Why onsite pharmacists will need more from GPs: opinion
It will be necessary to overcomin the barriers of doctors attending aged care homes for the embedded pharmacist program to achieve meaningful outcomes for residents, writes Marea O’Donnell.
Overcoming the barriers for doctors attending aged care homes must be one of the cornerstones of the embedded pharmacist program to achieve meaningful outcomes for residents, writes Marea O’Donnell.
We agree with the Australian Medical Association comments in their response to the Aged care onsite pharmacist consultation paper with supporting models of care where accredited pharmacists collaborate with general practitioners in aged care to assist with medication adherence, improve medication management and provide education about medication safety.
We also agree that mechanisms of transitions of care is a time of great importance to achieve these outcomes. The relationships that the AMA rightly suggests that need to occur between GPs and pharmacists and other health care professionals however will require greater engagement from GPs.
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This will only be overcome with addressing the barriers to the GPs’ involvement in attendance into the aged care home. This must be one of the cornerstones of this model of care otherwise no meaningful outcome for embedding pharmacists will occur for the resident.
At present it seems the approach to having an embedded pharmacist in aged care homes will immediately result in better and more consistent interaction with GPs.
In the 2017 AMA survey the average number of visits to the aged care home per month by the GP was eight, or two visits per week, where the GP would see six-to-seven patients.
While the timing of these visits was not discussed, our experience is that they often occur after-surgery hours, which would not suit an interaction with the embedded pharmacist.
Furthermore, the overall experience of the GP visiting residential aged care is very senior with greater than 75 per cent having more than 20 years of clinical experience and not used to participating in open multidisciplinary team approaches.
We envisage the junior pharmacy workforce that is being proposed in the consultation paper – perhaps no active aged care experience or at best less than two years – will at least initially have significant issues with GPs working as an equal experienced clinician.
Of course, we are in favour of increasing pharmacist input into aged care, but we also believe we need to understand why this is necessary and the drivers that got us to this point of considering embedding pharmacists at three-and-a-half times the cost of the current system.
Increasing complexity of residents
The high level of complexity and care needs of these vulnerable people in our aged care facilities is well documented. It is our experience that working with aged care providers and over 22,500 residents this data strongly suggests that care in residential aged care homes is no longer more akin to sub-acute care.
Skill of caregivers and rapid turnover of staff
The 2020 aged care workforce census reported 29 per cent of direct care staff leaving between November 2019 to November 2020. It is estimated that in the next two decades workforce demand in aged care will outstrip supply by approximately 164,000 or 78 per cent of the current workforce.
It is our experience working with over 220 aged care facilities that the turnover of facility and clinical managers at the individual sites approaches this number as well with aged care providers confirming this.
This high level of turnover of both staff who provide care but also who manage the facilities results in significant difficultly in providing coordinated care to the resident. While the government has many initiatives to mitigate the workforce risks in aged care it will take many years to change attitudes to working in this sector.
Increasing rates of dementia
The Australian Institute of Health and Welfare estimates 386,200-472,000 Australians were living with dementia in 2021 with 62 per cent female. Dementia was the leading cause of death for women and the second leading cause for men, after coronary heart disease.
And the prevalence of dementia is set to increase. We should therefore expect our aged care facilities to have significantly more residents with dementia as a co-morbidity thus increasing the complexity of care requirements for these residents.
Barriers for GPs to work in aged care
The availability and willingness of GPs to work in aged care and coordinate the multidisciplinary team approach is key. At present there are numerous barriers for GPs to work within aged care homes and decreasing numbers of GPs, particularly in metro areas. This results in aged care homes having difficulty in attracting GPs to provide services into the facility. The major barriers at present include:
- low levels of remuneration especially when compared to work in their surgeries
- time consuming – travel, finding the patient, relevant nurse clinical notes and so on
- a lot of non-remunerated work that makes it unattractive
- lack of younger GPs willing to commit to aged care work (they prefer specialties like cardiology) so potential workforce shortage into the future.
Numerous research figures have shown a lack of willingness of GPs to undertake RMMRs including the AMA’s 2017 survey. Yet medication reviews are shown to improve mortality.
At the extreme end of this disengagement of the GP from a multidisciplinary team approach to medication management is that we have facilities that have not offered an RMMR to any resident for more than 24 months despite multiple approaches from our pharmacists and the residential aged care facility clinical managers.
Model must be flexible and valuable
To be effective, the onsite pharmacist model must be flexible in its implementation. It cannot be a one-size-fits-all model. Most importantly, it must bring greater value and better outcomes to the residents in aged care.
It should:
- address the underlying issues that limit the effectiveness of the current program, for example, engagement of GPs
- be well considered in conjunction with critical key stakeholders, for example, current providers and GPs
- be accompanied by a robust model of care given the interplay of different external caregivers
- be implemented only once an appropriately trained workforce has been employed within the respective facility
- be measured using a national database, which determines outcomes and is established before implementation to ensure success and ongoing funding. Current researchers and thought leaders in geriatric pharmacology and deprescribing need to be engaged to design the measurement of success of this initiative.
Marea O’Donnell is chief clinical pharmacist at Mederev, which provides medication management services for aged care residents
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