Home Medicines Review Research Articles

Medication Management for Community-dwelling Older People with Dementia and Chronic Illness

The purpose of this paper is to report the findings of an integrative review of the literature on medication management for individuals who live in the community and have both chronic illness and mild to moderate dementia. The aim of the review was to summarise what is known about this topic, evaluate and compare previous research on the topic of medication management for people with dementia, and locate gaps in current work, thus pointing to directions for future research. Dementia is a national health priority for Australia. A significant component of community care for people with dementia is the management and administration of the medications required for other chronic conditions. Medication management is a broad term that encompasses several aspects, such as client-centred medication review, rational prescribing and support, repeat prescribing, client information/education, capacity to communicate with multiple health providers and having access to medicines. Cognitive impairment has been associated with medication management issues so it is important to ensure quality outcomes of medicine use by community-dwelling older people with dementia. The literature revealed a number of issues, such as the importance of person-centred care, the need for the coordination of care, and consumer partnerships in medication management. These are all important considerations in planning primary care services to support people with dementia and chronic illnesses. People with dementia who have chronic illness require coordinated, tailored, and flexible care processes in the community. There exists a range of services and programs such as home medicine reviews to support people living in the community with chronic illness and dementia; however, there is little coordination of care and evaluation of interventions is, at best, inconsistent. Currently, Australia lacks an integrative primary health care (PHC) framework, within which consumer involvement in decision-making and/or care planning is valued and sought. Current services are limited in the degree to which there is collaboration between key partners and Australian PHC initiatives are fragmented and have limited impact on service delivery.

General Practitioner Perceptions of Extended Pharmacy Services and Modes of Collaboration with Pharmacists

ABSTRACTAimsTo explore the perceptions of Australian general practitioners (GPs) towards extended pharmacy services, and to investigate the modes and extent of collaboration between community pharmacists and GPs.MethodSemi‐structured face‐to‐face and telephone interviews were conducted on a purposive sample of GPs from Sydney and surrounding areas. The data were thematically analysed, using qualitative data analysis software.Results23/68 (34%) GPs approached, agreed to participate in the interviews. The respondents practised in different settings (private/medical centre/specialised settings, rural/suburban/city areas), had been in professional practice for periods ranging from 6 months to several decades and included both female and male practitioners. Support for pharmacist provision of services varied. GP perceptions were mostly positive for home medicines review (HMR), information provision and monitoring. However, most GPs did not favour pharmacists' provision of screening and immunisation services. Most respondents believed that GP‐pharmacist collaboration would be beneficial to both the patient and the GP. However, despite this, collaboration was minimal in all extended pharmacy services discussed except HMR.ConclusionHMR is the extended pharmacy service most widely accepted by GPs and has proved to be an effective platform for inter‐professional collaboration. Considering the factors that promote effective collaboration in HMR will position us better to improve the GP‐pharmacist collaboration crucial for expanding other extended pharmacy services.

Classification of Findings in the Home Medicines Reviews of Post‐Discharge Patients at Risk of Medication Misadventure

ABSTRACTBackgroundThe risk of medication misadventure for patients is greatest during times of change, particularly on discharge from hospital. Patients at high risk of medication misadventure post‐discharge should be identified and provided with interventions to ensure the quality use of medicines and positive health outcomes. Home medicines reviews (HMRs) can be used to improve patient health outcomes and reduce the risk of medication misadventure.AimTo describe the impact of issues raised in post‐discharge HMRs, organised via a hospital medication liaison service.MethodHMR reports of participants were evaluated. Issues identified by the accredited pharmacist in each HMR report were classified as either a ‘pharmacist intervention’ delivered during the HMR or ‘information given’ that was previously unknown to the medical team. A potential clinical impact of these issues was assigned and the overall clinical significance of all the issues identified in each HMR report was ranked.ResultsIn 21 HMR reports, 98 issues were identified, with the mean per HMR report of 4.7 ±2.2. Of the 98 issues, 25 were classified as ‘pharmacist intervention’ and 73 were classified as ‘information given‘. On 2 occasions, a potential clinical impact of 4 (potentially life‐saving) was allocated to an issue identified in the HMR report. 90% of issues identified in the HMR reports were ranked as clinically significant.ConclusionThis pilot demonstrated that a liaison pharmacist was able to implement a hospital medication liaison model for patients at risk of medication misadventure. Evidence suggests that an HMR conducted post‐discharge can identify clinically significant medication‐related issues.

Improving medication safety: influence of a patient‐specific prescriber feedback program on rate of medication reviews performed by Australian general medical practitioners

To determine if patient-specific prescriber feedback for general medical practitioners (GPs), supported by educational material mailed to their patients, would increase home medicines review (HMR) rates. An observational study was conducted using the Repatriation Pharmaceutical Benefits Scheme (RPBS) Pharmacy Claims Database. The intervention group (n = 40 270) included all veterans aged >/=65 years, dispensed >/=5 unique medicines each month over a 4 month period. Comparison group veterans (n = 49,227) were those who did not have >/=5 or more unique medicines dispensed each month, but did have at least one prescription each month and >/=20 prescriptions over 4 months, of which five were unique medicines, Intervention GPs (n = 11,384) were subdivided into 2 groups: GPs with intervention veterans (n = 2097) and GPs with both intervention and comparison group veterans (n = 9287). The comparison group of GPs (n = 3630) were primary prescribers to the comparison veterans only. Rates of HMRs pre and post-intervention and the number of new GPs participating in HMR services were examined. There was a significant increase in HMR rates in intervention group, from 2.2 per 1000 in the pre-period to 4.6 per 1000 per month in the post-intervention period (Rate Ratio (RR) 2.06, 95% Confidence Interval (CI) (1.90, 2.22), p < 0.0001). HMR rates increased in the intervention group compared with the comparison group (p < 0.0001). HMR rates increased in the intervention group GPs compared with the comparison group (RR 1.79, 95% CI (1.58, 2.02), p < 0.0001). Patient-specific feedback provided to GPs, supported by educational material mailed directly to their patients increased HMR rates for targeted veterans and increased GP participation in the delivery of HMRs.

Enhancing Continuity of Care in Therapeutics: Development of a Post‐Discharge Home Medicines Review Model

ABSTRACTBackgroundThe Australian Pharmaceutical Advisory Council guidelines for the continuum of quality use of medicines between hospital and community aim to establish a coordinated approach that encourages continuity in all areas of health care and the community. However, the implementation of these guidelines has been problematic.AimTo identify the number and nature of barriers encountered when organising a home medicines review (HMR) for patients at high risk of medication misadventure, after discharge from hospital.MethodA liaison pharmacist organised an appointment for eligible patients (around 2 days post‐discharge) for the general practitioner to make an HMR referral. The pharmacist contacted the patient's community pharmacist to engage an accredited pharmacist to undertake the HMR and arranged for the HMR report to be sent to the outpatient clinic, the general practitioner and community pharmacist.Results38/50 patients consented to have their general practitioner contacted by the liaison pharmacist. General practitioners agreed to order an HMR for 34 patients. Barriers to HMR uptake included: low patient awareness of HMRs, a low level of general practitioner awareness of the HMR process, reluctance of some community pharmacists to participate in HMR delivery and the time taken for HMRs to be performed.ConclusionOnce aware of the HMR service, the majority of patients were willing to participate and general practitioners were prepared to refer their patients for such a service. However, time constraints impacted on both general practitioners and community pharmacists, hence, consideration should be given to extending the support from HMR facilitators to include pharmacies as well as general practitioners.

Mental health case conferences in primary care: Content and treatment decision making

Background Case conferences are multidisciplinary meetings of health professionals to plan treatment for specific people with chronic and complex care needs. The value of multidisciplinary teamwork in mental health care is well recognized. Objective This study aimed to explore the process of decision making in mental health case conferences involving community pharmacists and primary care physicians. Methods Case conferences were conducted for 44 people receiving one or more medicines for a mental illness. Before participating in the case conferences, pharmacists conducted home visits and produced written reports that detailed Home Medicines Review findings and recommendations. The case conferences were audio taped and transcribed verbatim. A framework, based on the 3 components of decision making (derived from the Model of Shared Decision Making), was used to code statements made at the case conferences. These components were (1) information exchange, (2) deliberation, and (3) decision making. Results Pharmacists and physicians exchanged personal and medical information. Pharmacists presented their treatment findings and recommendations, and generally a brief discussion about treatment options followed (deliberation). The responsibility for deciding which treatments to implement (decision) typically remained with the physicians. Conclusions The case conferences provided an opportunity for pharmacists and physicians to share information and discuss treatment options. Responsibility for deciding which treatment to implement generally remained with the primary care physicians.

A Novel Medicines Management Pathway

ABSTRACTBackgroundA novel medicines management pathway for patients with chronic heart failure was developed and commenced at the Prince of Wales Hospital in 2002.AimTo evaluate whether the novel medicines management pathway facilitated by the community liaison pharmacist and medication management review facilitator helped implementation of home medicines reviews and improved medication management.MethodA survey of general practitioners, community pharmacists, accredited pharmacists and patients was conducted.ResultsGeneral practitioners, community pharmacists and accredited pharmacists reported that the collaboration between the community liaison pharmacist and the medication management review facilitator improved the hospital and community link, and home medicines review implementation. Most patients noted they learnt something new about their medicines and that they could ask more questions of their general practitioner and pharmacist.ConclusionThis model improved communication between hospital and community and implementation of home medicines reviews in heart failure patients.

Drug-Related Problems in the Community Setting

Adverse drug events are a leading cause of morbidity in Australia and internationally. People taking psychotropic drugs for mental illnesses may be particularly susceptible. This study aimed to classify and describe pharmacists' Home Medicines Review (HMR) findings and recommendations for people with mental illnesses. This was a descriptive study conducted from March to November 2003. General practitioners and community pharmacists practising in two regions of metropolitan Sydney were invited to participate. General practitioners recruited and referred community-dwelling people with mental illnesses to receive HMRs conducted by accredited pharmacists. Reviewing pharmacists interviewed 49 people in their homes. During the interviews the pharmacists provided drug information, assessed drug knowledge and beliefs, and assessed drug adherence. Pharmacists then produced written referenced reports that outlined drug-, patient- and prescriber-related findings and recommendations. These findings and recommendations were presented to the referring general practitioners at follow-up case conferences. Drugs were classified using the Anatomical Therapeutic Chemical Classification System. Pharmacists' findings and recommendations were classified using the Clinical Pharmacy Activity Classification System. The most common types of nervous system drugs taken by people who received a HMR were antidepressants (n = 39.33%), analgesics (n = 29.24%) and antipsychotics (n = 17.14%). Pharmacists reported 403 findings and made 360 recommendations for 49 people, with 90% of recommendations being accepted by the referring general practitioners. The most common findings related to potential adverse drug reactions (n = 53, for 47% of people), suspected adverse drug reactions (n = 48, for 55% of people), potential interactions (n = 30, for 37% of people), and people taking additional drugs unbeknown to their referring general practitioner (n = 26, for 25% of people). The most common recommendations were to switch a drug (n = 37, for 49% of people), suggest a non-drug treatment (n = 29, for 41% of people) and to suggest a new drug (n = 27, for 49% of people). At the time of referral, general practitioners documented people to be taking 7.8 +/- 4.4 (mean +/- SD) drugs each (range 1-18). Following home interviews, pharmacists determined people to be taking 9.1 +/- 4.8 drugs (range 1-20). This difference was statistically significant (p < 0.001). Pharmacists identified a high incidence of drug-related problems among people receiving treatment for mental illnesses. Pharmacists also identified a higher incidence of overall drug use than documented by the referring general practitioners. HMRs and case conferences, undertaken collaboratively by general practitioners and pharmacists, may be a useful strategy to identify drug-related problems among people with mental illnesses.