BY ANDREW DANIELS
Dodging koalas,
kangaroos and squashed
bananas are all in a day’s
work for north Queensland
consultant pharmacist
Karalyn Huxhagen as
she takes pharmacy to
the farmhouse to deliver
HMRs.
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Australian Pharmacist January 2017 I © Pharmaceutical Society of Australia Ltd.
COVER
In June last year, she spent seven hours in her
car waiting for an overturned truck and its load
of bananas to be scraped off the Bruce Highway
next to Deadman’s Creek south of Proserpine –
just one of the more unusual obstacles the 2010
PSA Pharmacist of the Year has faced when
travelling to deliver Home Medicine Reviews
(HMRs).
The truck rolled early in the morning and when
Karalyn arrived at the scene just after lunch the
highway was still blocked. Another truck had crashed
south of Mackay and the only tow truck in the region
was there.
‘I had phone service so I did some paperwork, read
some articles and had a nap. I got through at nightfall
and saw my patient seven hours late. When I drove
back two hours later a Bobcat was still loading
bananas onto a tip truck,’ she said.
Koalas, emus, pigs and kangaroos are also road
hazards to be avoided. In the mating season koalas
are unpredictable and are more likely to run in front of
cars according to Karalyn.
Born and bred in Mackay, Karalyn studied pharmacy
at the University of Queensland and has worked in
many settings over the years including providing
pharmacy supplies to lighthouses, ships and mining
companies. An early adopter, she was accredited as
a consultant pharmacist in 1997. Active in PSA, she
was a Queensland committee member for many years
and a PSA National Board member in the early 2000s
including several years as National Treasurer.
For 28 years she managed a pharmacy in Mackay.
Her last role there was as professional services
manager. However, with the changes that came
in the Fifth Community Pharmacy Agreement the
pharmacy struggled to see the value of professional
programs with the reductions in pricing and closed its
professional programs, making Karalyn redundant in
the process.
‘I could see this coming and I established my own
consulting company in 2014 to provide medication
reviews,’ she told Australian Pharmacist.
Soon she picked up work in the pain management
area. Since January 2013 she has been the Clinical
Facilitator of the Mackay Pain Support Group. In 2015,
she was awarded the PSA Quality Use of Medicines
Award for Pain Management.
Just as the business was becoming established the
decision to cap HMRs was announced.
‘I was blown away by the announcement that HMRs
would be capped at 20 per month because I was
performing 50–60 per month. My little consulting
company hit a brick wall.’
Networking for success
Since then, Karalyn has networked to build the
business.
‘I diversified and looked at other things that I could
do. Luckily, I had five nursing home contracts that
kept me viable for a little while. Then I started doing
more consulting and putting myself out there for
whoever wanted to pay for a pharmacist to talk to
them.’
For example she works with the Mackay Health and
Hospital Service (MHHS) in the Health Pathways
Program (HPP) which educates GPs and health
professionals about the best pathway for a patient
through the health system. It looks at reducing
waiting lists, optimising patient care and finding the
right health professional for the right patient.
‘HPP has been a great project because I have been
able to have a lot of input into the role of community
pharmacists and consultant pharmacists in patient
health. Unfortunately it is an unpaid job but it has
given me the opportunity to meet and work with
people who use my services for HMRs and other
projects.
‘It is one of those jobs that you take on because
it leads you places. It pays dividends in terms of
networking.’
She also presents QUM lectures. For example, the
MHHS asked her to present to patients undergoing
bariatric surgery about medications before, during
and after surgery.
HMRs in western Queensland
HMRs remain at the core of Karalyn’s business.
She has focussed on becoming consultant
pharmacist to western Queensland and regularly
travels to isolated towns such as Clermont, Dingo,
Blackwater, Springsure, Capella and Moranbah.
‘I do a lot of work on the Gemfields. I go as far
as Belyando Crossing south of Charters Towers.
These are very rural areas so the patients are quite
scattered. I enjoy the work. It is really diverse. GPs in
the region come and go. It is very hard to keep them
for very long.
‘The patients access many specialists by travelling
long distances or by Skyping through Telehealth.
The patients have a multitude of problems. It is very
rewarding, hard work and a lot of travel.’
The travel comes with challenges not present in
urban areas. Often the HMR appointments are out of
town so after a long drive to get to the town she has
to tackle dirt roads to find her patient’s home.
Australian Pharmacist January 2017 I © Pharmaceutical Society of Australia Ltd.
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COVER
On the way to one HMR appointment, the patient
rang to warn her to ‘keep an eye out’ for the taipan
sunning itself in the front yard. However, before
she made it to the front yard she had to get past
a heavily pregnant Friesian cow guarding the
cattle grid at the entrance to the property’s home
paddock.
At various times she has also had to wait for flood
waters to subside between Clermont and Alpha and
when visiting outlying properties. She has driven
carefully past aggressive bulls defending their
territory.
As for kangaroos – ‘I was coming down an
embankment concentrating on staying on the
skinny concrete driveway out of the property when
four large red kangaroos bounded right over my
small Subaru. It scared me to death and I nearly
drove off the edge and into the gully,’ she said.
IN
KARALYN’S
WORDS
As told to
ANDREW DANIELS
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Australian Pharmacist January 2017 I © Pharmaceutical Society of Australia Ltd.
Another challenge is making enough from her
various roles for her company to be financially
viable. In February 2015 Karalyn began managing
a small pharmacy part time while continuing her
consultancy business over the rest of the week.
However, even with the part time community
pharmacy work she has to combine travelling
to deliver HMRs with her aged care work at local
hospitals (in Queensland local hospitals usually
have beds set aside for aged care because there
are no aged care facilities) and locum work to cover
costs. If she is lucky the local health service will have
accommodation for visiting doctors available to use.
‘I do a trip and combine seeing my HMR patients,
the nursing home work and also locum for any of
the pharmacists in the area who need help. [See
Australian Pharmacist, Oct 2016, page 22–3.] It all
keeps me busy. Performing locum work in rural
Queensland is very rewarding as the town’s people
On the way to one
HMR appointment
the patient rang
to warn her to keep
an eye out for the
taipan sunning
itself in the front
yard.
VALUE OF PSA
MEMBERSHIP
In a nutshell – mentoring,
support, fellowship and
development. PSA gives
me support clinically and
with mentoring. There
is always someone who
knows how to find what
I need. I have the best
support structure from
PSA Queensland office
and the national team.
I ask the question and I
receive an answer with
lots of advice and extras.
REWARDING
The most rewarding thing
about being a healthcare
provider is making a
difference. A patient
coming back to see me
and saying how much
I helped to make their
health journey easier to
navigate gives me the
best buzz of my day.
COVER
GP. If the community pharmacy sends me the HMR referrals I cannot claim the
travel allowance.
‘To drive that distance over several days and pay for accommodation makes the
service totally unviable. The HMR cap needs to be expanded for these locations
as there is very little economic sense sending a pharmacist these distances and
restricting how many patients they can see.’
To illustrate her point she cited three requests received for rural and remote
HMRs.1
The first, west of Mackay, was for 200 patients with travel time 5–7 hours one
way. Most of the patients were waiting for placement in one of the few aged care
facilities in the area.
‘The expectation is that they will never achieve placements,’ she said.
The second, west of Rockhampton, was for 60 patients with travel time of seven
hours one way. The third, west of Toowoomba, was for 300 patients with travel
time of 12 hours one way.
are really grateful that the pharmacy is operational.
Shutting the pharmacy so the pharmacist can have a
small break takes away a vital service in these small
communities.’
No shortage of HMR requests
There is plenty of potential HMR work in western
Queensland. However, the 20-a-month cap limits
how many HMRs she can do.
In a submission responding to the Review of
Pharmacy Remuneration and Regulation Discussion
Paper, Karalyn highlighted that at times she drove
1,800 kilometres in a round trip to see patients.1
She said: ‘The government pays me $125 per round
trip to see these patients and no accommodation
allowance. This is not $125 per patient. It is $125 per
trip and I must be sent the referrals direct from the
CHALLENGES
The greatest challenge is the poor
remuneration for working outside of a
community/hospital practice setting.
Another is the lack of understanding
of my worth and place in practice by
fellow allied health colleagues.
In each case no accommodation was provided and the maximum travel
allowance available was $125.
‘All of these areas have asked their local pharmacies if they can provide the
services and they cannot. All of these locations have health and hospital service
accommodation for visiting medical officers, pay their GPs to fly in and out and
have support services such as diabetes educators funded by CheckUp.’ (See:
www.checkup.org.au/page/Initiatives/Outreach_Services/)
All of the patients had been investigated and deemed to be at risk due to
multiple prescribers, poor health literacy, predominantly Indigenous heritage,
lack of recurring health services with the loss of Royal Flying Doctor Service and
other programs, and inability to access regional hospital and health services due
to a lack of money and ability to travel.1
‘I can only visit 20 patients per month so you can see I would have plenty of
work for several years. How do I triage who to see first? Why would I travel these
distances and pay for accommodation and travel and receive a measly $125?
While the current model is barely adequate in the regional locations, it is not
feasible when you have to travel distances that require overnight stays,’ Karalyn
said in her submission.1
PHARMACY GOALS
FUTURE
My main goal is to achieve a worthwhile remuneration
for what I do and the long distances I travel. The second
goal is to work on my succession plan to hand over my
remote Home Medicines Review work to someone who
loves central Queensland as much as I do.
Hopefully people like me
will be independently
funded for the roles we
perform. I hope the Review
of Pharmacy Regulation
and Remuneration looks
at dividing out the areas
such as ownership from
practice so we can start to
be recognised within the
health arena as needing
to be supported and
funded in the same way as
clinical consultant nurse
practitioners.
INSPIRATION
ADVICE
I enjoy being able to help people. My first choice of occupation was
nursing but I was not physically strong enough so I went to university
and became a pharmacist. I enjoy interacting with patients, their
families and carers. I particularly like being the ‘Ms Fixit’ who joins the
dots and helps them navigate their health pathway. I work closely with
the practice nurses and managers and have gained the respect of the
GPs. Their respect and confidence inspires me to keep doing what I do.
Never stop pushing
the boundaries. Make
sure your voice is the
loudest in the room.
Know your place but
push for inclusion and
respect.
Australian Pharmacist January 2017 I © Pharmaceutical Society of Australia Ltd.
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COVER
Karalyn told Australian Pharmacist there needed to
be an allowance for accommodation.
‘I can spend five or six days out there. At times, I barter
with health and hospitals services because I am doing
their aged care beds at the same time and if able they
will kindly give me accommodation at hospitals.’
In her view HMRs are a perfect example of a program
that needs a flexible funding agreement. She sees
the present HMR program as a very urban model
that does not allow for long distances travelled.
Sitting in a silo
According to Karalyn, because the community
pharmacy agreements (CPAs) sit in their own little
niche and because HMRs are in that niche they have
become contained in a little bubble.
‘It is one of my arguments for why HMRs should be
in the MBS system. It would be far easier to work in
a collaborative partnership with GPs and nurses in
these locations if we were not in the CPA. Doctors
have these perceptions that because we are being
funded out of the CPA bubble we are adequately
funded and it all happens.
‘They don’t understand that the only money we get
out of the MMR program is for actually performing
the HMR. The money I get paid, the $125 for travel,
comes out of a separate bundle of money under the
Rural and Remote Loading Program.
‘There is this misconception that the CPA agreement
completely funds what I do.
‘I really enjoy the medication management
programs – HMRs, QUM, RMMRs. It is the form of
pharmacy that I love.
‘I was one of the first people accredited in Australia
because it was exactly how I wanted to practice. I
became a better community pharmacist because of
the advanced practice learning that enabled me to
be an accredited pharmacist.
‘I really enjoy the fact that when I go to a home and
sit down with the patient, their carer and family,
and go through everything, the light bulbs come on
inside people’s eyes.
‘When you explain things and go through
techniques they are so appreciative that someone
has come and spent the time with them to make
improvements.
‘To change how people do things you have to keep
going back and revisiting it to get them to implement
change. When talking to them at an HMR interview
you lay the first seeds and then you ask a few more
questions and then you go back and lay the second
seeds, you talk a bit more and at the end in summing
up I write them a list and I leave it with them.
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Australian Pharmacist January 2017 I © Pharmaceutical Society of Australia Ltd.
‘I say well this is what I think you can do to manage better
but all the way through I have been laying down that
scenario. At the end I say I want you to do this, this and this
and they say – “ah that all makes sense” – because I have
given them time in the 30–40 minutes that I am there to
think it through.
‘A very busy GP has 7–9 minutes to get things into
someone’s head and get them thinking. They can’t possibly
get that whole change thing happening.
‘When we did the evaluation of the HMR project we ran
focus groups and I brought in some of my patients. They all
said how much they appreciated the fact that a pharmacist
came to them, sat down and talked their language and
explained things. Also, the pharmacist was contactable
after the interview. I always leave my business card.’
Karalyn believes western Queensland has many patients
who need help and who are getting bits of healthcare from
everywhere but do not have continuity in their care apart
from the community nurse. Doctors drive or fly in and out
and change often.
‘Those poor community nurses are really worn out. They are
running around doing the best they can for these patients. I
love being able to support the community nursing services.
I also support the community pharmacies in that region.
‘All this travelling and juggling roles is not making me rich.
[According to her accountant she received payments from
28 different entities last financial year] I am just making a
living.
‘My work in community pharmacy underpins it all. If I
can bring some of my costs down – accommodation for
example – it will be more viable. There needs to be more
money in the medication management program for more
people to take it on.
‘You couldn’t do it if you had kids and a mortgage!’
References
1. Huxhagen K. Review of Pharmacy Remuneration and Regulation Submission #81; 17-Sep
2016. At: http://www.health.gov.au/internet/main/publishing.nsf/Content/reviewpharmacy-remuneration-regulation-submissions-cnt-2/$file/81-2016-09-17-karalynhuxhagen-submission.pdf