US Pharm. 2013;38(1):16-18
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
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
Home Medicines Reviews
As pharmacists in the U.S. continue to develop and expand
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
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
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.
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.
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.
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 email@example.com.
1. U.S. Department of Health and Human
Services. A profile of older Americans: 2011. Updated February 10, 2012.
December 10, 2012.
2. American Society of Consultant
Pharmacists. ASCP fact sheet. Updated July 30, 2012.
www.ascp.com/articles/about-ascp/ascp-fact-sheet. Accessed December 10,
3. Institute of Medicine. Retooling for
an aging America: building the health care workforce.
www.iom.edu/CMS/3809/40113/53452.aspx. Accessed December 12, 2012.
4. Zagaria ME. Baby boomers on brink of health care crisis. US Pharm. 2008;33(6):20-26. www.uspharmacist.com/content/t/geriatrics/c/9780/. Accessed December 11, 2012.
5. Mann D. Study foresees shortage of
primary-care doctors: reasons include medical students pursuing
specialties, older physicians retiring. December 4, 2012.
Accessed December 12, 2012.
6. Doheny K. Are primary care doctors a
vanishing breed? Information and resources. WebMD Health News. December
4, 2012. www.webmd.com/news/20121129/primary-care-doctors-vanishing.
Accessed December 12, 2012.
7. Benjamin R. 2011 support letter from
United States surgeon general. Updated February 15, 2012.
December 12, 2012.
8. Rucker NL. Medicare Part D’s
medication therapy management: shifting from neutral to drive. Insight
on the Issues. AARP Public Policy Institute. June, 2012.
Accessed December 12, 2012.
9. USPHS Pharmacist Professional Advisory
Committee—report to surgeon general. Improving patient and health
system outcomes through advanced pharmacy practice. A report to the U.S.
surgeon general, 2011.
December 12, 2012.
10. Centers for Medicare & Medicaid
Innovation. Independence at home demonstration. CMS.gov. Updated August
Accessed December 30, 2012.
11. Centers for Medicare & Medicaid
Innovation. Independence at home fact sheet (PDF). Updated August 10,
Accessed December 30, 2012.
12. Centers for Medicare & Medicaid
Innovation. Details for demonstration project name: independence at home
Accessed December 30, 2012.
13. Centers for Medicare & Medicaid
Innovation. Work with CMS on independence at home demo. January 17,
2012. www.pharmacist.com/work-cms-independence-home-demo. Accessed
December 30, 2012.
14. Australian Commonwealth Department of
Health and Aging. Home medicines review programme fact sheet.
Commonwealth of Australia, Canberra. Updated April 2009.
Accessed January 7, 2012.
15. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47;533-543.
16. Zagaria ME. Medication-related problems in seniors: risk factors and tips for appropriate prescribing. Am J Nurse Pract. 2009;13(3):23-27.
17. Stafford AC, Tenni PC, Peterson GM,
et al. Drug-related problems identified in medication reviews by
Australian pharmacists. Pharm World Sci. 2009;31;216-223.
18. Roughead EE, Semple SJ, Gilbert AL. Quality use of medicines in aged-care facilities in Australia. Drugs Aging. 2003;20;643-653.
19. Ruths S, Strand J, Nygaard H.
Multidisciplinary medication review in nursing home residents: what are
the most significant drug-related problems? The Bergen District Nursing
Home (BEDNURS) study. Qual Safe in Health Care. 2003;12;176.
20. Roughead EE, Barratt JD, Ramsay E, et
al. Collaborative home medicines review delays time to next
hospitalization for warfarin associated bleeding in Australian war
veterans. Clin Pharm and Ther. 2011;36:27-32.
21. White L, Klinner C, Carter S. Consumer perspectives of the Australian home medicines review program: benefits and barriers. Res Soc Admin Pharm. 2012;8:4-16.