Pharmacists performing Home Medicines Reviews overcome many barriers in daily practice to deliver this vital service.
When Dr Lisa Kouladjian O’Donnell MPS first contacted patient Cynthia (not her real name) to make an appointment for a Home Medicines Review (HMR), she met resistance. The referral from the GP made it clear the review was important: apart from her own health issues, Cynthia’s husband, residing in the house, was living with dementia, and her adult son, also under the same roof, lived with schizophrenia. Cynthia was initially reluctant to meet in her home, but after careful discussion with Dr Lisa Kouladjian O’Donnell, she agreed to have her HMR appointment at home.
There was nothing unusual about the house when Dr Kouladjian O’Donnell pulled up outside: this was an ordinary street in Sydney’s north. But the reasons for Cynthia’s reticence became apparent as she answered the door: it could barely open enough to allow the pharmacist entry. This was a family of hoarders. ‘There was stuff everywhere,’ Dr Kouladjian O’Donnell remembers.
Once inside the home, Dr Kouladjian O’Donnell couldn’t find a chair to sit down, and eventually settled on the corner of a lounge. Tactful inquiries soon revealed that the hoarding extended to the family’s medicines – as Dr Kouladjian O’Donnell assessed them, she noted that a good proportion were expired. She explained the need to dispose of them – but again there was resistance, with the patient offering various objections, even citing the good condition of the packaging as an excuse to retain them. But the impact of the home’s disorganisation on their medicines regimens was soon revealed. After some investigation, it became apparent that the son had started using some of the husband’s medicines, while Cynthia had started using some of the son’s. Untangling their situation, and putting it back together, took enormous patience and great diplomacy.
Two and a half hours later, Dr Kouladjian O’Donnell left feeling utterly exhausted by the experience – but with a marked sense of achievement that she had averted a potential disaster. The patient’s GP was contacted and the medicines simplified to avoid problems.
The value of experience
Since their formal introduction under the Community Pharmacy Agreement (CPA) in 2001, HMRs have proven effective in enhancing the quality use of medicines and averting medicine misadventure (see research findings, page 20, Australian Pharmacist, May 2019 issue).
As detailed in PSA’s Medicine Safety: Take Care report earlier this year, 1 in 5 people are suffering an adverse medication reaction at the time they receive a Home Medicines Review, and 1.2 million Australians have experienced an adverse medication event in the last 6 months. Contributing to this is the fact that almost 1 in 4 older people prescribed medicines cleared by the kidneys are prescribed an excessive dose.
All told, this contributes to the 250,000 annual hospital admissions linked to medicine-related problems.
Debbie Rigby FPS, a consultant clinical pharmacist from Brisbane, has conducted more than 10,000 HMRs – and says there has not been a single case in which she didn’t identify a problem or suggest a potential improvement. ‘Not one,’ she says. ‘There has never been a single incidence where I have walked away knowing that I wasn’t needed.’
On average, four medication-related problems are detected for each person who has an HMR.
An HMR referral must be generated by a general practitioner (GP), based on the patient’s clinical need. Reasons for a referral can span from polypharmacy or recent discharge from hospital to suspected non-compliance or increasing frailty.
HMRs must be completed by pharmacists accredited to provide medication review services (which also includes Residential Medication Management Reviews). Accreditation programs are provided by the AACP and SHPA. PSA’s MMR Stage 1 is a preparatory training course aimed at preparing participants for the AACP accreditation assessment process and provides participants with an understanding of the MMR process, and the knowledge and skills required to successfully undertake an MMR.
Unless there are cultural reasons or safety concerns, HMRs must be conducted in the patient’s home. And while there are extensive guidelines for pharmacist accreditation and the conduct of an HMR (see Further Information, below), those who conduct them agree: one never knows what one might encounter once one crosses the threshold of a patient’s front door.
Dr Kouladjian O’Donnell, for example, is glad that she shadowed an accredited pharmacist on her first visit to see what was involved. In fact, in her role as Clinical Pharmacist Educator at the University of Sydney, she makes this an assignment for her pharmacy students.
Dr Jenny Gowan FPS, a clinical pharmacist and founder of MediCom Medication Management Services, became involved right from the implementation of HMRs, devising and running some of the first training courses for PSA. She agrees that while a pharmacist can prepare themselves for the clinical aspects of the review, it can be confronting for any pharmacist to enter a patient’s private domain.
‘It can be very challenging. For the last 10 years I’ve worked out of Banyule Community Health Centre – it’s in a low socio-economic area (in Melbourne’s north-east). We’ve got something like 55 different languages spoken here. I get a lot of people who are housebound.
We have drug and alcohol problems, mental health problems.’ Despite the demands, Dr Gowan says she finds HMRs one of the most fulfilling areas of her work. ‘What we have is the luxury of time,’ she says. ‘I allocate a minimum of an hour per consultation.
‘Many of these difficult people I see every few years. I have very detailed data collection. I know the names of their dogs, I know how many grandchildren they’ve got, I know the people that are living with them – with this information you’ve broken down barriers when you return.
‘Some of them might not see many people. They might have made a cake for me. It’s a matter of keeping your professional distance and being nonjudgmental, listening to them, letting them talk. And at the end of the interview, I will give them a brochure and I say, “These are the points that I’m going to bring up with the doctor on the report. What do you think?” And we discuss that, so that they also can drive it,’ Dr Gowan says.
‘This way, they might say, “Look, I really want to get off my sleeping tablets.” That message is there for them when they go for the next GP appointment. It’s a team approach. We’re not just doing the medication. In all cases, I try and look at the holistic view, the whole person. How is the patient managing meals, cleaning, shopping? Have they got a taxi card? Have they got an alarm around their neck in case they have a fall?’
Dr Gowan says that information can be fed back to the broader healthcare team to help secure extra support.
‘Patients are more relaxed in their homes,’ Ms Rigby says. ‘They can bring out complementary medicines that they might not bring into the pharmacy. You can observe all sorts of issues, such as falls risks. It is also an opportunity to have the patient’s spouse present, or their adult children – and there are benefits to that, because you get the bigger picture, and it also helps to educate the caregiver.’
PSA’s Pharmacists in 2023 report supports review of the remuneration structure regarding HMRs. Action 8 describes the change needed: ‘Remuneration for pharmacists must adequately reflect their standing in the healthcare system as well as their expertise, training and skills in addressing medicine management needs of consumers. Remuneration needs to incentivise best practice care, and to support integration and collaboration.
‘Remuneration models … need to support the evolution to a consultation-based and outcome-focused model of healthcare delivery that coexists with the logistical requirements of medicines supply. This remuneration model will recognise the complexity of care, achievement of health and process outcome measures and time requirements of pharmacist-delivered services, and should support practice change, allowing the pharmacy profession to take greater responsibility and accountability for medicines management.’
And action 9: ‘Allow greater flexibility in funding and delivery of pharmacist care to innovate and adapt to the unique patient needs in all areas, with a specific focus on regional, rural and remote areas.’
Rules of the road
For all their clinical benefit, two aspects of HMRs cause much frustration among their practitioners. The first is the cost of travel. In rural areas, pharmacists can claim a travel allowance of up to $125 (on top of the $219.69 they receive for the service itself).
This limits the feasibility of HMRs in the remote areas of the country. Karalyn Huxhagen, for example, conducts HMRs in rural Queensland, often driving long distances between patients. To make these trips break even, she needs to link patient visits across large distances – but an expenses payment of $125 for one round trip doesn’t even cover her fuel costs, let alone accommodation expenses for the overnight stays.
The second frustration is the cap of 20 HMRs a month per pharmacist. Ms Huxhagen says despite the fact that she may have 80 or 90 referrals waiting for her, once the tally of 20 is clocked up, she must wait for the calendar to tick over before she can get to work again. It is a common scenario.
‘Accessibility of healthcare underpins our very good Australian healthcare system,’ Ms Rigby says, ‘and yet we’ve got these artificial caps in place that reduce the capacity for accredited pharmacists to deliver their service in a timely manner.’
The cap was introduced due to mounting costs – with the suggestion that some were gaming the system.
‘I was chair of the Australian Association of Consultant Pharmacy at the time,’ recalls Ms Rigby. ‘To my knowledge there were six people or groups questioned around the large numbers of HMRs they were doing.
‘I’m worried that some of our powers-that- be are not prioritising Home Medicines Reviews. It’s an incredibly valuable service that has been shown to make a big difference to people.’
Read the PSA Guidelines for HMRs at: www.psa.org.au/download/practice-guidelines/home-medicines-review-services.pdf
PSA offers a preparatory stage 1 course for pharmacists wishing to undertake MMRs at: www.psa.org.au/mmr
Learn more at www.australianpharmacist.com.au