Why we need pharmacists integrated in Aboriginal Health Services

In 2001, after 20 years as a pharmacist in Sydney, I moved to Bathurst, a regional centre in NSW’s Central West. At the pharmacy, I was suddenly aware of a higher percentage of Aboriginal clients.

Although I treated everyone with compassion and respect, I was aware that my engagement with these clients should have been better. I had received no training and had little understanding.

As an accredited pharmacist, I experienced how HMRs could assist patient and GP understanding of the complexities of medicines, prescribing, patient self-management and the healthcare system. I wondered if HMRs might be useful for improving health outcomes for Aboriginal people and why I had never received an HMR referral for an Aboriginal client.

I began my PhD studies in 2009 in a quest to find a way to make HMRs useful and accessible for Aboriginal and Torres Strait Islander people. I ran focus groups with Aboriginal and Torres Strait Islander people (n=102) to explore their views of medication use and medication review. I conducted semi-structured interviews with Aboriginal Health Service (AHS) health professionals (n= 31) to explore perceptions of the HMR program and suggestions for a more readily accessible model of medication review service. I also used a cross-sectional survey to gather data from HMR accredited pharmacists (n=187) about their engagement with AHSs and their Aboriginal clients.

Participants from the patient, service provider and pharmacist groups confirmed that little or no medication education occurred with Aboriginal and Torres Strait Islander clients, and that these people were low users of the HMR program, despite their high burden of chronic disease.^1,2 All groups agreed medication review might be a useful tool to increase medication knowledge and adherence. However, most said they found the current HMR program rules and processes inappropriate for Aboriginal and Torres Strait Islander people, from both cultural and AHS systems perspectives.^1,2,3,4

The synthesised results from my research concluded that the most effective way to optimise medication outcomes for Aboriginal and Torres Strait Islander people was to have a pharmacist co-located within an AHS.⁵ This conclusion is discussed below. The full methods and findings of this study can be found in various publications as referenced 1–5.

Pharmacists co-located in AHSs are needed to drive the medication review processes and integrate medication review into AHS systems and chronic disease management programs. Closer working relationships between pharmacists and AHS GPs, nurses and Aboriginal Health Workers would facilitate improved inter-professional healthcare. The AHS pharmacist would have time to develop the trust, relationships and cultural competency needed to enable effective, appropriate communication with Aboriginal and Torres Strait Islander patients and AHS staff in a culturally safe environment. The AHS pharmacist would also be able to source or create appropriate written medication resources for their patients.⁵ Access to medical software and complete patient histories would enable the AHS pharmacist to make meaningful, informed clinical interventions.⁶

Co-location of a pharmacist within an AHS would allow the pharmacist to regularly engage with patients and deliver appropriate levels of service, be that stand-alone medication counselling, medication reconciliation, medication adherence coaching, a full medication review, a group medication education session, a tailored interaction to address a patient’s individual needs or a combination of all of the above.⁶

An AHS pharmacist would also assist patients to navigate our complex health and dispensing systems, overcome any medication access barriers and liaise closely with community pharmacies on such services as DAAs, prescriptions and medication supply. They could also assist administering programs such as QUMAX, and in remote AHSs where medicines are received in bulk and usually dispensed by nurses, GPs or AHWs, the pharmacist might also oversee some dispensing and supply processes.⁶

The few pharmacists who are employed by AHSs are mostly funded through chronic disease programs and sometimes funding from the Medical Specialist Outreach Assistance program for Indigenous Chronic Disease. It is complicated and time-consuming to achieve this funding, and often AHSs have to choose between employing pharmacy and nursing staff. While AHSs have little experience of a non-dispensing pharmacist’s role, and there is no remuneration specifically allocated for pharmacists, they will often continue to prioritise employment of nurses. Thus, the Government needs to provide specific funding for AHS pharmacist positions. Pharmacists in AHSs need to be salaried or able to receive extended MBS funding (not just HMR) for their services. If pharmacists were employed in salaried positions within AHSs they would not need to claim for HMRs through the MBS program and this would ‘free up’ some of this capped funding pool for HMRs. It would also free up pharmacists to deliver flexible medication review services, tailored to client needs, without the constraints of HMR program rules.

Follow-up research evaluating alternative medication review models and multiple interventions is needed. Therefore, I was thrilled to hear the recent announcements that under the 6CPA Pharmacy Trials Program, the Department of Health will fund two pilot programs exploring medication management and medication review models for Aboriginal and Torres Strait Islander people.

References

1. Swain L, Barclay L. They’ve given me that many tablets, I’m bushed. I don’t know where I’m going. Australian Journal of Rural Health 2013;21(4):216–9.
2. Swain L, Barclay L. Exploration of Aboriginal and Torres Strait Islander perspectives of Home Medicines Review. Rural and Remote Health 2015;15(3009).
3. Swain L, Barclay L. Medication reviews are useful, but the model needs to be changed: perspectives of Aboriginal Health Service health professionals on Home Medicines Reviews. BMC Health Services Research 2015;15(3666).
4. Swain L, Griffits C, Pont L, Barclay L. Attitudes of pharmacists to provision of Home Medicines Review for Indigenous Australians. International Journal of Clinical Pharmacy 2014;36(6):1260–7.
5. Swain L, Barclay L. Why pharmacists should be integrated into Aboriginal Health Services – a recent mixed methods study investigating medication review with Aboriginal and Torres Strait Islander patients. (In press)
6. Swain L. A day in the life of a clinic pharmacist. Australian Pharmacist 2014;2014(10):25.

LINDY SWAIN is a pharmacist academic at the University Centre for Rural Health, North Coast.