Community-Based Medication Management in the U.S. and Australia

While the older population—those aged 65 years and over—has increased from 35 million in 2000 to 40 million in 2010, the decades beyond are projected to show greater increases, to 55 million in 2020 and 72 million by 2030.^1,2 The significance of this situation with regard to its potential impact on the health care system became strikingly evident in the Institute of Medicine’s report “Retooling for an Aging America: Building the Health Care Workforce.” The 2008 report identified a severe shortage of geriatrics health care professionals, a health care system “unprepared for the surge of seniors about to enter the system,” and a future workforce that is “inadequate in its capacity to meet the large demand for health services for older adults if current patterns of care and of the training of providers continue.”^3,4

A recent study in the Journal of the American Medical Association confirms the concern that there will be a shortage of primary care physicians when older adults will need them most.⁵ Previously, the Association of American Medical Colleges predicted that a physician shortage would reach 91,500 by 2020, with approximately half that number expected to be primary care physicians.⁶ Particularly in the arena of primary care, pharmacists—given their advanced training, recognition as health care providers by United States Surgeon General Regina Benjamin, MD, and their involvement in current medication therapy management (MTM) programs and innovative practice models in the U.S.—certainly have a larger role to play in managing medication therapies, typically in some form of collaboration with the prescribing physician (see RESOURCES, Medicare Part D’s Medication Therapy Management: Shifting from Neutral to Drive).^7,8

In a letter supporting the U.S. Public Health Service Pharmacist Professional Advisory Committee’s report entitled, “Improving Patient and Health System Outcomes Through Advanced Pharmacy Practice,” Dr. Benjamin wrote that the report “demonstrates through evidence-based outcomes, that many expanded pharmacy practice models (implemented in collaboration with physicians or as part of a health team) improve patient and health system outcomes and optimize primary care access and delivery.”^7,9 Those in health leadership roles and policy makers are encouraged to explore and identify methods to “optimize the role of pharmacists to deliver a variety of patient-centered care and disease prevention, in collaboration with physicians or as a part of the health care team.”^7,9

Examples of the promise of MTM in drug benefit programs include the pharmacist-physician teams currently used in Iowa’s Medicaid MTM-like program and the optimal care standards achieved by Minnesota’s Medicaid recipients with diabetes who received pharmacist-delivered MTM. ⁸ Furthermore, the Affordable Care Act (ACA) contains provisions that aim to address the shortage of primary care providers, including both physicians and other health care professionals (e.g., nurse practitioners).^10-13 Demonstration projects associated with the health care reform law that promote primary care coordination of complex illnesses in some cases incorporate care delivered by the pharmacist as part of a multidisciplinary team.^10-13

Looking Abroad:
Home Medicines Reviews

As pharmacists in the U.S. continue to develop and expand   MTM programs and demonstration projects, such as the ACA’s Independence at Home Demonstration conducted by the Center for Medicare & Medicaid Innovation, in which the primary care teams also include pharmacists (see references 10-13), it is instructive to look at how similar practice models have been established and have evolved in other countries. Australia offers a model that is of particular interest because it encompasses government-funded, pharmacist-conducted medication reviews in the community setting, while utilizing U.S.-based certification processes for credentialing pharmacists.  

In Australia, arguably the most significant single development in the field of consultant pharmacy practice can be traced to 1997, when the federal government introduced a mechanism for publicly-funded medication review services.¹⁴ At that time, the program was initially limited to Residential Medication Management Review services (RMMRs; see Facility-Based Medication Management Review, below), provided by specifically accredited pharmacists for residents in aged-care facilities (ACFs). Subsequently, Home Medicines Reviews (HMRs) were introduced in October 2001. The HMR service is provided by accredited pharmacists, who visit patients residing in their own home in a community-based setting. With regard to both of these services, the pharmacist is the health care professional conducting a systematic evaluation of a patient’s prescription and nonprescription medications, as well as the management of those medications. The outcomes of the visit include counseling and education for the patient, an assessment of adherence, the resolution of practical medication-related problems (MRPs), and a detailed report that is used to form the basis of a medication management action plan to be implemented by the patient’s physician. Pharmacists use their own approach to create the report, although standard templates and software are widely available and in use. This pharmacist-conducted review identifies potential areas for attention, as well as any potential or actual MRPs; these have been described as undesirable events or circumstances that either actually or potentially result in interference with a patient’s medication therapy or medication regimen, compromising desired outcomes.¹⁵ MRPs are of particular concern in the elderly since adverse drug events are among the top five greatest threats to the health of older adults.^2,16

Achieving Accreditation

There are two separate processes by which Australian pharmacists can achieve accreditation to provide RMMR and HMR services, and these pathways are administered by the Australian Association of Consultant Pharmacy (AACP) and also by the Society of Hospital Pharmacists of Australia (SHPA).¹⁷ In the case of the AACP, the candidate undergoes preparatory training that can be undertaken as live workshops or distance learning. Candidates undertake assessment after completing preparatory training and furnishing a portfolio of experience. The assessment involves successfully completing a multiple choice examination accompanied by assessment based upon four hypothetical case studies. The AACP accreditation cycle spans three years, during which pharmacists must maintain continuing professional development (CPD) and must be able to furnish evidence of compliance upon request. In the accreditation program administered by SHPA, pharmacists furnish evidence of competency based upon an outsourced process, whereby a pharmacist must either hold the Certified Geriatric Pharmacist (CGP) credential or have Board Certification as a Pharmaco-therapy Specialist (BCPS) with the U.S. Board of Pharmaceutical Specialties. The same requirements for CPD are inherent to the SHPA process.

Patient Care and Economic Benefits

There is considerable evidence suggesting that the implementation of pharmacist-conducted medication reviews can lead to better health outcomes for older people.^17-20 HMRs allow for the identification of opportunities for changes to medication regimens to achieve optimal effectiveness and reduce or resolve undesirable side effects and medication interactions. Additionally, HMRs can bring about improved medication literacy, enhancing understanding and adherence.²¹ Over 400,000 HMRs have been conducted in Australia by accredited pharmacists. The patient’s primary care physician (known in Australia as the general practitioner, or GP) must determine that a review of the patient’s medications in the home setting is clinically appropriate as a means to help to ensure accurate and safe use of medicines or to address a patient’s specific needs. There are no strictly defined criteria that are used as a basis to initiate the HMR process for an individual patient, but factors that are widely employed as a basis to seek a review include:

• Using five or more different medications

• Twelve or more occasions of medication administration per day

• Using a drug of low therapeutic index (often warfarin or insulin)

• Suspected adverse drug reaction or drug interaction

• Suspected non-adherence

• Lack of expected response to drug treatment.

While practitioners can complete the HMR process at their own pace, seasoned practitioners can undertake up to 10 HMRs in a working day, depending upon the extent of preparation, patient-specific factors, and the time taken to travel between appointments. The current standard rate remuneration for each occasion of HMR service is A$200.92 (approximately U.S. $210.67 as of press time) per review. A loading (an increment added to the basic fee) is paid in addition if the patient resides in a rural or remote community; the extent of the loading is determined on the basis of the extent of the remoteness. Although the medication review is often considered as an annual process, in fact the HMR can be repeated as deemed clinically appropriate by the patient’s GP. Triggers that may prompt a repeat order for an HMR could include 1) the introduction of new drugs; 2) the appearance of new symptoms; or 3) a recent hospital admission. Only the patient’s GP can make a referral; this pathway is as yet not available to specialist physicians who may be involved in the patient’s care.  

While hospital inpatients and individuals who are residents in government-funded ACFs are not eligible to receive an HMR, they do qualify to receive an RMMR (see next section). When a patient has an established rapport with a community pharmacist, the pharmacist can be accredited and undertake the HMR, although commercial business pressures often dictate that this process be outsourced to an independent consultant pharmacist. Consent must be provided by the patient to the referring physician prior to proceeding with the pharmacist-conducted medication review.

Facility-Based Medication
Management Review

A residential medication management review (RMMR) is a service provided to a permanent resident of an Australian ACF upon request from the resident’s GP. Upon visiting the facility, the pharmacist collates information about the resident’s medications and clinical progress, forming the basis for a comprehensive assessment to identify, resolve, and prevent MRPs. A report of this assessment is provided to the resident’s physician. Current data suggest that pharmacists currently provide RMMR services to over 2,800 ACFs in Australia, and review the cases of approximately 180,000 residents. The current rate of remuneration, indexed annually against inflation, is A$100.60 (approximately U.S. $105.48 as of press time) per review.

Moving Forward

Future plans for development of the program in Australia continue to evolve on the basis of increasing evidence of the patient care and economic benefits of the medication reviews. Developments slated for consideration include the creation of a direct hospital referral pathway, whereby hospital-based physicians or pharmacists can initiate a referral for a medication review, and the possibility of referrals by specialist physicians requesting medication reviews. Basic claims data collected by the federal funding agency as a part of the administrative process for claiming payment may subsequently be used as a basis to design and implement other targeted programs to enhance quality use of medications for older people in Australia.

Conclusion

Using guidance from evidence associated with successful MTM programs and government-funded, pharmacist-delivered medication review services in the U.S. and abroad, the health care reform law may provide much opportunity for pharmacists to manage medication therapies for seniors as part of a collaboration with physicians or as part of a multidisciplinary health care team.

The authors would like to acknowledge Sarah Gillespie, staff pharmacist, Australian Association of Consultant Pharmacy, who contributed to this article.

Dislosure: Dr. Zagaria currently serves as a member of the Board of Commissioners for the Commission for Certification in Geriatric Pharmacy. Dr. Alderman is currently the chair-elect of the Board of Commissioners for the Commission for Certification in Geriatric Pharmacy.

To comment on this article, contact rdavidson@uspharmacist.com.

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