This is the first in a series of articles about Home Medicine Reviews and how they are, and how they should be done in the bush. They will be run in conjunction with my good friends at Auspharm
For those non-pharmacists, a home medicine review is designed to “assist consumers living at home to maximise the benefits of their medication regimen and prevent medication related problems.”
The objectives of HMR are to:
* achieve safe, effective, and appropriate use of medications by detecting and addressing medication-related problems that interfere with desired patient outcomes
* improve the patient’s quality of life and health outcomes using a best practice approach, that involves cooperation between the general practitioner, pharmacist, other relevant health professionals and the patient (and where appropriate, their carer)
* improve the patient’s, and health professional’s knowledge and understanding about medications
* facilitate cooperative working relationships between members of the health care team in the interests of patient health and well being.”
All the above is from the Medicare Australia website.
Setting up a Home Medicine Review (HMR) service has been an evolving process. There are only 5 private pharmacies in the region, 3 of those being in Broome (with a resident population around 12,000). The other 2 pharmacies are located in Derby (200 km from Broome) and Kununurra in the East Kimberley (over 1000 kms from Broome).
There have been many challenges to overcome to implement a HMR service in this region. Issues such as:
• high GP staff turnovers in private practice, Hospitals and Aboriginal Medical Services [AMS];
• no HMR accredited pharmacists in the Kimberley;
• very little in the way of Private Practice (there are only 3 private practices in the Kimberley, 2 in Broome including one solo GP and 1 in Kununurra);
• difficulties securing services of a visiting HMR pharmacist;
• a lack of understanding about HMRs across the general community and service providers; and
• a large influx of tourists during our dry season (the population increases more than three- fold in Broome at its peak) putting extra demand on our limited health resources..
The Kimberley region, at the top of Western Australia, covers around 421,000 square kilometers, almost twice the size of Victoria. The region is classed as very remote, according to the Accessibility/Remoteness Index of Australia (ARIA). This means that it is locationally disadvantaged - with little accessibility of goods, services and opportunities for social interaction.
HMR servicing for the Kimberley Division of General Practice (KDGP) started off in a small way. At first we located a visiting HMR pharmacist who was willing to come to Broome. We are perhaps quite fortunate as Broome is a tourist destination, which seems to make it easier to attract a pharmacist. We then canvassed long standing private practice GPs in town to see if they had any patients who would be suitable for HMRs. This process involved briefing them about the initiative and asking them if they would be willing to refer a number of clients to keep a HMR pharmacist busy over the course of 4 to 5 days.
At the same time we contacted the Broome pharmacies to see if they were willing and able to accept HMR referrals for a visiting pharmacist. The pharmacies and the HMR pharmacist negotiated a fee for each HMR referral accepted and processed by the pharmacy. Once we had the thumbs up from all concerned parties the Division arranged payment for visiting pharmacist’s flights, accommodation, hire car and subsequent meals and incidentals. Typical costs for a HMR visit of around 5 to 6 days ranges from around $5000 to $6000, depending on locality and seasonal accommodation and airfare rates.
We were fortunate to have a very skilled HMR pharmacist who visited us the first few times in Broome; which ensured that the HMR service was valued and appreciated by the referring general practitioners in town. Following on from this, we have been able to implement an ongoing visiting HMR service to Kununurra and Broome.
In Kununurra the local AMS generated all the HMR referrals, which were approved by an AMS doctor and passed onto the HMR pharmacist. The pharmacist visited each person referred with the help of an Aboriginal Health Worker (AHW). The AHW has been crucial for tracking down clients and giving the pharmacist credibility, thus enabling the pharmacist to quickly establish some rapport and trust. This relationship is often slow to establish in remote Indigenous populations, as they have seen a lot of services come and go and a lot of white fellas come into and go out of their lives relatively quickly. Trust and respect often takes a few years to develop, hence the AHW is essential for establishing an instant link to their people.
If possible, it is important to get the same pharmacist back into indigenous communities, as it helps to build trust and rapport. We have been very fortunate in that we have been able to attract a young pharmacist who wants to work with indigenous communities and has continued to service the same communities over the last 2 years.
To date the HMR visiting pharmacist’s income has been solely derived from HMRs, though we have plans to supplement their income through payment for provision of concurrent professional development sessions, delivered to doctors and pharmacists, on one or two evenings while they are in town.
I would like to see the day when we have a pool/database of visiting HMR pharmacists available for rural and remote regions nationally. I really feel that if HMR pharmacists are supported in terms of travel, accommodation and meals/incidentals and are in the position able to pocket all or most of the HMR fees, then we may have a sustainable, skilled and willing workforce. This would allow us to come closer to achieving the goals of HMRs in rural and remote localities, now wouldn’t that be wonderful!
Chris Phillips is the Senior Program Manager with the Kimberley Division of General Practice based in Broome, Western Australia. One of his many roles is working as the HMR facilitator for this region.
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