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Evaluation of the Residential Medication Management Review

Program

Appendix B: Call for Submissions

Prepared for

Department of Health and Ageing

GPO Box 9848 Canberra ACT 2601

May 2010

RMMR Evaluation Appendix B - Call for Submissions


TABLE OF CONTENTS

1. Introduction......................................................................................................................... 1

2. The submissions ................................................................................................................ 2

3. Overview.............................................................................................................................. 3

4. Findings............................................................................................................................... 4

4.1 The need for RMMRs................................................................................................... 4

4.2 Benefits of the RMMR Program ................................................................................... 5

4.3 Current arrangements .................................................................................................. 7

4.4 Funding and service model........................................................................................ 11

4.5 Impact of administrative arrangements...................................................................... 14

4.6 Provision of QUM services......................................................................................... 18

4.7 Gaps and future directions......................................................................................... 21



Please note that, in accordance with our Company’s policy, we are obliged to advise that neither

the Company nor any member nor employee undertakes responsibility in any way whatsoever

to any person or organisation (other than the Department of Health and Ageing) in respect of

information set out in this report, including any errors or omissions therein, arising through

negligence or otherwise however caused.



CR&C 1074 1

1. Introduction

The advertisement inviting submissions to the evaluation was published in The Australian

newspaper on 18 July 2009. The invitation was also distributed by a range of peak bodies and

stakeholder organisations.

The purpose of the Call for Submissions was to provide an opportunity for interested

stakeholders and individuals to have input. Stakeholders who responded included professional

associations representing Accredited Pharmacists, the pharmacy profession more generally,

GPs, and Aged Care Homes; as well as individual Accredited Pharmacists and RMMR

Providers and Directors of Nursing or senior managers within Aged Care Homes. The Call for

Submissions can be contrasted to the site visits which focused on the perspective of the

professionals involved in delivery of the RMMR Program. The site visits were recruited

independently and comment was provided in a non-identifying context. The Call for

Submissions process allowed for attributable comment unless confidentiality had been

expressly requested.

A list of submissions, along with the advertisement for the Call for Submissions is attached in

Appendix A.



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2. The submissions

In total, 67 responses were received in response to the Call for Submissions. Two submissions

were received where confidentiality was requested.

Submissions were made by stakeholders from a broad range of states and territories, with close

to one third of submissions from Victoria (not all identified their location). Most professional

associations representing the RMMR stakeholders made submissions.

Submissions were received from:

• Aged and Community Care Victoria

• Aged and Community Services Australia

• Aged Care Association Australia

• Aged Care Queensland

• Alzheimer’s Australia

• Australian and New Zealand Society for Geriatric Medicine

• Australian Association of Consultant Pharmacy

• Australian Medical Association

• Australian Nursing Federation

• Ethnic Communities’ Council of Victoria

• Pharmacy Guild of Australia

• Pharmaceutical Society of Australia

Submissions were also received from:

• 25 individual pharmacists (both Accredited and Non-Accredited Pharmacists

and RMMR Providers and Non-RMMR Providers)

• 17 Aged Care Homes, (from Directors of Nursing and senior managers)

• 2 individual GPs

• academics from Melbourne and Monash Universities and the University of

Tasmania.



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3. Overview

RMMRs were identified as being effective in improving the Quality Use of Medicines (QUM) for

individual residents and in improving the medication management processes in Aged Care

Homes. The overall effectiveness of the RMMR Program was identified in most submissions.

Collaboration between Aged Care Homes, Accredited Pharmacists, community pharmacies and

GPs, to the benefit of residents, was identified as a key benefit of the RMMR process.

The value of RMMRs was seen to be more limited if they were not conducted as Collaborative

Reviews. Peak bodies, Accredited Pharmacists, RMMR Providers, GPs and Directors of

Nursing (or their equivalent) of Aged Care Homes identified the value of Collaborative Reviews.

Several Accredited Pharmacists held a counter view - that Collaborative Reviews were not

necessarily any more effective in meeting the Program’s objectives.

Directors of Nursing and senior managers in Aged Care Homes identified that RMMRs played

an important role in achieving quality of medication management for residents in Aged Care

Homes, one of the 44 Expected Outcomes on which accreditation of the Aged Care Homes is

assessed.

Separation of payment for QUM services delivered to the Aged Care Home from the component

paid for the individual RMMR, was supported in a number of submissions. A range of options

was put forward on how such a separation may best occur.

The organisation-wide QUM services provided through the RMMR Program were considered

effective, particularly nurse education, medication audits, and Medication Advisory Committee

meeting involvement.



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4. Findings

The overall purpose of the RMMR Program - to improve medication management and promote

QUM in Aged Care Homes - was a paramount consideration in the analysis of submissions, in

conjunction with the objectives and key questions of the evaluation.

4.1 The need for RMMRs

An objective of the evaluation was to gain an improved understanding of the RMMR Program,

with a particular focus on who receives a service, what this service comprises, how it meets

identified needs and how it contributes to improved outcomes for residents.

Outcomes for residents

Submissions included many examples of outcomes for residents from the RMMR Program,

including the QUM component.

There is no doubt in our opinion, the RMMR has improved the delivery of

medications within the residential care program and that its continuance will

maintain a quality improvement path in the future.

(Aged Care Association of Australia)

Surveys provide staff with better information regarding medicine use. For example,

a survey on medicines used for constipation leads to more education to staff on

value of management rather than treatment and that in turn leads to a better quality

of life for residents because staff are more aware.

There have been instances of pain management being implemented rather than a

PRN dose and patient has become more mobile.

(Accredited Pharmacist)

RMMRs undertaken with little GP input were identified by the AMA and by many Aged Care

Home and Accredited Pharmacist submissions, as limiting the outcomes for residents.

Our GP members report that where pharmacists initiate a RMMR without significant

GP input, clinically relevant information is often overlooked.

(AMA)

Ultimately for the program to be more successful than it already is, increased

collaboration is needed between the doctor, Accredited Pharmacist and RACF

(Residential Aged Care Facility). The effectiveness of a Review is largely

determined by the receptiveness of the GP to make changes according to the

recommendations.

(Accredited Pharmacists and RMMR Providers)

The AMA noted the importance of taking other factors into consideration when assessing the

impact of RMMR on medication management outcomes for residents. The organisation

identified examples of matters which contribute to medication management outcomes, whether

positive or negative, but which are separate from RMMRs. One issue identified was what the

AMA described as the ‘lack of suitable information technology’ in some Aged Care Homes to

enable access to medical records and to improve medication management.



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4.2 Benefits of the RMMR Program

The invitation for submissions sought comment on the key benefits of the Program, particularly

addressing the questions: Who benefits most? What are the potential service gaps? And what

are the potential barriers to achieving these benefits?

Benefits of RMMRs

Most Aged Care Home submissions identified support for all or most aspects of the RMMR

Program.

I have total praise for this program.

(Aged Care Home Director of Nursing)

Key benefits for providers and residents:

1) Improved clinical outcomes for residents, especially where it is a Collaborative

RMMR.

2) Enhancing knowledge and skills of staff.

(Aged and Community Services Australia)

Reasons for Aged Care Home support of the RMMR Program varied, but many submissions

referred to the value of the service as a form of quality assurance. Others identified the

Accredited Pharmacist as a valuable resource and their RMMR reports to be of a high standard.

ACAA is highly supportive of the continuation of the RMMR as we feel it has

provided impetus to support aged care providers to ensure a continuous

improvement path in the medication management in place in their facilities.

There is no doubt in our opinion, the RMMR has improved the delivery of

medications within the residential care program and that its continuance will

maintain a quality improvement path in the future.

(Aged Care Association Australia)

The RMMR process is also an additional effective risk management and QA audit

activity that ensures that the contents of the packed dispensing system and

medication chart correlate.

In summary, the current RMMR program is a valuable process that facilitates many

aspects of the quality use of medications in the residential aged care setting.

Clinical Associate Professor / General Manager Medical Services

The actual reports produced by the clinical pharmacists are excellent with the

pharmacists cross referencing the medication to resident’s activities of daily living,

behaviours and complex health care needs.

(Aged Care Manager)

This service provides good follow-up and links for the (Victorian) DHS Quality

Indicators program. The visiting pharmacist has been a great resource for our

Health Service.

(Director Acute and Aged Care)



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Continuity of care for the resident was an additional benefit of the RMMR Program

noted in several Aged Care Home submissions from rural areas.

Medication Management Review by the pharmacist contributes directly to

continuity of care in a climate where the General Practitioner is not tending to stay

in communities long term.

(Aged Care Home Manager)

Younger residents living in Aged Care Homes or Multi Purpose Services are among those who

benefit from their eligibility to receive services under the RMMR Program. Some submissions

identified the importance of RMMRs for younger residents in particular.

Younger people are also seen in Aged Care Homes, often with a challenging

medical presentation and the additional consideration of much longer term care

(and exposure to the long term adverse effects of medications).

(Accredited Pharmacist and RMMR Provider)

Specific examples of how the RMMR could benefit a resident were provided by a number of

Accredited Pharmacists.

The dose of this medication had been decreased as toxic levels were discovered

on pathology monitoring. When the resident’s new chart was started, he was given

the old toxic dose of the anticonvulsant and was bed-bound, excessively drowsy

and not communicating well – signs of toxicity. Once the error in dosage was

detected by myself and subsequently corrected, this resident was able to mobilise

and converse, and needed much less intensive nursing care.


Several GPs also identified benefits of the RMMR Program.

I have found that the RMMR service is particularly useful for identifying prescribing

patterns that can be improved with the input from the Pharmacist’s evidence based

advice, and identifying mistakes within the RACF systems of medication

management – eg packing errors.

(GP)

Accredited Pharmacists and RMMR Providers identified benefits of the RMMR Program.

Aged Care is an area of medical/clinical specialty….A heightened awareness of

pharmacology, pharmacokinetics and pharmacotherapeutics is thus critical for

delivering optimal medication-related care for residents in Aged Care Homes and is

a key element in the need for, and benefit from, input by an Accredited Pharmacist.


Organisations representing residents with conditions such as Alzheimer’s noted benefits of the

RMMR Program.

RMMR is an excellent tool for people with dementia or cognitive impairment who

are vulnerable, and unable to self manage their medications, seek advice etc.

Many commonly used medications for common conditions have adverse effects on

cognition which exacerbate existing problems and reduce any potential benefit

from the Alzheimer medications.



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I believe that there is real value in routinely offering RMMR services to all residents

returning to the facility after an acute care admission.

(Alzheimer’s Australia)

Service gaps

The need for a greater emphasis on issues important in geriatric prescribing was identified by

the ANZ Society for Geriatric Medicine.

More emphasis should be given to issues that are important in geriatric prescribing,

which would include:

> Non-pharmacological approaches

> Appropriate symptom control and palliative care

> Cessation of unnecessary medication

> The flagging for Review of potentially hazardous long-term medications

(ANZ Society for Geriatric Medicine)

Currently only GPs can initiate a Collaborative Review. The option of geriatricians being able to

initiate Collaborative RMMRs was identified by one RMMR Provider as an option which would

be beneficial.

Many facilities will have visiting geriatricians. They have expressed a benefit in

being able to initiate a collaborative RMMR.


The ANZ Society for Geriatric Medicine did not comment on the matter of geriatricians being

able to initiate RMMRs but did identify referral to a geriatrician or psychogeriatrician as

improving the treatment of residents with ‘extreme polypharmacy, multiple symptomatology and

co-morbidities’.

4.3 Current arrangements

Evaluation objectives also included informing the broader barriers and enablers relating to

RMMRs, including those related to current arrangements, what encourages or discourages

participation and collaboration, processes and administration associated with undertaking a

Review and areas for potential improvement.

GP participation

The participation of GPs in RMMRs was canvassed in many submissions from RMMR Providers

and Accredited Pharmacists, Aged Care Home staff and peak bodies.

Issues related to GP participation related not only to Collaborative Reviews but also to

participation in Pharmacist Only Reviews and response to recommendations arising from a

RMMR.



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Some Accredited Pharmacist and Aged Care Home submissions referred to increased

participation by GPs in the RMMR Program in recent years.

We have seen significant reduction in GP resistance.


Barriers to GP participation

Where GPs were not participating in RMMRs, many Accredited Pharmacist, RMMR Provider

and Aged Care Home submissions attributed this to a lack of interest in Pharmacist Only

Review.

Major barriers to the effectiveness of the program include: GPs do not generally

initiate the RMMR. In addition, GPs do not always act on a Pharmacist Only

Review when the report has been initiated by either the pharmacist or the aged

care provider.

(Aged and Community Services Australia)

Pharmacist Only Review undertaken by the Accredited Pharmacist does not

require referral and is then forwarded to the GP (this often causes offence when

report arrives).

(CEO Health Service)

The AMA identified a range of structural factors relating to aged care more generally which were

seen as a barrier to GP participation.

GPs would also be encouraged to participate (in RMMRs) where there is adequate

(Government funding) support for the provision of medical services to residents.

(AMA)

A number of Accredited Pharmacists identified barriers to GP participation relating to the

claiming process under the Medicare Benefits Schedule.

Rejection of GP claims when multiple RMMRs are conducted within a 12 month

period. We are aware of many circumstances where this has occurred and from a

GP perspective is a barrier to accessing the program.


Collaboration

Respect for the skills and professional commitment of the Accredited Pharmacist were central

themes in many submissions, particularly those where RMMRs were identified as effective in

supporting collaboration.

The clinical pharmacists are involved in the local Medication Advisory Committees

and are a valuable resource to all who sit on those committees.

The clinical pharmacists are considered an expert in their field and are a highly

prized resource within and across our organisation.



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The relationships developed between the service staff, clinical pharmacist, general

practitioner and supplier pharmacist have improved immensely since the

introduction of RMMRs.

(Group Manager (Aged) Care Services)

I find the communication and collaboration invaluable in improving the medication

management of my aged care patients.

(GP)

Effective collaboration in the best interests of the resident was frequently identified as the most

important consequence of RMMRs. Co-operative relationships between the Aged Care Home

staff, the Accredited Pharmacist, the Community Pharmacist and GPs were seen to be

important and effective, especially when there was collaboration in smaller towns.

For example, (the Accredited Pharmacist) will notice if Mrs Jones is shuffling her

feet a little more - yes her (medication name) dose has gone up and yes it is extra

(medication name) side effects kicking in. The "fly in fly out" pharmacist is usually

under pressure to do a whole lot of RMMRs in the allotted time whereas the local

pharmacist can choose to do a few every week and keep her finger on the pulse

and keep in contact with the nursing staff.

The local doctors also don't appreciate strange comments from strange

pharmacists who have no understanding of what happens locally. The doctors have

a very good relationship with the hospital pharmacist who does the Reviews and

are much happier to discuss things on follow-up.

(Community Pharmacist)

The AMA identified the importance of GP involvement and effective working relationships with

Accredited Pharmacists.

The AMA supports medication management Reviews where the GP initiates the

Review and where there is collaboration between general practitioners and

Accredited Pharmacists in providing the RMMR.

(AMA)

Barriers to achieving effective outcomes

Lack of GP engagement in the RMMR process was frequently identified as the main barrier to

achieving effective outcomes from RMMRs. Accredited Pharmacists, Aged Care Home staff and

peak bodies were among those who identified the importance of GP engagement.

A significant barrier to the implementation of the recommendations from the RMMR

is a failure to engage the resident’s medical practitioner in the Review process. It is

H+P’s experience that adoption of the recommendations of an RMMR is at best

60%.

(CEO, Aged Care Home)

There is some frustration by Care Managers/Directors of Nursing and staff at

residential aged care facilities at the often lack of implementation of suggested

interventions provided by the pharmacists. It is our opinion that the most significant

factor that determines the success or failure of the RMMR hinges with the GP.



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Key blockages to the success of the program include:

> GPs are not usually initiating RMMR’s

> GPs not acting upon the ‘Pharmacist Only’ Reviews when the report has been

initiated by the aged care facility or the pharmacist.

(Aged Care Queensland)

GP involvement in RMMRs was not always considered to be required for effective outcomes, as

identified by one Accredited Pharmacist.

The recent emphasis on Collaborative RMMR appears based on the notion that

collaboration necessarily achieves a better resident outcome. In some cases this is

true, but in many cases I’ve found this not to be the case.


Some Aged Care Homes identified the importance of maintaining a focus on the outcome of the

RMMR rather than simply the completion of the RMMR process.

Currently the RMMR process has a compliance focus rather than an outcome

focus. As a result, many of the recommendations are not adopted.


Observing or interviewing the Aged Care Home resident as part of the conduct of a RMMR was

identified in some submissions as the optimum way of achieving the most effective outcomes.

A GP commented to me once, “How can a pharmacist possibly write a report

without even seeing the patient?”

… it is important for pharmacists to sight and, where possible, interview the

resident.


It is our experience that RMMRs conducted as part of a multi-disciplinary care

Review program, including behavioural and physical assessments, produce better

Residential Medication Management Review Program results.


There is obviously a big difference in the quality of RMMR reports that are

provided. Some RMMRs that I have seen are merely a chart Review and include

‘generic’ statements without any reference to the actual resident and their

particular concerns.


Remuneration as a barrier to participation by Accredited Pharmacist

Current levels of remuneration were identified in several submissions by Accredited

Pharmacists, as a barrier to patient Review.

In an ideal world I would like to make a patient interview part of the Review but this

is not possible under the current model and remuneration structure.


Several submissions from Accredited Pharmacists identified the level of remuneration for

RMMRs to be too low to allow sufficient time for the consideration of the needs of complex high

care residents.



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The patients in aged care facilities are often more complex than those still living in

the community but I cannot afford to allocate the time and effort I would like to give

to the task because of inadequate remuneration.


Areas for potential improvement

A range of potential areas for improvement of RMMR outcomes were identified by Aged Care

Home staff, Accredited Pharmacists and peak bodies.

The benefits of a RMMR will be enhanced through the development of an

electronic medication record and centralised monitoring system for resident

medications. This would allow residential care homes, pharmacists, medical

practitioners to Review and exchange recommendations regarding medication use

and review treatments.

(CEO, Aged Care Home service)

National Prescribing Service resources were identified as an opportunity to promote

collaborative team approaches:

A consideration to enhance a team approach to Review current medication use

would be to encourage and support the uptake of the following quality projects

through the National Prescribing Service Ltd http://www.nps.org.au/health

professionals / drug_use_evaluation_due_program DUE of antipsychotic use in the

management of dementia, DUE of benzodiazepine and non-benzodiazepine

hypnotics for insomnia, DUE of analgaesic use for persistent pain, DUE of laxative

use for chronic constipation


4.4 Funding and service model

The current funding and service model for the RMMR Program was a key component within the

evaluation, with a particular focus on accountability and cost effectiveness and Program inputs

and outputs.

The current fee for service payment model is now demand-driven. The evaluation examined

cost issues associated with the new arrangements.

The payment model

The applicability of the fee for service model for provision of the facility-wide QUM component of

the RMMR Program (the QUM provided to the Aged Care Home as a whole rather than in

relation to the individual resident) was addressed in a number of submissions from Accredited

Pharmacists and RMMR Providers. Most suggested that it may be more appropriate to pay for

the QUM separately to individual RMMRs. Payment on a per facility basis was identified as a

means of ensuring delivery of appropriate levels of service to meet the range of Aged Care

Home needs.

It is the opinion of ACQI (Aged Care Queensland) that the current fee for service

basis for funding the RMMRs is more cost effective than the previous fee per bed

funding that occurred prior to 2007.

(Aged Care Queensland)



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Some submissions argued that the fee for service payment model had improved accountability

for individual RMMRs but not for the QUM component.

The change to a fee-for-service model for RMMRs has provided greater

accountability and transparency. However the link between QUM services and

RMMRs has led to a similar inconsistency and poor accountability for QUM

services.


The payment for QUM and RMMR should clearly be separated as they are two

discrete services that are linked in an inappropriate way through funding. Also, the

service providers for QUM and RMMRs may in fact be different and this linking of

payment for the two services creates disquiet and angst amongst the service

providers.


The impact on Aged Care Homes (and Multi Purpose Services) with small numbers of residents

was one of the reasons identified for proposing a different payment model for the QUM

component. Submissions identified that little funding was available to cover the cost of providing

facility-wide QUM to a small Aged Care Home, yet the delivery of QUM support may have

required a similar investment of time to that required in a large Aged Care Home.

Payment according to the level of the QUM service provided would be appropriate.

Education payment is the same, i.e. per Review for a 15 bed facility as a 150 bed

facility. Often requiring the same work/time and preparation, the payment for

smaller facilities is a barrier to providing nurse education.


The ANZ Society for Geriatric Medicine submission referred to payment for GPs under MBS

Item 903. The submission identified that if the GP provided all the steps under the Item Number

903 (i.e. the referral initiated, consulting with the Accredited Pharmacist, preparing a medication

management plan as well as discussing the plan with the resident or their delegate) then the

Society considered the remuneration inadequate. A more appropriate level of remuneration was

not identified.

A submission from a Division of GPs identified no GP concerns with the funding and service

model.

The current funding and service model appears adequate from the GP’s viewpoint.

(Program Officer, Aged Care, DGP)

RMMR payments to Providers have not increased for several years nor have they been subject

to indexation, unlike HMR payments and the payments to GPs under Medicare.

Provision should be provided for regular Review of the amount paid for RMMRs, in

line with CPI.


A substantial number of submissions from Accredited Pharmacists or those who represent

them, including the AACP and the PSA, identified differential payment for Collaborative RMMRs

compared with Pharmacist Only Reviews as a solution for increasing the proportion of

Collaborative Reviews. Support for differential payment (higher payment for Collaborative



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Reviews) was based on the higher administrative burden of Collaborative Reviews compared

with Pharmacist Only Reviews.

It is suggested that pharmacists should be remunerated for the extra effort involved

in organising this service (Collaborative Reviews), with an extra payment over and

above that received for a pharmacist-initiated Review.

(AACP)

Demand for RMMRs

Demand for RMMRs is limited at present by the 12 month rule – where only one Pharmacist

Only Review is allowed per resident per 12 month period, with the option for additional

Collaborative Reviews initiated by the GP based on clinical need. Some Accredited Pharmacists

would prefer to have a wider range of opportunities to conduct RMMRs.

Accredited Pharmacists noted that the 12 month rule for RMMRs was based on the date of

Collaborative Reviews rather than the date when the Accredited Pharmacist had scheduled a

series of Pharmacist Only Reviews. The dating according to Collaborative Reviews is an aspect

of the business rules which supports collaboration and is in keeping with the overall intent of

RMMRs.

The AACP and the PSA, along with many other submissions from Aged Care Homes and

Accredited Pharmacists and RMMR Providers, requested additional RMMR referrals be

allowed. This is usually in circumstances where GPs are unable to be involved in a timely

manner, or without the requirement for specific GP authorisation.

<Referral> …from other health professionals including the Director of Nursing, to

be described as a ‘facility-initiated Review’ for additional urgent Reviews in special

circumstances within a 12 month period, where a GP referral cannot be arranged in

a timely manner .

(AACP)

On many occasions the director of the home has asked for a resident to be re-

reviewed when challenging behaviours emerge or the resident’s condition becomes

palliative and alterations in the medication regime are required. Enabling the facility

manager or director of nursing to authorise additional Reviews within the 12 month

period would be an improvement to the RMMR Program.


The AACP and individual Accredited Pharmacists and RMMR Providers also identified a need

for a RMMR to be authorised for each newly admitted resident regardless of timing of any prior

Review and without the requirement for specific GP authorisation.

When a resident is transferred from one facility to another, the record of RMMRs is

not always transferred across. Thus the Accredited Pharmacist may conduct a

Pharmacist-Initiated RMMR on admission. The claim may subsequently be rejected

as a Pharmacist-Initiated RMMR has been conducted in the previous 12 months,

with no way of confirming this before conducting the Medication Review. Residents

are usually transferred due to a change in clinical needs or level of nursing care

necessary. Hence the Review on admission is justifiable.




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The AACP also identified that it would be appropriate for RMMRs to be authorised for

intellectually disabled residents in community care facilities.

4.5 Impact of administrative arrangements

The evaluation included exploration of the impact of the administration arrangements for

providers who participate in the Program, across a variety of domains, including a focus on:

• the best balance between meeting accountability requirements and providing

the RMMR services (administrative versus clinical time)

• the streamlined processes with the new arrangements, such as payments,

registration, and service agreement relationships between RMMR Providers

and homes

• Building and maintaining partnerships to promote the successful and effective

provision of RMMR services was also a key evaluation question, including a

focus on:

o promoting collaboration and active participation/communication between

those who participate in the Reviews – including staff, providers, general

practitioners, and the residents and carers; and

o Collaborative Reviews, including barriers and other issues associated

with promoting participation

• Ensuring access and equity issues are addressed, including service provision

and funding issues, such as for rural and remote areas and to particular

population groups and regions

Medicare Australia processes

There were a number of areas which Accredited Pharmacists, RMMR Providers and peak

bodies identified as the cause of additional administrative burden.

Low remuneration and high administrative workload are barriers of the program.


The administrative rule which allows only five Medicare numbers to be obtained per call to

Medicare Australia was identified as a source of administrative burden on Accredited

Pharmacists. The AACP, along with a range of other submitting organisations and individuals,

addressed this matter. The limit was seen to be placing an administrative burden on Accredited

Pharmacists, as many Aged Care Home visits entailed providing RMMRs for more than 20

residents at a time. In these instances, four separate phone calls would need to be made to

obtain the required data.

Preparing and submitting a claim for a Review when that claim might not be accepted for

payment due to the 12 month rule, was identified as creating additional administrative and

financial burdens for RMMR Providers and Accredited Pharmacists and, at times, for GPs.

There are aspects of the RMMR program that GPs report discourage their

participation. They include: unavailability of an Accredited Pharmacist; inability to



CR&C 1074 15

bill a second consultation at time of RMMR when extra work is performed on the

same day, as it usually would be; and if/when Medicare rejects a claim because it

is less than 12 months.

(AMA)

The AACP identified one possible response to the ‘12 month’ rule - a Medicare Australia

telephone line where enquiries could be made about the current status of a new resident and

the date of their most recent Review.

Business rules around what constitutes a Collaborative Review referral from a GP were

identified by several Accredited Pharmacists as an area which may require clarification.

There needs to be clarification about what constitutes a referral for a RMMR. This

is ambiguous in the business rules.

> Does this need to be a formal separate referral?

> Is ticking the RMMR box as part of a CMA acceptable?

> Is a note in the resident’s chart that merely states “for RMMR” acceptable?


RMMR payment processes

The need to submit RMMR payment claims to Medicare Australia on paper rather than online

was identified as a source of additional administrative burden. While the claim form was

available online, it could not be submitted online once completed. Many submissions identified

an online claims submission system as the optimum response to this issue.

Currently pharmacist claims to Medicare Australia must be submitted manually

(mail or fax). The provision of editable pdf forms has streamlined documentation;

however it is preferable that these claims could be submitted electronically.


An Accredited Pharmacist identified options for addressing what he saw as gaps in the current

processing and payment arrangements for RMMRs:

> Options for ‘back-pay’ for those Reviews done in good faith but which were later

found to be ineligible through no fault of the Accredited Pharmacist.

> Payment for Reviews of residents who have since passed away.

I have had quite a few Reviews not paid because the patient had a Review

elsewhere in the last year.


Service provision in rural and remote areas

Travel costs of reaching rural and remote areas were identified by a number of Accredited

Pharmacist and RMMR Providers as an issue which limited timely access to RMMRs.

The current funding model does not include a travel allowance and implementation of such an

allowance was a solution identified in a number of submissions.

Equitable access to rural and remote communities is not addressed in the funding

model.



CR&C 1074 16


Aged care facilities in rural and remote areas may have limited access by local

Accredited Pharmacists. There is currently no additional travel allowance as an

incentive for Accredited Pharmacists to visit rural and remote areas. In many

instances, service is limited to annual or six monthly visits due to lack of a viable

business model for visiting Accredited Pharmacists.

Recommendation:

Implement a travel allowance for aged care homes in rural and remote areas.


Funding for travelling, especially when there are no Accredited Pharmacists

available locally to service a facility. We service many rural and remote facilities at

considerable expense in travelling and accommodation.


There is not currently an incentive for rural facilities to have a pharmacist visit. A

rural loading would improve access to the rural facilities, similar to the PHARIA

system in place for HMRs or the rural allowance given to pharmacies for

prescription dispensing.


We need more frequent visits.

They (the Accredited Pharmacist) could provide education especially for rural

facilities.

(Director Acute and Aged Care)

Access and equity issues

Respite care residents’ ineligibility for RMMRs was identified as an access gap, with

submissions noting the link between a recent hospital admission and a subsequent respite stay

in an Aged Care Home. Peak bodies as well as individual submitters identified the need for

RMMRs to extend to respite care residents.

Patients who are transferred to a residential facility, usually following a hospital

visit, often miss out on a Medication Review because their status is not clearly

defined.

Formally including transient or respite patients under the criteria of those who

qualify for a Collaborative RMMR would enable GPs to initiate this service if they

felt there was a benefit to the patient.


The AACP also identified a need for RMMRs to be authorised for intellectually disabled

residents in community care facilities.

Access for culturally and linguistically diverse residents was raised by one peak body, which

identified several areas where improvements may be required.

Ethno-specific aged care facilities represent 10% of aged care facilities in Australia

(DoHA 2009).



CR&C 1074 17

By 2011 approximately 38% of people over 65 years in the Melbourne metropolitan

area and 2% in the Victorian rural and regional area will be from a CALD

background.

CALD seniors have higher rates of advanced dementia and higher rates of

depression than the average Australian population…

There is a serious under-use of interpreters in aged care homes. In 2006 to 2007,

the use of only four interpreters was recorded in Commonwealth funded residential

care.

(Ethnic Communities Council of Victoria)

Service agreements and partnerships

Many Aged Care Home submissions stated that there was no need to make any changes to the

RMMR Program administration arrangements.

In many cases, the ongoing relationships between Aged Care Homes and RMMR Providers

formalised in service agreements for RMMRs, were seen to be a means of promoting

collaboration.

Active communication between those who participate in the Reviews was also identified as a

consequence of the ongoing partnership between staff, RMMR Providers, GPs, and the

residents. (Typically, involvement of carers in these partnerships was not discussed.)

For some Aged Care Homes, provision of both medication supply and RMMR services by the

one company was seen as a valuable, cost effective and efficient approach.

On the other hand, service agreement relationships were identified by a number of RMMR

Providers as the reason they had been unable to access or continue to provide RMMRs in some

Aged Care Homes. The submissions identified what they considered to be inappropriate

responses by the supply pharmacy in relation to the RMMR service agreement.

On one occasion a supply pharmacy refused supply when a nursing home changed

their RMMR contract to us. They had been sending clinical information on

residents to a pharmacist a long distance away for the completion of RMMRs.

They were supplying medications on the condition they held the contract for

RMMR.


The first and most important point I would like to make is that to keep the whole

process as transparent and ‘above board’ as possible the supply pharmacy should

not have exclusive rights to deliver the RMMR services.


I feel that the RMMR program is being rail-roaded by corporate companies who tie

up the contracts & provide minimal services.


Large organisations providing RMMR services are poaching RMMR / Aged Care

Home contracts and it is becoming very difficult to be a ‘small’ provider of a high

quality local RMMR service. Some organisations offer supply arrangements

(undercutting prices) and insist on also getting the RMMR contract.




CR&C 1074 18

4.6 Provision of QUM services

In addition to matters related directly to the provision of RMMRs, submitters were invited to

comment on the provision of QUM services as part of the RMMR Program, including the

number and range of QUM services provided, whether those QUM services are having an

impact, which QUM services have the greatest impact or are most effective, and what is good

practice in terms of content and delivery. The enhanced requirements for reporting on QUM

provision were also within the scope of submissions.

The evaluation sought to address the following questions:

• What QUM services are provided under the Program, in particular:

o Is there a better definition of a QUM service, including what it does and

(what it should) comprise;

o how these are currently remunerated

• What comprises a good QUM service, including how this should be defined

and what is good practice or acceptable; and

• What is the burden of QUM reporting, and what is the benefit.

Number and range of QUM services

The AACP identified the QUM component of reimbursement for RMMRs as inadequate.

The AMA notes that the QUM activities of the Accredited Pharmacist do not replace the QUM

activities conducted by the supply pharmacy, which is still obliged to do regular ‘chart Reviews’

as part of their PBS quality assurance.

The AACP and many other submitters identified the value of a number of QUM elements in

particular, including nurse education, medication audits, and Medication Advisory Committee

meeting involvement.

Good practice in QUM content and delivery

One of the ‘good practice’ approaches referred to in a number of submissions - and particularly

favoured by Aged Care Home Directors of Nursing and management - was the conduct of

Reviews on a case conferencing basis.

The collaborative process involving the range of health care providers would

generally be regarded as the ‘gold standard’ of health care provision in aged care

homes, yet pharmacists have never been paid for participating in a Case

Conference (or similar service).


In the case conferencing model, the GP, Accredited Pharmacist, the supply pharmacist (if

different from the Accredited Pharmacist), and the DoN conduct joint rounds of an Aged Care

Home to discuss medication management issues. A number of Accredited Pharmacists noted in

their submissions that most Aged Care Homes are serviced by multiple GPs limiting the ability

for case conference attendance to be cost effective for the RMMR Provider. A number of



CR&C 1074 19

submissions suggested the Accredited Pharmacist be permitted to charge an additional amount

for case conference attendance.

The most effective way to achieve positive change in GPs’ prescribing behaviour is

with face to face discussion. However at this stage, as a Consultant Pharmacist I

am not paid to attend case conferences whereas the GP is paid via various

Medicare item numbers and the facility staff are paid by their employer.


(RMMRs are) …more beneficial for low care facilities where a Registered Nurse is

not routinely available. Most beneficial to both low and high care when held in

conjunction with a case conference when Medical Officer, pharmacist and

Registered Nurse are all available at the same time.

Medications aren’t always the answer or the cause of a change in behaviour or

condition of the resident.

What is “in vogue” at the time is often what pharmacists suggest and may not be

relevant to RACF and often our experience is disregarded.

(this leads to)… our insistence that RMMR be conducted as part of a case

conference.


Recommendation: RMMR to take on a case conferencing format to enhance

collaboration and achieve improved outcome for the resident.


Many submissions identified examples of what they considered to be good practice in the

delivery of QUM services. The following extract is typical of the range of components identified

by Accredited Pharmacist submitters, although some other submitters indicated that they found

it difficult to offer some of these services due to costs, time and other factors.

As a minimum my facilities receive the following QUM services from me:

(i) Quality Use of Medicines information for RNs/Care Staff is included in a

dedicated section of each Medication Review completed e.g. information

regarding correct use of devices, how to keep inhaler devices clean,

monitoring for early signs of medication related side effects or toxicity etc.

This facilitates person-centred resident care.

(ii) A quarterly newsletter on a topic specifically relevant to medication

management in aged care. This is accompanied by a coloured laminated

resource or other resource that may be used for education purposes or

placed in with medication charts/signing sheets as an ongoing reference

for staff.

(iii) Regular attendance at MAC meetings and associated time spent after

hours reviewing and revising policies and procedures such as Nurse

Initiated Medication lists, Emergency Drug supplies, developing audit tools

and resources to improved medication management etc



CR&C 1074 20

(iv) Provision of staff education - either short sessions during the day or

attendance at dedicated staff training days to talk on one or more

pharmacy/medication related topics.

(v) Ongoing on-call provision of clinical pharmacy related information either in

response to an email request for assistance or in response to issues that

may arise during the course of spending a day at the facility completing

Medication Reviews.


Rurality and size of Aged Care Home

The small size of Aged Care Homes (or Multi Purpose Services) in some rural areas was

identified as a barrier to the delivery of QUM services.

Smaller facilities and in particular some rural facilities are more disadvantaged by

the limited number of residents and therefore the limited amount of potential

income but have the same needs for QUM services as very large metropolitan

facilities. This makes it financially unviable to meet these needs in many cases.


Reporting requirements for QUM

The quarterly reporting requirement for the QUM component of the RMMR Program was

identified by many Accredited Pharmacist, RMMR Provider and peak body submitters as

creating an additional administrative burden. Submitters identified no perceived benefits to any

stakeholder from the time required to undertake the QUM reporting, with a range of issues

identified, including:

• The reporting format was seen to be so general as to be of little value

• Different RMMR Providers completed the forms in a different way, reducing its

effectiveness as a means of comparison

• The only format available was hard-copy paper.

Many submitters suggested annual online reporting on QUM activities would be a more

appropriate requirement and that the format be re-designed to allow for consistency of

information provision.

Increased importance of the QUM component RMMR Program

The importance of the QUM component and RMMRs was highlighted in some submissions in

the context of changes to the nursing workforce in Aged Care Homes. The RMMR Program is

now seen to be playing an even greater role in providing support and advice for the high

numbers of nurses with lower qualifications who are working in aged care.

A significant increase in the importance of the QUM component of RMMRs due to the decrease

in numbers of registered nurses in Aged Care Homes was identified by the AACP.

A number of other Aged Care Home, Accredited Pharmacist and peak body submissions

identified the increased importance of RMMRs in the context of employment of fewer registered

nurses.



CR&C 1074 21

The support of QUM services has also enabled the aged care industry to

successfully adopt new models for medication management utilising less registered

nursing staff.


Submissions from Aged Care Homes identified the importance of established procedures for

administration of medications associated with fewer nursing staff.

Most residential care facilities are staffed by care staff and not professional nurses.

Medication is dispensed as a process without awareness of the resident’s

requirements.

Medicines such as antiplatelets agents, non steroidal anti-inflammatory drugs

(NSAIDs) and diuretics are high risk medicines because they are commonly used

and account for over 50% of medicine-related hospital admissions.


4.7 Gaps and future directions

An additional requirement for the evaluation was to review elements of the Program more

broadly, to ensure it continues to meet the needs of those who most benefit from receiving a

Medication Review.

Potential enhancements to RMMR Program

A range of options were identified by Accredited Pharmacists as potential enhancements to the

RMMR Program.

The usefulness of Reviews could be enhanced with a formal follow up on the

results of both individual Reviews and across multiple Reviews to inform better

practice, staff training, consumer education and quality improvement.

Incorporate in Reviews, the larger picture of the medication management across

the entire aged care facility not just the individual to identify systemic practices and

improvements.

(Aged and Community Care Victoria)

Options for the Aged Care Home DoN to further influence RMMR Program outcomes were

identified in a number of submissions, including from Accredited Pharmacists and academics.

One option identified was to standardise minimum requirements for reporting to Aged Care

Homes after each series of RMMRs.

Ability to source some overall data regarding medication management from

Accredited Pharmacists after ‘whole of home’ Review- more formalization of this

and possible standard areas for pharmacists to report to ACF on post Reviews may

be an improvement.


As nursing staff are often the main health professionals involved with the day-to-

day care of the resident one could argue that their comment regarding medication

management should be actively sought and that the recommendations written in

the RMMR report itself would be more likely to translate to changes in care if the



CR&C 1074 22

nursing staff were more actively involved in the Review process. The Review

should ideally include provision for nursing staff comment…

Involving nursing staff to a greater degree has the potential to improve the

outcomes of the RMMR process.

(Academic)

A number of potential enhancements to address access issues for culturally and linguistically

diverse residents were identified in submissions.

Pharmacists require the time and resources to acknowledge the residents’ diverse

values, cultural preferences and different understanding of medical treatment and

health care, in addition to appropriate interpreter and translation support.

ECCV believes that residential aged care facilities require additional guidelines in

responding appropriately to the multiple and complex health needs of CALD

residents with a Non-English Speaking Background (NESB).

(Ethnic Communities Council of Victoria)

Potential enhancements to QUM service

Along with many other submissions, the AACP and the PSA requested the separation of

payment for the QUM component from that for the RMMR component and suggest the option of

a ‘fee for service’ basis for QUM (ie per lecture, per audit, etc). Other submitters recommended

establishing minimum QUM requirements and rewards for a focus on outcomes from QUM.

Consideration should be given to defining a minimum requirement for QUM

services and rewarding outcomes-focussed delivery.

(PSA)

Potential enhancements to the delivery and content of QUM services were identified by a wide

range of Accredited Pharmacist and RMMR Provider submitters.

Dedicated funding for the facility to allocate appropriate resources to perform QUM

activities in conjunction with Accredited Pharmacists.

Remuneration should be focussed on service delivery, with incentives given to

service providers who deliver good QUM services that result in improved outcomes

(e.g. reduction in psychotropic drug use). It would be easy to develop quality

indicators around this, in fact there are some with the aged care standards.

The QUM services delivered to aged care should be measurable in their delivery,

auditable and focussed on outcomes, and in this case, we should have approved

QUM services that could be delivered in aged care that have shown to improve

QUM.

An improvement may be identification of systemic areas of concern / comments

regarding medication management as identified by Pharmacist with overall report

to ACF (in addition to individual resident reports).


A potential funding model for QUM services could be provision of a defined

minimum service on a tiered basis, based on the number of beds in the facility. For

example the time and cost for delivery of a lecture to nursing staff is the same for a



CR&C 1074 23

40 bed facility as a 200 bed facility. Similarly administration audits are usually

conducted on a sample rather than every bed to identify and resolve system errors

and deficiencies.


There is no coordinated accredited package of training, DUEs, consumer education

of QUM strategies available for pharmacists to provide to aged care homes.

There is no actual instruction associated with delivering staff training, and there is

limited support or promotion of the NPS DUEs.

(Academic)

Anticipated data needs

Although the RMMR Program has been in place for more than 12 years, there is no national

database of RMMR and QUM service data and health outcomes. The Pharmaceutical Society

noted the need for such a database to be compiled as a means of tracking the level of

effectiveness of the Program over time. A number of other submitters also identified the need

for such a database. However, the content of the database were not articulated nor was the

issue of how such a database could address privacy issues or be effectively implemented

without adding to the administrative burden of Accredited Pharmacists.

Consideration should be given to … establishment of a comprehensive national

database to compile RMMR and QUM service data and health outcomes.

(PSA)

A number of submitters, ranging from Accredited Pharmacists and RMMR Providers, to peak

bodies, identified that it would be beneficial to have a database of RMMRs to allow for

benchmarking between Aged Care Homes.

Recommendation: A data collection system to assist facilities in benchmarking

themselves against other facilities, in regard to the level of use of particular drugs

e.g. sedation etc. This would, in turn, provide a powerful evidence base for

Medication Advisory Committees to inform and evaluate targeted education and

continuous improvement strategies.

(Aged and Community Care Victoria)

A number of Accredited Pharmacists identified the need for additional information on outcomes

of RMMRs.

As a matter of priority, clinical practice research showing the effectiveness and

areas for improvement should be implemented. Also, best practice models should

be explored and extrapolated across the country.

National comprehensive dataset compiled for the evaluation of clinical practice

RMMR and QUM services – this could lead innovation on best practice.


While changes made as a direct result of a recommendation are easy to quantify it

is harder to measure changes in prescribing practices.


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