’s look at what’s causing their pain and if there’s a better option.

‘I think standards will increase ,’ Ms Haworth says, ‘because we’re there specifically looking at the medicines, whereas everyone else in the facility is looking at other things.’

However it is delivered, Adj A/Prof Page hopes the program will result in pharmacists providing new services, rather than simply funding existing services in a different way.

‘When a resident goes into an aged care facility, they can be disempowered. They don’t have access to their usual healthcare professionals the way they would in the community, and often don’t get told what they’re taking or why. ‘To have someone on site who can have those conversations is such a positive.

References

1. Royal commission into aged care quality and safety. Final report: care, dignity and respect. 2021. At: agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1_0.pdf
2. Royal commission into aged care quality and safety. Interim report: neglect. 2019. At: royalcommission.gov.au/publications/interim-report
3. Ministers, Department of Health and Aged care. Cheaper medicines to ease cost of living. 2023. At: www.health.gov.au/ministers/the-hon-mark-butler-mp/media/cheaper-medicines-to-ease-cost-of-living
4. Country SA PHN Annual Report 19/20. Aged care. p.22. At: countrysaphn.com.au/wp-content/uploads/2020/11/CSAPHN_Annual-Report-1920_eAW-hi-res.pdf
5. Kosari S, Naunton M, Koerner J, et al. Pharmacists in residential aged care facilities (PiRACF) study – final evaluation report. 2022. University of Canberra.
6. Pharmaceutical Society of Australia. Residential Aged care Pharmacist. 2023. At: psa.org.au/programs/residential-aged-care-pharmacist/
7. Australian Government Department of Health and Aged Care. Aged care on-site pharmacist. 2023. At: health.gov.au/our-work/aged-care-on-site-pharmacist
8. Page AT, Potter K, Naganathan V, et al. Polypharmacy and medicine regimens in older adults in residential aged care. Arch Gerontol Geriat 2022. Epub 2022 Nov 4.
9. Cross AJ, Hawthorne D, Lee K, et al. Factors influencing pharmacist interest and preparedness to work as on-site aged care pharmacists: insights from qualitative analysis of free-text survey responses. Arch Gerontol Geriat 2023. Epub 2023 Feb 23.
10. Australian Pharmacy Council. Accreditation standards for pharmacist training programs: aged care and comprehensive medication reviews consultation paper. 2023. At: pharmacycouncil.org.au/education-provider/standards/AgedCare-and-MMR-Pharmacist-training-programs/.
11. Pharmacy Programs Administrator. Home Medicines Review. 2023. At: ppaonline.com.au/programs/medication-management-programs/home-medicines-review