Improving health outcomes through integration of pharmacists into Aboriginal Health Services
LINDY SWAIN, BPharm , PhD CANDIDATE EMERITUS PROFESSOR LESLEY BARCLAY AO PHD
UNIVERSITY CENTRE FOR RURAL HEALTH, NORTH COAST
14TH NATIONAL RURAL HEALTH CONFERENCE, CAIRNS, APRIL 2017
Background Poor medication management in Aboriginal and Torres
Strait Islander communities may result in poorer control of chronic disease states and higher hospital admissions, morbidity and mortality1
Aboriginal and Torres Strait Islander people are low users of pharmacy medication management programs, such as Home Medicines Review (HMR)2
Home Medicines Reviews (HMR), have been found to improve medication management and medication adherence3
Pharmacists co-located in GP practices can significantly reduce medication related problems and improve medication adherence4
Home Medicine Review Flowchart Source: Pharmaceutical Society of Australia’s Guidelines for pharmacists providing HMR services, www.psa.org.au/downloads/practice-guidelines/home-medicines-review-services.pdf
GP
Pharmacist - patient
Pharmacist - GP
GP – patient
How could increasing medication reviews help?
Increase medication adherence5
Build rapport between pharmacist and patient6
Increase knowledge of patients about their medicines, disease state7
Education and support of GPs5
Reduce medication misadventure, reduce hospitalisations8,9
Encourage GP engagement with patients about medicines7
Empower patients to ask questions6
Home Medicines Review benefits
Patients: HMR interview provided increased medication knowledge and health literacy
affirmation, emotional reassurance
GPs: HMR reports assisted rationale prescribing and increased use of evidence based
medicine
identified drug interactions and adverse effects
assisted in understanding patient barriers to medication adherence
Reconciliation of medicines across variety of prescribers.
Research Aim: Improve medication management for Aboriginal and Torres Strait Islander people By: • Analysing barriers and enablers to HMR service delivery from
the perspectives of: o Aboriginal & Torres Strait Islander patients
o Aboriginal Health Service staff – AHWs, nurses, GPs
o Pharmacists
Developing strategies which may assist utilisation of medication management programs by Aboriginal and Torres Strait Islander people
Method
Aboriginal Advisory committee Sampling: Aboriginal Health Services (varying demographics) Approval AHS CEOs and Boards Ethics approval was sought and granted from:
– The University of Sydney Human Research Ethics Committee
– Aboriginal Health and Medical Research Council of NSW Ethics Committee
– Menzies School of Health Research, NT
– Aboriginal Health Research Ethics committee of the Aboriginal Health Council of SA
Method
Phase 1 Client perspectives: Focus groups (n=18) at AHSs (n=11) with
Aboriginal and Torres Strait Islander patients (n=102) Phase 2 AHS Health Professionals’ perspectives (: semi-structured
interviews (n=31; 14 AHWs, 11GPs, 5 nurses, 1 practice manager)
Phase 3 Pharmacists’ perspectives: online survey (n=187)
State Location Type Focus grp
HMR Users
Focus grp
HMR Non Users
Interviews
NSW Rural 3 9 1 AHW, 1 nurse, 1 GP
NSW Remote 1 8 1 AHW, 2 nurses, 1 GP
NSW Urban 0 13 1 AHW, 1 GP
NSW Regional 3 6 1 AHW, 1 GP
QLD Regional 0 10 3 AHWs, 1 GP,
QLD Remote 0 4 0
NT Regional 2 6 1 AHW, 1 GP
NT Remote 3 7 1 AHW, 1 GP
VIC Urban 3 5 1 AHW, 1 GP
SA Rural 8 3 3 AHWs, 1 GP
SA Remote 0 8 1 AHW, 1 nurse, 1 GP
SA Urban 0 0 1 AHW, 1 nurse, 1 GP
TOTAL 23 79 15 AHWs, 5 nurses, 11 GPs
Findings – medication issues Patients found medicines confusing and difficult to manage10
Patients had received little or no medication counselling, but wanted to know more about their medicines10
Lack of relationship with community pharmacist – didn’t ask advice10
GPs unaware of patients’ confusion about medicines11
25% nurses and GPs stated that patients did not want/need to know more about their medicines11
GPs: discussion of medicines, a low priority11
Findings: pharmacists & pharmacies
Patients had little understanding of the role of a community pharmacist10
Community pharmacies uncomfortable environments for health discussions10
Community pharmacies – culturally unsafe places10
Majority of pharmacists had received no cultural training12
Pharmacists expressed a desire to work more closely with AHSs but unsure how to broker a relationship with the AHS12
GPs hesitant to refer their patients to pharmacists11
Findings: medication reviews Patients and health professionals believed that HMR could increase medication
knowledge and medication adherence6,11
Current HMR processes are not culturally appropriate6,11
Barriers to current HMR model include 6,11: Lack of HMR awareness
Program name – Clients don’t want strangers in their home
Referral pathway
Lack of pharmacist – AHS relationships
Lack of systems & procedures
GPs & AHWs very busy
Current HMR model doesn’s work
Changes to medication review model need to include 6,11: Referrals from AHS staff (not just the GP)
Integration and payment of Aboriginal Health Workers
Patients to choose location of interviews ( don’t have to be a patient’s home)
Integrating medication review into AHS systems
Regular, rather than infrequent, medication reviews needed
Tiered, flexible medication reviews tailored to patient need
Need culturally sensitive/trained pharmacists integrated into AHSs
In summary
Poor health → complex medication regimes → difficulty managing medicines
Most patients want to know more about their medicines
Lack of knowledge → lack of medication adherence
Patients could be assisted by the patient medication education component of the HMR, but current model inappropriate
Pharmacists need to play a greater role in assisting Aboriginal clients with their medicines, but community pharmacy setting often inaccessible or inappropriate
Pharmacists in Aboriginal Health Services
Co-locating a pharmacist within an AHS would enable: The pharmacist to become more culturally competent
The pharmacist to develop trust with clients and AHS staff
Relationship brokerage between AHS and community pharmacies
Championing of medication issues
A dedicated organiser/driver of medication review processes
Integration of medication review into existing AHS systems
Improved collaboration and communication between health professionals in management of chronic disease clients
Pharmacists in Aboriginal Health Services
Regular health coaching, multiple patient interactions rather than once-only advice Appropriate level of service
Medication counselling Medication reconciliation Medication review Group education Tailored interaction to address client’s needs Monitoring medication adherence Health promotion Assist with medicines access
Effective communication tools, resources, aids
Pharmacists in Aboriginal Health Services
Assist GPs with prescribing Medication education for AHS nurses, GPs and AHWs Medication protocols and guidelines for AHS Monitor adverse effects, potential drug interactions Liaise with dispensing pharmacy Oversee QUMAX or S100 programs Allows a sustainable systems based approach to implementing
medication management processes
Conclusion
Co-location or integration of culturally responsive pharmacists in AHSs is the most effective way:
- to implement medication management services, such as medication review
- to engage clients and service providers in discussions about medicines
- to improve health outcomes for Aboriginal and Torres Strait Islander people.
References 1. Kelaher M, Taylor-Thomson D et al. Evaluation of the PBS Medicine Supply Arrangements for Remote Area
Aboriginal Health Services Under S100 of the National Health Act. Co-operative Research Centre for Aboriginal Health and Program Evaluation Unit, University of Melbourne. Found at: http://www.health.gov.au/internet/main/publishing.nsf/Content/
2. Urbis Keys Young. Evaluation of Home Medicines Review Program – Pharmacy Component. Prepared for the Pharmacy Guild of Australia. June 2005. Found at: http://www.guild.org.au/uploadedfiles/Medication_Management_Reviews/Overview/Urbis%20Keys%20Young%20evaluation.pdf
3. Holland R, Smith R, Harvey I. Where now for pharmacist led medication review? JECH. 2006; 60: 92-3 4. Freeman C, Cottrell W, Kyle G, Williams I, Nissen L: Integrating a pharmacist into the general practice
environment: opinions of pharmacist's, general practitioner's, health care consumer's, and practice manager's. BMC Health Services Research 2012, 12(1):229.
5. Tan ECK, Stewart K, Elliott RA, George J: Pharmacist services provided in general practice clinics: A systematic review and meta-analysis. Research in social & administrative pharmacy : RSAP 2013.
6. Swain L, Barclay L.(2015) Exploration of Aboriginal and Torres Strait Islander perspectives of Home Medicines Review. Rural and Remote Health, 15:3009 Found at: http://www.rrh.org.au/articles/subviewaust.asp?ArticleID=3009
7. Carter SR, Moles R, White L, Chen TF: Patients’ willingness to use a pharmacist-provided medication management service: The influence of outcome expectancies and communication efficacy. Research in Social and Administrative Pharmacy 2012, 8(6):487-498.
References
8. Castelino RL, Bajorek BV, Chen TF: Are interventions recommended by pharmacists during Home Medicines Review evidence-based? Journal of Evaluation in Clinical Practice 2011, 17(1):104-110.
9. Roughhead L SS, Rosenfeld E,: Literature Review: Medication Safety in Australia (2013). Australian Commission on Safety and Quality in Health Care, Sydney. In.; 2013.
10. Swain L, Barclay L. (2013) They've given me that many tablets, I'm bushed. I don't know where I'm going. Australian Journal of Rural Health, 21: 216–219. Found at: http://onlinelibrary.wiley.com/doi/10.1111/ajr.12053/pdf
11. Swain L, Barclay L. (2015,) Medication reviews are useful, but the model needs to be changed: Perspectives of Aboriginal Health Service health professionals on Home Medicines Reviews. BMC Health Services Research.
12. Swain L, Griffits C, Pont L, Barclay L.(2014) International Journal of Clinical Pharmacy; 36(6) 1260-1267. Found at: http://link.springer.com/article/10.1007/s11096-014-0030-y
