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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
Department of Health and Ageing
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
RMMR Evaluation Appendix B - Call for Submissions
Department of Health and Ageing
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.
RMMR Evaluation Appendix B - Call for Submissions
Department of Health and Ageing
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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Department of Health and Ageing
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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.
RMMR Evaluation Appendix B - Call for Submissions
Department of Health and Ageing
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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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Department of Health and Ageing
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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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Department of Health and Ageing
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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.
(Accredited Pharmacist and RMMR Provider)
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.
(Accredited Pharmacist and RMMR Provider)
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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Department of Health and Ageing
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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.
(Accredited Pharmacist and RMMR Provider)
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.
RMMR Evaluation Appendix B - Call for Submissions
Department of Health and Ageing
CR&C 1074 8
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.
(Accredited Pharmacist and RMMR Provider)
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.
(Accredited Pharmacist and RMMR Provider)
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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Department of Health and Ageing
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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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Department of Health and Ageing
CR&C 1074 10
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.
(Accredited Pharmacist and RMMR Provider)
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.
(CEO, Aged Care Home)
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.
(Accredited Pharmacist and RMMR Provider)
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.
(CEO, Aged Care Home)
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.
(Accredited Pharmacist and RMMR Provider)
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.
(Accredited Pharmacist)
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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Department of Health and Ageing
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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.
(Accredited Pharmacist)
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
(CEO Health Service)
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)
RMMR Evaluation Appendix B - Call for Submissions
Department of Health and Ageing
CR&C 1074 12
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.
(Accredited Pharmacist and RMMR Provider)
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.
(Accredited Pharmacist and RMMR Provider)
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.
(Accredited Pharmacist and RMMR Provider)
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.
(Accredited Pharmacists and RMMR Providers)
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
RMMR Evaluation Appendix B - Call for Submissions
Department of Health and Ageing
CR&C 1074 13
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.
(Accredited Pharmacist and RMMR Provider)
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.
(Accredited Pharmacist and RMMR Provider)
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Department of Health and Ageing
CR&C 1074 14
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.
(Accredited Pharmacist and RMMR Provider)
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
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Department of Health and Ageing
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?
(Accredited Pharmacist and RMMR Provider)
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.
(Accredited Pharmacist and RMMR Provider)
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.
(Accredited Pharmacist and RMMR Provider)
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.
RMMR Evaluation Appendix B - Call for Submissions
Department of Health and Ageing
CR&C 1074 16
(Accredited Pharmacists and RMMR Providers)
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.
(Accredited Pharmacist and RMMR Provider)
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.
(Accredited Pharmacist and RMMR Provider)
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.
(Accredited Pharmacist and RMMR Provider)
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.
(Accredited Pharmacist)
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).
RMMR Evaluation Appendix B - Call for Submissions
Department of Health and Ageing
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.
(Accredited Pharmacist and RMMR Provider)
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.
(Accredited Pharmacist and RMMR Provider)
I feel that the RMMR program is being rail-roaded by corporate companies who tie
up the contracts & provide minimal services.
(Accredited Pharmacist and RMMR Provider)
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.
(Accredited Pharmacist and RMMR Provider)
RMMR Evaluation Appendix B - Call for Submissions
Department of Health and Ageing
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).
(Accredited Pharmacist)
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
RMMR Evaluation Appendix B - Call for Submissions
Department of Health and Ageing
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.
(Accredited Pharmacist)
(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.
(Aged Care Home Manager)
Recommendation: RMMR to take on a case conferencing format to enhance
collaboration and achieve improved outcome for the resident.
(Aged Care Home Manager)
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
RMMR Evaluation Appendix B - Call for Submissions
Department of Health and Ageing
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.
(Accredited Pharmacist and RMMR Provider)
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.
(Accredited Pharmacist and RMMR Provider)
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.
RMMR Evaluation Appendix B - Call for Submissions
Department of Health and Ageing
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.
(Accredited Pharmacist and RMMR Provider)
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.
(CEO Health Service)
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.
(Accredited Pharmacist and RMMR Provider)
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
RMMR Evaluation Appendix B - Call for Submissions
Department of Health and Ageing
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).
(Accredited Pharmacist and RMMR Provider)
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
RMMR Evaluation Appendix B - Call for Submissions
Department of Health and Ageing
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.
(Accredited Pharmacist and RMMR Provider)
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.
(Accredited Pharmacist and RMMR Provider)
While changes made as a direct result of a recommendation are easy to quantify it
is harder to measure changes in prescribing practices.
(Accredited Pharmacist)