The Australian 2022 pre-election announcement of $345.7 million over 4 years to embed pharmacists in residential aged-care facilities (RACFs) follows more than 20 years of reports of medication management challenges in the aged-care setting. The Royal Commission into Aged Care Quality and Safety highlighted over-reliance on psychotropic medications as needing immediate action. Australia's flagship residential medication management review (RMMR) program, launched in 1997, is still regarded as an international best practice model.1 However, just 22% of residents received an RMMR within 3 months of admission from 2012 to 2015.2 Australia's Aged Care Quality and Safety Commission receives more complaints about medication management than falls prevention and management, personal and oral hygiene, and continence management.3 There is a strong case for needing greater medication management expertise in RACFs. Increasing polypharmacy has been linked to residents being frailer and having higher rates of multimorbidity on admission.4 High staff turnover, difficulty accessing general practitioners, and limited access to geriatricians and psychiatrists have the potential to contribute to medication management challenges. Nurse practitioners have adopted greater medication management roles in RACFs. Nevertheless, the Australian Government's announcement of funding for pharmacists should be welcomed by residents who, on average, experience three or four medication-related problems each.1 A pilot study in Canberra demonstrated that embedding a pharmacist in RACFs improved medication administration and the reporting of resident allergies, adverse drug reactions, and medication incidents.5 There is also anecdotal evidence of the benefits from embedded pharmacist models, with some aged-care providers already trialling the model to varying extents. Embedding pharmacists in RACFs is an opportunity to improve medication management. However, this opportunity will not be fully realised unless the current model of service provision is expanded from predominately resident-level to an integrated resident- and system-level model. System-level interventions recognise the need for holistic facility or provider level changes and have been shown to improve both patient and service outcomes in hospital and primary care settings.6 Improving RMMR uptake may help to improve safe and effective medication use, but this alone will fail to generate the level of change needed and which residents and carers have a right to expect. We advocate for integrated resident- and system-level pharmacy services. Pharmacists should continue to conduct RMMRs with the added advantage of greater time on-site to facilitate interdisciplinary communication and collaboration, including providing medication information and follow-up to residents and carers, medical practitioners, nurses, and care staff. However, pharmacists should also act as knowledge brokers at the RACF and aged-care provider level. Key activities of knowledge brokers include ‘knowledge manager’ (e.g. translate evidence-based guideline recommendations to local RACF policies and procedures), ‘linking agent’ (e.g. facilitate collaboration between all stakeholders in medication management), and ‘capacity builder’ (e.g. develop competencies related to quality use of medicines [QUM]).7 These system-level services could complement existing resident-level services (e.g. RMMR) and improve processes across the whole medication management cycle: procurement, audit and feedback using medication indicators, review of quality and safety systems, and timely communication of accurate, complete and comprehensive medication information across transitions of care.8 This may include chairing the Medication Advisory Committee to proactively identify and respond to emerging QUM issues at the RACF and aged-care provider level.9 A key example of how resident- and system-level pharmacy services could be integrated is in the implementation of national clinical practice guidelines. Poor uptake of guideline recommendations is a barrier to reducing avoidable medication-related harm. Australia's new Clinical Practice Guidelines for the Appropriate Use of Psychotropic Medications in People Living with Dementia and in Residential Aged Care10 and the Evidence-Based Clinical Practice Guideline for Deprescribing Opioid Analgesics11 are examples of new guidelines under development that are relevant to RACFs. These guidelines will target high-risk medications (i.e. antipsychotics, antidepressants, benzodiazepines, and opioids). Acting as a knowledge broker, the embedded pharmacist would be a knowledge manager by identifying relevant guidelines and preparing tailored resources to assist with local implementation, monitoring, and evaluation. The embedded pharmacist would conduct an environmental scan and needs assessment and then identify, engage, connect, and facilitate the relevant consumer, healthcare professional, and organisational stakeholders required for guideline implementation. Finally, the pharmacist would design tailored training or educational sessions for stakeholders and help build their capacity to support sustainable practice change. This knowledge broker role is being trialled in the new Medical Research Future Fund (MRFF) supported Evidence-based Medication knowledge Brokers in Residential Aged CarE (EMBRACE) study. Now is the time to create an integrated resident- and system-level model for pharmacy services in RACFs. This should build on and not replace RMMRs. The model should facilitate pharmacists to be integral members of the RACF healthcare team and be flexible enough to allow their roles and responsibilities to grow and adapt to emerging aged-care and QUM priorities. We have a responsibility to use this opportunity to elicit the real system-level changes needed to optimise medication management to the benefit of residents and carers. AJC is supported by an NHMRC Emerging Leadership 1 grant (APP2009633), has received grant funding from the Medical Research Future Fund (GA187306) and is currently a practicing accredited pharmacist. ALC has received grant funding from the Medical Research Future Fund (MRFF). MS has no conflicts of interest to declare. JSB has received grant funding or consulting funds from the National Health and Medical Research Council (NHMRC), Medical Research Future Fund (MRFF), Victorian Government Department of Health and Human Services, Dementia Australia Research Foundation, Yulgilbar Foundation, Aged Care Quality and Safety Commission, Dementia Centre for Research Collaboration, Pharmaceutical Society of Australia, GlaxoSmithKline Supported Studies Programme, Amgen, and several aged-care provider organisations unrelated to this work. All grants and consulting funds were paid to the employing institution. All authors have read and given approval for this editorial. None required. Data sharing not applicable - no new data generated.
Search from 250 M+ research papersSearch from 250 M+ research papers
Open Access
Apr 6, 2024
Mouna J Sawan + 4
