In the RACF setting, medication orders are written on the RACF medication chart by qualified prescribers, taking into account the needs and views of residents (or representatives), policies of the RACF, legislative requirements and professional standards. The qualified prescriber is usually the resident’s GP, but may also be a locum or hospital doctor, Hospital in the Home (HITH) prescriber, geriatrician or palliative care team member. In some situations, registered dental practitioners or registered nurse practitioners may be able to prescribe medications.
It is necessary for GPs to work closely with RACF staff to regularly review and rewrite medication charts and prescriptions to maintain a continuum of medication for residents. There is currently a transition from medication charts to the national standard medication chart, and also to electronic chart prescribing in accordance with mandatory legislative requirements.8
APAC’s National guidelines to achieve continuity in medication management should be referenced when a resident moves between different healthcare settings (eg hospital to RACF).7 The World Health Organization’s (WHO’s) Medication safety in transitions of care provides further detailed information to improve safety in transition from hospital to home or RACF.9
Residential medication management review
Under the sixth Community Pharmacy Agreement, Medicare requires contracts in order for accredited pharmacists to undertake a Residential Medication Management Review (RMMR; Medicare Benefits Schedule [MBS] item number 903) in a particular RACF10 sixth Community Pharmacy Agreement.
Residential Medication Management Reviews (RMMRs) are services provided to permanent residents of Commonwealth-funded RACFs. The RMMR is conducted by an accredited pharmacist when requested by a resident’s GP, and undertaken in collaboration with the resident’s GP and appropriate members of the resident’s healthcare team. A comprehensive assessment is undertaken to identify, resolve and prevent medication-related problems, and this assessment is provided to the resident’s GP. The RMMR is recommended for each resident on admission and regularly reviewed thereafter when there is a therapeutic need. As of April 2020, pharmacists are able to undertake two additional follow-up reviews after the initial RMMR. Referrals are no longer required by GPs and there is no MBS item number for follow-up reviews. Follow-up services should be provided by an accredited pharmacist and fed back to the resident’s GP. The first follow-up interview should be undertaken no earlier than one month and no later than nine months after the initial interview. If a second follow-up interview is required, it should be undertaken no earlier than one month after the first follow-up interview and no later than nine months after the initial interview.10
Quality Use of Medicines
The Quality Use of Medicines (QUM) program is a separate service provided by a registered or accredited pharmacist, and focuses on improving practices and procedures as they relate to QUM in an RACF.11
Home Medicines Review
In the community, medication should be reviewed regularly to identify discrepancies between medicines being taken and those prescribed. The initial Home Medicines Review (HMR) requires a GP referral. If follow-up services are required, this should be undertaken by an accredited pharmacist. The first follow-up interview should be undertaken no earlier than one month and no later than nine months after the initial interview. If a second follow-up interview is required, it should be undertaken no earlier than one month after the first follow-up interview and no later than nine months after the initial interview.12 The Home Medicines Review (HMR; MBS item number 900) is available for the GP and pharmacists to assess optimal medication management.
Dispensing, storage and disposal
Pharmacists work closely with GPs to dispense and supply medication safely, and accredited consultant pharmacists conduct medication reviews only on referral from a GP. All three can work closely as a team with the RACF staff to supply the dispensed medications in a suitable form and ensure their safe handling at the facility.
The Pharmaceutical Society of Australia has developed standards for pharmacy services to residents, outlining the following recommendations:13
- Maintain appropriate systems for the supply of medicines to the facility.
- Ensure medicines are delivered to the RACF in a timely manner.
- Ensure medicines are stored within the RACF in accordance with legislative and manufacturers’ storage requirements.
- Monitor stock medicines used in the RACF.
- Check medications brought into the RACF by new patients, as soon as practicable after admission, to ensure consistency with currently prescribed medications.
- Conduct a comprehensive medication review of all residents at regular intervals and maintain appropriate records.
- In consultation with medical practitioners, identify residents who may require therapeutic medication monitoring.
- Identify, monitor and document adverse medication events.
- Provide information on medicines that adequately meet the needs of the RACF.
- Provide an education program appropriate to the needs of the RACF.
- RACFs must have a mechanism in place for the disposal of returned, expired and unwanted medicines.
Medication can be administered by a registered nurse (RN), an endorsed enrolled nurse (EN) or a personal care assistant (PCA) who is qualified to administer medication, or can be self-administered by the resident if they are assessed to be competent to do so.1,2
Dose administration aids can be used to provide medications where an RN who is qualified to administer medications is unavailable, and can be used to assist residents to self-administer. ‘Blister’ packaging systems or medication sachets are packed and labelled by a pharmacist, and the medication is administered directly from the dose administration aid to the resident. If the prescriber alters any medication order, the entire dose administration aid must be returned to the supplying pharmacist for repackaging. RACF staff should refer to relevant state/territory legislation for further information on dose administration aids. Older people in the community may administer from original containers or use dose administration aids either packed by themselves, family members or the supply pharmacy.
Modifying oral products
Many older people have difficulty swallowing tablets and capsules. Wherever possible, oral dose forms of medicines should not be altered.1,2
Medications must not be crushed or altered without consultation with the pharmacist or drug information centre. Altering the form of medication by crushing, cutting or dispersing may result in the risk of toxicity, reduced effectiveness, gastrointestinal irritation, unacceptable presentation to residents in terms of taste or texture, or an occupational health and safety issue to nursing staff.1,2
Details about the suitability for dispersion, crushing or cutting for people with difficulties swallowing or with enteral feeding tubes are provided in The Society of Hospital Pharmacists Australia’s Don’t rush to crush.14 This resource is available as a text or as part of Monthly Index of Medical Specialities (MIMS) or Australian Drug Information (AusDI) as an additional subscription and should be used in conjunction with advice from a pharmacist.
Alterations in drug delivery should be recorded on the patient’s medication chart with the date reviewed, so that all members of the healthcare team are aware of the new procedures. Each RACF is required to have a policy for the administration of altered medications, and suitable techniques if the drug is approved for crushing.12
Review medication regimen
Difficulty in swallowing provides an opportunity to review the medication profile; before trying to cut, crush and/or dissolve a tablet or capsule, consider:2
- stopping medicines that are no longer necessary
- using an oral liquid
- using other available routes (eg rectal, topical, transdermal, parenteral) that may be appropriate
- changing to an alternative drug that is easier to give or has a liquid or dispersible preparation available.
If a resident has difficulties swallowing medicines, it can be assumed that they will also encounter difficulties with food. Referral to a speech pathologist and dietitian may also be considered.