Posts tagged as:

HMR

Pharmacists in Remote Areas

by Robbo on 31/08/2009

four_wheel_driveCroakey (The Crikey Health blog) has recently had a post on Home Medication Reviews and the “thorny issue of interprofessional practice”. The problem of pharmacists providing a “complete” role in rural and remote areas was mentioned.

I couldn’t help myself and made comment. It can almost stand alone so I have reproduced it below. I guess there will have to be more to follow on this subject in a future post.

Regarding the impact on rural and remote areas:
Home Medicine Reviews (HMRs) in remote areas have long been problematical. As discussed, solo pharmacists in remote rural areas cannot leave their pharmacy to perform them. In truly remote areas there is usually no pharmacist as part of the primary healthcare team.

The Australian Pharmacy Council (of which all Pharmacy Boards are members) released a report in June 2009 on the Remote Rural Pharmacists Project (PDF) looking at ways for pharmacists to be able to work outside the confines of a pharmacy in remote rural areas.

The Department of Health and Ageing in December 2008 released a report by Campbell Research & Consulting on the Home Medicines Review Program Qualitative Research Project (PDF) that contain strategies for providing alternative models of HMRs to reach Indigenous consumers.

OATSIH has also recently funded a pharmacist position with an Aboriginal Health Service. If this continues and some points in these reports are acted on there is hope for better service delivery of HMRs by pharmacists in remote areas.

Robbo
(Disclosure: I had some input into both reports)

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Tagged as: Croakey, HMR, Home Medicine Reviews, pharmacy, Remote health

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Improving Access to Home Medicine Reviews (HMRs) in Remote Aboriginal Communities

by Robbo on 16/10/2008

by Cathy Larkin.

Modification is required to the current HMR process before it will be viewed as a workable and useful process for clinicians and clients in remote Aboriginal communities. Below are suggested opportunities for modification. These comments are based on my experiences as a remote pharmacist in the Kimberley.

Referral Process

Comment: The current referral process requires a preferred community pharmacy. This concept is largely foreign to many members of Aboriginal communities who access medicines through the S100 supply scheme. Often access to pharmacy services is limited to the supplying community pharmacy and the visiting pharmacist (often an outsourced arrangement). The pharmacist may or may not be an accredited pharmacist.

Suggestion: The opportunity for a doctor to refer a patient to an accredited pharmacist who is known to be familiar with the community is essential.

Comment: The referral process is based on the doctor seeking consent from the patient. In many remote communities, a doctor visit may be once a week and it is usually the resident nursing and Aboriginal Health Worker (AHW staff) who are more familiar with the patients.

Suggestion: Remote area nursing staff and AHWs to be able to refer patients to pharmacist for HMRs. I would strongly recommend that the referral is done in consultation with the prescriber (ie the prescriber is phoned to alert them to this). However, consent and explanation of the process can be done by the nursing staff & AHWs.

Comment: The current referral process means that there will always be a delay between referral and actual HMR interview. This is often exaggerated in remote communities, because the pharmacist may only be visiting once every 3 months. Opportunistic care is often a very successful option for patients in remote area communities and this concept can be extended to HMRs for Aboriginal people.

Suggestion: The ability of remote area nursing staff and AHWs to refer patients will allow patients to be referred more promptly. For example, patients can be referred opportunistically on the day the pharmacist is in the clinic.

Referral form

Comment: With agreement from the clinic and patient (and as part of the clinic team), I was often able to access the patient’s information from their file. This included their progress notes, lab results and medication chart (as well as old medication charts). As the prescriber knew I had access to this information, they were often in the position to reduce the amount of medical history they had to provide me with.

Suggestion: The workload of the clinician writing the HMR referral can be reduced by a form where the referring clinician signs that themselves and the patient have given the accredited pharmacist permission to access the patient’s file (and electronic data if a patient information recall sheet exists). This means that the referring clinician need not provide lab results etc.

HMR interview

Comment: Frequently, the visiting pharmacist is largely unfamiliar with the client base of a remote AMS. Therefore, they are often reliant on the patient knowledge, community knowledge and cultural knowledge of the local staff, in particular the AHWs. The delivery of the HMR interview can be enhanced enormously by this local knowledge.

Suggestion: The financial recognition of the participation of AHWs and nursing staff in the HMR process is essential. Not only do these staff add to the outcomes of the HMR process, but they also usually expend a lot of energy and time co-ordinating the pharmacist visit. Therefore, there should be an opportunity for the AMS to claim for their involvement in the process.

Comment: I know that I used different HMR resources for different people. In particular, I used a large human body to show where all the tablets were working. I imagine there are many other pharmacists with useful tools for delivering HMRs.

Suggestion: I believe that many pharmacists (particularly new pharmacists) would benefit from a centralised location for accessing information about HMRs for remote populations.

Increased Prescriber Familiarity with the HMR Process

Comment: In my experience, there are a large number of prescribers who do not consider the option of HMRs for their patients. This may be due to lack of familiarity or due to the complexity associated with participating in this process.

Suggestion: There is a need for increased publicity of the HMR service to clinicians in remote area practice. There also needs to be an update on claiming process for those involved in MBS claiming at AMSs.

Cathy Larkin is an accredited pharmacist who has worked in the Kimberley as the Rural Pharmacist Academic and with the Kimberley Aboriginal Medical Service. She has now “turned to the dark side” and is studying medicine at Flinders University.

This is the third guest post in a series on Home Medicine Reviews in remote aboriginal Australia.
The first was by Chris Phillips and the second by Lisa Crisp.

Published in conjunction with my 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.”

This section is from the Medicare Australia website.

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Tagged as: health, HMR, home medicine review, Remote Blogs

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Home Medicine Reviews in the Bush

by Robbo on 09/09/2008

A little over a week ago I posted the first on what I hope is a series on Home Medicines Reviews out bush. This post is written by pharmacist Lisa Crisp who has been doing the Bush HMRs for the Kimberley Division of General Practice.

The Kimberley presents some unique challenges for pharmacy practice, but as I have found, the greater the challenge, the greater the reward. The distances are vast and the patients often unsure and mistrusting of this new service. But providing a valuable service to people in remote locations has been one of the best jobs I have ever done.

For the past two years I have been fortunate enough to work across the Kimberley region of Western Australia. It is one of the most beautiful offices in the world and this is the story of how I established a career in this wonderful workplace.

Before moving to the Northern Territory in 2007 I contacted as many different pharmacists and others with an interest in pharmacy practice as I could find in the area. Initially the response to my call for employment was slow, but once word spread that there was a pharmacist willing to travel to rural and remote NT and WA, the work flowed. One of the first (and best) positions I took up was working with the Kimberley Division of General Practice (KDGP) to provide a HMR service to the Kimberley region of WA.

With the support of KDGP I am able to travel to the Kimberley and the towns within it at no cost to me. Without this support it would not be economically feasible to make the trip. With KDGP funding my travel, I am also able to venture out to aboriginal communities to provide some patients with the first pharmacy service of their lives. Because many indigenous Australians collect (or have delivered) their medications directly from the aboriginal health service (AHS), they may never enter a pharmacy or come into contact with a pharmacist. While AHS staff are competently trained, it is rare that an AHS staff member would have the time to provide the type and quantity of medicines education that can be passed on during a home medicine review. Over and over again I find myself spending much time providing medication counselling and education to remote patients, but it is this basic medicine information that allows people to better self-manage their medications and avoid adverse outcomes and medication misadventure. For these patients, the education provided at the HMR interview is easily the most valuable part of the process and is always wonderfully rewarding for me.

Each time I visit an aboriginal community I am accompanied by an aboriginal health worker who introduces me to the patient to rapidly establish a level of trust that would otherwise be unachievable in a single visit. I vividly remember my first visit to a remote aboriginal community in the Kimberley. We were so far out of town that we were almost back in the NT and we were completely isolated. Although there were several houses in the community, it felt completely deserted. In the middle of nowhere, with no mobile phone coverage, in a community where I was not known or trusted, I was especially grateful to have a health worker with me that day. It’s a very different place to do a HMR as compared to my home town of Launceston that’s for sure!

I have also found that I have been able to establish much closer working relationships with the GPs that I report to. At some AHSs I spend time discussing the patients face-to-face with the GP both before and after the interview; a luxury very rarely found elsewhere. Remotely located GPs (AHS or other) also seem even more grateful for the service than urban doctors – I figure that they are so used to facing barriers to service provision that to have a willing pharmacist provided through KDGP at no extra work or cost for the GP, is an absolute dream!

The community pharmacies should also receive a mention here. Without their cooperation and support the process would cease. Across the Kimberley community pharmacists have been nothing but helpful and supportive, which makes the process that much easier for me.

It takes a lot more planning to conduct HMRs in the Kimberley. It’s many phone calls and time for KDGP to arrange the logistics of getting me to the Kimberley, and accommodating me there (they provide a hire car, flights, hotel room etc). There’s more preparation to be done at my end for a week on the road, and of course it’s a day’s travel each way to get there, but at the end of a busy week I am always happy to reflect on how much has been achieved and how great it has been to provide home medicine reviews for remotely located patients that otherwise would have missed out on such a service.

For any accredited pharmacist willing and able to travel, there is unmatched reward waiting in rural and remote Australia. With the support of local divisions of general practice, a two week working “holiday” to remote Australia may just be the best thing you ever did! And once you’ve been once, I’m sure you’ll be back because it’s very hard to give up once you get the taste for it!

Lisa Crisp is an accredited pharmacist based in Katherine, NT. She graduated from the University of Tasmania in 2004 and achieved DMMR accreditation with AACP in 2006. Despite living in the Top End, Lisa continues to work in Tasmania, across the Kimberley and the Top End in many roles; accredited pharmacist, locum pharmacist in both community and hospital pharmacies as well as consulting for divisions of general practice and other pharmacy-linked groups.


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Tagged as: HMR, Indigenous, Kimberley, pharmacy, Remote Blogs

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Rural and Remote HMR’s in the Kimberley Region of Western Australia

by Robbo on 01/09/2008

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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Tagged as: HMR, Indigenous, Kimberley, pharmacy, Remote Blogs

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