Publication Date 29/07/2011         Volume. 3 No. 7   
Information to Pharmacists

Editorial

From the desk of the editor

Welcome to the August 2011 edition of i2P- Information to Pharmacists.
Direct distribution by pharmaceutical manufacturers is back in the news once more.
This disruptive attack on an efficient community pharmacy business model must be checked before it gets too far out of hand.
Neil Retallick discusses some of the issues as does Mark Coleman in the Pharmedia section of i2P.
Read and see what you can do to help.

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Post- discharge Home Medicines Reviews

Kay Dunkley - BPharm, Grad Dip Hosp Pharm, Grad Dip Health Admin, MPS, MSHPA

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Kay Dunkley is a pharmacist who has worked in hospital and organisational pharmacy for over 20 years.  She has a broad experience working in public hospitals and in providing support to health professionals through government funded bodies and professional organisations.  Kay also has a strong interest in the health and well being of health professionals and especially the role of peer support.  Kay first became involved as a volunteer with the Pharmacists’ Support Service, a group which has been providing telephone support for pharmacists in Victoria since 1995.  In 2005 Kay became the Program Coordinator for the Pharmacists’ Support Service and has assisted the service to become an independent organisation which is currently seeking to expand to provide support to pharmacists throughout Australia.  In 2007, when AMA Victoria approached the Pharmaceutical Society of Australia (Victorian Branch) with a view to establishing their own Peer Support Service; Kay accepted an invitation to assist.  The AMA Victoria Peer Support Service commenced operation in February 2008.  Kay currently coordinates both of these services and also works part-time as a consultant pharmacist in Residential Care Facilities.

Through the 5th Community Pharmacy Agreement hospital initiated HMRs will now be available for high-risk patients recently discharged from hospital. This is an important step in addressing the fact that patients recently discharged from hospital are at risk of medication misadventure. The question I would like to raise is who is best placed to undertake these HMRs. The traditional model of HMR referral has been through a General Practitioner (GP) to the consumer’s community pharmacy. Under this model the HMR may be undertaken by an accredited pharmacist directly involved with or employed by the community pharmacy or be outsourced to an independent accredited pharmacist. Under the 5th Community Pharmacy Agreement this model has now been modified to enable direct referral from a GP to an accredited pharmacist and also direct referral from a hospital based medical practitioner for a newly discharged patient. The traditional model will continue in tandem with this new model.

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The advantages of the traditional model are that it builds on established relationships between the GP, the local pharmacy and the consumer.  Even when an independent accredited pharmacist is engaged to undertake the interview and report preparation the referral through the community pharmacy facilitates three way communication as the accredited pharmacist is reliant upon the community pharmacy for background information about a consumer including their dispensing record.  Also the community pharmacy will usually refer to an accredited pharmacist with whom they have an established and trusting relationship.  It is my experience that the consumers associate the interviewing pharmacist with their regular community pharmacy, even when they are not directly employed by that pharmacy.  The disadvantages of this model have been that there may be delays in organising an HMR due to the involvement of a consultant who may not be readily available.  Also, in my opinion it is possible that there is an increased risk of a breakdown in communication when an external consultant pharmacist is involved.

Timing of HMRs in a patient recently discharged from hospital can be critical in preventing medication misadventure.  Hospital discharge is a critical time as a recovering patient and those involved in their care can become confused about changes to medications, especially when generic substitution is involved and medication regimes have been altered.  Sometimes the hospital does not have a complete medication history available or may be unaware of a patient’s idiosyncrasies or factors such as the financial implications of medication changes for an individual which may impact on the patient’s adherence.  Likewise when a consumer first visits their GP after discharge a discharge summary or notification of changes to medication may not be available.  Similarly the community pharmacy may not even be aware that the consumer has been in hospital, let alone that their medications have been altered.  Although work has been done to try and address these issues at the community hospital interface; without timely and accurate electronic communication and good patient education there is a potential for misadventure.

Many large public hospitals have a pharmacy outreach program in place and have pharmacists who contact patients after discharge and organise home visits.  The programs aim to reduce readmission rates for recently discharged patients.  In my experience the reports written by the outreach pharmacist are shared with the GP and the community pharmacy (with the patient’s permission) as well as being incorporated into a patient’s hospital medical record.  Outreach pharmacists are a great bridge between hospital and community care.  However I do not have any figures on the timeliness of outreach visits across the various hospital services.  My personal observation is that visits are often delayed for longer than a week after discharge from hospital for a variety of reasons.  In the private hospital sector pharmacy outreach services are not usually available due to absence of funding incentives.  Many elderly people are treated in private hospitals and are thus not able to benefit from hospital pharmacy outreach program after discharge.  Thus this group of consumers has been totally reliant on the community HMR model.

A recent South Australian study showed evidence that hospital initiated HMRs were conducted sooner than HMRs organised by community processes.1  This study was undertaken at three large teaching hospitals in South Australia over nine months.  High risk patients were identified through a risk stratification instrument.  These patients received HMRs either using existing community processes with GP referral using Item 900 or alternately a hospital initiated HMR was undertaken, sometimes using the community pharmacy and sometimes using a rapid response team of accredited pharmacists.  In all cases a hospital liaison pharmacist was involved in initiating the HMR.  The results showed that patients who had a hospital initiated HMR, without referral by their GP received their HMR sooner than those who were referred by their GP.1  This study also showed that direct referral by the hospital to an accredited pharmacist enabled an HMR to be undertaken sooner than when the HMR was organised through the community pharmacy.  Thus involvement of a community pharmacy also delayed the HMR.1  Thus the model of hospital initiated HMRs which by-passes both the GP and the community pharmacy enabled the fastest route for a recently discharge patient to receive an HMR.

Based on the model from the South Australian research it is likely that public hospitals will engage their own accredited pharmacists to undertake post-discharge HMRs, in a similar manner to current outreach programs.  It is unclear to me at this stage whether the hospitals will be able to be paid directly for the reviews and employ accredited pharmacists to undertake the reviews or whether they will arrange referrals with a range of consultant accredited pharmacists.  What is of concern to me is that the process may by-pass community pharmacists and GPs.  Collaboration is an important part of the HMR process.  Collaboration is not just communication of findings by sharing a report after an HMR.  Collaboration means working together for the benefit of the individual consumer or patient.  Collaboration will improve patient care. The roles of doctors and pharmacists in the community are complementary.2  In a similar manner I believe that the roles of hospital pharmacist, community pharmacist, hospital doctors and GP are all complementary.  I do hope that this does not become a turf war between the various groups of professionals or result in empire building by any particular group, but rather that a suitable model is developed to involve all of these health professionals for the benefit of patients who are discharged from hospital.

Hospital based pharmacists are in a good position to undertake an HMR after discharge as they are able to access the medical record of the patient and consult with the hospital medical team about changes to the medication regime.  They will also be familiar with generic substitution and medication changes made during a hospital stay.  However the community pharmacist may have a well established relationship with a consumer and is more likely to be aware of issues that may impact on the consumer’s ability to adhere to prescribed medication.  They are also more likely to be aware of non-prescription medications the consumer is using.  Together with the GP the community pharmacist is responsible for providing ongoing care to the consumer in their home environment.  In the current Australian healthcare system the GP is also the key care provider who is responsible for co-ordination of care for a consumer; though this may change with the advent of Medicare Locals.  Generally the GP has an established relationship with their patient and will know the full history of that person and often their family as well.

Where does the role of the independent accredited pharmacist fit in this process?  While all community pharmacists are not all able to become accredited, independent consultant accredited pharmacists are essential to the HMR process.  Accreditation is not for all pharmacists.  It is also likely that patients discharged from private hospitals and small public hospitals may benefit from the services of a consultant accredited pharmacist.  It is also my belief that there is a benefit to be had from an independent review as a pair of fresh eyes may see something which has been missed through over-familiarity.

This new model of direct hospital initiated referral will bring benefit to people at risk of medication misadventure after hospital discharge.  I hope that the model developed is truly collaborative and uses the skills and knowledge of all those involved to provide patient-centred care.

Please note all the views expressed in this article are my personal opinion and do not necessarily reflect the opinion or attitude of any of the organisations that I am employed by or associated with.

 

1. Angley M, Ponniah AP, Spurling LK et al. Feasibility and timeliness of alternatives to post-discharge home medicine reviews for high-risk patients. J Pharm Pract Res 2011; 41: 27-32.
2. Rigby D. Collaboration between doctors and pharmacists in the community. Aust Presc 2010;33:191-3.

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Submitted by Manya Angley on Tue, 02/08/2011 - 13:20.

As the project leader of the SA post-discharge medication review implementation trial referred to in this article I would like to clarify that the rapid response team (RRT) of accredited pharmacists used in our study were all independent accredited pharmacists. RRT accredited pharmacists were not employed by the hospitals involved and were directly funded by the project. The RRT was assembled purposefully for the project with the assistance of HMR facilitators. The study methodology was as follows: the patient's GP was contacted in the first instance and organisation of post-discharge reviews for all patients occurred via the HMR pathway whenever GPs were confident the HMR could be conducted within 7 days post-discharge. The community pharmacy was the second port-of-call. Post-discharge review referrals were only made directly to members of the RRT in the event that GPs or community pharmacies were not confident reviews could be conducted within 7 days. In all instances the GP and community pharmacy were kept in the loop because as highlighted by Ms Dunkley the relationships they have with patients are integral to optimum patient care. GPs remained responsible for developing the medication management plan with their patient regardless of the pathway followed. Thus if the model implemented within the fifth pharmacy agreement is based on our study, there is no doubt it will be truly collaborative. What is needed is a flexible model that is both collaborative and patient centered and ensures that post-discharge medication reviews are conducted within 2 to 10 days post-discharge when patients are known to be at the greatest risk of medication misadventure.

Submitted by Kay Dunkley on Sun, 07/08/2011 - 23:40.

Thank you for this clarification. I agree that the model you used is preferable. I hope that a similar flexible and collaborative patient centred model is implemented under the 5th pharmacy agreement.

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