Bringing pharmacists into the primary healthcare fold

As Australia gathers persuasive evidence from the Health Care Homes trial, it’s becoming clearer how to integrate pharmacists into primary healthcare.

Doors are opening: there are now more opportunities than ever for Australian pharmacists to be embedded in primary healthcare teams.

The national Health Care Homes trial recently welcomed community pharmacists to join care teams through the Community Pharmacy in Health Care Homes trial, while around the country more pharmacists are being invited into general practice clinics.

The integration of community pharmacy in Health Care Homes is a seismic shift in integrating the work of community pharmacists alongside the work of general practitioners. This model of care, which is fully supported by the Pharmaceutical Society of Australia, provides an opportunity for holistic medication management for patients with chronic and complex conditions by community pharmacists and is a welcome addition to the services delivered by community pharmacists.

PSA General Manager – Program Delivery Jan Ridd welcomes the shift towards pharmacists working to their full scope of practice. ‘In addition to a greater role for community pharmacists in managing medicines, we see that the placement of pharmacists in GP clinics, residential care facilities and Indigenous health centres would ensure appropriate prescribing, reduce errors, enhance adherence and improve patient outcomes,’ she says. ‘Pharmacists should be embedded wherever medicines are used.’

Community pharmacy in the Health Care Homes Trial Program

The Community Pharmacy in Health Care Homes Trial Program¹ aims to support the incorporation of medication management planning and programs within the Health Care Homes model. It began late last year and 300 pharmacies had registered by December.

PSA National President Dr Chris Freeman sees this model of care as a gamechanger for the role of community pharmacy. ‘Never have we had a program for patients with multiple chronic and complex illnesses that allows us to provide ongoing care through consultations with patients about their medications,’ he says. Dr Freeman encourages every community pharmacy that could be involved to register in the program to show that they can deliver this type of longitudinal integrated medication management support for patients with chronic disease.

‘The training programs that have been built by PSA for this program are extremely useful not only for participation in the trial, but also for identifying how to integrate consultations with patients into care delivery and to better integrate with other care providers,’ he says.

Says PSA’s Jan Ridd: ‘In the coming months, community pharmacies in close proximity to the primary health networks participating² in the Health Care Homes trial can expect to receive invitations to access patient Shared Care Plans and to participate in the Trial Program.’

Once a pharmacy registers, receives a referral and gains patient consent, an initial consultation can occur.

The PSA Guidelines for pharmacists participating in the Community Pharmacy in Health Care Homes Trial Program outline the professional standard to which the services should be delivered.³ During the consult, pharmacists can work with a patient and their Health Care Home to:

• reconcile medicines;
• identify and resolve medication-related issues;
• identify and deliver supporting services for Tier 2 patients (those with increasingly complex multiple morbidity) and Tier 3 patients (those with highly complex multiple morbidity);
• provide medicine and disease-state education;
• develop a Medication Management Plan;
• collect patient health outcomes data.

The pharmacist then provides supporting medication adherence and medication management services, and has the opportunity to complete three follow-up reviews with each patient.

TABLE 1. Training Modules for Community Pharmacy in Health Care Homes Trial Program (available at mypsa.org.au/Health-Care-Homes-Trial-Program)

General practice pharmacists

More than 80 non-dispensing pharmacists have now been integrated into general practices around the country. That’s up from just 26 pharmacists who were working in, or from, a general practice medical centre in 2014.⁴

In one ongoing pilot, pharmacists have joined general practice teams within the North Western Melbourne Primary Health Network (NWMPHN). The program brings together workforce capacity building, chronic disease prevention and management, and Quality Use of Medicines principles.

NWMPHN CEO Adjunct Associate Professor Christopher Carter says general practice pharmacists have been a valuable addition to the healthcare teams.

‘One of the key successes we’ve seen so far is how the program promotes teamwork and collaboration between pharmacists and GPs, which directly benefits patients,’ he says.

Meanwhile, in Sydney, the WentWest General Practice Pharmacist Project (WGPPP) has seen the integration of six general practice pharmacists. Analysis shows that 88% of their recommendations have been accepted by GPs.⁵

Report co-author, UTS doctoral candidate Helen Benson MPS, says the general practice pharmacists were able to develop good professional relationships with community pharmacies and patients.

‘Initially the pharmacists had a bit of difficulty recruiting because patients didn’t really understand what they’d get out of seeing a general practice pharmacist,’ she says. ‘But once they’d had up to 45 minutes with somebody who was interested in improving their medication management, they were often asking for repeat visits.’

A number of general practices around the country not only have a general practice pharmacist on-site, but they’re also participating in the Health Care Homes trial, which is aiming to improve outcomes for the one in four Australians who have at least two chronic health conditions.⁶ It involves general practices or Aboriginal Community Controlled Health Services (ACCHS) serving as a ‘Health Care Home’ – a hub that takes responsibility for coordinating patient care. Typically, the Health Care Home team is led by a GP and involves the patient’s specialists, allied health providers, practice nurses and care coordinators who work together to address the needs of the patient.

Dr Walid Jammal’s Western Sydney general practice was one of the early adopters of the model – his on-site team includes a general practice pharmacist, Timothy Perry MPS.

‘The use of a consultant pharmacist in our practice is a normal part of the way we look after our patients now. This definitely should be the norm,’ says Dr Jammal, Principal of Hills Family General Practice and Clinical Lecturer at the University of Sydney. ‘It has improved our communications with pharmacies and hospitals and almost certainly prevented re-admissions due to medication errors.’

Mr Perry adds that with Health Care Homes patients he is able to work to improve adherence, manage medication, monitor impact of medication changes and update action plans without consulting the GP.

‘By the time the doctor sees the patient, I’ve updated the patient’s medication list, identified problems related to medications, and made suggestions about what to do,’ he says. ‘Another job I have taken charge of is liaising with local pharmacies and hospital pharmacists to ensure we have all the information we need, or to clarify or change instructions.’

Indicators of success

Given the ongoing status of these integration initiatives, comprehensive data and analysis of outcomes is yet to emerge. There are, however, numerous early indicators of success and previous studies showing the benefits of integration in primary healthcare. One recent systematic review and meta-analysis of 38 studies of pharmacist-delivered services in general practice showed that 25 studies reported positive effects on at least one primary outcome, while 13 demonstrated no effect.⁷ Another analysis, from Deloitte Access Economics, shows that if general practices were supported to employ non-dispensing pharmacists, they could deliver the health system $1.56 in real cost savings for every dollar invested.⁸

UTS researcher Ms Benson adds that the model is beneficial for the pharmacy sector as a whole. ‘If the general practice pharmacist is quite proactive in contacting the pharmacies around them, and involving them, it can actually improve the communication between the GP surgery and the pharmacy,’ she says.

‘And the general practice pharmacist is able to refer patients to the pharmacy for the services they can provide, like dose administration aids, medication delivery, MedsChecks and ongoing care.’

Dr Freeman notes that we await the trial findings from the Community Pharmacy in Health Care Homes Program, which has been extended, and it is envisaged that some of this evidence will be used to inform future Community Pharmacy Agreements. Dr Freeman has indicated that most of the PSA members he has discussed the program with are overwhelmingly supportive of funding being allocated to community pharmacy based on achieving better outcomes of medication management and providing holistic care.

Throwing open the doors

For pharmacist integration within primary healthcare settings to become the norm, more funding and government support is required, says UTS researcher Ms Benson.

‘Whenever somebody thinks, ‘This is just a pilot, it’s going to stop in six months’ time’, they don’t really invest in developing it to its full capabilities. A lack of funding and support has really limited what we’ve been able to show to date,’ she says.

PSA’s imminent 2023 Action Plan will support pharmacists working to their full scope of practice in integrated settings. It proposes the embedding of pharmacists wherever medicines are used.

This plan involves building on the accessibility of community pharmacy to take a greater level of responsibility and accountability for medication management for people living with chronic disease. The Community Pharmacy in Health Care Homes model of wrap-around medication management support for these patients is supported by PSA as a welcome start and there is hope that the evaluation of these programs provides the evidence for this type of model of care in the future.

‘Pharmacists need to be embedded into general practices to assist with education and training of clinical staff, to support clinical governance around quality use of medicines, and to assist patient care in consultations when needed,’ says Ms Ridd.

‘Medicine is the primary intervention in primary care, so it is only appropriate that the medicine experts play a primary role in managing medication use,’ she says.

References

1. 6th Community Pharmacy Agreement. Community Pharmacy in Health Care Homes Trial Program. 2015. At: 6cpa.com.au/medication-management-programs/community-pharmacy-in-health-care-homes-trial-program-interim/
2. Australian Government Department of Health. Participating Health Care Home practices by Primary Health Network (PHN) region. 2018. At: health.gov.au/internet/main/publishing.nsf/Content/health-care-homes-cp/$File/Health-Care-Homes-participating-practices%2023November2018.pdf
3. Guidelines for pharmacists participating in the Community Pharmacy in Health Care Homes Trial Program. At: http://6cpa.com.au/wp-content/uploads/Trial-Program-Guidelines.pdf
4. Freeman C, Cottrell N, Rigby D, et al. The Australian practice pharmacist. J Pharm Pract Res 2014;44:240-8. At: https://onlinelibrary.wiley.com/doi/abs/10.1002/jppr.1027
5. Benson H, Lucas C, Benrimoj S, et al. Pharmacists in general practice: recommendations resulting from team-based collaborative care. Aust. J. Prim. Health 2018. At: doi.org/10.1071/PY18022
6. Australian Institute of Health and Welfare. Australia’s Health. 2016. At: aihw.gov.au/getmedia/9844cefb-7745-4dd8-9ee2-f4d1c3d6a727/19787-AH16.pdf.aspx?inline=true
7. Tan E, Stewart K, Elliott R, et al. Pharmacist services provided in general practice clinics: a systematic review and meta-analysis. Res Social Adm Pharm 2014;10(4):608-22. At: ncbi.nlm.nih.gov/pubmed/24161491
8. Deloitte Access Economics. Analysis of non-dispensing pharmacists in general practice clinics. 2015. At: deloitte.com/content/dam/Deloitte/au/Documents/Economics/deloitte-au-economics-analysis-non-dispensing-pharmacists-general-practice-clinics-010415.pdf