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As Australian health professionals and policymakers grapple with the pressures and realities of caring for a growing community with changing needs, there s an opportunity to uncover better ways of using the skills and expertise of one group of health professionals pharmacists. Our community is changing. We are ageing, more of us are managing chronic illnesses such as diabetes, heart disease, asthma and arthritis, and the cost of providing medical and hospital care is escalating. In recognition of these challenges, the Australian Government is placing a stronger focus on helping people get the services they need in their local communities, and keeping them well and out of hospitals. As medicines are an integral part of healthcare pharmacists are part of the solution. The Pharmacist Coalition for Health Reform The Pharmacist Coalition for Health Reform represents more than 20,000 Australian pharmacists working in partnership with the community. We work in hospitals, community pharmacies, GP clinics, regional and remote health centres and across the health system. We want to create a voice for pharmacists in the ongoing development of our health system because we know we have so much more to offer. We want to work with the Australian Government, doctors, nurses and allied health professions to create a health system that responds to the needs of the community. The Coalition comprises members of: The Pharmacists Division of the Association of Professional Engineers, Scientists & Managers, Australia (APESMA) National Australian Pharmacy Students Association (NAPSA) Pharmaceutical Society of Australia (PSA) The Society of Hospital Pharmacists of Australia (SHPA). www.pharmacistsforhealth.com.au Email: pchr@pharmacistsforhealth.com.au 2
Working together in teams Studies from all over the world have shown that people are better cared for when health professionals work together in teams and that these teams are more successful when they include pharmacists. After all, the use of medicines is integral to healthcare. A major study in 2010, for example, analysed the role of pharmacists in healthcare teams across 298 different studies across the globe including Australia. It concluded pharmacists involvement led to improved outcomes for patients with different illnesses in hospitals, residential care, community health facilities and GP clinics. 1 These important findings were attributed to pharmacists being highly trained health professionals, whose specialist knowledge in medicines can make a significant contribution to the health of the community. Pharmacists are the only health professionals whose four-year education is almost entirely devoted to medicines and their use across the healthcare system, with expertise that extends well beyond the dispensing of medicine from behind a counter. Many pharmacists working in local community pharmacies want to spend more time with patients on their premises or visiting their homes to provide advice about taking medicines safely and effectively. However, these services aren t universally available due to current funding arrangements. Some pharmacists are already working and making a difference in health professional teams in Australian hospitals, GP clinics and regional health services where they play a pivotal role in supporting doctors and nurses to make decisions about the medicines they prescribe, to manage medicine regimens and, help patients understand and use their medicines safely and effectively. For example, apart from talking to patients pharmacists in hospitals use their skills to attend medical ward rounds, prepare chemotherapy medicines, support the clinical trials of new medicines and advise on the introduction of new medicines into the hospital. This model is proven to deliver better care to patients as well as saving costs. Finding new ways to expand this model across the health system will deliver significant benefits including: improving access to healthcare improving patients understanding of their medicines reducing adverse drug reactions and unnecessary hospital admissions saving the community money; and saving lives. 3
CASE STUDY Christopher, pharmacist in general practice Unlike many pharmacists, Christopher, 29, works in a multidisciplinary practice team alongside dieticians, psychologists, diabetes educators, community nurses, mental health nurses and external pharmacy services to provide coordinated care for each of his patients. Chris approached a GP practice in Brisbane about taking on the unique role of a consulting pharmacist after witnessing a lack of collaboration among the pharmacists doing medication reviews and the GP who was reviewing the report. His main role in the GP practice is conducting medication reviews for patients and working collaboratively with other health professionals at the surgery to care for patients. The difference between a pharmacist being in the medical centre compared to the community is you often get to provide advice at the point of prescribing rather than reacting after the medicine has already been prescribed. He says consulting pharmacists in general practices are beneficial because they complement the services provided by other health care professionals. We re not duplicating any services that are already within general practice. I m not currently prescribing or giving vaccinations because, my role is to add something different to the mix and that s with medicine knowledge and review, he says. Chris believes that pharmacists are being under utilised and have the skills and depth of knowledge to contribute much more to the health profession. Pharmacists are often thought of as one of the most over trained yet under utilised health care professionals in Australia. We have the skills and depth of knowledge to be able to do a lot more than we are perceived to be doing, Chris says. Beth, cancer ward pharmacist In cancer wards in hospitals around the country, a dedicated pharmacist oversees the way medicines are used for every patient. Beth is one of these pharmacists and is currently working in a cancer ward at the Peter Mac Callum Cancer Centre in Melbourne, which treats 25,000 patients every year. Beth is responsible for working within a multidisciplinary team to ensure that all the medicines prescribed for and administered to each patient are safe and effective. I provide support to the nurses who administer the medicines and monitor the special tests required to ensure the medicines are working properly. I also liaise with the prescribing doctors to make adjustments to the dosages if needed. 4 CASE STUDY She is involved in caring for the patient throughout their treatment and plays a key role in advising on the correct dosages and coordinating medicines to help reduce the side-effects of chemotherapy treatment. Each patient chart is reviewed on a daily basis to ensure that all of the patient s regular medicines have been ordered as intended and that any new medicines will not interact badly with the other medicines the patient is taking, she says. Beth works with other pharmacists, including a senior clinical pharmacist and education pharmacist to ensure patients are receiving the best level of care. She regularly also helps educate other staff on the ward. When it is time for the patient to go home, I make sure they have the appropriate medicines and an understanding of how to take and manage them, Beth says.
Improving access to healthcare Booming demand for healthcare services is placing pressure on our doctors with increasing waiting times becoming a big issue, especially in regional and rural areas. 2 Poor access to health services can create a ripple effect though local communities. A Productivity Commission report into Australia s Health Workforce notes that for those who need ongoing care for chronic conditions, a lack of access to healthcare impacts on employment, education and family and community life. 2 As more people are affected by these conditions, the use of medicines is growing, and so is the need to properly monitor the way they are used. Pharmacists are the most easily accessible health professionals in the community, providing an untapped resource able to actively monitor and advise patients who manage chronic conditions with a combination of medicines. There are approximately 5000 community pharmacies across Australia, each serving an average community of 4000 people. It is estimated that the average person receives prescription medicine more than 12 times a year. 3 Greater use of pharmacists in circumstances where there is no need to diagnose a problem or start a new medicine would mean people get easier access to a healthcare professional when they need it. Improving understanding of medicines A large proportion of Australians take some kind of medicine everyday and many are taking combinations of different medicines to manage a health condition. Understanding how medicines work and the risks associated with not following instructions, adding or leaving out a medicine or stopping them altogether can be complicated and have serious health consequences. Misuse of medicines is often accidental and caused by a lack of understanding about those medicines. That s why the expertise of pharmacists is so important. Pharmacists can help explain what medicines do, why they should be taken, how they should be taken, and the risks associated with them. Pharmacists are also one of the first points of call if people are unable to take their medicines for any reason. A 2007 worldwide study found that pharmacists play an important role in promoting good health and educating people in the use of medications. It concluded that the role of pharmacists in the community includes more than dispensing medications. It involves identifying, preventing and resolving drug-related problems, as well as encouraging proper use of medications and general health promotion and education. 4 While educating patients about medicines and their use is critically important, the expertise and knowledge of pharmacists cannot be distilled into a simple fact sheet or one conversation. 5
Karalyn, rural pharmacist In her role as a pharmacist in rural Queensland, Karalyn works in an integrated team alongside 11 other pharmacists to meet the health needs of the community. Karalyn says that a highlight of being a rural pharmacist is the close relationships you form with your patients. A pharmacist is a very integral part of the healthcare team when you live in rural and regional Australia. We serve the fourth or fifth generation of community members. Karalyn says she has a responsibility to integrate as many services as possible into the daily practice of the pharmacy. CASE STUDY We try to be a one-stop-shop for the community. In my role as a professional programs manager I work to identify what programs are available, how we access it, what the payment protocols and business plans are and then integrate them into the pharmacy business, Karalyn says. The pharmacy provides many programs including a dosage administration service, a text message reminder service and a specialised program for people with sleep apnoea. As part of our home medicine review service we visit the patient at home to gain the best knowledge as to how they re handling their medicine. We are really a major part of this community, as we provide support to the community as a whole to inform them of ways to better manage their health outcomes, Karalyn says. CASE STUDY Kyrillos, hospital outreach pharmacist In hospital, patients receive help with taking their medicines and information about these medicines. But things can be difficult when it comes time to go home and they need to manage a combination of medicines by themselves. Kyrillos, a hospital outreach pharmacist in Melbourne, is responsible for making this transition a lot easier for patients. Kyrillos is an experienced hospital pharmacist who visits patients in their own home after they have left hospital. I talk with each patient about how they use their medicine, including those they buy from supermarkets, health food shops, other therapists or a community pharmacy and discuss any problems they have with their medicines, he says. Using this information, he talks to the patient about how they could better use their medicines and how they can overcome any problems they are experiencing. After visiting the patient, I write a report for the patient s GP and community pharmacist detailing any difficulties the patient is having with their medicines, and provide advice on improvements and changes that I think may be necessary, Kyrillos says. 6
Reducing adverse drug events and unnecessary hospital admissions The risks associated with Adverse Drug Events (ADEs), or bad reactions to medicines, can be extremely serious, even fatal. Overall it is estimated that in Australia 190,000 people are admitted to hospital every year as a result of an ADE. 5 This is a significant and avoidable pressure on our overloaded hospital system and causes untold pain and distress for many Australians who require hospitalisation after an ADE. Ten percent of patients seen by GPs in Australia experienced an ADE in the past six months, and 25% of high risk patients reported an ADE in the past three months. 6 This study also highlighted that overall 5.6 per cent of hospital admissions in Australia are related to an ADE. A further 30 per cent of admissions for elderly Australians are related to an ADE. Studies into the use of hospital-based pharmacists have shown that ADEs can be reduced where clinical pharmacists work as part of health care teams. 7 If pharmacists reduce ADEs inside hospitals, they can also reduce this problem in the broader community. By playing a more active role in ensuring the safe and effective use of medicines, pharmacists can prevent ADEs from taking place, and protect patients from the potential harmful consequences of medication misadventure to produce better health outcomes. By preventing ADEs and playing a more active role in the handover and subsequent monitoring of patients after they leave hospital, pharmacists can also prevent unnecessary harm and hospital admissions. 7
Robbo, remote and Indigenous community pharmacist When Robbo began working in remote indigenous communities in outback Australia, none of his patients knew what a pharmacist did, let alone had ever met one. As the only pharmacist in Australia living and working in a remote area as part of the Primary Health Care team, Robbo uses his range of skills. I do a lot of counselling and education about medicines and safety, dispensing from remote clinics, and reviewing policies and procedures to make sure things have been done correctly. I deal with wounds, reviewing allergies and adverse events to identify the causes and helping people deal with other adverse reactions to medicines. Robbo works in a multidisciplinary team and provides education about medicines and managing chronic conditions to health professionals servicing the patients in remote and Indigenous communities. CASE STUDY I work closely with a chronic disease nurse; and other nurses or doctors will refer patients to me as well, Robbo says. Robbo says more pharmacists are needed in remote areas to help people manage health conditions and get access to and understand medicines. You wouldn t build a new hospital without having a pharmacy department, you wouldn t build a new suburb without having a pharmacy in there and yet there seems to be this philosophical view that we re not needed out bush but we can make a real difference, he says. 8
Saving the community money Adverse reactions to medicines and their misuse come at a high financial cost adding to the ever-growing financial pressures on our hospital system. In fact, it has been estimated that the cost of ADEs to the Australian health sector is around $660 million a year. 6 Research has shown that the use of pharmacists in hospitals can lead to substantial savings in the cost of treating patients. An Australian study found that for every dollar spent on a hospital pharmacist to make changes in medicine therapy or management, approximately $23 was saved on length of stay, readmission, other medicines, medical procedures and laboratory monitoring. 8 A US study of more than 14 million hospital admissions showed that inpatients treated by a health care team with a pharmacist had significantly shorter length of stay and lower pharmacy costs compared with inpatients whose health care teams did not include a pharmacist. 7 Greater use of pharmacists skills and expertise to reduce these unnecessary costs not only saves precious health dollars, it also improves people s lives. Saving lives Most importantly, expanding the role of pharmacists beyond dispensing in healthcare can save lives. A US study identified a link between reduced mortality rates and seven pharmacy services drug use evaluation, in-service education, adverse drug reaction management, drug protocol management, involvement in cardiopulmonary resuscitation teams, involvement in ward rounds and admission drug histories. 7 Similarly, a study of 49 National Health Service organisations in the United Kingdom found a correlation between the number of pharmacists employed and mortality rates. 9 In other words, with more pharmacists on staff, and more pharmacists involved in clinical activities, fewer people died while in hospital. 9
The future role of pharmacists Pharmacists have skills and expertise that are not being fully utilised, particularly in the community. Given a broader role, pharmacists are poised to help solve challenges and help make health care more effective and more affordable for Australians. The next generation of pharmacists is leaving university more prepared than ever to provide specialist professional services that will make a significant contribution to meeting the healthcare challenges facing our community over the coming decade. The Pharmacist Coalition for Health Reform has a vision for a future where pharmacists: Work in healthcare teams to provide integrated care for patients in GP practices, clinics, hospitals, rehabilitation centres and community health centres Provide follow up support to patients leaving hospital to help them manage their medicines, keep an eye out for possible adverse affects and prevent them from relapsing and being readmitted to hospitals Are funded to consult with patients in their pharmacy, or during home visits, to review, monitor and educate them about their medicines Are part of the team working in and through Medicare Locals, helping to make decisions about the healthcare services needed by their communities Work in or closely with aged care facilities to support residents to take medicines safely and effectively, and to monitor and recommend changes to their medicines. PCHR another partner in health reform The Pharmacist Coalition for Health Reform wants to work closely with governments, doctors, nurses, allied health professionals and the community to uncover the benefits of the best kept secret in healthcare pharmacists. We want to contribute constructively to discussions and be involved in helping to develop workable models that will make our health system stronger, more efficient and more affordable for Australians. 10
Endnotes 1. Chisholm-Burn, MA, et al. US Pharmacists Effect as Team Members on Patient Care, Medical Care, 2010, 48 (10) 923-3 2. Productivity Commission 2005, Australia s Health Workforce, Research Report, Canberra. 3. Medical News Today Most Aussies buy prescription medicine more than 12 times a year, 30 May 2011, www.medicalnewsstory.com/releases/226858php (accessed 8 June 2011) 4. Nkansah N, et al. Effect of outpatient pharmacists non-dispensing roles on patient outcomes and prescribing patterns. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD000336. DOI: 10.1002/14651858.CD000336.pub2 5. Roughead E and Semple S. Medication safety in acute care in Australia: where are we now? Australia and New Zealand Health policy 2009, 6: 18 6. Easton K, Morgan T, Williamson M. Medication safety in the community: A review of the literature. National Prescribing Service. Sydney, June 2009. 7. Bond CA, Raehl CL. 2006 National Clinical Pharmacy Services Survey: Clinical Pharmacy Services, Collaborative Drug Management, Medication Errors, and Pharmacy Technology. Pharmacotherapy. 2008;28(1):1-13. 8. Dooley MJ, Allen KM, Doecke CJ et al. A prospective multicentre study of pharmacist initiated changes to drug therapy and patient management in acute care government funded hospitals. Br J Clin Pharmacol 57:4;513-21 9. Borja-Lopetegi A, Webb D, Bates I, Sharott P: Association between clinical medicines management services, pharmacy workforce and patient outcomes. Pharmacy World & Science, 30: 418-19 www.pharmacistsforhealth.com.au Email: pchr@pharmacistsforhealth.com.au 11
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