Engaging geriatric medicine pharmacists in hospital and aged care settings will help to cut Australia’s high rates of medication-related unplanned hospital admissions, says a leading advocate.
Kristin Michaels of the Society for Hospital Pharmacists of Australia writes below that supporting this specialised, targeted care is long overdue.
Kristin Michaels writes:
Medication errors have an enormous impact on our health and wellbeing. Disproportionately impacting older Australians, medication errors account for an estimated 20–30 percent of all hospital admissions in those aged 65 years and over.
After the overwhelming testimony of the Royal Commission into Aged Care Quality and Safety, the worthy recommendations of its Final Report: Care, Dignity and Respect have highlighted the need for greater pharmacist involvement in clinical medication management.
The following five priorities to mitigate the risks of medication-related harm in older Australians provide a blueprint for action, supporting Quality Use of Medicine and Medicine Safety, which was declared in 2019 as Australia’s 10th National Health Priority Area.
1. Geriatric medicine pharmacists
Medicines are essential in treating chronic health conditions in older people and, when used safely, are effective and improve health outcomes and quality of life.
However, studies indicate that 20 percent of all medications used in older Australians are potentially inappropriate. Crucially, up to 30 percent of hospital admissions of older people are medication-related, and about half of these are preventable.
If overprescribed, poorly monitored, or otherwise mismanaged, medicines have the potential to cause or worsen common geriatric syndromes and symptoms such as dementia, delirium and incontinence, and increase the risk of falls.
As highlighted in Care, Dignity and Respect, pharmacists are critical to providing medication management services, and geriatric medicine pharmacists are uniquely skilled to manage the more complex medicines and treatment needs of older Australians.
Their expertise includes adapting care to lower physiological reserve and resilience; defining different goals of care, especially in frail individuals; and handling limited evidence on medicines’ efficacy, as older people are often excluded from clinical trials.
To fully utilise geriatric medicine pharmacists in preventing hospitalisation (or re-hospitalisation) and harm they need to be:
- Embedded into hospital medical teams to support rapid and responsive prescribing and deprescribing decisions;
- In place to facilitate safer transitions of care upon hospital discharge; and
- Integrated, onsite, in all aged care settings to ensure equity of access to crucial pharmacy services (including regular medication reviews and medication optimisation for aged care residents).
Avenues for action:
- Specifically recognising medication management services as a need of residential aged care residents under the Australian Government’s Australian National Aged Care Classification (AN-ACC) funding model;
- Dedicated funding for these geriatric medicine pharmacist positions and services by state and federal governments (this could potentially be built into aged care packages and home care packages}; and
- Legislating minimum geriatric medicine pharmacist–to–aged care resident ratios; both the Society of Hospital Pharmacists of Australia (SHPA) and the Pharmaceutical Society of Australia (PSA) support a minimum of 1FTE pharmacist for every 200 residents.
2. Broader care teams
As uncovered by Royal Commission into Aged Care Quality and Safety, older people are at their most vulnerable during the movement between hospitals and residential aged care facilities. Amid the logistics, paperwork and emotion, there is urgent need for a multidisciplinary care team to wrap around each individual and their family.
The geriatric medicine pharmacist must be part of these teams – regardless of whether the care is being provided in a residential facility or private home – to ensure better care for older people while placing less strain on hospital emergency departments.
Avenue for action:
The Australian Government should work with state and territory governments to develop a multidisciplinary geriatric outreach and in-reach service and funding model that includes pharmacists, which aims to prevent avoidable hospitalisations for older Australians.
3. Interim Medication Administration Charts
Patients discharged to residential aged care facilities are prescribed an average of 11 medications, of which seven are new or were modified during their hospital stay. Up to 23 percent of these patients experience delays or errors in receiving this new medication regime after their transition of care.
Sometimes, aged care residents returning from hospital are administered medicines according to their old medication chart (which may have caused the hospital admission in the first place).
The Interim Medication Administration Chart is a key document that must accompany the patient to their residential aged care facility.
- Is populated with the patient’s details and discharge medication information, usually completed and signed by the hospital pharmacist;
- Helps ensure medications are safely administered immediately after arrival at the facility; and
- Fills the information gap while the patient’s GP prepares a long-term care medication chart (which can take up to seven days).
Avenue for action:
- Aged care standards and guidelines should reflect the need to utilise Interim Medication Charts for older people transitioning between hospital and aged care settings to ensure timely and safe access to medications.
- Provide education to doctors, pharmacists and nurses to increase uptake and use of Interim Medication Administration Charts.
4. Sorting out psychotropics
Psychotropic medications affect our mind, behaviour and emotions, and are recognised as high-risk medicines by the Australian Commission for Safety and Quality in Health Care.
Sadly, inappropriate use of antipsychotic medications in older people is common. Care, Dignity and Respect identified an over-reliance on antipsychotics as a means of chemical restraint in the purported ‘care’ of older people in aged care, and the subsequent recommendation to restrict the use of these medications has been supported by the Australian Government.
This is another area in which the skill and experience of hospital pharmacists can be put to best use, as specialty geriatric medicine pharmacists can:
- Lead or shape psychotropic stewardship programs, a proven and effective medicines governance strategy to prevent inappropriate use and reduce risk of harms associated with psychotropic medicines;
- Determine whether psychotropic medication prescribing is appropriate and in accordance with clinical practice guidelines;
- Determine if antipsychotic medicines are being used therapeutically or for chemical restraint, as part of facility-wide audits; and
- Identify cessation dates, or determine a de-escalation plan to prevent unnecessary, ongoing long-term use of psychotropics.
The avenue for action is simple: widespread embedding of geriatric medicine pharmacists into all settings where older people receive care.
5. Whole person care
As in all areas of healthcare, prevention is better than cure.
Although medication-related problems are highly prevalent in older people preparing to enter residential aged care, the multidisciplinary teams that assess care needs and eligibility for aged care services do not usually include a pharmacist.
As recommended by Care, Dignity and Respect, older people should have greater access to medicine reviews conducted on entry to residential aged care, and repeated annually or more often if there has been a significant change to their condition or medicine regime.
Including a geriatric medicine pharmacist in Aged Care Assessment Teams (ACATs) will ensure:
- People experiencing medication-related problems or at high risk of medication-related harms are identified; and
- Appropriate services are put in place to reduce harm, improve independence and prevent decline in health, function and wellbeing.
The clearest path of action is again a simple one: dedicated funding by state governments for these positions to be embedded in ACAT teams.
Now we are equipped with overwhelming evidence, it is the time to act.
The shocking testimony of the Aged Care Royal Commission highlighted with brutal clarity the need for new strategies to ensure older Australians are taking the right medicine, at the right time in the right way.
These five measures identified by the SHPA Geriatric Medicine Leadership Committee will ensure specialised, targeted care is readily available to improve the health and wellbeing of this vulnerable cohort of Australians, while aligning with recommendations 38, 58 and 65 in the Royal Commission’s Final Report.
This is more than good policy – it is the right thing to do, and it is long overdue.
Kristin Michaels is CEO of the Society for Hospital Pharmacists of Australia.
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