Optimal medication management for older people in RACFs involves a systematic and multidisciplinary team approach (refer to Part B. Collaboration and multidisciplinary team-based care. This multidisciplinary team will generally involve the resident or their representative, general practitioners (GPs), other specialist medical practitioners, nurses, nurse practitioners, pharmacists, allied health professionals and other relevant staff. A similar approach can also be applied, where necessary, to older people living in the community.
The Australian Government Department of Health has developed Guiding principles for medication management in residential care facilities (Guiding Principles), which provides a series of recommendations around medication management in RACFs.9
Importantly, the Guiding Principles highlight the importance of having a medication advisory committee (MAC) comprising GPs, pharmacists, management staff, nursing staff and resident advocates, which will oversee the quality of medication delivery and use.
The Guiding Principles also aim to support RACFs to achieve high-quality use of medications from initiation, storage, supply, administration, review and cessation. This requires efficient and effective partnerships between all those involved in the prescribing process.
Specific aspects of medication management in RACFs:
- Monitor and record adverse reactions or interactions.
- Regularly review medication where indicated by changes in comorbidities or progression of disease.
- Consider prescribing as required (pro re nata [PRN]) and nurse-initiated medications for anticipated situations (refer to Part B. Anticipatory care).
- Use alternative oral formulations or alternative forms of drug delivery.
- Use of complementary and self-selected medications should be consistent with the RACF’s MAC policy.
- Avoid potentially inappropriate medications.
- Deprescribe where necessary.
- Consider medication requirements during end-of-life care.
Some of the concerns driving these principles include:
- older, frailer populations entering RACFs
- use of high-risk medications in RACFs (eg insulin, chemotherapy agents)
- changing staff profiles (more non-nursing qualified personal care staff)
- problems with timely access to GPs
- use of nurse practitioners.
The National Inpatient Medication Chart (NIMC) – Long stay is generally used for residents in RACFs. In most cases, the patient’s regular GP completes the chart; however, medications may be prescribed in certain circumstances by other visiting medical specialists, locums, hospital junior doctors or nurse practitioners. The GP has the important role of regularly reviewing and rewriting the medication charts of those in RACFs, working closely with the nursing staff to ensure continuity of treatment and to address any concerns or modifications needed.
All new RACF residents are eligible to receive a Residential Medication Management Review (RMMR) via the Medicare Benefits Schedule (MBS), and this should ideally be performed as soon as possible after admission. The RMMR should generally be undertaken by:
- the resident’s usual GP
- a doctor from the medical practice providing the majority of the previous and/or future care
- a GP contracted to provide care on a facility-wide basis
- a GP who provides services as part of an aged care panel arrangement.
Once the process of the RMMR has been discussed with the resident and/or their representative, and consent has been obtained, the GP provides details of the resident’s most recent comprehensive medical assessment and any other relevant clinical information to the accredited pharmacist for review. After patient consent is obtained, a patient’s GP needs to provide a written referral, which should include the reason for referral and all relevant prescribing and clinical history to the RMMR service provider.
The RMMR is conducted by an accredited pharmacist who identifies actual and potential causes of medicine-related problems and presents suggested solutions in a written report to the GP.
After the pharmacist performs the analysis, they discuss the outcomes of the review with the GP (usually in a written report), including findings, medication management strategies or recommendations, means of implementation, and follow-up. The GP then develops or revises the medication management plan, and finalises it after discussion with the resident and/or their representative. Copies of the plan are provided for the patient’s records, RACF nursing staff, and (if desired) resident/representative.
Two follow-up services can be provided by an accredited pharmacist if necessary. 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. Outcome of the follow-up services are provided to the GP.10
A post-review discussion with the pharmacist is not necessary if there are no, or only minor non-urgent, changes to the older person’s treatment, or if the issues require discussion as part of a case conference.
Older people who do not live permanently in an RACF (eg respite patients) and those living in the community are not eligible for the RMMR. Instead, the GP can initiate a Domiciliary Medication Management Review (DMMR) or home medicines review in conjunction with their community pharmacist. The pharmacist performs a comprehensive medication review during a home visit, and provides a report and findings to the GP. The GP and patient and/or representative are then able to agree on an appropriate medication management plan.