Majority of aged care medication plans going unchecked

Anastasia Tsirtsakis

8/12/2020 4:11:09 PM

Contrary to guideline recommendations, only one in five older Australians receives a timely Residential Medication Management Review.

GP and older woman
New research found just 6% of all residential aged care facilities review more than half of all new residents’ medication programs.

That is the finding of new research from the Registry of Senior Australians at the South Australian Health and Medical Research Institute (SAHMRI).
The study analysed data collected from 143,676 residents across all 2799 residential aged care facilities (RACFs) nationally from 2012–15. It found just 30,883 (21.5%) individuals received a Residential Medication Management Review (RMMR) within 90 days of entry.
And just 6% of all facilities reviewed more than half of all new residents’ medication programs.
Current Australian guidelines recommend an RMMR be provided as soon as possible after an individual first enters permanent residential care.
Lead researcher Dr Janet Sluggett told newsGP the findings point to potential dangers, as older people can be more susceptible to medication-related adverse events.
‘We know that from our previous research … there can be quite a few changes to medications in the 12-month lead-up to entering residential aged care, and also after a person first enters,’ she said.
‘We’ve previously done some work looking at changes in antipsychotic use, antidepressant use, and benzodiazepine use in the 12 months before and after entry to residential aged care, and found that there were sharp increases in the use of those medicines.
‘Also, some residents may enter aged care facilities from hospitals, and we know that when a person’s in hospital that can be a time that medications can change as well.’
The research did note that residents with dementia and those who speak a primary language other than English were 5% and 4% more likely to receive a timely RMMR, respectively.
While Dr Sluggett says the slightly higher provision among cohorts who may have difficulty reporting any side effects is ‘definitely an encouraging finding’, further statistical analysis of individual resident factors associated with higher or lower provision showed very little difference.
There was, however, considerable geographical variation in RMMR provision among individuals in non-metropolitan areas, found to be 25–33% less likely to receive a timely review.
RMMRs are conducted collaboratively by the resident’s GP and a pharmacist. The GP initiates the process, and considers any recommendations when preparing the resident’s medication management plan.
A recent systematic review conducted by Dr Sluggett looking into the impact and outcomes of RMMRs showed clear benefits. It found that 2.7–3.9 medication-related problems are identified on average per resident, and that GPs accept between 45% and 84% of recommendations.
Professor Dimity Pond, a GP with a special interest in aged care, says she has found RMMRs to be ‘very helpful’.
‘No doctor can be aware of all the interactions and side effects of medications from memory, and older people are particularly vulnerable to these. I have found that the pharmacy reviews identify issues which I had never thought of,’ she told newsGP.
‘But it is essential that they are interpreted by the prescribing doctor, because that is the person who knows the patient best.’
The study’s data period of 2012–15 is noted as a limitation, but Dr Sluggett says Medicare Benefits Schedule (MBS) data suggests few improvements have occurred over the five-year period.
‘When you look at the raw numbers of medication reviews that are paid for just at the crude level, it doesn’t suggest to me that the situation has changed dramatically since that time period,’ she said.
This was reflected in the online submissions to the current Royal Commission into Aged Care Quality and Safety, one-third of which were medicine-related.
In the recent royal commission interim report, the counsel assisting identified the need for regular and targeted RMMRs for people taking high-risk medications as a national priority.
It was announced in June that the Federal Government would fund pharmacist delivery of the medication reviews via telehealth, and that two follow-up consultations by pharmacists would be remunerated. However, the same provisions have not been made for GPs.
In a submission to the royal commission in November, the RACGP extended its in-principle support to increase access to medicine reviews, but noted that GP involvement is central to better patient outcomes.
‘Though it is stated that “different funding criteria [for GPs and pharmacists] make little sense and cause difficulties” pharmacists are not doctors. They do not have the complete clinical and personal history of the patient or expertise to manage a patient, and reviews should not take place without
GP awareness and oversight,’ the RACGP stated.
‘While in principle this recommendation will support medication management for patients, there must be a mechanism for GP review, including mandatory information sharing with a patient’s GP.’
To ensure optimal medication management for older people in RACFs, the RACGP’s aged care clinical guide (Silver Book) states that it ultimately involves ‘a systematic and multidisciplinary team approach’.
Dr Sluggett agrees.
‘I really do believe that medication safety is a shared responsibility and that GPs, pharmacists, aged care facility staff, and the nurses within the aged care facility are all involved in medication management in some ways for these residents,’ she said.
‘It’s essential that we are all working together in a team to ensure that what we’re doing is resident centered, and that will be the way that we can improve medication safety in this area definitely.’
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Dr Gaurav Tewary   9/12/2020 8:18:20 AM

The recommendation is that once people enter an RACF they have a Comprehensive Medical assessment (CMA), the LMO review their care plan, which is created by the RACF and for the patient to have an RMMR.
Yet, all these items have numbers which are the same as for people living in the community and if they’ve had these items used prior to getting admitted to the RACF, Medicare rejects the claims!
This is true even for item 731 which is cross checked against item 732. The item descriptors are completely different.
MBS needs to be completely overhauled for RACF patients. And let’s not forget that visiting an RACF for any of these items doesn’t allow item 90001 to be billed either.
This mess is of your making. Don’t blame the end user

Dr Graham James Lovell   9/12/2020 8:29:28 AM

One of the issues for me with utilising RMMRs until now has been the Total lack of any effective review or complaints process for Pharmacists who hold these RMMR Contracts. I have kept the damning evidence for future publication of examples of 3 line templated RMMRs used by one pharmacist saying no drug interactions,no side effects,and no monitoring required (even for a Clozapine patient), who walked away from an AHPRA report organised via the Pharmacist trainer for RMMRS with no findings against him , and more frighteningly a complete suppression of the review process by his fellow Pharmacists.Also no action by Medicare complaints secondary to this inappropriate action by AHPRA.
The second issue being that the contract process prevents any right of choice by either the GP or the patient to use their own choice of trustable Pharmacist. This is a complete abuse of patient rights ,that isn’t allowed in any other part of their care- ie their choice of doctor, physio, podiatrist.

Prof Max Kamien, AM   10/12/2020 2:43:09 AM

The dementia units are awash with risperidone. As one nurse said when exhorting me to prescribe it. " Everyone else is on it".