Evaluation of the
Residential Medication
Management Review
Program
Appendix C
Diary Based Case Study
Report
Prepared for
Department of
Health and Ageing
GPO Box 9848
Canberra ACT 2601
May 2010
101-103 QUEENS PARADE, CLIFTON HILL, VICTORIA 3068 PO BOX 441, CLIFTON HILL, VICTORIA 3068
PHONE +613 9482 4216 FAX +613 9482 6799 ABN 29 073 813 144
www.campbellresearch.com.au
RMMR Evaluation
Appendix C - Diary Based Case Studies
Department of Health and Ageing
TABLE OF CONTENTS
1.
Overall findings................................................................................................................... 1
1.1
Quantitative analysis of cost efficiency ........................................................................ 1
1.2
Qualitative considerations ............................................................................................ 2
2.
Methodology ....................................................................................................................... 4
2.1
Quantitative component ............................................................................................... 4
2.2
Qualitative component ................................................................................................. 7
2.3
Case Study 1 (CS1) ..................................................................................................... 8
2.4
Case Study 2.............................................................................................................. 16
2.5
Case Study 3.............................................................................................................. 22
2.6
Case Study 4.............................................................................................................. 29
2.7
Case Study 5.............................................................................................................. 36
2.8
Case Study 6.............................................................................................................. 45
2.9
Case Study 7.............................................................................................................. 52
2.10
Case Study 8.............................................................................................................. 59
2.11
Case Study 9.............................................................................................................. 65
2.12
Case Study 10............................................................................................................ 71
2.13
Case Study 11............................................................................................................ 78
2.14
Case Study 12............................................................................................................ 84
2.15
Case Study 13............................................................................................................ 90
2.16
Case Study 14............................................................................................................ 96
2.17
Case Study 15.......................................................................................................... 102
2.18
Case Study 16.......................................................................................................... 108
2.19
Case Study of a Provider of Medication Reviews to an Indigenous Aged Care Home .
................................................................................................................................. 114
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INDEX OF TABLES
Table 1:
Case Study 1 Characteristics .......................................................................................13
Table 2:
Detailed Expenses – Average Times and Costs ..........................................................15
Table 3:
Case Study 2 Characteristics .......................................................................................19
Table 4:
Detailed Expenses – Average Times and Costs ..........................................................21
Table 5:
Case Study 3 Characteristics .......................................................................................26
Table 6:
Detailed Expenses – Average Times and Costs ..........................................................28
Table 7:
Case Study 4 Characteristics .......................................................................................33
Table 8:
Detailed Expenses – Average Times and Costs ..........................................................35
Table 9:
Case Study 5 Characteristics .......................................................................................42
Table 10:
Detailed Expenses – Average Times and Costs ..........................................................44
Table 11:
Case Study 6 Characteristics .......................................................................................49
Table 12:
Detailed Expenses – Average Times and Costs ..........................................................51
Table 13:
Case Study 7 Characteristics .......................................................................................56
Table 14:
Detailed Expenses – Average Times and Costs ..........................................................58
Table 15:
Case Study 8 Characteristics .......................................................................................62
Table 16:
Detailed Expenses – Average Times and Costs ..........................................................64
Table 17:
Case Study 9 Characteristics .......................................................................................68
Table 18:
Detailed Expenses – Average Times and Costs ..........................................................70
Table 19:
Case Study 10 Characteristics .....................................................................................75
Table 20:
Detailed Expenses – Average Times and Costs ..........................................................77
Table 21:
Case Study 11 Characteristics .....................................................................................81
Table 22:
Detailed Expenses – Average Times and Costs ..........................................................83
Table 23:
Case Study 12 Characteristics .....................................................................................87
Table 24:
Detailed Expenses – Average Times and Costs ..........................................................89
Table 25:
Case Study 13 Characteristics .....................................................................................93
Table 26:
Detailed Expenses – Average Times and Costs ..........................................................95
Table 27:
Case Study 14 Characteristics .....................................................................................99
Table 28:
Detailed Expenses – Average Times and Costs ........................................................101
Table 29:
Case Study 15 Characteristics ...................................................................................105
Table 30:
Detailed Expenses – Average Times and Costs ........................................................107
Table 31:
Case Study 16 Characteristics ...................................................................................111
Table 32:
Detailed Expenses – Average Times and Costs ........................................................113
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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.
.
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1.
Overall findings
To address the cost efficiency (or otherwise) of the RMMR payment for Accredited Pharmacists
at its current level, Campbell Research invited Accredited Pharmacists to keep a diary of
expenses and reimbursement in relation to the conduct of RMMRs. The diary included fields
where pharmacists could record:
•
Costs incurred through the conduct of RMMRs including time-based costs
(salary), travel costs (petrol, flights etc) and other expenses such as parking,
accommodation etc.
•
The number of RMMRs conducted and financial returns from those RMMRs.
•
Demographic characteristics of the pharmacists as well as the Aged Care
Homes visited.
From the data reported in the diaries, Campbell Research estimated two key figures:
•
The relative cost efficiency of different Accredited Pharmacists in terms of
financial input (payment received) compared to the financial outlay required to
conduct RMMRs
•
The allocation of costs for different pharmacists in terms of expenses relating
to pharmacist salary, administrative salary, travel costs and other expenses.
The quantitative findings from the diary component of the case studies closely match the
qualitative evidence gathered to accompany the case studies. It should be noted that the
qualitative information was gathered independently of the diary data analysis.
1.1
Quantitative analysis of cost efficiency
Overall, RMMR was cost efficient for pharmacists, though cost efficiency varied greatly from
very small margins approaching break-even, to very high margins where the return on RMMRs
was several times that of invested time and money.
Generally, the key determining factors in the level of cost efficiency of providing RMMRs were:
•
The overall number of Reviews conducted and for which payment is sought
•
The number of visits required to accumulate these Reviews - Reviews per visit
•
The proportion of Reviews conducted as Collaborative Reviews
The pharmacists who took part in the case studies tended to fall into one of two camps: high
throughput or low throughput.
Characteristics of a high throughput pharmacist included the minimisation of the number of visits
required to attain the maximum number of Reviews – a simple economy of scale. Travel and
administrative time expenses were minimised, while the number of Reviews conducted at each
visit was maximised leading to greater return. Another common characteristic of high
throughput pharmacists was the relatively low (or absent) number of Reviews conducted as
Collaborative Reviews. It is known from the qualitative fieldwork that Collaborative Reviews can
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require additional administration and co-ordination of visits and Reviews, thus representing an
additional cost that is not off-set by an increased payment for the Accredited Pharmacist.
A small number of Accredited Pharmacists reported a high volume of Reviews overall, though a
large number of visits was required to conduct this relatively high volume of Reviews. For these
Accredited Pharmacists, RMMRs were considerably less cost-efficient compared with highthroughput Accredited Pharmacists.
At the opposite end of the spectrum from the high throughput Accredited Pharmacist is the low
throughput Accredited Pharmacist. These Accredited Pharmacists typically conduct fewer
Reviews; invest more time in each visit/Review and conduct a far higher proportion of their
Reviews as Collaborative Reviews (there are of course exceptions to this). Accordingly, cost
efficiency for these pharmacists is considerably lower, bordering on break-even in some case
studies.
1.2
Qualitative considerations
Based on an extensive amount of qualitative research conducted for this evaluation, it is
arguable that the quality of the Reviews conducted by low-throughput pharmacists, as indicated
inter alia by the proportion of Reviews that were conducted as Collaborative Reviews, may be
higher than that of high-throughput pharmacists. However, the diary component did not attempt
to measure quality or outcomes resulting from the Reviews (self-reported data on these
measures was thought to be subject to a high degree of social desirability bias). An
assessment of the relative quality of Reviews under these two modes of delivery is explored in
more detail in the qualitative component of the case studies.
In addition to the log of entries which were collated as a result of this process, qualitative
research was undertaken to support the case study. Each Accredited Pharmacist was
interviewed at length, either prior to the diaries commencing (during field visits) or after the
diaries were completed. In addition, in-depth qualitative interviews were conducted with at least
one GP and Director of Nursing (or equivalent) at an Aged Care Home where Reviews had
been conducted.
The information collated through the diary-based case studies revealed differences in the cost
efficiency of various models under current payment arrangements.
The case studies reflected the additional costs entailed in conducting a RMMR as a
Collaborative Review and supported the need to adopt a differential payment structure
compared with Pharmacist Only Reviews, which were clearly more cost effective for the
Accredited Pharmacist/RMMR Provider.
An additional major contributor to RMMR cost effectiveness relates to whether the reviewer has
attempted to meet with or observe the resident as part of the Review. Very few Accredited
Pharmacists seem to follow this practice, even though guidelines clearly state that it is best
practice. Two of the diary-based case studies illustrate the cost elements of this practice, but it
is noted that this practice is most likely to be aligned with those who conduct most of their
RMMRs as Collaborative Reviews.
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Based on the diary-based case studies, overall, RMMR is cost efficient for pharmacists, though
cost efficiency varied greatly from very small margins approaching breakeven, to very high
margins where the return on RMMRs was several times that of invested time and money.
A business versus a service model
The current funding structure allows a variety of models to exist. The business model is typical
of some RMMR Providers and is characterised by a high throughput, low amount of time per
Review approach. In this model, the Review is done according to how it fits into the reviewer’s
schedule as opposed to on a needs basis. This is a model used by many Accredited
Pharmacists and RMMR Providers. It is driven primarily by the cost efficiency of conducting
visits at regular times.
The service model is clearly preferred by GPs. It involves Reviews being conducted when the
need arises. In this model, a much larger amount of time is expended in conducting the Review
and the approach may include best practice elements such as case conferencing and/or
meeting with or observing the resident.
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2.
Methodology
2.1
Quantitative component
Campbell Research designed the quantitative component of the diary-based case studies to
assess the cost efficiency of the RMMR Program. The quantitative component measured the
total dollar amount claimed from Medicare Australia with expenses incurred by Accredited
Pharmacists in the conduct of RMMRs. From this comparison, cost efficiency was assessed by
determining the financial return of pharmacists as they conducted RMMRs under a range of
different scenarios.
Diary development and content
The diary system was developed in conjunction with health economist associates Professor Jim
Butler and Dr Ian McRae of the Australian National University. Their input to the design,
analysis and reporting of the case studies provided the necessary health economics expertise
and rigour to this stage of the evaluation.
Cognitive testing was conducted with an Accredited Pharmacist to inform the final diary. Some
adjustments were made to the diary as a result of the testing, so that the diary was written in
language understood by pharmacists, to ensure the highest quality results.
The diaries contained sections that asked Accredited Pharmacists to record:
•
Basic demographic information for the pharmacist and pharmacy/business
including state, region, years’ experience in the pharmacy sector and
business type (community pharmacy, sole contractor, employee of a company
that specialises in the conduct of Reviews)
•
Information for each visit to an Aged Care Home to conduct RMMRs,
including information relating to the Aged Care Home:
•
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The location of the Aged Care Home
o
Number of beds, including a count of both high and low care beds
o
Number of Reviews conducted
o
Number and nature of recommendations made
o
Number and nature of QUM activities conducted
Information for each visit to an Aged Care Home, including information
relating to the expenses incurred by pharmacists in the conduct of the visit:
o
Time costs for the pharmacist, administrative staff and other staff in the
period leading up to the visit, including activities such as phoning GPs
and Aged Care Homes to schedule the visit, and arranging for travel and
accommodation
o
Travel costs to and from the Aged Care Home, including car costs and in
a small number of cases airline costs
o
Time costs for pharmacists and other staff during the visit as the RMMRs
were conducted
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o
Time costs for pharmacists and other staff after the visit spent on
activities such as preparing reports and Medicare Australia claims.
The cost of pharmacist and administrative time was based on rates that were derived through
consultation with Accredited Pharmacists during the qualitative research phase of the evaluation
the sector. This information was gathered during the qualitative fieldwork phase of the project.
$50 an hour was allowed for pharmacist time and on-costs, and $30 an hour was allowed for
administrative time and on-costs. Travel costs were calculated at 60 cents per kilometre, or the
cost of air-fares as reported by pharmacists. Other expenses such as parking, accommodation
etc were included as recorded by pharmacists.
Recruitment and fieldwork
Selection of pharmacists for the case studies
In order to understand the range of settings in which Accredited Pharmacists provide RMMRs,
Accredited Pharmacists from various backgrounds were selected as participants in the case
studies. The Accredited Pharmacists selected differed by geographical location, size of
business, contracting arrangements, the size and number of Aged Care Homes visited, and
remoteness of access.
From the stakeholder consultations, it was clear that individual Accredited Pharmacists often
have more than one contractual arrangement within the RMMR Program. For example, some
Accredited Pharmacists contracted directly to Aged Care Homes as independent Providers,
whilst also providing RMMR services through a Community Pharmacy. The Accredited
Pharmacists selected for the case studies cover the range of scenarios explored during
consultations, to reflect the diversity of RMMR processes.
Accredited Pharmacists also differed in the number of visits they made to Aged Care Homes.
Some who were working for large businesses may have conducted nearly two thousand
RMMRs a year, whilst those working purely as independents, contracting directly to Aged Care
Homes may have only conducted two visits a month. Information from the range of Accredited
Pharmacists was sought to provide an understanding of the issues, efficiency of processes and
achievements of both smaller businesses and larger ones.
Campbell Research ensured that selection of Accredited Pharmacists covered all six PhARIA
regions, to identify differences of servicing busy metropolitan areas compared to remote, difficult
to access regions. One Accredited Pharmacist may provide services across a number of
PhARIA regions.
Accredited Pharmacist servicing an un-accredited Aboriginal Aged Care Home
case study
An Accredited Pharmacist who serviced an un-accredited Aboriginal Aged Care Home was also
included. Whilst accredited, the Accredited Pharmacist could not claim for the RMMRs
conducted at this Aged Care Home. This pharmacist’s story provided a valuable addition to the
information provided by the Accredited Pharmacists who met the full criteria for the case
studies.
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Conduct of fieldwork
Campbell Research briefed participating pharmacists on the correct use of the diary system.
Campbell Research also followed-up with and monitored participating pharmacists to encourage
them to keep their diaries up-to-date, and to ensure required fields were correctly completed.
The diaries were provided to pharmacists in electronic form. Some pharmacists completed hard
copy print-outs of the diary by hand, others completed the form electronically. The data
provided by pharmacists was entered into a single document for analysis.
Eighteen Accredited Pharmacists were recruited to complete the diaries, with sixteen Accredited
Pharmacists providing completed diaries for analysis. The remaining two pharmacists did not
provide the required information during the fieldwork. The fieldwork period commenced in
September 2009 and concluded in November 2009. Pharmacists provided information about
the RMMRs they conducted over a four week period during this period, though not always the
same four week period, as different pharmacists commenced at different times.
Analysis and reporting
The collated data was analysed for each pharmacist on a per-visit basis. The number of visits
to Aged Care Homes made by pharmacists varied greatly during the period with a minimum of
one and a maximum of 14. Costs and outputs reported by pharmacists were averaged across
all visits to provide the key measures of:
•
The pharmacists financial return or loss from the conduct of RMMRs over the
period;
•
The distribution of expenses incurred across staff time, travel expenses and
other expenses; and
•
Average time spent and expenses incurred by pharmacists before, during and
after the RMMR visit, including a comparison for the average for all case
studies.
The above three analyses are presented for each case study alongside the qualitative findings
for each case.
Caveats and cautions
The reader should note the following caveats and limitations inherent to the quantitative
component of the case studies:
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•
The cost per hour of pharmacists and administrative staff may not be allinclusive of all costs incurred by pharmacists. In particular, costs associated
with software and IT may not be truly reflected in the dollar per hour estimate.
It is therefore possible that the financial return reported for some Accredited
Pharmacists in this report may be somewhat higher than would otherwise be
the case.
•
The sample of Accredited Pharmacists used for the analysis (16 completed
studies) was small. The quantitative component of the case studies should
not be considered a survey that is representative of the population of
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pharmacists who conduct RMMRs. The reader is encouraged to focus on the
data reported for individual Accredited Pharmacists in each case study, and
not to assume that the averages reported for all case studies are
representative of all pharmacists who conduct RMMRs in Australia. The
results instead provide a guide to the range of approaches to RMMRs and the
processes involved.
•
2.2
The data collected and collated for the case studies was self-reported by
pharmacists. No audit or observation of pharmacists was made to verify the
accuracy of the data.
Qualitative component
The quantitative component of the case studies that focussed on financial expenditure and
return was complemented by qualitative interviews.
This component further explored
approaches to and attitudes towards RMMR. Each of the pharmacists recruited for the case
studies was extensively interviewed. In many cases additional interviews were conducted with
representatives of the Aged Care Homes serviced by the pharmacists, and GPs who may (or
may not) have collaborated with the pharmacist in the delivery of RMMR.
At the conclusion of the diary-keeping period, Campbell Research conducted telephone follow
ups with each Accredited Pharmacist to discuss:
•
The initial findings of the diaries in terms of the financial and administrative
requirements of conducting RMMRs; and
•
The pharmacist’s perception of these requirements and how they relate to the
successful operation (or otherwise) of their business.
Specifically, the interview component provided a qualitative assessment of the following
elements:
•
Accredited Pharmacists Background, including scale of RMMR experience,
geographic setting, contract or salary arrangements
•
Proportion of Reviews done as Collaborative Reviews
•
The approach to seeking the involvement of the GPs
•
The processes by which Reviews were scheduled, conducted and reported
•
The approach to the provision of QUM services within the Aged Care Home
and
•
Other relevant matters such as travel.
The quantitative findings of the diaries were combined with the qualitative findings of the
interviews to form the 16 case studies. If the case study pharmacist had not been interviewed
during the Qualitative Fieldwork stage, they were interviewed separately over the phone.
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Findings of Individual Case Studies
*Note that names and identifying information have been removed and some details have been
changed to protect the confidentiality of the case study participants.
2.3
Case Study 1 (CS1)
Qualitative discussion
The Case Study also included interviews with 1 DoN and 1 GP.
CS1 Background
The pharmacist had been practising for more than a decade and owned a community pharmacy
where she worked part-time. She became accredited several years ago and now provides
RMMRs to one Aged Care Home through her own pharmacy, which also supplies to the Aged
Care Home. In addition, the pharmacist spent part of her time as a contracted Accredited
Pharmacist to a number of other supply pharmacy RMMR Providers. She noted that she was
given the freedom to conduct all Reviews as she saw fit.
Aged Care Home
The Accredited Pharmacist estimated they conducted 500 Reviews each year across four Aged
Care Homes. She had made a concerted effort to cement relationships with local GPs for the
Aged Care Homes, and this appeared to be working effectively.
With RMMRs you’ve actually got the opportunity to introduce yourself to the GP
and then discuss what’s the best model for communication …I would meet at least
once a year and discuss their patients with them.
(Accredited Pharmacist)
RMMR Process
The pharmacist said that more than 90% of all RMMRs she conducted in the course of a year
were ‘collaborative in nature as well as formal Collaborative Reviews’ and she believed this to
be atypical of RMMRs in Australia, where many formal Collaborative Reviews did not feature
much actual cooperation between Accredited Pharmacists and GPs. The predominance of
Collaborative Review and co-operative practice was not stipulated by either of the pharmacies
with whom she held contracts but instead was driven by the Accredited Pharmacist herself.
Some GPs routinely referred RMMRs when they were due and had their own system of referral.
For others, an Aged Care Home resident list was obtained and residents were identified for
RMMR. GPs were then invited to participate. Some GPs preferred for the Accredited
Pharmacist to partially prepare RMMR referral forms and to send them with the final RMMR
reports, in order to minimise the GP’s personal administrative load and to facilitate the process.
This was the case with the GP interviewed, who indicated that he occasionally directed the
Accredited Pharmacist if he had specific queries regarding a resident’s condition, but that this
happened infrequently. New GPs were sent a covering letter explaining the Collaborative
Review process and Medicare Australia data requirements. At the time of taking on a new Aged
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Care Home, the Accredited Pharmacist would send a letter of introduction highlighting the
services available.
Routinely, residents the Aged Care Home identified as requiring an RMMR within the 12 month
period were reviewed without GP referral. The Accredited Pharmacist was willing to conduct
such Reviews free of charge and felt that the next Review in six months would be somewhat
less time consuming, seeing this as some form of compensation for the additional Review.
Once residents had been identified, templates of preliminary reports were printed out and the
Accredited Pharmacist then visited the Aged Care Home to review events since the last RMMR,
and to draft preliminary reports prior to the RMMRs. The Accredited Pharmacist would speak
with nursing staff as well as any newly admitted residents to the low care home or the family or
carer of that resident.
I think this is a very important thing to do also if they’ve changed not just from
home to the aged care setting but also doctors…it often means that the doctor
doesn’t really know what’s happening. I can provide that doctor with information
that is really appreciated and time saving for the doctor.
(Accredited Pharmacist)
This practice was not considered to be the case for high care residents, who were not usually
visited by the Accredited Pharmacist.
Some homes provided administrative and clinical support. The Accredited Pharmacist’s partner
also provided administrative support. Data was then entered into a computer at each Aged
Care Home and reports were written off-site. RMMRs in the residents’ files were updated
throughout the year if there were significant changes.
In 75% of cases the Accredited Pharmacist recommended at least one change and one out of
10 Reviews picked up what she considered to be a critical issue. Reports were sent to all GPs
and Aged Care Homes.
Follow-up with GPs varied from phone calls to meetings at the Aged Care Home or a visit to the
GP’s clinic.
As previously agreed with GPs I await their contact for follow up; when it is a
serious matter then I will contact them directly at the time the issue arises.
(Accredited Pharmacist)
I chat with (the Accredited Pharmacist) on the phone sometimes, not often, but if
there is an issue; recently a patient couldn’t swallow so we talked about how to
best address this – this is a good example of how we communicate.
(GP)
The interviewed GP indicated that he read all reports sent to him and reviewed any
recommendations at the surgery. Whilst the GP felt it would be better to review the reports at
the Aged Care Home with the resident he admitted that time did not allow for him to do this. He
also claimed to not always send reports back to the Accredited Pharmacist even if he had
actioned the recommendations. He also stated that he sometimes forgets to lodge a financial
claim with Medicare Australia, especially if the RMMR had not resulted in medication change or
the ordering of pathology:
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I’m supposed to do a report on what I’ve done, but sometimes (the Accredited
Pharmacist) has done all her side and I don’t send the report back even though I
read it and even made changes. Sometimes I don’t even claim – I suppose this
might affect the Medicare figures of doctor participation?
(GP)
The Accredited Pharmacist stated that 50% of the suggestions she made were taken up and
implemented by the GP, and she felt that this was directly a result of her success with
Collaborative Reviews.
My feeling is that there are real outcomes at the end of it, even if I don’t have proof,
but such as avoiding hospitalisation, improving the quality of life.
(Accredited Pharmacist)
QUM
Staff education, especially for Enrolled Nurses and Registered Nurses, was a major QUM
component for the Accredited Pharmacist. Sessions usually took the form of informal
workshops where she encouraged questions and discussion. Her approach was to make herself
available to the Aged Care Home during her visits, which could be as often as weekly, in order
to allow staff to ask questions there and then. The Accredited Pharmacist took a conscious
decision to limit Aged Care Home-wide formal QUM activity as she considers it to be
unjustifiable given the reimbursement.
Well, the remuneration component is non-existent in my view. I know it’s supposed
to be part of the RMMR, but I still believe it’s essentially non-existent.
(Accredited Pharmacist)
The pharmacies to which the Accredited Pharmacist sub-contracted provided QUM. She felt
that adequate QUM was provided by these sources and this was confirmed in the interview with
the DoN for this case study.
Issues
The Accredited Pharmacist spent considerable time educating GPs about the RMMR process
and Medicare Australia requirements and visited the surgeries for face-to-face meetings. She
felt the majority of her Reviews were ‘truly collaborative’.
Once you have a relationship established with the GP for two or three years….if
they always have high quality (reports) and they are brief then the GPs tend to take
note.
(Accredited Pharmacist)
The Accredited Pharmacist perceived that RMMRs were insufficiently remunerated.
Remuneration at the moment - and this is after two years of work - works out to
$30 an hour for RMMRs. The first RMMR conducted on a new resident is
disproportionately time consuming as is educating GPs into RMMRs and speaking
to family members or residents themselves.
(Accredited Pharmacist)
She recognised that as a business model, it required some time for the RMMRs to deliver some
degree of financial return.
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It only sort of works when you have been there for at least two years, if you can
make it work within two years then I think it’s quite good. I believe Collaborative
RMMRs should be paid at the same rate as HMRs. In my view they are even more
complicated because the patients are sicker and it’s hard to understand the clinical
situation. With HMRs you may not need to understand the patient clinically to the
nth degree but with RMMRs you do.
(Accredited Pharmacist)
Administrative support was also considered to be important, and the pharmacist stated that she
would be unable to complete the RMMR workload without the administrative support she
received.
The Accredited Pharmacist felt that many Aged Care Homes preferred to source supply and
RMMR provision together, even though she personally considered this arrangement to be a
conflict of interest.
The Accredited Pharmacist questioned the need for every resident to receive an RMMR
annually and indicated that the Aged Care Home believed it was in the legislation to do so. She
believed that all RMMRs should be Collaborative Reviews and ‘not one where the doctor just
ticks boxes’. She believed it poor practice to not invite the GP to become involved, and
indicated that some of her peers baulked from this practice due to perceived timidity or
inexperience.
If a Collaborative Review takes three hours, then I’d say to invite the GP is 10
minutes maximum…and perhaps half an hour to talk to the GP or meet that person.
(Accredited Pharmacist)
The Accredited Pharmacist stated that some community pharmacies shifted the risk of claiming
to the subcontractor.
The RMMR Provider puts in the claims first, then waits to get paid. If there’s one
that’s not paid, it’s the Accredited Pharmacist who has to bear that cost.
(Accredited Pharmacist)
The GP - who had two residents in one home and eight in a second – considered that many
GPs were not interested in servicing residents in Aged Care Homes. This GP also felt that the
RMMR was often reviewed in the surgery due to time constraints and other priorities when the
GP is visiting the Aged Care Home.
Potential RMMR Improvements
This Accredited Pharmacist realised the preference of GPs to have a short concise report:
Reports need to be kept short and to not tell GPs what they already know, for
example recommended monitoring periods for certain drugs as per guidelines.
Recommendations should be kept to clinical observations or issues arising from
the Review.
(Accredited Pharmacist)
The Accredited Pharmacist thought QUM to be convoluted and, often shared between the
RMMR Provider and the subcontracted Accredited Pharmacist. There were also quarterly forms
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to be completed and sometimes arrangements were not felt to be fair. The QUM activities
previously undertaken by the supply pharmacy were the responsibility of the RMMR provider:
We had to negotiate with the supply pharmacy. They took over the supply not
realising that I actually had the RMMR Provider service agreement and that threw a
spanner in the works because they didn’t like that idea and then wanted to shift the
QUM to me…I said yes fine happy.
(Accredited Pharmacist)
The Accredited Pharmacist said that the Aged Care Home was often unaware of what they
could and could not expect as part of QUM. She believed that more streamlined QUM should be
considered, for example by introducing a mandatory number of sessions a year requested by
the Aged Care Home, or annual Drug Usage Evaluations.
The Accredited Pharmacist believed that a lower reimbursement for Pharmacist Only Reviews
should be provided, in order to discourage the practice of RMMR Providers only visiting a home
once a year and completing all necessary RMMRs over a short period of time; or failing this, a
review of the system so Reviews cannot all be done on the one day of the year (for example,
one visit per quarter).
Qualitative Comment
The interview with the DoN in relation to this Accredited Pharmacist confirmed the extremely
high standard of her RMMR service and the level of diligence involved, as reflected in the period
of up to three hours that each of her Reviews were reported to take. The DoN agreed that the
Accredited Pharmacist provided an extremely thorough service of great benefit to residents and
that she was very highly regarded by the GPs who attended patients at the Aged Care Home.
The approach taken by this Accredited Pharmacist was among the most extensive of all those
investigated as part of the qualitative research conducted for the evaluation.
Quantitative analysis
While CS1’s overall reported time and cost for RMMR was lower than average, the very low
volume of Reviews conducted meant that CS1 only operated at a marginal financial return. The
relatively high proportion of Reviews conducted as Collaborative Reviews and the long length of
time spent on each Review indicated CS1 was a pharmacist who placed great emphasis on the
way the Reviews were conducted.
Characteristics
CS1 was a pharmacist located in a rural centre in a state which had overall, a lower rate of
Collaborative Reviews. CS1 claimed an average of $123 of the RMMR fee from the RMMR
Provider. The case study is based on 11 visits, averaging a relatively small 6.2 Reviews per
visit, 74% of which were done as Collaborative Reviews. CS1 travelled an average of 134
Kilometres per visit, higher than the average for all cases.
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Table 1:
Case Study 1 Characteristics
Pharmacist’s Characteristics
Years in Pharmacy
Years accredited
Location
All Cases
10-15
18.6
4-5
6.8
Rural
Independent
RMMR
Provider and
through
contracts to
another
RMMR
Provider, an
Aged Care
Home supply
pharmacy
Mode of payment
Average amount received
payment for RMMR services
Case 1
in
$123
$104
Number of visits during period
11
8.0
Average Reviews per visit
6.2
10.8
Proportion of Reviews done as
Collaborative Reviews
72%
61%
Average travel distance (km)
134
113
Cost summary
CS1 conducted RMMRs at a marginal financial return. For the average $625 reported
expenses, CS1 received an average of $761 in Medicare Australia payments.
57% of costs associated with CS1’s RMMRs were associated with pharmacist salary and oncosts. 14% were associated with administrative salary and on-costs and 6% with other staff
costs. Travel accounted for 18% of costs and other expenses accounted for the remaining 6%.
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Figure 1:
Salary costs
Salary Admin
$89 14%
Salary:
Pharmacist
$355 57%
Salary: Other
$29 5%
Other
expenses
$40 6%
Travel $111
18%
Detailed expenses
CS1 showed a lower average cost per visit compared with the costs reported when all cases
were combined.
Detailed times and costs for CS1 are provided in the table below (Table 2). Areas where CS1
differed from times and costs associated with all cases included:
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•
Lower costs incurred before the visit, due to a relatively high amount of time
spent by administrative staff compared with pharmacists
•
Slightly higher travel costs reflecting the distance travelled by CS1
•
Lower costs incurred during the visit, due to the relatively high amount of
administrative staff time compared with pharmacist time
•
Lower costs incurred after the visit, with relatively less time spent on all tasks
during the follow-up period.
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Table 2:
Detailed Expenses – Average Times and Costs
Before the visit
Time
(Hours)
0.40
1.24
0.93
-
Pharmacist
Administration
Other
Other expenses
Subtotal
Travel costs
Travel costs
Time travel costs
Subtotal
All
Cases
$91
$33
$6
$28
$158
$111
$80
$192
$92
$86
$178
2.3
2.1
0.2
$115
$52
$5
$$1712
$233
$11
$1
$9
$254
2.8
0.3
0.0
Subtotal
$141
$7
$$8
$155
$222
$25
$2
$9
$257
Total Costs
$625
$848
During the visit
Pharmacist
Administration
Other
Other expenses
2.23
Subtotal
After the visit
Pharmacist
Administration
Other
Other expenses
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Cost
$20
$1
$23
$32
$107
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2.4
Case Study 2
Qualitative discussion
The Case Study included interviews with 2 DoNs. An interview was not conducted with a GP
because name and contact details could not be obtained from the respondent.
CS2 Background
The Accredited Pharmacist, along with a number of others, subcontracted for a company which
specialised in the conduct of RMMRs. She had been a pharmacist for more than a decade,
accredited in recent years and had been part of the company since soon after gaining
accreditation. The Accredited Pharmacist reported that the RMMR Provider actively
discouraged GP involvement and GPs were not routinely notified of the RMMR taking place.
Some GPs were referring for Collaborative Reviews.
Aged Care Home and RMMR Provider Background
As an organisation, well over 500 RMMRs were conducted each month across a number of
Aged Care Homes in the state. The state in which this Accredited Pharmacist practiced had a
lower proportion of Collaborative Reviews as a whole. Most Aged Care Homes covered by the
RMMR Provider were of ‘average size’ and were typically run by not-for-profit organisations.
The Accredited Pharmacist personally conducted around 70-100 RMMR visits each month. The
majority of these visits were in the state’s capital city, the remainder were in rural or regional
areas.
Rural areas take a large chunk of my time and require an overnight stay and I
usually set aside two whole days.
(Accredited Pharmacist)
The Accredited Pharmacist typically reviewed the records of 20-30 people a day and visited
each home at least 2-3 times a year to ensure each resident had an annual RMMR. New
arrivals were also included.
At any one time we can do 100 people a time across two people. Normally I do 20
– 30 people a day.
(Accredited Pharmacist)
RMMR Process
All upfront administration and paperwork was conducted in the office by support staff who
liaised with the Aged Care Home to identify those residents due for an RMMR, as well as any
new residents and any residents about whom staff were concerned. Support staff also
assessed the eligibility of residents (for example, by checking Medicare numbers and expiry
dates, DOB, dates of previous RMMRs). A list of residents for review, including their
demographic and personal details, was then provided to the Accredited Pharmacist.
At the Aged Care Home the Accredited Pharmacist checked to see if the previous RMMR had
been commented upon or acknowledged by the GP as having been seen. All information
available on site was then scanned into a laptop from the relevant resident files. The Accredited
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Pharmacist did not actively liaise with the staff about the RMMRs or liaise with the residents
themselves. A Review Report was compiled off site if the Accredited Pharmacist had a concern
about a resident or if action was required. The Review Report was sent to the GP, the DoN or
Care Manager, and the office, usually as a one page summary.
I try to write them up (a full Review report) but not for each patient, I just do it for 67 as it’s pointless to send them to the GPs especially if there is nothing to discuss –
I send only when there is an issue.
(Accredited Pharmacist)
A covering letter accompanies the report to the home specifying any areas which should be
considered specifically for the resident.
We try to be forward thinking for patients. Point out if we can see if they should
stop or adjust a dose in the future not just what is happening now.
(Accredited Pharmacist)
Reports would include recommendations at the Aged Care Home level, such as suggested
improvements to filing systems, as well as praise when due.
At the completion of the RMMR, administrative staff in the RMMR Provider’s office would submit
RMMR claim forms and ensure the secure storing of all RMMR-related documentation to enable
retrieval for ongoing record keeping and audit purposes.
QUM
Administrative staff identified the need for Aged Care Home staff education, advice, information,
compliance assistance and development of medication-related management strategies.
Education sessions led by the Accredited Pharmacist were provided in the home but were not
necessarily well attended by staff. QUM activities took place during the site visits for conducting
Reviews.
The Accredited Pharmacist stated that she addressed any concerns the
carers/nursing staff had with any medications whilst on site, and initiated operational
discussions with care managers. The Accredited Pharmacist no longer sits on the Medication
Advisory Committee at one Aged Care Home where the DoN was interviewed.
Issues
The business owner of this RMMR Provider reported that they actively discouraged GP
involvement, and GPs were not routinely notified of the RMMR taking place. The owner
considered RMMRs to be a ‘revenue making exercise’ for the GPs and abused by GPs. The
company disregarded referrals if the GP was considered to have shown no interest in the
RMMR or if they had refused to participate in RMMRs in the past. GPs were not always notified
that the RMMR was taking place. At the claim stage, where no Collaborative Review had taken
place, the box indicating ‘Collaborative Review’ on the RMMR claim form was erased in order to
alert Medicare Australia that the RMMR had no GP involvement and to try and prevent GPs
claiming retrospectively. The concern expressed by the Accredited Pharmacist was focused on
GPs not using the Review material.
It is a threat to the Review if people (GPs) don’t use it correctly and it will mean it
will be binned one day.
(Accredited Pharmacist)
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One Aged Care Home DoN claimed the GPs ‘feel threatened’ by the RMMR and did not want
them. The Review itself was considered by the Aged Care Home to be thorough, yet information
on liaison between the Aged Care Home staff and the Accredited Pharmacist was contradictory,
indicating a possible absence of regular liaison between the Accredited Pharmacist and Aged
Care Home staff.
Administration was considered to be a ‘huge time waste’. The Accredited Pharmacist reported
that Medicare Australia ‘make it difficult’ due to issues around the validity of Medicare numbers,
non-payment, late payment, and privacy. These factors were reported to negatively impact on
the Accredited Pharmacist’s ability to obtain information on who has been reviewed. Each of
these issues was raised by the Accredited Pharmacist as major concerns.
Potential RMMR Improvements
The Accredited Pharmacist reported that all homes had different filing systems; some were
electronic, some were not, and some were a mix of both. She stated that it would be helpful for
filing systems to be standardised as this would make information more readily accessible.
If they could all stick to a way of recording so there is not individuality (of home)
then we would be able to possibly access the information off site and so not have
to travel at all … or if there was missing information there would be no need to call
and hassle them again, like for blood sugar levels.
(Accredited Pharmacist)
The Accredited Pharmacist feels strongly that the practice of Collaborative Review should
cease.
Qualitative Comment
The diaries provided show identical processes for each RMMR and there were some
discrepancies between what the Accredited Pharmacist stated in the interview and what was
noted in the diary. The Accredited Pharmacist was unwilling to provide contact details for Aged
Care Homes and the evaluator was referred to the business owner for Aged Care Home
contacts. Details of GPs were not provided. Neither of the Aged Care Homes contacted
provided GP information on GPs who visited the Aged Care Home and could be interviewed by
the evaluators.
Quantitative analysis
CS2’s diary indicated a pharmacist who focussed on high throughput and higher financial
returns. CS2’s operating costs were somewhat lower than average, while the total number of
Reviews conducted was substantially higher. Travel expenses were the only area where CS2
showed a greater than average cost. Travel costs were offset by a very high volume of
Reviews, none of which were conducted as Collaborative Reviews. This reduced the
administrative time and cost required by the Accredited Pharmacist.
Characteristics
CS2 conducted RMMRs for a company specialising in Medication Reviews. CS2 received $70
of the $130 Medicare Australia payments for each Review; the remaining funds were allocated
to administrative and other resources maintained by the company for whom CS2 works. The
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Department of Health and Ageing
case study is based on 4 visits, averaging a high of 23 Reviews per visit. None of the Reviews
were done as Collaborative Reviews. CS2 travelled an average of 167 kilometres per visit,
higher than the average for all cases.
Table 3:
Case Study 2 Characteristics
Pharmacist’s Characteristics
Years in Pharmacy
Years accredited
Location
Case 2
All
Cases
10-15
18.6
2-3
6.8
Metro and Rural –
(these cases rural)
Mode of payment
Average amount received in
payment for RMMR services in
payment for RMMR services
$70 (the balance of
$130 to the RMMR
Provider company)
$104
Number of visits during period
4
8.0
Average Reviews per visit
23
10.8
Proportion of Reviews done as
Collaborative Reviews
0%
61%
Average travel distance (km)
167
113
Cost summary
CS2 (and the RMMR Provider for which she works) conducted RMMRs at a relatively high
financial return. For the average $731 reported expenses, CS2 received an average of $3,023
in Medicare Australia payments.
68% of costs associated with CS2’s RMMRs were associated with pharmacist salary and oncosts. 11% were associated with administrative salary and on-costs and 6% with other staff
costs. Travel accounted for the remaining 18% of costs.
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Department of Health and Ageing
Figure 2:
Salary costs
Salary:
Pharmacist
$500 68%
Salary Admin
$78 11%
Other
expenses
$14 2%
Travel $139
19%
Detailed expenses
CS2 showed a lower average cost per visit compared to the costs reported when all cases were
combined. Detailed times and costs for CS2 are provided in the table below (Table 4). Areas
where CS2 differed from times and costs associated with all cases included:
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Substantially lower costs incurred before the visit, with only minimal
administration time reported as a cost
•
Higher travel costs reported reflecting the amount of travel to rural areas for
CS2
•
Costs during the visit that closely matched the average for all cases – though
it should be noted that on average, a substantially greater number of Reviews
were conducted by CS2 when compared with all other case studies
•
As with pre visit costs, post visit costs were substantially lower for CS2 when
compared to all cases.
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Table 4:
Detailed Expenses – Average Times and Costs
Before the visit
Time
(Hours)
0
Pharmacist
Administration
Other
Other expenses
1
0
-
All
Cases
$91
$25
$$$25
$33
$6
$28
$158
$138
$99
$239
$92
$86
$178
4.6
1.4
0.0
$231
$34
$$$266
$233
$11
$1
$9
$254
3.4
0.8
0.0
Subtotal
$168
$19
$$14
$202
$222
$25
$2
$9
$257
Total Costs
$731
$848
Subtotal
Travel costs
Travel costs
Time travel costs
Subtotal
During the visit
Pharmacist
Administration
Other
Other expenses
2.78
Subtotal
After the visit
Pharmacist
Administration
Other
Other expenses
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Cost
$-
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2.5
Case Study 3
Qualitative discussion
The Case Study also includes interviews with 1 DoN and 1 GP.
CS3 Background
The Accredited Pharmacist has been in the industry for several decades and became
accredited 6-8 years ago. She had 15-20 agreements with RMMR Provider pharmacies. She
was paid on a per Review basis. Some of the RMMR Providers were also supply pharmacies.
The Accredited Pharmacist estimated that she conducted 1,500 - 2,000 RMMRs per year.
Aged Care Home
The Accredited Pharmacist conducted RMMRs amongst 12-15 nursing homes, each of which
had around 90-100 beds. Most of the homes visited were centred in and around the
metropolitan area but there were also some which required air travel and two days on site.
RMMR Process
The Accredited Pharmacist would identify which residents required an RMMR, based on the
date from the last Review in the Aged Care Home as well as a number of criteria such as: on
five or more medications, risk of falling, sedation, length of time on medication. A list was then
compiled and sent to the local GP inviting him/her to amend or add to the list and to invite a
referral if they wanted the Reviews to be conducted as Collaborative Reviews.
The Accredited Pharmacist estimated she spent 5-6 hours identifying up to 20 people for
RMMRs. When the list was complete and any GP referrals were received, administrative staff
would then ensure all patient details were completed before the RMMRs took place. At the
Aged Care Home, where available, the Accredited Pharmacist accessed the pharmacy
medication list via a secure login, in order to identify any drug related problems. This used to
take 2-3 hours of the Accredited Pharmacist’s time at the pharmacy, but now she can access
this information online and this allows her more time with the Aged Care Home staff.
The DoN interviewed for this case study was unsure who actually nominated the residents for
Review but stated that the process worked really well and allowed for the Aged Care Home to
include any newly admitted residents or those residents for whom they had a particular concern.
In the Aged Care Home, the Accredited Pharmacist accessed all resident files. No help was
required from staff at this stage. The Accredited Pharmacist said she investigated outcomes of
previous Reviews and then talked to staff about the relevant residents to gain a fuller picture of
their situation or concerns they may have had, although the DoN does not recall her doing this.
The Accredited Pharmacist then completed the Reviews off site, taking 1-2 weeks to analyse
and complete the Reviews for each visit.
If the Review was a Collaborative Review, a copy was sent to the GP to form an action plan and
a second copy was sent to the Aged Care Home. The Accredited Pharmacist encouraged GPs
to formulate an action plan but the GP may just sign off with no comment. If the Aged Care
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Home conducted case conferences, usually one month after all RMMRs had been conducted;
the Accredited Pharmacist would attend and discuss all the RMMRs with the GP.
Generally the GP will organise a case conference for 5-6 patients and I’ll sit in for
an hour to discuss all aspects and services and I also then check with staff how
things are going – this provides a better level of service.
(Accredited Pharmacist)
The GP interviewed confirms this process
She forwards me a report; I act on the report, sign and send back. At the back is a
form and she wants to know the action taken or not so I tick and comment and
send it back. And we have a case conference; the Registered Nurse, me and (the
Accredited Pharmacist) to see if any action should be taken. I call up the home
and say a time, they contact (the Accredited Pharmacist)…it’s all collaborative.
(GP)
The GP says he is very grateful to the Accredited Pharmacist who also visits the surgery and
gives education sessions for the staff there.
If the RMMR is not a Collaborative Review, the GP does not receive a report but the Accredited
Pharmacist will follow up with the GP if there is an urgent or life threatening concern.
QUM
The Accredited Pharmacist indicated that QUM is a fairly large part of her role and that she was
currently conducting drug usage surveys on crushed medicines across all of the Aged Care
Homes in order to develop a usage benchmark for comparative purposes. The Aged Care
Home stated that the Accredited Pharmacist provided education sessions and good information
and that she was very willing to offer help and advice.
Issues
The Accredited Pharmacist reported that pharmacists had been forced into providing education
and information to GPs to facilitate the conduct of Collaborative Reviews, and that they should
be paid more for doing this or that a graded payment system should be introduced.
We are educating GPs who have very little knowledge about the system. 70 - 80%
of pro-active GPs have very little knowledge about the system. We are educating
them about Medicare, educating them about the process and getting them on
board.
(Accredited Pharmacist)
However, the Accredited Pharmacist also conceded that the revised funding model had
encouraged GP participation.
We were doing non-collaborative and when the system changed it triggered us to
do collaborative so we get paid. GP referral ensures payment regardless of the 12
month rule.
(Accredited Pharmacist)
She also said that by encouraging GP involvement, better quality information was obtained and
the process became more streamlined, as it was routinely difficult to obtain information about
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Department of Health and Ageing
residents who had transferred from an Aged Care Home, as their Review status was not
transferred with them and Medicare Australia would not advise on this.
The Accredited Pharmacist felt that potential gaps occurred when residents were not reviewed
within three months of arrival, as that was when most mistakes occurred through incorrect
transcription of medication orders. She stated that if the RMMR was provided as part of the
admission process, then a lot of mistakes could be prevented.
The Accredited Pharmacist said there had been a significant increase in the amount of
paperwork as a result of the introduction of the Collaborative Review.
Now we have to record details for each resident – Medicare number, date of birth,
whether the Review is a Collaborative Review or not, the provider number of the
GP if Collaborative. Essentially this means that for 20 Reviews we are filling out 5
pieces of paper, where before there was just one. Then each piece of paper is
signed by the DoN, the pharmacist providing the Review service, and the service
provider principal when sending in to be claimed. This paper-based system is very
user unfriendly, and I cannot see why we should not change to a software based
system so that the paper work is reduced.
(Accredited Pharmacist)
The Accredited Pharmacist reported that obtaining Medicare numbers could be problematic.
Commonly the Medicare card would be retained by the resident’s family on admission, and it
was not always available for perusal when the RMMR took place.
The Medicare rules provide anxiety for medical officers, and some of them have
refused to participate in Collaborative Reviews due to having their previous claims
rejected because of less than twelve months between Reviews. They too cannot
access who did a previous RMMR but at least they are told when the previous
RMMR was claimed by a GP. I believe the same courtesy should be extended to
RMMR pharmacists.
(Accredited Pharmacist)
The Accredited Pharmacist acknowledged that where the GP participated in Collaborative
Reviews, the outcomes were generally more favourable in that more recommendations were
accepted and acted on. Additionally, where RMMRs were discussed as part of a case
conference the best outcomes were thought to be achieved. However, funding for case
conferences allowed for payment to the GP for participation, but not for the other health
professionals such as the Accredited Pharmacist or registered nurse.
The Accredited Pharmacist believed that payment for RMMR service should be indexed.
The current stagnation in fees, as well as the increased paperwork, has resulted in
many good pharmacists leaving for better payments in other areas.
The current payment carried no allowance for rural loading which has resulted in a
two-tired system where city based facilities receive excellent service and rural
based facilities receive less excellent service.
(Accredited Pharmacist)
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Potential RMMR Improvements
The Accredited Pharmacist felt that the RMMR process was efficient but was frustrated by the
payment and claiming procedures which she feels could be streamlined. For example, she
suggested electronic claiming and payment for increased amount of paperwork required.
The Accredited Pharmacist also suggested allowing nursing staff to initiate RMMRs.
If nursing staff could initiate it would be good as they have a better idea on how to
manage the patient.
(Accredited Pharmacist)
Some of the Accredited Pharmacist’s Aged Care Homes had case conferencing with their GPs
and staff to discuss the RMMRs as well as other aspects of care. The Accredited Pharmacist
considered that this was a good initiative and she attends these conferences but is not paid for
her time. She believed that QUM should be provided at a global level (across the facility) and
not just on a per resident basis.
Qualitative Comment
The GP was particularly enthusiastic about the role of Accredited Pharmacists in RMMRs and
had embraced the use of RMMRs.
Quantitative analysis
CS3’s diary indicated an Accredited Pharmacist operating in a similar fashion to CS1. CS1
operated at only a small financial return. While CS1 reported a relatively high number of
Reviews during the period, most of these Reviews were conducted collaboratively, entailing the
need for greater administration and co-ordination before and after the visit. However, CS3
reported relatively little administrative support to cover these expenses, with almost all costs
reported against more expensive pharmacist’s time.
Characteristics
CS3 conducted RMMRs as the owner of a community pharmacy which is a registered RMMR
Provider. CS3 received an average of $78 of the $130 Medicare Australia payments for each
Review, the balance going to the pharmacy at which CS3 owned, and which provided
administrative and other support. The case study was based on 14 visits, averaging 20
Reviews per visit. 83% of these visits were done as Collaborative Reviews. CS3 travelled an
average of 71 kilometres per visit, lower than the average for all cases.
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Table 5:
Case Study 3 Characteristics
Pharmacist’s Characteristics
Case 3
All Cases
Years in Pharmacy
20-25
18.6
Years accredited
8-10
6.8
Location
Mode of payment
Average amount received in
payment for RMMR services
Metropolitan
Pharmacy
owner
$78/ $130
$104
Number of visits during period
14
8.0
Average Reviews per visit
20
10.8
83%
61%
71
113
Proportion of Reviews done as
Collaborative Reviews
Average travel distance (km)
Cost summary
CS3 conducted RMMRs at some financial return. For the average $1,156 reported expenses,
CS3 received an average of $1,610 in Medicare Australia payments.
83% of costs associated with CS3’s RMMRs were associated with pharmacist salary and on
costs. 11% were associated with administrative salary and on-costs and 5% with other staffcosts. Travel accounted for the remaining 5% of costs.
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Figure 3:
Salary costs
Salary Admin
$129 11%
Salary:
Pharmacist
$958 83%
Other
expenses
$10 1%
Travel $59
5%
Detailed expenses
CS3 reported a higher average cost per visit compared to the costs reported when all cases
were combined.
Detailed times and costs for CS3 are provided in the table below. Areas where CS3 differed
from times and costs associated with all cases included:
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•
Higher than average costs before the RMMR due to greater time required of
both the pharmacist and administrative staff
•
Slightly lower costs for travel and time spent during the visit
•
Slightly higher costs incurred after the visit, again due to pharmacist and
administrative time invested.
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Table 6:
Detailed Expenses – Average Times and Costs
Before the visit
Time
(Hours)
7
Pharmacist
Administration
Other
Other expenses
4
0
-
All
Cases
$91
$93
$$$443
$33
$6
$28
$158
$59
$97
$157
$92
$86
$178
4.2
0.0
0.0
$211
$$$$211
$233
$11
$1
$9
$254
6.0
1.4
0.0
Subtotal
$300
$36
$$10
$346
$222
$25
$2
$9
$257
Total Costs
$1,156
$848
Subtotal
Travel costs
Travel costs
Time travel costs
Subtotal
During the visit
Pharmacist
Administration
Other
Other expenses
1.19
Subtotal
After the visit
Pharmacist
Administration
Other
Other expenses
CR&C 1074
Cost
$350
28
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Appendix C – Diary Based Case Studies
Department of Health and Ageing
2.6
Case Study 4
The Case Study also included interviews with 1 GP and 1 DoN.
Qualitative discussion
CS4 Background
This Accredited Pharmacist had been a pharmacist for several decades and had significant
experience as a community pharmacist and as a mentor for pharmacists gaining accreditation.
He had also sat on numerous advisory committees during his career and had been very active
in the industry. He started conducting RMMRs prior to the accreditation system and
subsequently became accredited over 10 years ago. He was now a RMMR Provider and held
contracts with Aged Care Homes directly. He lived in a regional centre with a population
between 50,000-80,000 where there were several Accredited Pharmacists and around 30
pharmacists.
Aged Care Home
The Accredited Pharmacist serviced 5 facilities; 4 in town (3 of which were low care facilities)
and one other Aged Care Home 30 minutes drive away. He conducted some 300 Reviews
annually, visiting his main Aged Care Home once a month and the smallest one every 6
months. He reported conducting around 10 RMMRs per visit which usually took 6-8 hours on
site. Around 5%-10% of the RMMRs were collaborative. In the smaller home out of town, all
RMMRs involved the GP, largely because there was little information filed at the home, there
was no full-time Registered Nurse with whom to consult, but only 2 GPs, making the
collaborative process easier.
RMMR Process
The Accredited Pharmacist obtained an updated list of residents from the Aged Care Home and
reported spending around an hour before each visit determining which residents were due an
RMMR, which were new residents, and accessing Medicare numbers from the Aged Care
Home. He then printed out their previous RMMRs and determined residents’ medications from
his database. He updated his database according to the Aged Care Home details and arranged
visits to the homes. The Accredited Pharmacist then sent the list of residents due to receive an
RMMR back to the Aged Care Home, and requested a list of symptoms for each resident. At the
Aged Care Home the Accredited Pharmacist made a point of visiting the Clinical Nurse
Coordinator, of DoN and the carer in order to determine if there are any issues regarding any of
the residents. The DoN interviewed was unaware of this procedure and reported that the
Accredited Pharmacist provided a pro forma questionnaire designed to illicit information from
the nursing staff about each resident, for example cognitive skills, gait, or dizzy spells.
It’s not arduous.
(DoN)
The Accredited Pharmacist then accessed the full medical charts for each resident and called
the supply pharmacy should there be any ambiguity. The Accredited Pharmacist stated that he
would compile a complete profile of the resident including their mobility, risk of falls, pain levels,
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Appendix C - Diary Based Case Studies
Department of Health and Ageing
eating disorders, adverse reactions and other relevant factors. He wrote reports off-site and sent
a copy to the GP and the Aged Care Home.
The DoN reported that he would put a note in the resident’s file for the GP in order to check if he
wanted to follow through any recommendations. If the issue was important the Aged Care
Home would raise it with the GP directly. The Accredited Pharmacist considered the reports to
be detailed and thorough and directed largely at the Aged Care Home rather than at the GP,
addressing issues such as ensuring medications were not crushed, checking the timing of
dosing, monitoring risks, and ensuring resident hydration. This was supported by the GP
interviewed. Some reports did not contain any recommendations for the GP. The Accredited
Pharmacist stated that some GPs respond to his report but that this was not common and he
usually received no feedback on his recommendations unless it was an urgent matter and then
staff provided informal feedback.
I could check but I am not paid to check, only in 12 months time… and beside it’s
not practical and I have no time.
(Accredited Pharmacist)
This was again supported by the GP interviewed, who reported having little time to read the
reports and that the Accredited Pharmacist would call if he had encountered something urgent.
The GP also claimed that although the Accredited Pharmacist’s reports were very thorough:
They are often too detailed for me. A one line summary would be sufficient. It’s offputting so I just try and quickly scan them. It’s wasted talent!
(GP)
The Accredited Pharmacist claimed that the overall process differed little if the RMMR was a
Collaborative Review, unless there was an issue highlighted by the GP, and then the focus
would be different.
Your focus changes then…you delve into that more as he usually wants your
advice.
(Accredited Pharmacist)
This practice was supported by the DoN.
The GP did few Collaborative Reviews, relying on staff to inform him of the condition of his
residents.
I’m happy to get the information but usually it’s not necessary or of an immediate
nature. It’s a nice to know not a need to know.
(GP)
At the conclusion of the RMMR the Accredited Pharmacist updated his database, faxed claim
forms to Medicare Australia and recorded claims for later reconciliation of payment and for
taxation purposes.
QUM
The Accredited Pharmacist reported delivering audits of medication charts and to be particularly
vigilant in ensuring medication and doses were given at the correct times, not crushed, with food
if necessary, and other relevant requirements. The Accredited Pharmacist also reported
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RMMR Evaluation
Appendix C – Diary Based Case Studies
Department of Health and Ageing
providing charts audits, assistance with ACFI, providing newsletters to staff on drug related
issues for the elderly, attending MACs usually on a quarterly basis, attending case conferences,
and providing informal assistance and education whilst on site.
Education and QUM at the Aged Care Home interviewed was provided by the supply pharmacy.
The DoN at this Aged Care Home had only recently become aware of QUM.
Issues
The Accredited Pharmacist used to conduct 600+ Reviews each year but since the advent of
large organisations which allegedly offer ‘deals’ on supply and RMMRs, half of his service
agreements have been ‘poached’.
The Accredited Pharmacist was critical of the administrative process through Medicare Australia
for RMMR claims and reported that claims were often rejected because the resident had
received a Review in the previous 12 months.
This is usually because a resident has been transferred…. (I get no payment so) I
feel undervalued.
(Accredited Pharmacist)
In addition, checking Medicare numbers was seen as time consuming. Upfront time was also
reported to be demanding and not seen as being remunerated.
It takes ages and ages just to work out a schedule!
(Accredited Pharmacist)
He considered that accessing information at the various homes could be problematic as all
Aged Care Homes worked with different systems, processes and procedures. Some Aged Care
Homes were thought to be very helpful and have all the files ready for the Accredited
Pharmacists visit; others were reported to have files in different locations, some with no easy
access. The Accredited Pharmacist felt that he did not want to continually ‘hassle staff’ but this
leads to not all information being used in the Review. He felt that one Aged Care Home in
particular did not make him feel welcome, there had been many staff changes, he believed that
reports were not being correctly filed and that he was not provided with the necessary
information he felt he required such as assessments for the Aged Care Funding Instrument
(ACFI) despite repeated requests to the Aged Care Home.
A further problem reported by the Accredited Pharmacist was that some GPs could be
possessive about their own information and did not always keep information at the Aged Care
Home so that not all residents would have a full list of diagnoses.
The Accredited Pharmacist believed that for Collaborative Reviews he should be supplied with
clinical information by the GP but that this did not always occur.
The GP is supposed to get consent, and discuss with the pharmacists and do a
management plan. But I think that the dollars are the trigger…I don’t know if they
do a management plan…sometimes you need a referral if you don’t know if it has
been 12 months….the GP probably will claim when he gets the reports.
Collaborative Reviews are not working all that well.
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(Accredited Pharmacist)
The Accredited Pharmacist considered that GPs should be more involved with RMMRs but that
many have trouble visiting the Aged Care Home, especially if they only have one or two patients
at the home.
It’s an inconvenience to them...they can’t find the staff…or if low care, the resident
is sometimes out. It is frustrating for the GP.
(Accredited Pharmacist)
The Accredited Pharmacist believed quarterly reports to be ‘meaningless and a waste of time’;
that they did not indicate to Medicare Australia the amount of QUM provided; only that it had
been provided.
The GP and DoN felt that annual RMMRs for all residents were unnecessary and that those on
a simple medication regime such as two over-the-counter analgesics a day did not require this
level of service.
Potential RMMR Improvements
The Accredited Pharmacist felt that new admissions to an Aged Care Home should trigger a
RMMR regardless of the length of time since the last Review. He also stated that the claims
process required simplification and that quarterly QUM reports should be made more
meaningful or that the requirement be removed.
Qualitative Comment
This Accredited Pharmacist has many years’ experience, presents as dedicated and thorough in
his Reviews although he does not try to encourage GP participation. All interviewees appeared
to speak openly and provided justification for their comments.
Quantitative analysis
CS4 indicated that he was conducting RMMRs at a loss. While time spent before and during
the visit was not notably different from the average, CS4 reported that he spent a very large
amount of time in writing Review reports and other activities. The relatively small number of
Reviews conducted during the period did not offset these high costs.
Characteristics
Case Study 4 was a pharmacist located in a rural centre. CS4 had worked for several decades
in pharmacy, and was accredited in the late 1990s. CS4 conducted RMMRs as an independent
RMMR Provider in his own right. CS4 always received the full $130 Medicare Australia
payments for each Review. The case study is based on 6 visits, averaging a relatively small 9.6
Reviews per visit. 22% of these visits were done as Collaborative Reviews. CS4 travelled an
average of 27 kilometres per visit, far lower than the average across all cases.
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Appendix C – Diary Based Case Studies
Department of Health and Ageing
Table 7:
Case Study 4 Characteristics
Pharmacist’s Characteristics
Case 4
All Cases
Years in Pharmacy
28-33
18.6
Years accredited
11-13
6.8
Location
Rural and regional
Mode of payment
Independent/consultant
pharmacist
Average amount received
in payment for RMMR
services
Number of visits during
period
Average Reviews per visit
Proportion of Reviews done
as Collaborative Reviews
Average travel distance
(km)
$130
$104
6
8.0
9.6
10.8
22%
61%
27
113
Cost summary
CS4 conducted RMMRs without any financial return, and incurred a loss. For the average
1,613 reported expenses, CS4 received an average of $1,248 in Medicare Australia payments.
98% of costs associated with CS4’s RMMRs were associated with pharmacist salary and on
costs. CS4 did not report any administrative expenses, with all activities undertaken by the
pharmacist. Travel and other expenses accounted for the remaining 2% of costs.
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Appendix C - Diary Based Case Studies
Department of Health and Ageing
Figure 4:
Salary costs
Salary:
Pharmacist
$1,579 98%
Other
expenses
$12 1%
Travel $23
1%
Detailed expenses
CS4 showed a higher average cost per visit compared to the costs reported when all cases
were combined.
Detailed times and costs for CS4 are provided in the table below. Areas where CS4 differed
from times and costs associated with all cases included:
CR&C 1074
•
A lower than average cost for the period before the visit
•
Lower than average travel costs given the reported low distances travelled
•
Slightly greater costs during the visit as a result of higher levels of pharmacist
time
•
Substantially greater costs after the visit, possibly as a result of a lack of
administrative support, but also as a result in a great deal of pharmacist time
invested during this period.
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Appendix C – Diary Based Case Studies
Department of Health and Ageing
Table 8:
Detailed Expenses – Average Times and Costs
Before the visit
Time
(Hours)
1
Pharmacist
Administration
Other
Other expenses
0
0
-
All
Cases
$91
$$$$59
$33
$6
$28
$158
$23
$16
$39
$92
$86
$178
6.0
0.0
0.0
$298
$$$$298
$233
$11
$1
$9
$254
24.1
0.0
0.0
Subtotal
$1,205
$$$12
$1,217
$222
$25
$2
$9
$257
Total Costs
$1,613
$848
Subtotal
Travel costs
Travel costs
Time travel costs
Subtotal
During the visit
Pharmacist
Administration
Other
Other expenses
0.46
Subtotal
After the visit
Pharmacist
Administration
Other
Other expenses
CR&C1074
Cost
$59
35
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Appendix C - Diary Based Case Studies
Department of Health and Ageing
2.7
Case Study 5
Qualitative discussion
The Case Study also included interviews with 2 GPs and 1 DoN.
CS5 Background
The Accredited Pharmacist had been in the industry for over 10 years working as a specialist
clinical pharmacist in the public sector. She had been accredited for several years and started
conducting RMMRs as the work was more flexible and allowed her time to share raising her
children. She is a consultant pharmacist for a number of supply pharmacies and conducted
around 1,900 RMMRs across 25 facilities. 10-20% of RMMRs conducted by this Accredited
Pharmacist were Collaborative Reviews. This Accredited Pharmacist saw her role as reducing
medication and increasing the residents’ quality of life and she considered herself to be
independent of the pharmacies for which she worked.
Aged Care Home
The Accredited Pharmacist serviced a number of Aged Care Homes: some metropolitan and
one requiring three hour’s drive out of the metropolitan centre. The Accredited Pharmacist
stated that she introduced herself to the relevant GPs before starting at a new Aged Care
Home, to ask if they would like to be part of the RMMR process. This was substantiated by the
DoN interviewed, who reported that the Accredited Pharmacist had an excellent relationship
with the GPs serving the Aged Care Home. The GPs interviewed in relation to this Accredited
Pharmacist expressed general dissatisfaction at not being given an opportunity to be involved in
the RMMRs conducted for their patients in Aged Care Homes (likely to have been different
Aged Care Homes from those where the interviewed DoN worked). The Accredited Pharmacist
stated she had found GPs to be unresponsive and that most do not know about the Medicare
Item 903 or how the RMMR process works. Most Collaborative Reviews the Accredited
Pharmacist did conduct were a result of Comprehensive Medical Assessments on new
residents, where the GP had actively requested a RMMR.
RMMR Process
In order to obtain the flexibility she desired for her work hours, the Accredited Pharmacist
worked on RMMRs during the day and night and this required a high level of organisation and
forward planning.
I know what I am doing 3 months ahead of that day.
(Accredited Pharmacist)
She reported that she was still flexible in her schedule to enable her to visit residents outside of
the RMMR scheduling, such as residents identified by the Aged Care Home as having changed
behavioural symptoms. The DoN reported the Accredited Pharmacist visited the Aged Care
Home every two weeks or so and was always available and willing to assist the Aged Care
Home staff should they have any queries or issues they would like to discuss with her.
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Prior to the visit to the Aged Care Home, the Accredited Pharmacist and administrative staff
entered updated resident details obtained from the Aged Care Home, into a database. At the
Aged Care Home the Accredited Pharmacist obtained medication profiles, drug chart Reviews,
case note Reviews, and other data relevant to the RMMR. She then spoke with staff to
determine if there were any specific issues for residents. Resultant data was later entered into
a database by administrative staff. The Accredited Pharmacist analysed the data and the report
was then complied. The report contained two sections, one for the GP and one for the Aged
Care Home.
The Accredited Pharmacist did not invite GP participation and did not advise GPs of up coming
Reviews.
I don’t go fishing for it. I believe every Review should be Collaborative but GPs
don’t really respond to having a piece of paper chucked in front of them….they
screw it up and put it in the bin. But if I make a recommendation I would ring up the
GP and have a chat about it.
(Accredited Pharmacist)
As a result of failing to be notified about impending RMMRs for their Aged Care Home patients,
the relevant two GPs interviewed stated they would not follow through on reports as much as
they would had they been given the opportunity for the Reviews to be done as Collaborative
Reviews. Each of the two interviewed GPs were strong and active supporters of Collaborative
Reviews and stated that they always authorised these when advised by the Accredited
Pharmacist of an impending Aged Care Home RMMR visit.
If I am perfectly honest, I am less likely to interact with them (the Accredited
Pharmacists) because…I feel a bit left out of the loop and I know I am much more
likely to leave it (the report) to one side. I am not going to ignore any important
information but the process is sub-optimal.
(GP)
One GP had a small number of residents spread across a number of homes but did not feel this
was the reason he was not being contacted by the Accredited Pharmacist. He expressed a
desire for the Accredited Pharmacist to contact him prior to a Review visit, so that he could have
an opportunity to collaborate fully in RMMRs. The GP did collaborate with a second Accredited
Pharmacist in the area and met with her every 3 months to discuss and go through various
problem areas. In regard to the Accredited Pharmacist interviewed however, the GP was not
given this opportunity.
To be fair as it (the report) says, ‘if you would like any further information or wish to
discuss the above please contact me’. So I can, but the point is it’s not the case of
‘we need to talk doctor.’ It’s a case of ‘here’s my telephone number!
(GP)
The DoN (at another Aged Care Home which accommodates the interviewed GPs’ patients)
said the RMMR process worked effectively and considered the Accredited Pharmacist to be a
valuable asset to the home. All reports to the Aged Care Home were placed in the doctor’s
book and raised with the GP on his/her rounds.
So they get a double whammy. The report from the Accredited Pharmacist and a
follow up from us.
(DoN)
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Most Collaborative Reviews the Accredited Pharmacist did conduct were a result of
Comprehensive Medical Assessments on new residents, where the GP had actively requested
a RMMR.
QUM
This Accredited Pharmacist reported spending a lot of time on QUM.
Last year I calculated two months of the whole year was meetings…the real
advantage is to teach nursing staff, then they tell GPs and you know, it rubs off in a
roundabout sort of way. I know a lot of this is about reducing hospital admissions.
(Accredited Pharmacist)
She also provided benchmarking against other homes. For example, benchmarking error rates
for medication charts compared against pharmacy packing or performance of the individual
Aged Care Home in relation to use of benzodiazepine. The DoN noted that these services were
particularly useful. Other QUM involved recommendations and auditing of pain management,
Continuing Professional Development, a variety of education topics such as pain management,
policy and procedure development, advice on medication management and development of
quality indicators as well as DUEs and regular participation in MACs. The DoN also reported
that the Accredited Pharmacist was involved in Case Conferencing and discussed RMMRs in
this environment. He also commented that GPs were not always present at these meetings.
The DoN claimed that the Accredited Pharmacist worked very actively with Aged Care Home
staff and had in the past also supported student pharmacists on site. He also felt that the staff
had a good working relationship with the Accredited Pharmacist, who had been servicing the
Aged Care Home for five years and helped ‘keep on top of issues.’
The Accredited Pharmacist is here probably twice a month. She is very much part
of the team. She has presented to the accreditation agency, keeps education
sessions and advice on her PC and is always open to training.
(DoN)
Issues
This Accredited Pharmacist reported frustrations including when she is not paid by Medicare
Australia, when the Medicare number is invalid or she is unable to determine if a resident had
an RMMR within the past 12 months. She would therefore often not claim for some Reviews.
The Accredited Pharmacist found dealing with GPs difficult as she considered that each GP
wanted the report sent in different ways. This was considered to create a hassle. She did not
invite GPs to participate in RMMRs.
It’s not worth the time involved in setting that up (GP participation). I did start
having referral forms and stuff but to tell you the truth, I do a fairly substantial
amount of Reviews that aren’t paid for. That doesn’t worry me because the service
that you provide, the people want you to be there at the end of the phone if they
want to make a drug information enquiry or they want you to come and look at a
resident or something. I don’t go through the hassle of trying to get the GP to sign
a referral.
(Accredited Pharmacist)
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Department of Health and Ageing
The Accredited Pharmacist felt that GPs saw the benefit of the RMMR when they recognised
the Accredited Pharmacist was genuinely trying to help with problems they had and not just
telling them silly things….not what you get out of a text book…practical advice…any drug
effects to look out for… This view was supported by the GP interviewed.
They are good quality Reviews and there is lots of useful information in them and
not infrequently there is information I actually need to act on….
(GP)
However, the GP stated that she still would prefer to be given the opportunity to become
involved in the Review and disliked being sent a report after the event.
I am just sent a copy…I haven’t been given the opportunity to appraise them of
what my questions and concerns are that they could focus on before going there.
(GP)
The Accredited Pharmacist considered that QUM quarterly reporting was tedious due to the
large volume of paperwork and the signatures required. The Accredited Pharmacist considered
remuneration for QUM to be sufficient but complains that the amount paid was not indexed and
neither was there any allowance provided for travel.
Last week I was over in <town> for some meetings but there were no Reviews
there. I will spend ½ a day but I won’t get paid. I don’t worry about it because it’s a
service that you offer sort of thing.
(Accredited Pharmacist)
The Accredited Pharmacist also felt that a lot of Accredited Pharmacists were unaware of their
QUM responsibilities and the type of services they could or should provide, and that sometimes
when different pharmacies and RMMR Providers were involved, there was some confusion
regarding who was responsible for the various QUM components.
The Accredited Pharmacist was concerned that demand for RMMRs was high and increasing
and that large Aged Care Homes were becoming corporatised and were voicing a preference
for single sourcing. She was uncertain of how she would cope in such a situation.
I did the stats once and you need about 70 beds, between 60-70 beds. Some of
these (smaller) homes require more work than a 140 bed facility.
(Accredited Pharmacist)
She also expressed concern about the number of Aged Care Homes where RMMRs had never
been conducted in the past or did not know which residents have been reviewed.
More and more I come across facilities (where) I have started at (and) they haven’t
had Reviews... no one knows if they have had a Review…. when they had a
Review and quite honestly they haven’t had a Review for a very long time…
(Accredited Pharmacist)
Some Aged Care Home where the Accredited Pharmacist is new do not file
Reviews or they cannot be found or I find that some people (Accredited
Pharmacists) just write a sentence to you or something like that.
(Accredited Pharmacist)
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Appendix C - Diary Based Case Studies
Department of Health and Ageing
Potential RMMR Improvements
The Accredited Pharmacist suggested allowing the Aged Care Home to refer as they were in a
position to know the residents. For example some residents may require more frequent
RMMRs, for some diseases, where medication becomes less effective over time.
The Accredited Pharmacist also suggested simplifying paperwork and allowing access to
Medicare RMMR data to identify Review dates.
The GP interviewed requested the development of mechanisms to encourage more GP
involvement.
I believe there is a strong risk …that the process is severely compromised by not
involving the GP upfront. I just don’t think looking at a drug chart and trawling
through notes is guaranteeing them having (the Accredited Pharmacists) all the
information available to them…GPs will often make….brief notes at the nursing
home (but) keep the main notes with them.
(GP)
Qualitative Comment
This case study reflected the approach of an experienced and capable practitioner who
nevertheless did not pursue the added benefits to residents able to be obtained through
arranging Collaborative Reviews and working closely with the GPs, due to a perceived lack of
benefit to the Review process. The Accredited Pharmacist’s approach was highly valued by the
Aged Care Homes involved as they felt they received considerable benefits from the QUM
component.
Quantitative analysis
CS5’s diaries indicated a high-throughput approach to RMMRs, similar to CS2. In line with the
approach taken by CS2, CS5 reported:
•
A very high number of Reviews conducted over a relatively low number of
visits
•
A complete absence of Collaborative Reviews
•
Very low operating costs across all categories in the conduct of Reviews.
As with CS2, this approach led to relatively high financial return.
Characteristics
Case Study 5 was a pharmacist located in a metropolitan area in a state with no Collaborative
Reviews. CS5 conducted RMMRs for her own company and as contractor to an RMMR
Provider for another company. CS5 always received the full $130 Medicare Australia payments
1
for each Review . The case study is based on 6 visits, averaging a high 20 Reviews per visit.
1
CR&C 1074
CS5 did not provide financial information for some reviews, the total $130 has been assumed based on the
reports completed. Therefore the cost estimates presented in this case study may be over-stated in terms of
financial return.
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Appendix C – Diary Based Case Studies
Department of Health and Ageing
None of CS5’s Reviews during the period was a Collaborative Review.
average of 30 kilometres per visit, far lower than the average for all cases.
CR&C1074
CS5 travelled an
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Appendix C - Diary Based Case Studies
Department of Health and Ageing
Table 9:
Case Study 5 Characteristics
Pharmacist’s Characteristics
Years in Pharmacy
Years accredited
Case 5
All
Cases
10-12
18.6
4-6
6.8
Location
Metropolitan
Mode of payment
Owner of a company
specialising in Reviews,
consultant pharmacist for
another company
Average amount received in
payment for RMMR services
$130
$104
Number of visits during period
6
8.0
Average Reviews per visit
20
10.8
Proportion of Reviews done as
Collaborative Reviews
0%
61%
Average travel distance (km)
30
113
Cost summary
CS5 conducts RMMRs at a relatively high financial return. For the average $597 in reported
expenses, CS5 received an average of $2,600 in Medicare Australia payments.
79% of costs associated with CS5’s RMMRs were associated with pharmacist salary and oncosts, 17% were associated with administrative salary and on-costs. Travel accounted for the
remaining 18% of costs.
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Appendix C – Diary Based Case Studies
Department of Health and Ageing
Figure 5:
Salary costs
Salary
Admin, $104
, 17%
Other
expenses
$1 0%
Salary:
Pharmacist
$468 79%
Travel $25
4%
Detailed expenses
CS5 showed a far lower average cost per visit compared to the costs reported when all cases
were combined. Detailed times and costs for CS5 are provided in the table below. Areas where
CS5 differed from times and costs associated with all cases included:
CR&C1074
•
Higher than average costs before the visit associated with pharmacist’s time
•
Significantly lower travel costs, reflecting the very small distances travelled
•
Lower than average costs during the visit reflecting the relatively short visits
reported by CS5
•
Lower overall costs after the visit, with relatively small amounts of time
invested by the pharmacist, and greater amounts of time spent by
administrative staff.
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Appendix C - Diary Based Case Studies
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Table 10:
Detailed Expenses – Average Times and Costs
Before the visit
Time
(Hours)
4
Pharmacist
Administration
Other
Other expenses
1
0
-
During the visit
Pharmacist
Administration
Other
Other expenses
$33
$6
$28
$158
$25
$18
$42
$92
$86
$178
3.5
0.0
0.0
$175
$$$$175
$233
$11
$1
$9
$254
1.8
2.8
0.0
$92
$71
$$1
$164
$222
$25
$2
$9
$257
0.49
Subtotal
After the visit
Pharmacist
Administration
Other
Other expenses
Subtotal
Total Costs
CR&C 1074
All
Cases
$91
$33
$$$217
Subtotal
Travel costs
Travel costs
Time travel costs
Subtotal
Cost
$183
$597
$848
44
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Appendix C – Diary Based Case Studies
Department of Health and Ageing
2.8
Case Study 6
Qualitative discussion
The Case Study also includes interviews with 1 GP and 1 Nurse Practitioner
CS6 Background
The Accredited Pharmacist had been a pharmacist for several decades and became accredited
8-10 years ago. He had been conducting RMMRs for almost 10 years and was an independent
provider who also worked within a community pharmacy.
Aged Care Home
This Accredited Pharmacist serviced nine Aged Care Homes which were predominantly not-forprofit or privately run. Three homes were low care only, three were combinations of low and
high and the remainder were high care. The Accredited Pharmacist conducted about 600
RMMRs a year; 40-50 per month. The Accredited Pharmacist was based in a rural area and
travelled ½ -1 hour to reach rural Aged Care Homes. The proportion of Collaborative Reviews
varied with Aged Care Home from 100% to around 12% in those Aged Care Homes where the
Accredited Pharmacist had been unable to encourage staff to organise a standard form he had
designed to act as GP referral.
RMMR Process
The Accredited Pharmacist considered himself to be well supported and that this support had
improved significantly over time. He now received feedback from the Aged Care Home as well
as more constructive comments from those GPs involved in Collaborative Reviews.
Prior to conducting the Reviews the Accredited Pharmacist emailed the Aged Care Home in
order to obtain an updated list of residents. He also sourced any feedback provided on previous
RMMRs. If there was a new resident from another home he checked with this home to
determine if a Review had been conducted in the last 12 months. Aged Care Home staff would
also suggest Reviews for residents if they had a concern regarding their well being. The
Accredited Pharmacist had designed a standard form for the Aged Care Home to obtain the
GPs referral for residents so that he could claim for the Review. This also facilitated Reviews
allowing for the DoN to work with the GP to refer residents requiring a Review within the 12
month guidelines. The Accredited Pharmacist determined who would receive an RMMR and
advised the Aged Care Home and the GP. If the Review was a Collaborative Review, the GP
sent all pathology and history to the Accredited Pharmacist. The GP confirmed this process and
stated that the process worked well.
It all works really well, I have no complaints. I wish there were two of (name of
Accredited Pharmacist).
(GP)
The nurse practitioner also states that she appreciated the Accredited Pharmacist and the
RMMRs conducted.
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At the Aged Care Home the Accredited Pharmacist was provided with an office from which to
work, access to computers, progress reports, notes and other relevant information. He reported
that staff were generally very supportive and that the Registered Nurse very willing to speak
with him, so that he obtained updated information, particularly about new residents. The Aged
Care Home also reported that the Accredited Pharmacist’s system worked well. Residents,
especially those in low care, were usually spoken with.
It’s necessary as you can get a lot from looking at a patient, seeing their
expression, posture.
(Accredited Pharmacist)
The report was then compiled off site and sent to the GP and the Aged Care Home. The GP
considered the reports were succinct, to the point and always relevant. She did not feel she
always needed to act on recommendations but appreciated the input from the Accredited
Pharmacist.
I sign off, and suggestions I take on board. I think the practice manager sends a
copy to <the Accredited Pharmacist> and the home.
(GP)
The GP visited the Aged Care Home in question once a week and had numerous residents she
treated there. The Aged Care Home stated that all reports were put into the residents’ files and
a note was left for the GP advising her that an RMMR had been conducted. The Registered
Nurses read all reports and brought them to the attention of the GP on her next visit, although
some GPs instigated changes prior to then. If there was an urgent matter the Aged Care Home
would call the GP directly.
The Accredited Pharmacist claimed that the majority of residents received an annual Review but
the specific criteria for RMMR eligibility usually determined who receives a Review.
With my turnaround time, it takes 18 months to 2 years to Review everyone unless
a GP or Registered Nurse brings it to my attention.
(Accredited Pharmacist)
The Aged Care Home would also email resident histories and medications to the Accredited
Pharmacist if there were any residents about whom they had a concern or any new residents
they felt require attention before the Accredited Pharmacist’s next visit.
QUM
The Accredited Pharmacist felt the greatest benefit of RMMRs was to the staff, through QUM.
He provided information, with all reports, on medications and the best times to administer them
and spoke to care staff for 10-30 minutes each visit. The Accredited Pharmacist also provided
in-service (PowerPoint) twice a year, for 1 hour each time, and in addition discusses things such
as pain management, adverse reactions, behaviour management with medications, laxative
use, urinary and continence and alternative therapies. Amongst other things, he also provided
audits, attended MAC, assessed the competency of residents to self-administer medications
and participated in case conferences.
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Issues
New residents often did not have detailed records if they came from another area ‘or have a GP
who is poor at writing a full history’. As such the Accredited Pharmacist felt there was potential
to miss out on payment with new residents.
The Accredited Pharmacist also reported that Medicare numbers were not always available
from the Aged Care Home and that the number was sometimes recorded inaccurately.
The Accredited Pharmacist felt that Accredited Pharmacists need to be persistent and develop a
relationship with the GP for RMMRs to work well. Collaborative Reviews were thought to be
more effective now that GPs were more familiar with the Accredited Pharmacist, understood the
RMMR process and recognised that there is a payment involved for their time; however, not all
GPs wanted to be involved.
The Accredited Pharmacist felt there were time constrictions on Aged Care Home staff in being
able to read all RMMRs and QUM information and to attend in-service sessions. He also
considered QUM reporting to be burdensome.
Ridiculous. I can’t see how it is useful, other than that it has a signature on it and
the signature doubles up on what is on the claim form anyway.
(Accredited Pharmacist)
The Nurse Practitioner felt that some GPs were unaware that they could claim for involvement
in the RMMR and that they need to be better educated about the process.
Potential RMMR Improvements
The Accredited Pharmacist felt that there should be a separate payment for QUM
You get paid $130 just for a Review and it costs that much to conduct a Review
anyway.
(Accredited Pharmacist)
For other QUM, such as talks to nurses, he believed the Accredited Pharmacist should be paid
at an hourly rate, for example $80 per hour.
He also suggests that QUM reporting be eliminated or that Medicare claims forms be amended
to include a QUM section.
Qualitative comment
Both the GP and the Aged Care Home were very willing to discuss the Reviews, spoke well of
the Accredited Pharmacist and considered his contribution to the well-being of patients to be
significant. The use of the referral form in homes appeared to work well and was thought to
have encouraged GP participation.
Quantitative analysis
CS6 presented as a low-throughput-low cost pharmacist. While CS6 showed some return on
time invested in RMMRs, that return was relatively low given both the low costs and the low
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Department of Health and Ageing
number of Reviews conducted. CS6’s costs were minimised through travelling relatively short
distances, and spending relatively small amounts of time before, during and after the visit.
Characteristics
Case Study 6 was a pharmacist located in a rural centre. CS6 had worked for several decades
in pharmacy, and was accredited nearly ten years ago. CS6 conducted RMMRs as a consultant
pharmacist for a community pharmacy. CS6 always received the full $130 Medicare Australia
payments for each Review. The case study is based on 6 visits, averaging a relatively low 7
Reviews per visit. 68% of these visits were done collaboratively. CS6 travels an average of 54
kilometres per visit, half that of the average for all cases.
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Table 11:
Case Study 6 Characteristics
Pharmacist’s Characteristics
Case 6
All
Cases
Years in Pharmacy
30-40
18.6
Years accredited
8-10
6.8
Location
Rural centre
Consultant
pharmacist for a
community
pharmacy
Mode of payment
Average amount received
payment for RMMR services
in
130
$104
Number of visits during period
6
8.0
Average Reviews per visit
7
10.8
68%
61%
54
113
Proportion of Reviews done as
Collaborative Reviews
Average travel distance (km)
Cost summary
CS6 conducted RMMRs at some financial return. For the average $380 reported expenses,
CS6 received an average of $910 in Medicare Australia payments.
87% of costs associated with CS6’s RMMRs were associated with pharmacist salary and oncosts. No administrative salary costs were reported. Travel accounted for the remaining 12%
of costs, with a small amount reported for other expenses.
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Figure 6:
Salary costs
Other
expenses
$2 1%
Salary:
Pharmacist
$330 87%
Travel $45
12%
Detailed expenses
CS6 showed a substantially lower average cost per visit compared to the costs reported when
all cases were combined. Detailed times and costs for CS6 are provided in the table below.
Areas where CS6 differed from times and costs associated with all cases included:
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Lower costs before the visit, with only a small amount of pharmacist time
spent in preparation
•
Very low travel costs given the small distances travelled
•
Lower costs incurred during the visit
•
Very low costs reported after the visit, with minimal pharmacist time spent in
follow-up and no other staff costs.
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Table 12:
Detailed Expenses – Average Times and Costs
Before the visit
Time
(Hours)
1
Pharmacist
Administration
Other
Other expenses
0
0
-
All
Cases
$91
$$$$67
$33
$6
$28
$158
$45
$33
$78
$92
$86
$178
3.9
0.0
0.1
$196
$$2
$$198
$233
$11
$1
$9
$254
0.7
0.0
0.0
Subtotal
$35
$$$2
$38
$222
$25
$2
$9
$257
Total Costs
$380
$848
Subtotal
Travel costs
Travel costs
Time travel costs
Subtotal
During the visit
Pharmacist
Administration
Other
Other expenses
0.90
Subtotal
After the visit
Pharmacist
Administration
Other
Other expenses
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$67
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2.9
Case Study 7
The Case Study includes interviews with an Accredited Pharmacist and owner of an
independent company providing RMMRs, (Senior Accredited Pharmacist), an Accredited
Pharmacist employed within the company, (Junior Accredited Pharmacist) 2 DoNs and 1 GP.
Qualitative discussion
CS7 Background
The Senior Accredited Pharmacist was an independent full-time RMMR Provider and had been
involved in the industry for many years, specialising in aged care issues. He had been involved
in the early development of the RMMR Program and subsequently the establishment of an
independent medication management company comprising a small number of Accredited
Pharmacists. This case study reflects the comments of both the Senior Accredited Pharmacist
and his employee, another Accredited Pharmacist who had been in the industry for several
years and became accredited two to three years ago. Comments from both Accredited
Pharmacists regarding processes were consistent.
The Junior Accredited Pharmacist
completed most of the fields in the diaries.
Aged Care Home
The company owned by the Senior Accredited Pharmacist held the RMMR contract for 60 Aged
Care Homes and serviced some 3,500 residents. Many rural facilities were serviced due a lack
of Accredited Pharmacists in those particular areas. 85% of RMMRs conducted were
Collaborative Reviews with the provider working closely with GPs. The Senior Accredited
Pharmacist stated that the company’s practitioners adhered to PSA guidelines for the provision
of RMMRs, including best practice guidelines, and evidence gathered from the qualitative
interviews supported this statement.
RMMR Process
At regular intervals, a list of residents was sent from the Aged Care Home from which the
supplier identified new residents. Not all Aged Care Homes sent admission dates and these
dates needed to be confirmed by RMMR Provider staff. The Senior Accredited Pharmacist
determined Medicare due dates and scheduled Aged Care Homes whilst support staff advised
the GP of upcoming RMMRs and offered him/her an opportunity to refer for Collaborative
Reviews. Accredited Pharmacists advised any new GPs of the process. Clinical data sheets
and consult notes from previous Reviews were sourced by support staff. The GP interviewed
for this case study provided a printout of individual patient notes at this stage, and would ensure
all pathology was up to date for the Review.
It’s a lot of work for us and the money could be better…it’s a pain in the … but it’s
worth it for the patient.
(GP)
At the Aged Care Home, the Accredited Pharmacists obtained the updated files; spoke to the
nurses at floor level as they have the best understanding of the resident, and to the Registered
Nurse. This stage of the Review could be time consuming as staff were located throughout the
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homes. The Accredited Pharmacists also visited the residents to determine how they were
functioning, meeting best practice guidelines for the conduct of RMMRs.
We talk to the residents, we are trained in dementia. How can you do an RMMR if
you are not? Most pharmacists don’t do this – maybe 20% do. Some staff do say
‘why do you want to see them? They have dementia!’ But I assess side effects; I
look at them, take their pulse if necessary, look for signs of pain and get a total
impression, and are they contracted in their posture in bed? Do they have swollen
ankles? Very rarely do we have a situation where we do not see a resident.
(Senior Accredited Pharmacist)
Information was written down and then entered into a database off site; this had proven to be
faster and more efficient than using a PC on site. The Accredited Pharmacists analysed and
compiled reports, the Accredited Pharmacists followed up referrals and support staff collated
reports and dispatched them. All reports were entered into the database.
She does an exhaustive and very thorough Review …she’s great. She really
knows her stuff!
(DoN speaking of Junior Accredited Pharmacist)
If the GP requested a report then one was sent directly to the GP (this happened in about 50%
of cases). The Senior Accredited Pharmacist preferred to send the report to the Aged Care
Home and notify the GP of its presence at the Aged Care Home. The Senior Accredited
Pharmacist preferred this process as it encouraged GPs to comply. (The Senior Accredited
Pharmacist felt that signing off the Review in the surgery did not comply with the funding
management plan.) The GPs response was documented (30% respond directly to the
Accredited Pharmacist) or checked on return to the Aged Care Home. It was reported that 80%
of reports were actioned in some way by the GP.
At this facility the report isn’t filed until the GP has read it. Our GPs here are up
regularly and they all need to read his reports so they sign as evidence and we
make notes as to if he has made any changes.
(DoN)
The GP interviewed provided an example of best practice, scheduling an afternoon with the
Accredited Pharmacist to go through the recommendations and seeing every patient who had
received an RMMR where it contributed to the resident’s care.
Accredited Pharmacist has been doing this for a long time and it works well…
(GP)
QUM
The Senior Accredited Pharmacist stated that they took QUM very seriously and evidence
suggested this was the case. He and his company supplied education and advisory services on
demand and had also developed a number of static QUM resources such as a Drug Guide for
Enrolled Nurses and Registered Nurses, a Diagnosis and Care Plan Manual for Registered
Nurses, a Pathology Interpretation Guide and various topical newsletters. They also produced a
number of voice-over PowerPoint presentations and delivered specialised advice on dementia.
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We are provided $30 per Review for this (QUM) and we attempt to provide value.
(Junior Accredited Pharmacist)
Issues
The Senior Accredited Pharmacist said that the cost of funding QUM, combined with travel
expenses and the conduct of high quality RMMRs, was economically marginal. All information
gathered as part of the qualitative component of this case study supported this assertion.
I have to work within a budget. I am paid to spend time with the resident. If there
was more remuneration there would be more time to spend talking to GPs. It’s
uncommon for us to meet or talk about the Reviews. We use written reports like
specialists. If something is exciting or interesting we may ring….but we talk more
to the nurses.
(Senior Accredited Pharmacist)
The Senior Accredited Pharmacists relied on the Aged Care Home staff to remind the GP to
look at the report.
Some files and reports are just stacked up on the cabinet but we are contracted to
the facility and have to keep everything OK, but we can’t pester them.
(Junior Accredited Pharmacist)
The Senior Accredited Pharmacist believed that large supply pharmacy companies had a
significant competitive advantage in providing RMMRs in the following ways:
•
The RMMR service agreement supplements the cost of supply
•
Some suppliers insisted on a combined supply and RMMR service or refused
to supply if not given the RMMR service agreement.
The senior Accredited Pharmacist believed that this situation not only put smaller RMMR
Providers at a disadvantage but also did not encourage best practice delivery of RMMR/QUM.
We are much more specialised than the normal RMMR Provider with much more
extensive services than normal. I follow the guidelines and I want to see how much
influence we can have in the management of residents, so economically we can
only just survive. Large providers spend millions of dollars on machines for
packaging; they have teams of pharmacists for RMMRs. They get the contract for
both but provide the packaging for free and do the clinical RMMRs. It’s separately
funded and so these should be kept separate. They need the RMMR service to
support supply.
(Senior Accredited Pharmacist)
The QUM was considered to be provided at considerable time and expense. The Accredited
Pharmacist said that working closely with the GP required significant additional input over and
above the RMMR itself. For example, GPs were busy and might forget to request an RMMR,
and the Provider needed to remind them.
They are busy people and they forget but we get sick of reminding them!
(Senior Accredited Pharmacist)
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The Junior Accredited Pharmacist reported that a lot of time was spent in low care homes
simply trying to find the resident, but it was considered important to speak to low care residents
as they know about their own condition and may also be self medicating.
Potential RMMR Improvements
Both Accredited Pharmacists suggested indexing RMMR payment, and to have their travel to
rural and remote areas funded. They also asserted that contracts for supply and RMMR/QUM
services should be distinct to avoid leveraging of RMMR provision by larger supply companies.
Qualitative Comment
GPs and nursing staff were highly supportive of this RMMR Provider and its Accredited
Pharmacist staff and this case study provided a good example of best practice based on PSA
guidelines. The Aged Care Home comments suggested a good relationship had developed
between the different disciplines and this has had major benefits for the Aged Care Homes and
their residents.
Quantitative analysis
CS7’s diary indicates a profile of low throughput for each visit, and therefore modest financial
return (similar to CS1 and CS3). CS7 conducted a relatively small number of Reviews for each
visit, with the majority of these Reviews being conducted collaboratively. However, while the
number of Reviews conducted per visit was low, the total number of visits across the period was
relatively high (similar to CS10). This large number of visits added substantially to travel time
required overall, and thus negatively affected the financial return for CS7.
Characteristics
Case Study 7 was a pharmacist located in a metropolitan area. CS7 conducted RMMRs as a
consultant pharmacist to a company specialising in Medication Reviews. CS7 claimed an
average of $65 of the $130 Medicare Australia payments for each Review, the balance of the
$130 went to the RMMR Provider, which provided administrative support, at which CS7 worked.
Calculations on cost efficiency for this case study were therefore based on the overall amount of
$130. The case study is based on 22 visits, averaging a relatively low 9 Reviews per visit. 79%
of these visits were done collaboratively. CS7 travelled an average of 158 kilometres per visit,
higher than the average for all cases.
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Table 13:
Case Study 7 Characteristics
Pharmacist’s Characteristics
Case 7
All
Cases
Years in Pharmacy
2-5
18.6
Years accredited
1-3
6.8
Location
Metropolitan
Mode of payment
Consultant pharmacist
for a company
specialising in
Reviews
$104
Average amount received
payment for RMMR services
$65 (the balance paid
to the pharmacy to
cover administrative
overheads)
Number of visits during period
22
8.0
Average Reviews per visit
9
10.8
Proportion of Reviews done as
Collaborative Reviews.
79%
61%
Average travel distance (km)
158
113
in
Cost summary
CS7 conducted RMMRs at a slight financial return. For the average $869 reported expenses,
CS7 received an average of $1,164 in Medicare Australia payments.
69% of costs associated with CS7’s RMMRs were associated with pharmacist salary and on
costs. Travel accounted for 15% of costs and the remaining 10% was associated with other
costs.
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Figure 7:
Salary costs
Other
expenses
$10 1%
Salary:
Pharmacist
$596 69%
Travel $132
15%
Detailed expenses
CS7 showed a lower average cost per visit compared to the costs reported when all cases were
combined.
Detailed times and costs for CS7 are provided in the table below. Areas where CS7 differed
from times and costs associated with all cases included:
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Lower than average costs before the visit, with less amount of time spent by
the pharmacist, and greater amounts of time spent by administrative staff
•
High travel costs reflecting the higher-than-average distance travelled
•
Similar costs incurred during the visit (noting the lower-than average number
of Reviews conducted and amounts claimed)
•
Costs incurred after the visit matched the average across all cases.
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Table 14:
Detailed Expenses – Average Times and Costs
Before the visit
Time
(Hours)
1
3
0
-
Cost
$39
$82
$$$122
All
Cases
$91
$33
$6
$28
$158
$132
$95
$226
$92
$86
$178
4.4
0.1
0.0
$219
$1
$$$220
$233
$11
$1
$9
$254
4.9
1.9
0.0
Subtotal
$243
$47
$$10
$301
$222
$25
$2
$9
$257
Total Costs
$869
$848
Pharmacist
Administration
Other
Other expenses
Subtotal
Travel costs
Travel costs
Time travel costs
Subtotal
During the visit
Pharmacist
Administration
Other
Other expenses
2.63
Subtotal
After the visit
Pharmacist
Administration
Other
Other expenses
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2.10 Case Study 8
The Case Study included interviews with 2 DoNs and 1 GP.
Qualitative discussion
CS8 Background
The Accredited Pharmacist had been in the industry for 11-14 years and became accredited
several years ago. He was an independent Accredited Pharmacist who contracted to an RMMR
Provider in the area and was paid on a per Review basis. He visited 5 Aged Care Homes
annually.
Aged Care Home
In the current financial year, the Accredited Pharmacist had visited 3 Aged Care Homes, all of
which were within a 10 km radius of his home. The homes varied in size and included a 120
bed home, a 110 bed home and a home with 55 beds. The Accredited Pharmacist stated that
the proportion of Collaborative Reviews was high, around 70%. Most of the Aged Care Homes
with which he dealt had only 1 GP and this made the RMMR process and collaboration easier.
The Accredited Pharmacist worked at the home during the various shifts including weekends
and nights and reported that this gave him a sound appreciation of the Aged Care Home and a
good insight into what was happening at the home. He also felt he was accepted as part of the
team due to the length of time he spent at the Aged Care Home, often up to two weeks. He
usually reviewed around 10 residents per day. All work was conducted on site. New residents
were given an RMMR outside of the routine visit when required throughout the year.
RMMR Process
The Accredited Pharmacist approached the RMMR process in a different manner to many other
Accredited Pharmacists involved in case studies, whereby all residents were given an RMMR at
the same time each year.
I do the entire nursing home in a short period of time rather than over the year. It’s
intense but it’s more satisfying for the staff and the residents. Back when I started
we just picked a date and made it all fall into sync. Some residents did lapse 18
months but now that’s all behind us.
(Accredited Pharmacist)
Initially the Aged Care Home sent an updated resident list to the pharmacy which was then sent
to the Accredited Pharmacist. One month prior to the visit to the Aged Care Home, the
Accredited Pharmacist informed relevant GPs of impending RMMRs and invited them to
collaborate. A letter was sent to all GPs involved and worded to allow for a group referral;
Accredited Pharmacist experience showed that the GPs would not individually refer residents.
The Accredited Pharmacist stated that GPs usually referred all their residents or none. The
Accredited Pharmacist went to lengths to explain the relationship he had with the Aged Care
Home to any new GP and to make sure they understood that the Aged Care Home was asking
him to conduct the RMMRs. This sometimes involved a visit to the GP to introduce himself. He
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also educated the GP in what they needed to do in order to receive payment for a Collaborative
Review – review the report, act accordingly, sign the report and send it back to the pharmacy.
Prior to visiting the Aged Care Home the Accredited Pharmacist downloaded medication profiles
from the remote pharmacy site and inputted patient information such as DOB, GP information,
and pharmacy information into the file.
At the Aged Care Home the Accredited Pharmacist accessed resident files and added the
relevant data into a pro forma form on his lap top. He checked all pharmacy and Aged Care
Home records to ensure there were no discrepancies. The Accredited Pharmacist then spoke
to Aged Care Home staff.
DoNs reported that the Accredited Pharmacist also visited residents when he felt this was
necessary to the Review. The report was then written and sent to the pharmacy to print out and
send to the GP (regardless of whether the Review was formally Collaborative or not) and the
Aged Care Home. The DoNs reported that they read the Review and followed up
recommendations with the GP. The homes regarded this as part of their role. Most GPs visited
the facilities regularly and therefore the Review was actioned promptly.
They (the Reviews) are really excellent. GPs are taking a lot of notice and we are
learning a lot too. This year has been a turning point. <Accredited Pharmacist>
contacted all the GPs personally and it has been working well. The GPs have
been more responsive and they write back too!
(DoN)
The GP response was sent to the pharmacy and copies were sent to the Accredited
Pharmacist. The Accredited Pharmacist then entered any changes the GP made into the
database for future planning or resident feedback.
Then it pretty much ends until next year.
(Accredited Pharmacist)
The GP interviewed confirmed this process, and reported receiving a report even if he had not
referred a resident.
I get a report for each resident even if not referred. I read it and take it up to the
patient and chat to them or the family and decide whether to take up the
recommendations or not. I recognise they are useful. I do all this because the
Item number is not an inconsiderable amount and it implies there is some work
behind the RMMR. I write to <Accredited Pharmacist> and let him know what I
have done, if there are no changes I still write. It would be good to meet in person
but we are really so busy.
(GP)
QUM
Because the Accredited Pharmacist was on site for a prolonged period of time he felt the home
benefited as he was available to answer queries and train and educate as required. The
Accredited Pharmacist had only given one lecture to one Aged Care Home so far, the QUM
component was provided by the pharmacy and he felt it would be too time consuming to provide
QUM as well as RMMRs.
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Issues
The Accredited Pharmacist experienced some frustration trying to get GPs to collaborate in the
Review process.
Potential RMMR Improvements
Improved compensation was suggested by the Accredited Pharmacist as a potential
improvement.
The hourly rate is OK if you base 10 residents over 9 hours but the other
background work knocks down the rate! We are always patient focussed and we
are trained as pharmacists to give free advice in a retail environment so we tend to
work more for free; now I feel we have proven ourselves (in the RMMR) and should
get paid accordingly.
(Accredited Pharmacist)
The Accredited Pharmacist believed that consideration should be given to positioning the
RMMR as preventative medicine as this was thought to be better understood by the GP. Aged
Care Home staff interviews supported this position.
Pharmacists and GPs have a huge bridge to build and only time will tell. We have
only just started inviting Collaboratives this year and they have been well received
but the lack of education of GPs is a problem and they have a million other
schemes running too. It’s taken 5-6 years to get the credibility and trust of GPs and
Collaboratives have certainly helped. We are building a better relationship and I
see things have been taken on board over the years.
(Accredited Pharmacist)
The Accredited Pharmacist also felt that the Aged Care Home should be allowed to refer for
RMMRs without GP approval.
Qualitative Comment
The Accredited Pharmacist used a different method of Review which appeared to work well and
ensure good relationships were developed between all parties. He has visited many of the GPs
involved at the respective Aged Care Homes in order to explain the RMMR process, and
appeared very committed to making the RMMRs Collaborative.
Quantitative analysis
CS8 reported a low-cost, low-volume approach to conducting RMMRs. Overall costs for
RMMRs for CS8 were substantially lower than average, largely because of very small distances
travelled and small amount of time spent in preparation and follow-up before and after the visit.
While these costs were maintained at a very low level, return on Reviews was also low as a
result of the small number of Reviews conducted. These factors together led to a very low
financial return for CS8.
Characteristics
Case Study 8 was a pharmacist located in a regional area. CS8 conducted RMMRs as an
independent Accredited Pharmacist (a sole RMMR Provider). CS8 always received $100 of the
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$130 Medicare Australia payments for each Review. The case study was based on 8 visits,
averaging a relatively low 7 Reviews per visit. 55% of these visits were done collaboratively.
CS8 travelled an average of 8 kilometres per visit, far lower than the average for all cases.
Table 15:
Case Study 8 Characteristics
Pharmacist’s Characteristics
Years in Pharmacy
Years accredited
Case 8
All
Cases
11-15
18.6
2-3
6.8
Location
Regional centre
Mode of payment
Independent/consultant
pharmacist
Average amount received in
payment for RMMR services
$100
$104
Number of visits during period
8
8.0
Average Reviews per visit
7
10.8
Proportion of Reviews done as
Collaborative Reviews
Average travel distance (km)
61%
55%
8
113
Cost summary
CS8 conducted RMMRs at a low financial return. For the average $507 reported expenses,
CS8 received an average of $675 in Medicare Australia payments.
85% of costs associated with CS8’s RMMRs were associated with pharmacist salary and on
costs. 13% were associated with administrative salary and on costs. The remaining 2% of
costs were reported against expenditure on travel and expenses.
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Figure 8:
Salary costs
Salary:
Pharmacist
$430 85%
Salary
Admin, $64 ,
13%
Other
expenses
$6 1%
Travel $7
1%
Detailed expenses
CS8 showed a lower average cost per visit compared to the costs reported when all cases were
combined.
Detailed times and costs for CS8 are provided in the table below. Areas where CS8 differed
from times and costs associated with all cases included:
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Very low expenditure before the visit, with minimal pharmacist time spent and
no other staffing costs
•
Very low travel costs, reporting less than 10 kilometres travelled for all visits
•
Similar costs reported during the visit, with average time spent by the
pharmacist very close to the average across all cases
•
Low expenditure after the visit, with a relatively smaller amount of pharmacist
time and a relatively higher amount of time spent by administrative staff.
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Table 16:
Detailed Expenses – Average Times and Costs
Before the visit
Time
(Hours)
1
0
0
-
Cost
$72
$$$$72
All
Cases
$91
$33
$6
$28
$158
$7
$5
$11
$92
$86
$178
5.1
0.0
0.0
$256
$$$$256
$233
$11
$1
$9
$254
1.9
2.6
0.0
Subtotal
$97
$64
$$6
$167
$222
$25
$2
$9
$257
Total Costs
$507
$848
Pharmacist
Administration
Other
Other expenses
Subtotal
Travel costs
Travel costs
Time travel costs
Subtotal
During the visit
Pharmacist
Administration
Other
Other expenses
0.13
Subtotal
After the visit
Pharmacist
Administration
Other
Other expenses
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2.11 Case Study 9
Qualitative discussion
The Case Study also included an interview with 1 DoN. An interview with a GP could not be
obtained as the most relevant GP was said to be on leave at the time.
CS9 Background
The Accredited Pharmacist described himself as a “late starter” graduating in pharmacy almost
10 years ago, after some time out of education. He became accredited four years ago. He was
an independent provider contracted to a community pharmacy which held the supply contract
for some of the Aged Care Homes he serviced. He held service agreements directly with two
Aged Care Homes. These two homes formed the greatest part of the discussion with this
Accredited Pharmacist and both are in located in PhARIA Region 4.
Aged Care Home
One home serviced by this Accredited Pharmacist had around 100 beds and comprised both
high and low care residents; the second was a low care home with almost 50 beds. The
Accredited Pharmacist reported visiting both facilities every 4-6 weeks and had conducted
around 120 RMMRs in the last year. He reported usually spending a week at each Aged Care
Home.
RMMR Process
The Accredited Pharmacist stated that around 50% of his RMMRs were Collaborative; this was
mainly with 2 GPs who were also involved in case conferencing with him. A list of residents and
their medication was obtained from the Aged Care Home and collated. Practice Managers were
then informed about the Reviews and the GPs were invited to participate. The Accredited
Pharmacist informed the DoN of his impending visit and once at the home he spoke to the
Nurse Unit Manager or the Registered Nurse on duty about the residents he was to Review. He
accessed charts, blister packs and notes, and if requested provided an in-service session. The
Accredited Pharmacist did not visit residents in the high care home as he felt there was little to
be gained from this. He occasionally saw residents in the low care setting, especially if they
were self-medicating. Reports were written off-site and sent to the Aged Care Home. Copies
were sent to the GP only if the Review was Collaborative.
Initially all GPs got a report but they didn’t acknowledge it or claim for it; so I
stopped – I know this is what happened as the practice manager reviewed it for
me.
(Accredited Pharmacist)
The Accredited Pharmacist reported that most GPs who Collaborated acknowledged his report
and he would sometimes receive a copy of a management plan or a note on the bottom of his
report summarising ‘done this’ or ‘great will do this.’ The Accredited Pharmacist felt that Aged
Care Home staff ‘love’ to have him come on site and as the Aged Care Home needed to be
accredited, were very keen for him to visit. The DoN supported the stated popularity of the
Accredited Pharmacist
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The GPs just love him! He has a way with them. … (a GP) said to me the other
day ‘You know, <Accredited Pharmacist>, he is really fantastic!
(DoN)
New residents were reviewed within 4-6 weeks of arrival and the Accredited Pharmacist
requested a referral from the GP for these. The DoN reported that new arrivals were reviewed
during the Accredited Pharmacist’s next visit but if they had concerns about any resident
between visits, medication lists and histories were emailed to the Accredited Pharmacist and he
gave advice. The DoN stated that if the Accredited Pharmacist did not have time to include an
additional, unplanned RMMR, he would review the resident and provide verbal advice. The
Accredited Pharmacist also reported that if the Aged Care Home requested a Review within the
12 month period and a referral could not be easily obtained, he conducted an RMMR and
provided a verbal report free of charge.
QUM
QUM activities for one Aged Care Home were contracted to the supply pharmacy, although the
Accredited Pharmacist assisted with queries and some informal in-service training as well as
taking phone calls requesting drug information, adverse effects, options for particular patients
and similar requests. Staff at the home where the Accredited Pharmacist held the QUM service
agreement were not nurses and there was only one Registered Nurse, thus he reported
spending a significant amount of time advising on procedures, medications and reviewing charts
and blister packs. Significant education was required at this Aged Care Home and the
Accredited Pharmacist had developed presentations on pain management, constipation,
understanding medication and administering medication, the use of opioids and chronic pain
management to meet this need.
Issues
The Accredited Pharmacist stated he would like more case conferencing with the residents’
families but that travel was difficult. The DoN also felt that case conferences were difficult for
the Accredited Pharmacist to attend given the logistics and travel time involved, but that the
Accredited Pharmacist attempted to overcome this through conference calls. The Accredited
Pharmacist believed that many GPs were threatened by the RMMRs and were confused about
their responsibilities
But once they get into it, the majority come around.
(Accredited Pharmacist)
The Accredited Pharmacist was also concerned about companies setting up specifically to
conduct RMMRs en masse and having little, if any, relationship with Aged Care Home staff.
I feel that the RMMR Program is being rail-roaded by corporate companies who tie
up the contracts and provide minimal services, using contracted pharmacists who
have little or no connection to the facility they visit. I feel these contracts should
only be available to individual pharmacists and a minimum of service/ contacts be
specified. Currently the bigger groups may only visit a facility every 3-4 months.
This really is inadequate”.
(Accredited Pharmacist)
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He also cited the following issues:
Lack of awareness of QUM in many rural and remote areas as well as lack of
access to a pharmacist for these services. This is why I travel over 400 km from
home to work - at my own cost!
Rejections of payments by Medicare for incorrect birthdates and difficulty in
tracking Medicare numbers are added difficulties we face.
Rejections where the resident dies after the Review date but prior to the claim
being submitted.
(Accredited Pharmacist)
Potential RMMR Improvements
The Accredited Pharmacist felt that remuneration for QUM should be increased.
The facility still call me when they have an issue or need clarification with side
effects. Current payment is inadequate as I have to research things too and drug
evaluation can take hours.
(Accredited Pharmacist)
He also suggests the following:
Speed up payments. I still have a payment waiting from July but Medicare Australia
say they can do nothing about it. Its $6,000 -7,000 which is a lot to me.
Improve claim forms - only 6 claims per page; too much information required on
resident; pages do not save to the PC can only print not re-use and so all has to be
entered again. Have to tab in between each letter – not user friendly.
(Accredited Pharmacist)
Qualitative Comment
This Accredited Pharmacist was very willing to participate but was unable to provide a GP
referral claiming the GP to be on leave. However, the DoN claimed that the Accredited
Pharmacist is well liked by GPs and has been extremely effective in obtaining their collaboration
to date.
Quantitative analysis
Characteristics
Case Study 9 was a pharmacist located in a rural centre. CS9 had worked for 8-12 years in
pharmacy, and was accredited 3-5 years ago. CS9 conducted RMMRs as a pharmacist
contracted to a community pharmacy RMMR Provider and as an independent RMMR provider.
CS9 received an average of $117 of the $130 Medicare Australia payments for each Review.
The case study was based on 3 visits, averaging a very high 34 Reviews per visit (the highest of
all case studies). 75% of these visits were done as Collaborative Reviews. CS9 travelled an
average of 148 kilometres per visit, higher than the average for all cases.
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Table 17:
Case Study 9 Characteristics
Pharmacist’s Characteristics
Case 9
All
Cases
Years in Pharmacy
8-12
18.6
Years accredited
3-5
6.8
Location
Rural centre
Mode of payment
Consultant pharmacist
for a community
pharmacy and as an
independent/consultant
pharmacist
Average amount received in
payment for RMMR services
$117
$104
Number of visits during period
3
8.0
Average Reviews per visit
34
10.8
Proportion of Reviews done as
Collaborative Reviews
75%
61%
Average travel distance (km)
148
113
Cost summary
CS9 conducted RMMRs at a high financial return. For the average $1,386 reported expenses,
CS9 received an average of $3,928 in Medicare Australia payments.
90% of costs associated with CS9’s RMMRs were associated with pharmacist salary and on
costs. No administrative time was reported. Travel accounted for 9% of costs, the remaining
1% for other expenses.
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Figure 9:
Salary costs
Salary:
Pharmacist
$1,239 90%
Other
expenses
$15 1%
Travel $124
9%
Detailed expenses
CS9 showed a higher average cost per visit compared to the costs reported when all cases
were combined. Detailed times and costs for CS9 are provided in the table below. Areas where
CS9 differed from times and costs associated with all cases included:
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Substantially lower costs before the visit, with minimal pharmacist time
recorded, and no other staffing costs
•
Travel costs slightly higher than the average across all cases
•
Costs during the visit that were similar to the average across all cases, noting
that a substantially higher number of Reviews were reported to have been
conducted and claimed during each visit
•
Substantially higher costs after the visit, with significant pharmacist time
invested, and no administrative time.
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Table 18:
Detailed Expenses – Average Times and Costs
Before the visit
Time
(Hours)
1
0
0
-
Cost
$67
$$8
$8
$83
All
Cases
$91
$33
$6
$28
$158
$124
$89
$213
$92
$86
$178
5.8
0.0
0.0
$292
$$$$292
$233
$11
$1
$9
$254
15.8
0.0
0.0
Subtotal
$792
$$$7
$798
$222
$25
$2
$9
$257
Total Costs
$1,386
$848
Pharmacist
Administration
Other
Other expenses
Subtotal
Travel costs
Travel costs
Time travel costs
Subtotal
During the visit
Pharmacist
Administration
Other
Other expenses
2.47
Subtotal
After the visit
Pharmacist
Administration
Other
Other expenses
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2.12 Case Study 10
The Case Study included interviews with 1 Accredited Pharmacist, 1 business manager, 2 DoNs
and 1 GP.
CS10 Background
The pharmacist had been in the industry for several decades and had been accredited for over
10 years. After a varied history including involvement in RMMRs since they were first
introduced, the Accredited Pharmacist now acted as a consultant to a company which
specialises in Medication Reviews.
Aged Care Home and RMMR Provider Background
The RMMR Provider held service agreements with several hundred homes and conducted a
high number (well over 5,000) of RMMRs annually, as well as providing the full range of QUM
activities. The RMMR Provider company comprised 10 Accredited Pharmacists plus a number
of administrative and back-up staff. The company had developed software which allowed for the
more efficient management of data. The Accredited Pharmacist involved in this case study
personally managed 50-60 Aged Care Homes covering the full spectrum of Aged Care Home
types and areas within the state. She stated that she conducted 1200+ RMMRs each year and
that 60-70% of all RMMRs conducted by the group as a whole were Collaborative Reviews.
RMMR Process
Support staff contacted the Aged Care Home to obtain new admission or discharge details and
to ask for any residents with high risk factors or those the Aged Care Home felt required a
Review. DoNs stated that at least 6 weeks’ notice was given to them to provide this information.
A list was generated for the Accredited Pharmacist. GPs were informed of impending RMMRs
and invited to participate. Data was updated from the Aged Care Home lists and Medicare
numbers and latest medication charts accessed from the database.
We set it all up so they (Accredited Pharmacists) can do what they’re best at.
(RMMR Provider staff)
At the Aged Care Home, all information for Reviews was gathered, (some Aged Care Homes
were computerised and had different levels of systems, some worked on hard copy; some
records were at the surgery which could cause problems with needing to contact the GP). The
Accredited Pharmacist worked on a laptop at the Aged Care Home and accessed a centralised
database in the office where she entered and merged the new Aged Care Home data and made
any changes required.
The Accredited Pharmacist spoke to staff about the residents and any concerns they may have
and all residents under Review were spoken with or observed, depending upon their physical
and cognitive status. The resultant data was then analysed and the report was dictated and sent
to the office where support staff transcribed the report onto the database. The Accredited
Pharmacist uploaded the report and edited it accordingly. The office then sent the report to both
the Aged Care Home and the GP. The process was similar regardless of whether it was a
Collaborative Review or not, although the GP’s response might have differed.
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Any comments received from GPs were also entered into the database and tracked; most GPs
who were involved in Collaborative Reviews sent comments back to the Accredited Pharmacist.
The Accredited Pharmacist recognised that someone should follow up at the resident level in
order to determine the outcome of the RMMR but due to time constraints this was not
systematically done.
Every Review is different for them (the Accredited Pharmacist); it’s like an exam
and we come from a holistic point of view, trying to get to know the resident and
how we can best give the GPs information about them.
(RMMR Provider staff)
The GP supported the Accredited Pharmacist’s statements and confirmed the Accredited
Pharmacist spoke with both Aged Care Home staff and residents and sent any advice to the
surgery. This particular GP then reported going to the Aged Care Home with the Review and to
see the patient if necessary.
I’m quite happy with the process; it’s a great reminder and you do get complacent.
They remind me of things, they do a good job…I’m not always aware of
everything…they write suggestions really well…they don’t tell me what to do…
(GP)
One DoN in a remote location describes a somewhat different approach where for her home the
GP, Aged Care Home staff and the Accredited Pharmacist would discuss the RMMRs. She
noted the area’s Division of General Practice had instigated peer Reviews in the past. This was
developed and refined and RMMRs were also now included in the process.
<Accredited Pharmacist> comes in and does what they have to do; there are
usually 3-4 GPs here and we discuss the findings of <Accredited Pharmacist>. I
was sceptical of how it would work but it works well and the GP gets paid and its
good education for the staff, they get involved in the process; the report is handed
out at the meeting and changes are made on the spot.
(DoN)
QUM
Extensive services were delivered by the RMMR Provider including education, medication
management system audits, drug evaluation studies, MAC attendance, assistance in the
development of policies and procedures for best practice medication management, regular
newsletters and informal laminates on key aspects of medication management. The Provider
recognised that different levels of QUM were required for different levels of staff such as
Personal Care Assistants, Enrolled Nurses and Registered Nurses and reported that the RMMR
Provider addressed this.
Issues
The RMMR Provider company manager and Accredited Pharmacist both reported that the new
funding model provided less flexibility to deliver QUM, especially where it was required to
improve overall Aged Care Home and resident outcomes. Smaller Aged Care Homes and
some rural Aged Care Homes were said to be in great need of QUM but were disadvantaged
due to the low number of residents. Providing the required sophisticated level of QUM to small
homes was considered financially unviable for the RMMR Provider although it continued to
provide this service due to long standing relationships with the Aged Care Homes. QUM had
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also been provided to residents, and their carers and families. Linking QUM to RMMRs was
seen to potentially increase health and safety risks to residents and impacted the Aged Care
Home accreditation requirements.
The old model was more flexible although open to abuse. Some facilities require
more QUM and the current funding model is insufficiently flexible to address this.
It’s not cost effective…there are higher QUM and time costs and we just can’t
recoup the dollars eg meetings at the Aged Care Home, meeting with relatives to
contain their expectations.
(Accredited Pharmacist)
The new program had added significant overhead costs. It was estimated that there was an
additional 15% added cost per Review under the new approach to QUM.
We’ve had to resort to marketing products as we are not making enough money.
Times are so lean we had to think of other ways to stay afloat, so we develop and
market products to nursing homes such as information on risk management,
policies in place, handling of drugs during pregnancy…
(Accredited Pharmacist)
The Accredited Pharmacist noted that there was no indexation of RMMRs, but Accredited
Pharmacist salaries have been increasing at a greater rate than non-Accredited Pharmacists.
Rural and remote facilities with poor access were considered particularly difficult to service
because of travel and associated costs which were not reimbursed.
The administrative process was also considered time consuming and costly.
There’s lot of pre-work but I do get lots of support from office staff. But setting up
appointments, contacting GPs to let them know, getting information on new
residents and new discharges all takes time. But that help allows me to be more
effective.
(Accredited Pharmacist)
It was reported that income was often lost due to the inability to identify whether new residents
had been reviewed in the past 12 months. Much time and expense was also spent in
contacting GPs to support Collaborative Reviews and case conferences to improve quality of
outcomes. There was no framework for the Aged Care Home to refer an RMMR within the 12
month period without GP authorisation.
The manager felt that GPs appeared to pick up on current pharmacological/medication issues
more quickly as a result of the RMMR, and applied any learnings to other residents.
Potential RMMR Improvements
Improvements suggested by the Accredited Pharmacist and manager included the provision of
specific funding for QUM service, or a separate amount for all required services which was not
linked to the RMMRs They also suggested pay for different levels of Reviews accordingly.
‘Chasing’ GPs and Collaborating was reported to take additional time and effort which was not
remunerated.
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They also requested a method to determine the timeliness of a Review for new admissions,
such as access to Reviews completed in a different home for Accredited Pharmacists where
there is a new admission or alternatively, to allow access to Medicare in order to determine if a
Review has occurred within the past 12 months.
If it’s a new admission the RMMR may be rejected, we are just trying to fulfil our
responsibilities….its like a stab in the back.
(Accredited Pharmacist)
Qualitative Comment
The RMMR Provider appears to offer a thorough and extensive RMMR service. Whilst formal
communication with the GP after RMMR reporting was not routinely practiced, all GP comments
were captured on the central database and utilised in any subsequent Review. All interviewees
appeared open and willing to participate in the evaluation.
Quantitative analysis
Overall CS10 presented as ‘middle of the road’ in terms of costs and approach to RMMRs.
CS10 operated at a moderate financial return, and the overall costs of conducting a visit were
similar to the average across all cases. While the number of Reviews conducted for each visit
was relatively low, the number of visits overall for the period was high, resulting in a large
number of claims. High travel costs and a relatively large amount of time spent at each home
was offset by relatively lower amounts of time spent before and after the visit
Characteristics
Case Study 10 was a pharmacist located in a metropolitan area. CS10 conducted RMMRs as a
pharmacist contracted to a RMMR Provider specialising in Medication Reviews. CS10 received
an average of $70 of the $130 Medicare Australia payments for each Review, the balance going
to the company for whom CS10 worked. The company provided administrative and other
support. The case study is based on 16 visits, averaging 14 Reviews per visit. 62% of these
visits were done as Collaborative Reviews. CS10 travels an average of 144 kilometres per visit,
higher than the average for all cases.
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Table 19:
Case Study 10 Characteristics
Pharmacist’s Characteristics
Case 10
All Cases
Years in Pharmacy
35-45
18.6
Years accredited
10-15
6.8
Location
Metropolitan
Mode of payment
Consultant pharmacist
for a company
specialising in Reviews
Average amount received in
payment for RMMR services
$70/130
$104
Number of visits during period
16
8.0
Average Reviews per visit
14
10.8
Proportion of Reviews done as
Collaborative Reviews
62%
61%
Average travel distance (km)
144
113
Cost summary
CS10 conducts RMMRs at a positive level of financial return. For the average $1,053 reported
expenses, CS10 received an average of $1,803 in Medicare Australia payments.
74% of costs associated with CS10’s RMMRs were associated with pharmacist salary and on
costs. 10% were associated with administrative salary and on-costs. Travel accounted for 12%
of costs, and other expenses for the remaining 4%.
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Figure 10:
Salary costs
Salary
Admin, $106
10%
Other
expenses
$41 4%
Salary:
Pharmacist
$746 74%
Travel $120
12%
Detailed expenses
CS10 showed a higher average cost per visit compared to the costs reported when all cases
were combined.
Detailed times and costs for CS10 are provided in the table below. Areas where CS10 differed
from times and costs associated with all cases included:
•
Costs for CS10 before the visit were lower than the average across all cases,
with no time recorded for the pharmacist, and a small amount of
administrative time recorded
•
Travel costs for CS10 were higher than the average
•
Costs during the visit were substantially higher than average for CS10, with a
relatively high amount of pharmacist time spent
Costs after the visit were lower than average for CS10, with relatively little time spent by the
pharmacist in follow up and other activities.
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Table 20:
Detailed Expenses – Average Times and Costs
Before the visit
Time
(Hours)
0
1
1
-
Cost
$19
$29
$29
$30
$107
All
Cases
$91
$33
$6
$28
$158
$120
$229
$348
$92
$86
$178
7.5
1.8
0.0
$373
$44
$$$418
$233
$11
$1
$9
$254
2.5
1.3
0.4
Subtotal
$125
$33
$11
$12
$180
$222
$25
$2
$9
$257
Total Costs
$1,053
$848
Pharmacist
Administration
Other
Other expenses
Subtotal
Travel costs
Travel costs
Time travel costs
Subtotal
During the visit
Pharmacist
Administration
Other
Other expenses
2.39
Subtotal
After the visit
Pharmacist
Administration
Other
Other expenses
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2.13 Case Study 11
The Case Study included interviews with 1 DoN and 1 GP
Qualitative discussion
CS11 Background
The Accredited Pharmacist owned a community pharmacy where he was now the sole
Accredited Pharmacist. He qualified as a pharmacist several decades ago and became
accredited 8-10 years ago. He had been conducting RMMRs since accreditation.
Aged Care Home
The community pharmacy held service agreements with three homes in regional and rural areas
- a 35 bed high care Aged Care Home, a 52 bed high care Aged Care Home and a 95 bed Aged
Care Home providing both high and low care. The RMMR Provider was the supply pharmacy to
all these Aged Care Homes. The Accredited Pharmacist aimed to conduct 5 RMMRs every
week and 99% of Reviews were said to be Collaborative Reviews.
The Aged Care Home interviewed tended to use the one clinic and all GPs had committed to
conduct CMAs at the end of each month. The Accredited Pharmacist therefore aimed to
schedule RMMRs for residents who were due for a CMA. There was reportedly a Division of
General Practice in the area which fostered strong relationships between the various disciplines.
Instigated by the Aged Care Home, the Accredited Pharmacist took the approach of not only
trying to align the RMMRs and CMAs, but to ensure collaboration of GPs he was also present
when the GP conducted the CMAs and participated in the associated meeting to which the GPs
had committed. The DoN saw this process as invaluable.
We are all there together, the GP, <Accredited Pharmacist> the Div 1 <Division 1
nurse> and me, plus another nurse in and out, and we can discuss all the
resident’s issues like the Medication Review, the resident behaviour, weight
management, Warfarin management, as well as changing practice. It’s a bit hotch
potch but it works really well, we get what we want and the GP gets paid.
(DoN)
RMMR Process
The Accredited Pharmacist identified those residents due for their annual RMMR as well as
residents due for a CMA via a spread sheet at the pharmacy. A nurse at the Aged Care Home
confirmed with the Accredited Pharmacist those residents due for a CMA and a month in
advance of the CMA, the Accredited Pharmacist requested referrals from the GP for those
residents who will receive a CMA and/or an RMMR. On receiving the referral request, the GP
ensured all resident diagnoses and pathology was correct and sent individual referrals to the
Accredited Pharmacist. The organisation of aligning the RMMRs and CMAs was apparently
quite significant and required the skills of a nurse in the home.
At the Aged Care Home the Accredited Pharmacist accessed all resident’s notes on a PC. He
cross-referenced with pharmacy files to check for any discrepancies, checked with nursing staff
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to establish any concerns regarding the resident and talked to the resident, if feasible. Reporting
was carried out off site. A report was sent to the GP and the nurse who read the report and
placed it in the resident’s file. If there was anything of concern, the Accredited Pharmacist
would call or fax the GP. The DoN reported the nurse also does this; otherwise the GP received
the report and acts accordingly. The Aged Care Home took no other responsibility to ensure the
GP had read/acted upon the RMMR.
I think they’re terrific (RMMRs). The pharmacist gives me advice, and I think ‘Oh
…! I should’ve known that!’ <Accredited Pharmacist> gives a really good
explanation of why they want something done, they list their points and I make
comments like ‘No that’s impractical’, or ‘Yes, we should have done this before’,
and I make adjustments accordingly.
(DoN)
The CMA was scheduled for a whole afternoon at the end of the month and the Accredited
Pharmacist was present.
I align with the CMA. That way the GP is there for the CMA and the RMMR is
discussed and he can claim collaborative. It works well. I am sometimes looking
at a patient I have reviewed earlier and the GP is standing there at the same time.
(Accredited Pharmacist)
Any residents who received an RMMR but did not receive a CMA were still discussed.
The GP said she already acted on reports before the CMA and thus felt discussion of the
RMMR is not an essential element of the RMMR process.
QUM
The Accredited Pharmacist provided lectures and education but said that other QUM
components were more difficult to organise as they required a planned outcome by which to
measure the degree of success. The Accredited Pharmacist stated that the Aged Care Home
could get carried away with QUM on occasion. The DoN stated that the Accredited Pharmacist
had not only assisted with education but with protocols, and admitted to being somewhat slow in
identifying issues and not taking as much advantage of the QUM component of the contract.
Issues
The Accredited Pharmacist reported that in order for RMMRs to make business sense he
needed to conduct 5 RMMRs each week.
The GP appreciated the role of the pharmacist and noted that Accredited Pharmacists need to
be confident and assertive with GPs.
They are criticising our management of patients so they need to be confident and
give good reasons. I don’t feel threatened as it’s my decision anyway but in reality
the pharmacist knows far more about pharmacology than we do….I learn a lot from
it, it’s very very helpful. I think it’s great and it’s helped improve an already good
relationship.
(GP)
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The Aged Care Home was reportedly seeing the benefits of the way in which the MAC, CMA
and RMMRs are integrated:
When we first started I couldn’t get anyone to come to MAC. Now they are all
sitting in a room – it’s not a MAC – but we’ve got charts and they all listen, and the
nurses can come in and listen and I join in the middle of things and talk even about
general items as well.
(Accredited Pharmacist)
Potential RMMR Improvements
The Accredited Pharmacist would like to see the DoN allowed to initiate an RMMR.
If the GP’s on holiday or the patient has gone a bit off….sometimes there’s no
opportunity to corner the GP and it can take a few days.
(Accredited Pharmacist)
The Accredited Pharmacist would also like to see Medicare paperwork improved as well as
contracting requirements.
I have not updated my Medicare contract and I got a letter. It’s up to ME to initiate.
Can’t they send US a reminder that it’s time to renew?”
(Accredited Pharmacist)
Qualitative comment
The individuals in this case study clearly worked well as a team and comments by the GP and
DoN supported the Accredited Pharmacist’s description of the RMMR process, which is
thorough and dovetailed with other information regarding the resident. From the perspective of
the Aged Care Home and GP, the RMMR was another piece of information which may or may
not have been relevant to them; however, by ensuring the GP’s referral and full involvement, the
Accredited Pharmacist was guaranteed payment for all RMMRs conducted, and residents
benefited.
Quantitative analysis
Only limited conclusions can be drawn for CS11 as the diary submitted for the evaluation was
incomplete for a number of visits. CS11 indicated a moderate-throughput, low-cost approach to
RMMRs. CS11’s reported costs for RMMR were substantially lower than the average, while the
number of Reviews conducted per visit was very close to average. These factors combined led
to a relatively high financial return for CS11.
Characteristics
Case Study 11 was a pharmacist located in a rural centre. CS11 conducted RMMRs as the
owner of a community pharmacy. As a pharmacy owner, CS11 received the total $130
2
Medicare Australia payment for each Review. The case study is based on 3 visits, averaging
12 Reviews per visit, similar to the average across all cases. 100% of these visits were done as
2
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Collaborative Reviews. CS11 travelled an average of 30 kilometres per visit, far lower than the
average for all cases.
Table 21:
Case Study 11 Characteristics
Pharmacist’s Characteristics
Case 11
All Cases
Years in Pharmacy
20-30
18.6
Years accredited
8-10
6.8
Location
Rural centre
Community
pharmacist
owner
Mode of payment
Average amount received
payment for RMMR services
in
Number of visits during period
Average Reviews per visit
Proportion of Reviews done as
Collaborative Reviews
Average travel distance (km)
130
$104
3
8.0
12.0
10.8
100%
61%
30
113
Cost summary
CS11 conducted RMMRs at a relatively high financial return. For the average $462 reported
expenses, CS11 received an average of $1,560 in Medicare Australia payments.
90% of costs associated with CS11’s RMMRs were associated with pharmacist salary and on
costs. 10% were associated with administrative salary and on costs. Travel accounted for 6%
of costs, and other expenses for the remaining 2%.
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Figure 11:
Salary costs
Salary
Admin, $106
10%
Salary:
Pharmacist
$406 90%
Other
expenses
$8 2%
Travel $25
6%
Detailed expenses
CS11 showed a substantially lower average cost per visit compared to the costs reported when
all cases were combined.
Detailed times and costs for CS11 are provided in the table below. Areas where CS11 differed
from times and costs associated with all cases included:
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Lower costs before the visit, with only a few hours of pharmacist’s time
recorded
•
Very low travel costs reflecting the relatively small distance travelled for visits
•
Very low expenses incurred during the visit, with minimal time recorded for the
pharmacist
•
Lower than average expenses after the visit, again with minimal pharmacist
and administrative time recorded.
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Table 22:
Detailed Expenses – Average Times and Costs
Before the visit
Time
(Hours)
2
0
0
-
Cost
$100
$8
$6
$6
$121
All
Cases
$91
$33
$6
$28
$158
$25
$18
$43
$92
$86
$178
1.8
0.0
0.1
$88
$$2
$$90
$233
$11
$1
$9
$254
4.0
0.1
0.2
Subtotal
$200
$2
$4
$2
$208
$222
$25
$2
$9
$257
Total Costs
$462
$848
Pharmacist
Administration
Other
Other expenses
Subtotal
Travel costs
Travel costs
Time travel costs
Subtotal
During the visit
Pharmacist
Administration
Other
Other expenses
0.50
Subtotal
After the visit
Pharmacist
Administration
Other
Other expenses
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2.14 Case Study 12
Qualitative discussion
The Case Study also included interviews with 1 DoN and 1 Practice Nurse, and the clinic on
behalf of a GP.
CS12 Background
This pharmacist serviced a rural community and had been in the pharmaceutical industry for
over ten years. He became accredited 6-8 years ago. He worked two days at a supply
pharmacy for which he conducted RMMRs: 2 days in the local hospital and at a 60 bed home
for the conduct of their RMMRs. There were only two Aged Care Home facilities in the vicinity
and the Accredited Pharmacist was reluctant to travel to others given the lack of financial
support under the RMMR Program to do so. He therefore consciously limited his services to the
one Aged Care Home which was around 15 minutes away by car.
Aged Care Home
Until last year the Accredited Pharmacist held service agreements with both local Aged Care
Homes until one Aged Care Home broke the agreement and started obtaining RMMRs from a
large provider group from the city. He now had only the one Aged Care Home which had 30
high care and 30 low care beds. Most of the RMMRs the Accredited Pharmacist conducted
there were Collaborative Reviews; there are only 7 GPs in the area. The Accredited Pharmacist
has lived in the area for some time and he believed that working at the community pharmacy
and hospital as well as conducting HMRs meant that he knew the history of many residents at
the Aged Care Home. He felt this to be a major benefit when conducting RMMRs, and the DoN
spontaneously mentioned this also:
He knows all the residents and has often done their HMRs. It’s a major plus.
(DoN)
It’s a small country town so I know the people sometimes better than staff. They
were having a problem with one woman and I said ‘you know she’s feeling like that
because she has <description of medical condition> don’t you?’ And they (Aged
Care Home staff) were amazed. But I used to do her HMRs, she’d come into the
pharmacy and I saw her in hospital too.
(Accredited Pharmacist)
RMMR Process
The Accredited Pharmacist had been servicing this Aged Care Home for 5 years, reported to be
fairly organised and with such a small home found it easy to determine which residents required
an RMMR. Nonetheless, he utilised his database and checked with the Aged Care Home if
there were any new residents or if there were any residents which needed reviewing within the
12 month cycle. He obtained up to date charts from the supply pharmacy as all the Drug
Administration Aids were packed there and he could access the data on the pharmacy
computer. The Accredited Pharmacist advised the Practice Nurse of the clinic who was due for
a Review, and he liaised with the GP on behalf of the Accredited Pharmacist to obtain referrals.
The Practice Nurse confirmed this process and reported that all Reviews were collaborative
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(however, based on the data provided in the Accredited Pharmacist’s diary, only three quarters
of Reviews were conducted as Collaborative Reviews overall). The GP may add a resident,
signed a referral and sent any relevant information to the Accredited Pharmacist. At the Aged
Care Home the Accredited Pharmacist accessed all the relevant files. He then spoke with Aged
Care Home staff and later residents themselves, especially if they were self-medicating. The
Accredited Pharmacist believed in the importance of speaking with nursing staff in order to
obtain the most up-to-date information on the condition of the resident and any issues staff may
have.
I feel it’s important to have a bit of a conversation with residents. Providing they
are able to. I know most of them anyway.
(Accredited Pharmacist)
The report was then written off site using a standard template. The report had a separate
section specifically for nursing staff advice or recommendations. The Accredited Pharmacist
sent a copy of the report to the GP irrespective of whether the Review was Collaborative or
pharmacist only. The Aged Care Home put the report in the doctor’s book and staff raised any
issues with him on his next rounds. The Accredited Pharmacist said he tried to schedule his
visits to coincide with those of the GPs, but working 4 days a week elsewhere, this was not
always possible.
However, the Practice nurse stated it is common for the Accredited
Pharmacist to call the clinic and to speak with the Practice Nurse as well as visit the GP
regarding any RMMRs which he believed need urgent attention, or issues which were
uncommon or he felt require verbal feedback.
He calls quite regularly and I speak to her and make an appointment for her to see
<GP>. He is well known here and she speaks to me and runs us through the
Reviews. We are very happy with the process. There are three other GPs here
who also do Reviews (with different facilities and Accredited Pharmacists) and we
think we have the best pharmacist and the best process.
(Practice Nurse)
QUM
The Accredited Pharmacist was contracted to provide QUM and stated that he attended the
MAC and provided a quarterly newsletter. He had also provided a couple of lectures but they
had not been that well attended. Most of QUM activity was said to be verbal and involved
discussion and queries whilst he was on site.
And they phone me - its someone to talk to - that’s what they need. They would
probably like a pharmacist on site every day; someone who knows their patients …
I can actually be there for 2 hours just answering queries or researching something
before I even do a Review and then you leave and think ‘I won’t even get paid for
that.’
(Accredited Pharmacist)
The Accredited Pharmacist reported to be doing DUEs and audits but that neither he nor staff
had sufficient time to do these properly.
We attempt! But they are very time consuming. We have done smaller ones.
(Accredited Pharmacist)
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Issues
The Accredited Pharmacist felt that the administrative side of RMMRs was ‘fine’ but that it was
time consuming. He has more of an issue with what he considered to be insufficient payment
for QUM, lack of payment for travel and ‘the annoying quarterly report.’
I don’t know why I do them! I get paid more in the pharmacy setting and it’s a
guaranteed salary every week; no claims, no rejections…..
(Accredited Pharmacist)
He felt that GPs could be difficult but because he worked in a small town he has - over the years
- managed to demonstrate to GPs that RMMRs are worthwhile.
I’ve managed to talk most of them round and they think they’re fantastic. It’s a
small town so I know them all well and I talk to them and slowly they give in. And
now of course, they (GPs) get paid.
(Accredited Pharmacist)
Where GPs were not prepared to collaborate, he would work through the DoNs to identify the
value of the RMMR.
The Accredited Pharmacist was also concerned about large organisations providing RMMRs
from out of town and with the service being provided by an individual who was unfamiliar with
the resident and their history and who had no continuity with the resident.
They’re just filling out this form and saying this and that but they don’t know the
resident and they do not provide ongoing support to the Aged Care Home.
(Accredited Pharmacist)
He was concerned that if RMMRs became better remunerated that this would act as an
incentive for ‘the big mobs’ to take on more Aged Care Homes.
Potential RMMR Improvements
The Accredited Pharmacist would like to see separate funding for QUM at an hourly rate
Qualitative Comment
The Accredited Pharmacist clearly enjoyed his work and was seen to be a very valuable
member of the health team by both the clinic and the Aged Care Home.
Quantitative analysis
Case Study 12 presented as a very low throughput pharmacist who, while minimising expenses,
only made a small financial return from Reviews. CS12 reported some of the lowest operating
costs of all pharmacists in terms of time spent and travel costs. However CS12 also reported
one of the lowest numbers of Reviews conducted per visit.
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Characteristics
Case Study 12 had worked for over 10 years in pharmacy, and was accredited in 7-9 years ago.
CS12 conducted RMMRs as an independent contractor. CS12 claimed the full $130 Medicare
Australia payments for each Review. The case study was based on 5 visits, averaging a very
low 2.8 Reviews per visit. 73% of these visits were done as Collaborative Reviews. CS12
travelled an average of 24 kilometres per visit, lower than the average for all cases.
Table 23:
Case Study 12 Characteristics
Pharmacist’s Characteristics
Years in Pharmacy
Years accredited
Case 12
All Cases
10-14
18.6
6-8
6.8
Location
Rural centre
Mode of payment
Independent
contractor
Average amount received
payment for RMMR services
in
Number of visits during period
Average Reviews per visit
Proportion of
collaboratively
Reviews
Average travel distance (km)
done
$130
$104
5
8.0
2.8
10.8
73%
61%
24
113
Cost summary
CS12 conducted RMMRs at a low financial return. For the average $260 reported expenses,
CS12 received an average of $364 in Medicare Australia payments.
92% of costs associated with CS12’s RMMRs were associated with pharmacist salary and on
costs. The remaining 7% was reported against travel costs. No administrative support or costs
were reported.
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Figure 12:
Salary costs
Salary:
Pharmacist,
$239 , 92%
Travel, $20 ,
8%
Detailed expenses
CS12 showed a substantially lower average cost per visit compared to the costs reported when
all cases were combined.
Detailed times and costs for CS12 are provided in the table below. Areas where CS12 differed
from times and costs associated with all cases included:
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Very low costs reported for all cost categories, including time before, during
and after; and travel costs
•
However, CS12 also reported a very low throughput of RMMRs conducted
and claimed, meaning that the very low costs associated with visits with Aged
Care Homes corresponded to a very low amount paid from Medicare.
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Table 24:
Detailed Expenses – Average Times and Costs
Before the visit
Time
(Hours)
1
0
0
-
Cost
$40
$$$$40
All
Cases
$91
$33
$6
$28
$158
$20
$14
$34
$92
$86
$178
1.9
0.0
0.0
$95
$$$$95
$233
$11
$1
$9
$254
1.8
0.0
0.0
Subtotal
$90
$$$1
$91
$222
$25
$2
$9
$257
Total Costs
$260
$848
Pharmacist
Administration
Other
Other expenses
Subtotal
Travel costs
Travel costs
Time travel costs
Subtotal
During the visit
Pharmacist
Administration
Other
Other expenses
0.40
Subtotal
After the visit
Pharmacist
Administration
Other
Other expenses
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2.15 Case Study 13
Qualitative discussion
The Case Study also included an interview with 1 Accredited Pharmacist, 1 DoN and 1 GP.
CS13 Background
The Accredited Pharmacist was an independent pharmacist; she had been involved in the
industry for over 20 years and became accredited close to 10 years ago. She was now
operating a business delivering Medication Reviews (RMMRs and HMRs) with another
Accredited Pharmacist. The Accredited Pharmacist focussed on RMMRs and the business
partner on HMRs. The business model provided for flexibility in working hours that supported a
family focussed lifestyle. Whilst still working in excess of 40 hours a week, the Accredited
Pharmacist enjoyed the flexibility her role afforded her and the ability to spend time with her
young family.
She now serviced 20 Aged Care Homes, some through a direct service agreement which she
preferred, as she is paid the full Medicare fee, and some via contracts with supply pharmacies
which paid her a rate per RMMR. She conducted approximately 1,500 RMMRs each year. This
figure had grown considerably over the last 2 years due to higher demand and a lack of
Accredited Pharmacists in the area. Prior to then, the Accredited Pharmacist typically
conducted 90-100 RMMRs per annum. She stated that around 80% of all RMMRs she
conducted were Collaborative Reviews.
Aged Care Home
The Accredited Pharmacist serviced 20 Aged Care Homes spread across the greater
metropolitan area as well as some in rural areas. She had commenced independent service
agreements with rural Aged Care Homes over the past 2 years. She reported there were no
Accredited Pharmacists available in many rural areas. The rural homes required more travel
time and thus she visited these homes less often than she would like, about every 6 weeks
compared to local Aged Care Homes which she visited every three or four weeks. She stated
that she offset this by spending a longer time on site in country homes, which also made
travelling more cost effective.
RMMR Process
The Accredited Pharmacist obtained a resident list from the Aged Care Home which may have
also included specific residents the Aged Care Home wished to see reviewed. Once residents
were identified as due for an annual Review, the Accredited Pharmacist contacted the GP via
fax or email and requested a referral and any information the GP may have wished to add to the
information available at the Aged Care Home. Often this comprised pathology results or extra
doctor’s notes or simply a note informing the Accredited Pharmacist that all relevant files were
at the Aged Care Home. Some GPs signed the bottom of the Accredited Pharmacist’s form
which the Accredited Pharmacist believed acts as a referral provided the GP had signed and
acknowledged that the Review was going to happen.
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At the Aged Care Home, the Accredited Pharmacist accessed current drug charts, collected all
the information from resident history files or accessed data directly from the Aged Care Home
software program if available. She then spoke with care staff regarding the residents. If
residents were low care or self-medicating she would also speak to the resident directly. If the
resident was in high care, she felt speaking to them was unproductive and indicated that this
was where nursing staff became important in providing resident information. Data was analysed
and reports compiled off site. All GPs were sent a copy of the report regardless of whether they
had collaborated in the Review or not. However for Collaborative Reviews the report contained
a section for GP comment which the GP could then fax back to the Accredited Pharmacist. This
was usually the only communication the Accredited Pharmacist had with the GP. When the
Accredited Pharmacist started at a new Aged Care Home, she contacted the various GPs and
asked their preference for communication; she stated that 90% preferred fax or email
communication over phone or face-to-face simply because of time pressures:
There’s one particular GP that we always arrange that I’m there on the same day
so we discuss the issues right there and then but I would say out of my
collaborative Reviews probably 90% of them are done through written
communication, obviously if there’s a major issue I phone them straight away, just
for the general report it would be by written/faxed communication.
(Accredited Pharmacist)
The Aged Care Home reported that there was a shortage of GPs in the area with GPs
overstretched. There were four major group practices but a range of other doctors based on
patient preference. The Aged Care Home reported that some GPs were “antagonistic” to
RMMRs noting that they do not like having inconsistencies drawn to their attention. However,
the Accredited Pharmacist reported that her focus on collaboration and commitment to
personally tailored communication strategies resulted in productive relationships, and GPs who
did not collaborate were very much in a minority. She felt that doctors were concerned about
the clinical background of the pharmacist and took the attitude that she “just had to prove them
wrong” by providing relevant and focussed information from RMMRs.
Case conferencing was considered to be the best way to get results from GPs.
If the Review was a Pharmacist Only Review the Accredited Pharmacist tailored the report to
the Aged Care Home and nursing staff but ensures she notifies the GP of any issues arising
from the RMMR; she considers this to be her duty of care.
The Accredited Pharmacist used software to aid data collection but disliked the use of it for
report generation. A colleague was currently designing a customised software program and the
Accredited Pharmacist was quite excited about its potential.
QUM
Where she had a service agreement with the Aged Care Home the Accredited Pharmacist
provided all QUM; where the pharmacy was the RMMR Provider the Accredited Pharmacist
provided some QUM on a fee basis. The Accredited Pharmacist subscribed to a company in
[state] who supplied the Accredited Pharmacist with guides, drug information booklets and
education packages which she then provided to the facilities. She aimed this QUM at
Registered Nurses and Personal Care Assistants as well as Nurse Unit Managers. She was
also involved in monthly or quarterly newsletters for the staff, newsletters for GPs and other
allied health professionals, and attended MAC meetings.
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The Accredited Pharmacist was not convinced that QUM needed to be done by the Accredited
Pharmacist doing RMMRs.
The quarterly reporting required was considered to be useless with queries as to whether it was
even read by the Department.
Issues
The Accredited Pharmacist was concerned that many supply pharmacies were overwhelmed by
the volume of packing Dose Administration Aids and as a result no longer had the time or
resources to be able to check for interactions and adverse drug affects; she felt therefore that
the RMMR system was vital for reviewing medication use in Aged Care Homes.
She felt that initially GPs were wary of RMMRs:
I think once the GPs see what is involved in the Review system they have found it
quite beneficial to them. Initially I think some of them thought that it was just like an
audit on them.
(Accredited Pharmacist)
Potential RMMR Improvements
The Accredited Pharmacist considered the largest obstacle to RMMRs to be the response of
GPs:
Some are very accepting of the process, collaborate well with the Accredited
Pharmacist, take onboard the comments and suggestions made whereas others
flatly refuse to even read the reports and see the process as an intrusion on their
work. Ultimately increased collaboration is needed.
(Accredited Pharmacist)
The Accredited Pharmacist believed the Aged Care Home should be able to provide referrals for
new residents and residents with changes to medications if one is not provided by the GP.
She was also concerned about QUM activities:
QUM activities have the potential to make a significant impact …however a fee for
service would be better and perhaps lead to more uniform service (across Aged
Care Home)
(Accredited Pharmacist)
Qualitative Comment
The Accredited Pharmacist appeared to be committed to developing a business around
Collaborative Reviews. The business included developing resources for quality assurance and
standardised processes that worked to include GPs. She found that personal contact was
important in cementing relationships and reported developing successful long term relationships
with both GPs and Aged Care Homes.
The cost of servicing rural areas, where substantial travel was involved, was identified as a
barrier to access to the service in rural regions, compounded by a workforce shortage in rural
Accredited Pharmacists.
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Quantitative analysis
CS13’s reported costs could be considered typical of ‘the average Accredited Pharmacist
conducting RMMRs’. In all instances costs reported by CS13 were close to the average across
all cases, or were slightly higher in some places, offset by slightly lower costs in others. Levels
of throughput and collaboration were also close to the average for all cases.
Characteristics
Case Study 13 has worked for 21-24 years in pharmacy. CS13 conducts RMMRs as an
independent contractor. CS13 claims an average of $127 of the $130 Medicare Australia
payments for each Review. The case study is based on 10 visits, averaging a moderate 8.7
Reviews per visit. 75% of these visits were done collaboratively. CS13 travels an average of
143 kilometres per visit, slightly higher than the average for all cases.
Table 25:
Case Study 13 Characteristics
Pharmacist’s Characteristics
Years in Pharmacy
Years accredited
Case 13
All Cases
21-24
18.6
8-10 years
6.8
Location
Metropolitan
Mode of payment
Independent
contractor
Average mount received
$130
$104
Number of visits during period
10
8.0
Average Reviews per visit
8.7
10.8
75%
61%
143
113
Proportion of
collaboratively
Reviews
Average travel distance (km)
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Cost summary
CS13 conducts RMMRs at a slight return. For the average $868 reported expenses, CS13
received an average of $1,105 in Medicare Australia payments.
85% of costs associated with CS13’s RMMRs were associated with pharmacist salary and on
costs. 14% of costs were associated with travel. No administrative time was reported, with a
small fraction of costs allocated to other expenses.
Figure 13:
Salary costs
Salary:
Pharmacist,
$741 , 85%
Travel, $123
, 14%
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Detailed expenses
CS13 showed a cost per visit that was similar to the costs reported when all cases were
combined.
Detailed times and costs for CS13 are provided in the table below. Areas where CS13 differed
from times and costs associated with all cases included higher than average costs during the
visit, offset by lower costs associated with pharmacists’ time after the visit.
Table 26:
Detailed Expenses – Average Times and Costs
Before the visit
Pharmacist
Administration
Other
Other
expenses
Time
(Hours)
3
0
0
-
5.89
Subtotal
During
the visit
Pharmacist
Administration
Other
Other
expenses
Subtotal
Total
Costs
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$123
$88
$211
8.2
0.0
0.0
$410
$$$$410
Subtotal
After the
visit
Pharmacist
Administration
Other
Other
expenses
All Cases
$91
$33
$6
$28
$143
Subtotal
Travel
costs
Travel costs
Time
travel
costs
Cost
$143
$$$-
2.0
0.0
0.0
$100
$$$5
$158
$92
$86
$178
$233
$11
$1
$9
$254
$222
$25
$2
$9
$105
$257
$868
$848
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2.16 Case Study 14
Qualitative discussion
The Case Study also included interviews with 1 DoN and 1 GP
CS14 Background
The Accredited Pharmacist had been in the industry more than ten and became accredited 2-3
years ago. She was an independent sole trader and had one service agreement with an Aged
Care Home which she had serviced for 18 months. She also worked in a community pharmacy
several days a week.
Aged Care Home
The Aged Care Home serviced had 135 beds and was both a high and low care home. The
Accredited Pharmacist visited the Aged Care Home fortnightly and usually conducted 6 RMMRs
each visit. A maximum of 20% of these were Collaborative Reviews. When she formed the
service agreement with the Aged Care Home the Accredited Pharmacist sent a letter to GPs
asking if they would be interested in collaborating in the Reviews; she reported receiving little
response.
RMMR Process
When the Accredited Pharmacist commenced working with the Aged Care Home she
systematically reviewed each resident and this now formed the basis of when Reviews fall due.
All residents were reviewed annually using the Accredited Pharmacist’s data base. She was
advised of new residents or identified them from the Aged Care Home files once at the home.
This process was confirmed by the DoN who reported that the Accredited Pharmacist was very
efficient and worked closely with the Aged Care Home.
It’s easy to identify eligibility, I go through the list and tick them off, but it still takes
a fair bit of time.
(Accredited Pharmacist)
At the Aged Care Home the Accredited Pharmacist checked for new residents; if they had been
transferred from another Aged Care Home she sought referral from the GP. Occasionally the
Aged Care Home would suggest a Review; the Accredited Pharmacist again would seek a
referral in such cases. The Accredited Pharmacist had developed a pro forma referral sheet
which was kept at the home. If she required a referral she completed the form and left it in the
GP book with a note explaining to the GP that he/she would be able to claim for providing a
referral for the resident. She also informed staff that she has requested a referral. The
Accredited Pharmacist stated that this process was time consuming and complained that it was
often difficult to later trace the referral.
It could be in the GP’s book, in the residents file or somewhere else, anywhere!
Then I have to hunt down the Registered Nurse to see if she knows <where it is>.
(Accredited Pharmacist)
However, the DoN appeared unaware of the Accredited Pharmacist’s issue and stated that the
form was simply left in the GP’s file for when he/she next visited.
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I think it works well…if she needs a referral she leaves a form in the GP’s file and
when the GP comes in he completes it.
(GP)
The Accredited Pharmacist accessed all resident files available at the Aged Care Home,
transcribing relevant details onto an A4 sheet for each resident. As a rule, the Accredited
Pharmacist tried to inconvenience the Aged Care Home as little as possible and visited the
home when she knew files would be readily available for use. She reported that she required
clarification from nursing staff for around half of the residents she was reviewing. She did not
speak to the residents themselves. The 6 Reviews usually took until lunchtime and she
completed the reports off site which took around 5 hours additional work. The following day the
Accredited Pharmacist returned to the Aged Care Home and placed the reports in the relevant
resident files:
I like to make sure it’s in the file. I used to hand the reports to the nurse but they
didn’t always put them in the correct spot and there was no annotation anywhere
that the Review had been conducted. They had no processes as no Accredited
Pharmacist had been there before. Most other professionals go there physically
and write in the patients notes so I do it too.
(Accredited Pharmacist)
The Accredited Pharmacist did not send a copy of the report to the GP, having explained to
them that the report would be in the resident’s file for their action. When she advised GPs of
this procedure only one GP requested to receive reports directly. This GP was interviewed and
stated that whilst he always read the Accredited Pharmacists report she never spoke directly
with him. The GP would initiate changes if he considered them to be relevant:
They often do find things that I miss and bring things to my attention but they also
waffle a lot and much of the content is nurse related. “Sit the patient up in bed’ –
what’s that got to do with me? I comment on the thing. They’re relevant at least
30% of the time and if they make the Aged Care Home better and improve
resident’s quality of life it’s worthwhile”
(GP)
The Accredited Pharmacist did not routinely check that recommendations had been actioned by
the GP and she estimated that 50% of all of her Reviews were not acknowledged. She reported
that her recommendations were usually ‘not that major’ and that a quarter of them were mainly a
reminder to order pathology tests. Should any serious issue arise from the RMMR the
Accredited Pharmacist advised the Registered Nurse and gave her the report; the Aged Care
Home then faxed the report through to the GP. The DoN felt that staff brought the RMMR to the
attention of the GP; some were responsive while others were less so but he felt that staff
pointed out issues to the GP and thus ensured that the Review was noted and acted upon
where necessary.
QUM
The Accredited Pharmacist stated that she did little QUM and did not actively encourage it in the
Aged Care Home. She felt that if the Aged Care Home was to become aware that she could
provide QUM, they may ask for a higher level of service which she did not have the time to
provide and for which she felt she was not sufficiently remunerated. However she met with the
MAC on a bi-monthly basis and reported providing information to staff when necessary:
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providing guidelines and assisting in procedures. She had not been involved in audits. This
level of activity was confirmed by the DoN who indicated she was very satisfied with the level of
service this Accredited Pharmacist provided. Prior to this Accredited Pharmacist, the Aged
Care Home did not have any Reviews conducted.
Issues
The Accredited Pharmacist stated that there was more work associated with conducting
Collaborative Reviews and the lack of additional payment for this time acted as a disincentive to
involve the GP. In addition she had been disappointed by the lack of growth in opportunity for
RMMRs and attributed this to the increase in larger companies servicing the area:
There are more large companies around; they have many contracts and employ a
lot of Accredited Pharmacists. Many of the larger chains (Aged Care Homes) have
<name> as their Accredited Pharmacist. Me as an individual, I find it hard to
attract that market.
(Accredited Pharmacist)
The Accredited Pharmacist was also dissatisfied with the funding arrangement for QUM:
It’s easy for facilities to realise QUM could and has to occur at no extra cost (to
them). The more they get us to agree to do the less they have to do themselves.
It’s free work. If it’s absorbed into RMMR then QUM seems cheap and they could
hold us to ransom. I put almost as much effort into an RMMR as an HMR so I don’t
go out of my way to provide (QUM)
(Accredited Pharmacist)
Potential RMMR Improvements
The Accredited Pharmacist wanted to see separate funding for QUM or a cap on the time an
Accredited Pharmacist should spend providing the service. She also felt that the payments for
RMMR should be more in line with HMR which are indexed.
Given the increase in large corporate entities providing RMMRs the Accredited Pharmacist
believed the number of RMMRs conducted by a single entity should be capped. The Accredited
Pharmacist also felt that Accredited Pharmacists should be able to access information for new
residents regarding the timing of their previous RMMR.
Qualitative Comment
This Accredited Pharmacist appeared to work within the parameters of the guidelines but largely
due to lack of remuneration, failed to provide added value service as exhibited by other
independent providers.
Quantitative analysis
Like CS12, CS14 represented as a relatively low throughput and thus low-financial return
Accredited Pharmacist. CS14’s profile of expense and income closely matched CS12’s,
however a slightly higher number of Reviews per visit, possibly coupled with a substantially
lower number of Collaborative Reviews (CS14 did no Collaborative Reviews in the period) lead
to a slightly higher financial return overall for this Accredited Pharmacist.
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Characteristics
Case Study 14 had worked for over 10 years in pharmacy, and was accredited several years
ago. CS14 conducted RMMRs as an independent contractor. CS14 claimed an average of $70
of the $130 Medicare Australia payments for each Review (the remainder going to a company
specialising in Reviews). The case study was based on 5 visits, averaging 6 Reviews per visit,
slightly lower than the average for all cases. None of these visits were done as Collaborative
Reviews. CS14 travelled an average of 99 kilometres per visit, slightly lower than the average
for all cases.
Table 27:
Case Study 14 Characteristics
Pharmacist’s Characteristics
Years in Pharmacy
Years accredited
Case 14
All
Cases
10-12
18.6
2-3
6.8
Location
Regional centre
Mode of payment
Independent
contractor
Average amount received in
payment for RMMR services
$70 (the remainder
going to a company
specialising in
Reviews).
$104
Number of visits during period
5
8.0
Average Reviews per visit
6
10.8
Proportion of Reviews done as
Collaborative Reviews
0%
61%
Average travel distance (km)
99
113
Cost summary
CS14 conducted RMMRs at some financial return. For the average $350 reported expenses,
CS14 received an average of $780 in Medicare Australia payments.
76% of costs associated with CS14’s RMMRs were associated with pharmacist salary and on
costs. The remaining 24% of costs were associated with travel. No administrative time or costs
were reported.
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Figure 14:
Salary costs
Salary:
Pharmacist,
$259 , 76%
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Travel, $82 ,
24%
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Detailed expenses
CS14 showed a substantially lower average cost per visit compared to the costs reported when
all cases were combined.
Detailed times and costs for CS14 are provided in the table below. Areas where CS14 differed
from times and costs associated with all cases included:
•
Substantially lower time and costs reported for all periods: before, during and
after the visit
•
Slightly lower than average travel costs
•
However, CS14 also conducted relatively fewer RMMRs during each visit,
leading to only a relatively modest income in dollar terms.
Table 28:
Detailed Expenses – Average Times and Costs
Before the visit
Time
(Hours)
0
0
0
-
Cost
$10
$$$$10
All
Cases
$91
$33
$6
$28
$158
$82
$59
$142
$92
$86
$178
1.8
0.0
0.0
$90
$$$$90
$233
$11
$1
$9
$254
2.0
0.0
0.3
Subtotal
$100
$$8
$1
$108
$222
$25
$2
$9
$257
Total Costs
$350
$848
Pharmacist
Administration
Other
Other expenses
Subtotal
Travel costs
Travel costs
Time travel costs
Subtotal
During the visit
Pharmacist
Administration
Other
Other expenses
1.65
Subtotal
After the visit
Pharmacist
Administration
Other
Other expenses
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2.17 Case Study 15
Qualitative discussion
The Case Study also included an interview with one 1 Clinical Director
Accredited Pharmacist Background
The Accredited Pharmacist had been practising in the pharmaceutical industry for 13-17 years
and although accredited since 2001 had only recently returned to doing RMMRs again in the
past 2 years, given the shortage of Accredited Pharmacists in the area and a request to assist a
colleague. He was now an independent consultant conducting RMMRs for 6 nursing homes in
the area.
Aged Care Home
The Accredited Pharmacist serviced three homes in the immediate town and three others within
close proximity. He conducted around 300 RMMRs each year.
RMMR Process
Typically, this Accredited Pharmacist called the Aged Care Home and requested an updated
copy of the resident list. He updated his database accordingly and determined who was due for
an RMMR. If a new resident has been admitted the Accredited Pharmacist said he tried to
contact Medicare to determine if an RMMR could be conducted but this has proven to be
unsuccessful in the past and was time consuming.
Time at the Aged Care Home was often spent finding drug charts, resident histories and talking
to nursing staff about any changes in the residents or any problems they may have. The Clinical
Director reported that the Accredited Pharmacist spoke to those residents who were selfmedicating as well as staff in order to obtain a clearer picture of the residents’ status. RMMR
reports were prepared off site and sent to the Aged Care Home and GP irrespective of whether
the RMMR was Collaborative or not. The Accredited Pharmacist understood that the Aged
Care Home ensured the GPs saw the report usually via Medical Director, prior to their rounds,
and that any recommendations were actioned. The Clinical Director interviewed confirmed this
process. The Accredited Pharmacist acknowledged that if the GP did not visit the home
frequently, there was no guarantee the RMMR report would be read or acted upon. The Clinical
Director commented spontaneously that GP involvement was difficult for the Accredited
Pharmacist to achieve especially amongst those GPs who visit the home infrequently. He also
stated that one particular GP who managed around half of the Aged Care Home residents was
often unresponsive to RMMR reports.
They [the recommendations] usually mean more work for her as well as us; for
example daily blood pressures, trials of medications. But on the whole it’s OK.
(Clinical Director)
The Accredited Pharmacist reported that only a few of his Reviews were Collaborative Reviews
despite past attempts to involve GPs. For the few Collaborative Reviews this Accredited
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Pharmacist conducted, he reported to get direct feedback from only 2 or 3 GPs despite
providing a space on all reports for the GP to add any comments.
Usually I don’t see what they write on my report unless I ask for it or look it up at
the nursing home at my next visit.
(Accredited Pharmacist)
On the few occasions when a GP genuinely collaborated the Accredited Pharmacist found the
process to be exceptionally useful.
Occasionally a GP sends me information on a patient. This is fantastically helpful
as some information is hard to track down and I get all the information and I can
prepare everything before I go to the home, for example demographic data,
medication list etc so I need to spend less time on site.
(Accredited Pharmacist)
QUM
This Accredited Pharmacist reported providing lectures, drug audits and discussing issues with
staff as and when required. In conjunction with his colleague he also provided a newsletter for
residents, a number of PowerPoint presentations for the Aged Care Home which were delivered
across the year, drug audits, and drug usage evaluations. He felt this was an important element
of his work and helped to facilitate a good working relationship with the Aged Care Home. He
believed the QUM activities he provided were welcomed by the Aged Care Home, especially
those individuals who traditionally tended to receive little medical training.
Issues
The Accredited Pharmacist believed that many GPs considered the RMMR to be “a waste of
time”. Initially he wrote to GPs inviting them to participate in RMMRs. If they expressed an
interest he sent them a referral form. However, mostly this had not proven to be successful
despite the fact that the Accredited Pharmacist welcomed GP collaboration:
GP feedback makes my Reviews better and we have more discussion and
coordination
(Accredited Pharmacist)
Even if some GPs stated they wanted to collaborate, the Accredited Pharmacist said that many
GPs did not respond to him nor send additional information and he found this lack of feedback
discouraging.
The Accredited Pharmacist questioned if such Collaborative Reviews were truly collaborative;
even when a GP had indicated he/she wanted to be involved in the RMMR and had provided a
referral, there was often no further contact between the Accredited Pharmacist and the GP.
So (when I claim) do I mark it as a Collaborative or not? Probably not as I have no
hardcopy or any proof the report has been read or acted upon and we’ve not
spoken. But I don’t want to do the GP out of a claim.
(Accredited Pharmacist)
The few Collaborative Reviews the Accredited Pharmacist did conduct were felt to be
particularly time consuming – he needed to obtain a referral, and he stated the GP and the
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Accredited Pharmacist need to “line up when (we) claim”. The Accredited Pharmacist believed
that if the GP and Accredited Pharmacist claims were not synchronised, this could impact on the
12 monthly cycle of claiming.
QUM payment as part of the RMMR was thought to be problematic. Some Aged Care Home
needed and received significant QUM whilst some receive little.
Potential RMMR Improvements
The Accredited Pharmacist felt that the remuneration for QUM should be separated from
RMMRs; he also felt strongly that the paperwork associated with quarterly reporting should be
reduced. The Accredited Pharmacist stated he had simplified and re-designed the reporting
form required by Medicare and he used this form to report QUM activity. He indicated he
occasionally forgot to send in the quarterly report.
I’ve received no response about the amended form, and if I forget to send it off
there are no questions asked!
(Accredited Pharmacist)
Qualitative Comment
The Clinical Director was very willing to speak about the Accredited Pharmacist and the RMMR
process and was critical of the lack of involvement of GPs at that particular home. The
Accredited Pharmacist interviewed appeared open and his comments suggested a thorough
appraisal of residents and QUM delivery.
Quantitative analysis
CS15’s cost profile is again similar to CS14’s and CS12’s. Like these other Accredited
Pharmacists, CS15 reported a low number of Reviews in total matched by low costs incurred in
conducting these Reviews, leading to a modest income and a small financial return from
RMMRs.
Characteristics
Case Study 15 had worked for 13-17 years in pharmacy, and was accredited 7-9 years ago.
CS15 conducted RMMRs as an independent contractor. CS15 claimed the full $130 Medicare
Australia payments for each Review. The case study is based on 9 visits, averaging a very low
4.3 Reviews per visit. 34% of these visits were done as Collaborative Reviews. CS15 travelled
an average of 27 kilometres per visit, substantially lower than the average for all cases.
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Table 29:
Case Study 15 Characteristics
Pharmacist’s Characteristics
Years in Pharmacy
Years accredited
Case 15
All Cases
13-17
18.6
7-9
6.8
Location
Rural centre
Mode of payment
Independent
contractor
Average amount received
payment for RMMR services
in
Number of visits during period
Average Reviews per visit
Proportion of
collaboratively
Reviews
Average travel distance (km)
done
$130
$104
9
8.0
4.3
10.8
34%
27
61%
113
Cost summary
CS15 conducts RMMRs at a modest financial return. For the average $400 reported expenses,
CS15 received an average of $557 in Medicare Australia payments.
94% of costs associated with CS15’s RMMRs were associated with pharmacist salary and on
costs. The remaining 6% of costs were associated with travel. No administrative time or costs
were reported.
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Figure 15:
Salary costs
Salary:
Pharmacist,
$376 , 94%
Travel, $23 ,
6%
Detailed expenses
CS15 showed a lower average cost per visit compared to the costs reported when all cases
were combined.
Detailed times and costs for CS15 are provided in the table below. Areas where CS15 differed
from times and costs associated with all cases included:
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•
Lower than average costs in all categories, including time before during and
after the visit; and travel costs
•
Like many independent contractors, the relatively low number of Reviews
conducted per visit led to a relatively low financial return in dollar terms.
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Table 30:
Detailed Expenses – Average Times and Costs
Before the visit
Time
(Hours)
2
0
0
-
Pharmacist
Administration
Other
Other expenses
Cost
$83
$$$$83
All
Cases
$91
$33
$6
$28
$158
$23
$16
$39
$92
$86
$178
3.9
0.0
0.0
$193
$$$$193
$233
$11
$1
$9
$254
0.0
0.0
$$$2
$85
$87
$25
$2
$9
$257
$293
$400
$848
Subtotal
Travel costs
Travel costs
Time travel costs
Subtotal
During the visit
Pharmacist
Administration
Other
Other expenses
0.46
Subtotal
After the visit
Pharmacist
Administration
Other
Other expenses
Subtotal
Total Costs
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2.18 Case Study 16
Qualitative discussion
The Case Study also included an interview with 1 DoN.
CS16 Background
The Accredited Pharmacist had been in the pharmacy industry for over 20 years and became
accredited 7-9 years ago. He lived in and serviced a regional centre. The Accredited
Pharmacist was paid a salary from the community pharmacy which he owned and ran, and
which was also the supply pharmacy to Aged Care Home where the DoN was interviewed.
Aged Care Home and RMMR Provider Background
The Accredited Pharmacist conducted around 250 RMMRs per annum; up to 50% of which he
reported were Collaborative Reviews. However, there appeared to be few collaborative Reviews
conducted at the Aged Care Home interviewed. The Accredited Pharmacist stated he tried to
visit the home every month and to conduct 20-30 RMMRs per visit. However, some homes he
visited only twice a year and in these cases the number of RMMRs conducted per visit was
higher.
RMMR Process
As the Accredited Pharmacist managed the supply pharmacy for the Aged Care Home
interviewed he was privy to most of the medication pertaining to residents and both he and DoN
interviewed consider this to be a major advantage when conducting Reviews. The 106 bed
Aged Care Home was not required by the Accredited Pharmacist to provide lists of residents or
to inform the Accredited Pharmacist of new or deceased residents and often, the DoN claims,
the Accredited Pharmacist was aware of the profiles of a new resident even before the Aged
Care Home itself.
He has a list of all residents and is well aware of who we have and what
medications they are on. Reviewing is more of an ongoing process. He knows the
residents so well and he picks up any changes to their medication fairly quickly at
the pharmacy
(DoN)
The Accredited Pharmacist stated he had a good relationship with GPs at this Aged Care Home
and this reinforced the DoN’s perspective:
A large number of changes are often undertaken outside of the official Review
process purely through the GP contacting the Accredited Pharmacist for advice at
the time of seeing the resident. This process of continued dialogue (rather than an
ad hoc Review) ensures the pharmacists input is continual (the GP is also very
amenable to being contacted and accepting advice from the Accredited Pharmacist
in between these Reviews).
The Review process as part of the supply pharmacy roles, ensures that the GP
knows who and where to obtain advice from regarding prescribing decisions, and
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the supply pharmacy is also always aware of issues relevant to the resident’s
management when dealing with medication changes.
(Accredited Pharmacist)
Prior to his visit to the home, the Accredited Pharmacist obtained print outs of residents’ current
medication profiles from the pharmacy including drug usage history and drug usage reports.
Once at the Aged Care Home, notes for all residents were reviewed including any relevant
laboratory results. The Accredited Pharmacist then liaised with Aged Care Home staff regarding
any medication management issues they may have, either in general or for specific residents.
The Accredited Pharmacist reported a good knowledge of the residents and good relationships
with the GPs and stated that this assisted in conducting the Reviews. The DoN confirmed that
this was the case.
It’s the relationship we have established with the local doctors, and that we often
have lots of input, I have a lot of input on a more day to day basis where they’re
contacting me, and I guess that’s why … we’re in the facilities when they’re in the
facilities, … I just think that that approach works a little bit better, you can have
more input at the actual decision making steps
(Accredited Pharmacist)
The DoN claimed that Collaborative Reviews were not common at the Aged Care Home
interviewed.
The Accredited Pharmacist usually visited this Aged Care Home twice throughout the year and
completed RMMRs on roughly half of the residents each visit. Once reviewed, a report was
provided to the GP and the Aged Care Home. The Accredited Pharmacist encouraged GPs to
indicate that any non-urgent changes be timed with the delivery of Dose Administration Aids in
order to reduce the changing of medication packs and paperwork at the home. The DoN stated
that reports were shown to GPs when they visited although most were reluctant to acknowledge
their value and many she believed feel threatened by the Reviews. She went on to explain that
the Accredited Pharmacist and DoN were trying to encourage some Collaborative Reviews with
GPs but she was unsure of their success.
QUM
The Accredited Pharmacist sat on MAC meetings often in the capital city; these meetings often
covered a number of different Aged Care Homes. Education sessions were also provided
mainly to nurses and support staff who administered medications. The Accredited Pharmacist
found it difficult to ensure all relevant staff attended. The DoN considered that the Aged Care
Home provided a lot of staff education as well as audits themselves and so had little need for
assistance from the Accredited Pharmacist in this regard. She also felt the Accredited
Pharmacist Reviewed the incident logs which were sent to the pharmacy and assisted in their
resolution. The DoN further stated that the Accredited Pharmacist or his staff at the supply
pharmacy were consulted several times a week on various issues or information needs.
Issues
The Accredited Pharmacist believed standardised, computer generated reports are off-putting
for GPs.
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It’s I think sometimes I’ve had another feedback certainly from some but where
they use - I don’t like to use these programs, I’d rather do it on my clinical
knowledge, and make it more structured in terms of what’s important to the doctor,
what’s important to the facility staff, rather than just list every last little problem
that’s potentially there, and I think that also the doctors find it very laborious to
actually go through the reports sometimes.
(Accredited Pharmacist)
He was also concerned about the number of GPs involved in the Aged Care Homes and the
difficulty of encouraging processes and procedures when GPs all had different opinions and
ideas. He believed it was difficult to obtain GP involvement in MAC and that many GPs
knowledge of what really happens in the facilities was poor.
Potential RMMR Improvements:
Neither the Accredited Pharmacist nor the DoN mentioned any specific improvements to the
system.
Qualitative Comment:
The Accredited Pharmacist was unwilling to provide details of the GP from one home despite
describing a good working relationship with him/her. The Accredited Pharmacist was however,
happy to give details of a GP at another Aged Care Home where the Accredited Pharmacist
also conducted Reviews.
The Accredited Pharmacist was re-contacted to query the number of Reviews in the diary and
he claimed some of these Reviews to be ‘chart Reviews’ or ‘Reviews of audits.’ He claimed on
average to try to do 20- 30 RMMRs per visit, but yet appeared to undertake considerably more
at the Aged Care Home which was the subject of the diary for this evaluation.
Quantitative analysis
CS16 represented an outlier when reported costs were considered for all case studies for one
major reason: the sheer volume of RMMRs conducted in a single visit. This high through-put
led to a very high amount claimed and thus high financial return. Only one visit was recorded
during the period and the findings should be interpreted with caution.
Characteristics
Case Study 16 had worked for over 20 years in pharmacy, and was accredited 7-9 years ago.
CS16 conducted RMMRs as a pharmacy owner. CS16 claimed the total $130 Medicare
Australia payments for the visit. The case study is based on 1 visit and thus the results should
be interpreted with caution as this one visit may not be representative of all visits conducted by
CS16. CS16 reported that a very high 47 Reviews were conducted for this visit, 47% of which
were done as Collaborative Reviews. CS16 travelled only 1 kilometre for the visit, far lower
than the average for all cases.
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Table 31:
Case Study 16 Characteristics
Pharmacist’s Characteristics
Years in Pharmacy
Years accredited
Case 16
All
Cases
20-25
18.6
7-9
6.8
Location
Regional centre
Mode of payment
Claimed as a
pharmacy owner
Average amount received in
payment for RMMR services
$130
$104
Number of visits during period
1
8.0
Average Reviews per visit
47
10.8
Proportion of Reviews done
collaboratively
47%
61%
Average travel distance (km)
1
113
Cost summary
CS16 conducted RMMRs at a high financial return. For the average $1,177 reported expenses,
CS16 received $6,110 in Medicare Australia payments.
98% of costs associated with CS16’s RMMRs were associated with pharmacist salary and on
costs. Less than 1% of costs were reported for travel and other expenses
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Figure 16:
Salary costs
Pharmacist,
$1,150 ,
98%
Travel, $0 ,
0%
Detailed expenses
CS16 showed a higher than average cost per visit compared to the costs reported when all
cases were combined. Detailed times and costs for CS16 are provided in the table below.
Areas where CS16 differed from times and costs associated with all cases included:
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Time and expense incurred before the visit were comparable to the average
for all cases
•
Travel time was substantially lower than average (it is assumed that CS16
walked a short distance for the visit)
•
Time and costs during and after the visit were substantially higher than the
average for all cases
•
The very high reported number of Reviews conducted and claimed for the visit
offset the higher cost of conducting the Reviews leading to a high financial
return for CS16.
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Table 32:
Detailed Expenses – Average Times and Costs
Before the visit
Time
(Hours)
3
0
0
-
Pharmacist
Administration
Other
Other expenses
Subtotal
Travel costs
Travel costs
Time travel costs
Subtotal
During the visit
Pharmacist
Administration
Other
Other expenses
$1
$92
$86
$178
8.0
0.0
0.0
$400
$$$$400
$233
$11
$1
$9
$254
12.0
0.5
0.0
$600
$13
$$14
$626
$1,177
$222
$25
$2
$9
$257
$848
0.01
Subtotal
After the visit
Pharmacist
Administration
Other
Other expenses
Subtotal
Total Costs
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Cost
$150
$$$$150
$0
$0
All
Cases
$91
$33
$6
$28
$158
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2.19 Case Study of a Provider of Medication Reviews to an Indigenous
Aged Care Home
Qualitative discussion
The Case Study also included 1 Registered Nurse (in place of a DoN). The relevant GP could
not be reached for an interview.
Accredited Pharmacist Background
The Accredited Pharmacist had been in the industry for several decades and became
accredited in the last few years in order to conduct HMRs in the Indigenous community. He was
now employed one day a week as a pharmacist by the Aboriginal Health Service (AHS) and
conducted ‘Medication Reviews’ on behalf of the clinic at one Aged Care Home. The Aged
Care Home was a non-accredited Aboriginal Aged Care Home outside a regional centre. The
Accredited Pharmacist visited the Aged Care Home about every three months or when
requested by the local GP at the clinic.
Aged Care Home
The Aged Care Home was a 26 bed Aged Care Home whose residents were mainly in high
care. As the Aged Care Home was non-accredited, any Reviews were non-claimable. Given
this, clinic staff took a different approach to the conduct of the Reviews. Initially the Accredited
Pharmacist was asked by the Senior Medical Officer of the Aboriginal Health Service to conduct
Medication Reviews on all residents at the home. The GP had recently become involved with
HMRs and therefore considered Medication Reviews in the aged care setting to have merit.
The Accredited Pharmacist spent two full days conducting and reporting on Medication Reviews
but the GP left and the reports were not read or acted upon.
In the most recent year, a new GP at the clinic suggested the Accredited Pharmacist Review
residents in an informal manner. As a result the Accredited Pharmacist accompanies the GP to
the Aged Care Home for annual CMAs. Initially all 26 residents were given an informal
Medication Review and a CMA over the period of a few days. However, Reviews were now
spaced across the year and the Accredited Pharmacist visited the home with the clinic GP every
3 months for the CMAs and Medication Reviews. All residents fell under the care of the clinic
and the Accredited Pharmacist stated the GP visited the Aged Care Home at least once a week
and as a result was very familiar with the current 24 residents in the home and their diagnoses.
Medication Review Process
At the time of a resident’s CMA, the Accredited Pharmacist attended the Aged Care Home with
the GP and the clinic Registered Nurse. All three met with the Aged Care Home’s Registered
Nurse. Until arriving at the Aged Care Home the Accredited Pharmacist had no firm indication of
the number of Reviews he would be required to conduct other than those receiving a CMA. New
residents or residents the GP or Aged Care Home were concerned about may be added to the
list of residents requiring a Medication Review once the team was on site. Medical charts and
Drug Administration Aids of residents along with any other relevant information available from
residents’ files are reviewed in conjunction with the GP and the Aged Care Home staff. Being
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present with the GP and Registered Nurse meant the Accredited Pharmacist was able to obtain
relevant, topical background information about the residents.
This is really beneficial, we all three talk and its good, The RN is there so she can
tell me any issues with the residents and it works well.
(Accredited Pharmacist)
The Accredited Pharmacist also considered this process saved time searching through medical
records. The Aged Care Home nurse also identified any pressing issues and thus the resident
was discussed from a multidisciplinary team approach. The Accredited Pharmacist considered
this process to be a much less time consuming exercise than the prescribed RMMRs procedure
and both the Accredited Pharmacist and the Registered Nurse at the Aged Care Home claim
the Reviews work well.
If there are any changes, they (the GP) call the pharmacy and the GP writes out a
new script and it all happens there and then. I’m doing a course at <institution>
and the other Registered Nurses I talk to say it doesn’t work like that in their
facilities and they ask me ‘How come you manage to get CMAs done and all those
Reviews?’ So I reckon it’s brilliant!
(RN)
The team visited all residents requiring a CMA and a Review and discussed all medication and
care options at that time. Medicines were ceased or changed immediately as the team decided.
The team also visited any other residents requiring attention at that time. The Accredited
Pharmacist no longer wrote long reports but ‘findings are actioned based on timely, relevant
information and decisions made during the Review and CMA’. The Accredited Pharmacist
acknowledged that conducting the Review in this manner may not have been considered best
practice but he was convinced that the process worked well. Results were later recorded on the
clinic database, along with any changes to medication, and a short report was written for the
Aged Care Home and stored in the resident’s file.
Until recently, the GPs updated the electronic medical records but this was now the
responsibility of the Accredited Pharmacist. The Accredited Pharmacist also liaised with the
supply pharmacy to notify them of any changes made during Review, although the GP still wrote
any new script/s. The Reviews formed part of the job the Accredited Pharmacist held at the
clinic and for which he was paid a salary. The GP was able to claim for his/her time spent at the
home via ‘Cycle of Care’ funding which was specific to Aboriginal Health Care. The fee was
paid directly to the Aboriginal Health Service and not the GP.
QUM
Informal education and advice was provided on an as needs basis and discussion was
commonplace on the days the Accredited Pharmacist visits the Aged Care Home.
I provide advice there and then and it’s truly a collaborative exercise
(Accredited Pharmacist)
The Registered Nurse reported to learn a lot through listening to the GP and Accredited
Pharmacist discuss each resident.
We all sit there afterwards and met and talk about each resident. I just sit and
listen to them talk. It’s fantastic. I love it
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(RN)
In addition the Accredited Pharmacist claims to provide drug information, advice on the practical
requirements of medication management and generally advises members of the health care
team within the Aged Care Home and clinic on medication issues.
Issues
The Accredited Pharmacist felt this approach worked well and was both time and cost efficient
I know this is a unique situation as not many clinics employ a pharmacist but it is
definitely cheaper for everyone and less time consuming also. I find this
arrangement more beneficial for the client as their care is discussed with all
information being considered - something that is not always possible to achieve
from reading the medical records alone. Important things - at that very spot in time
- are communicated to me. The GP and nurse have also commented positively on
my involvement in this process so it helps support the multidisciplinary team
approach.
(Accredited Pharmacist)
The Accredited Pharmacist felt his work was recognised and being used by the GP and Aged
Care Home, and interviews support this.
Potential Improvements
The Accredited Pharmacist considered his method to be a much more cost-effective approach
to conducting Reviews.
Qualitative Comment
This case study provided an example of Medication Reviews being conducting in a nonaccredited Indigenous Aged Care Home. The Accredited Pharmacist and Aged Care Home
claimed to find the Reviews useful and interviewees seemed open and frank.
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