How Julian Soriano MPS found his passion for aged care

Peter [00:00:00] From the Pharmaceutical Society of Australia, hello and welcome to Pharmacy and Me, the podcast that explores how pharmacists do the extraordinary things they do. I’m Peter Guthrey from PSA and a community pharmacist at a 24/7 pharmacy in Melbourne.

Hannah [00:00:25] And I’m Hannah Knowles, a senior pharmacist at the Royal Brisbane and Women’s Hospital.

Peter [00:00:30] Each episode, we speak to a pharmacist doing outstanding work about the highs and lows of their career, unpacking what they’ve learned and how you can put their experience into your practice.

Hannah [00:00:42] Today we’re speaking with Julian Soriano, an embedded aged care pharmacist at Tanunda Lutheran Home in South Australia. Julian finished his pharmacy degree in 2014 and quickly found his passion for aged care. We’re really excited to have him on the show to talk about such an important topic. So, joining us from the facility today, here’s Julian.

Julian [00:01:03] Thanks for having me, guys.

Peter [00:00:55] So, Julian, to start off with, tell us a little bit about yourself: who are you and what do you do?

Julian [00:01:1] One of the probably overlaying things is I’m a pharmacist, but we’re probably going to talk about that quite a bit. So outside of that, I am a sports enthusiast. I really love my football, and when I talk football, I talk round ball, the world game. So aside from that I enjoy a bit of food, a bit of wine, which makes working in the Barossa a fantastic place to be.

Peter [00:01:27] Sounds fantastic. To those that aren’t familiar with the concept, what is an aged care pharmacist? What do they do?

Julian [00:01:33] My method or my role as an aged care pharmacist being embedded at a nursing home is, I work three days a week at the nursing home, now for the nursing home. And I’m essentially responsible for everything medication-related, but as I’ve very quickly discovered, being here for a while, there are so many other things that we can do and that I do get involved in when it comes to resident care in nursing homes.

Peter [00:01:56] So if we break it down to a bit more detail, when you walk through the doors as a pharmacist on-site, what does an average day look like for you?

Julian [00:02:02] As probably most pharmacists will appreciate, when you’re working with patients there’s no average days. But I’ll try and break down probably what I’m doing the most. So we have quite a few meetings and we have clinical team meetings and that’s with our nursing staff. It’s normally with allied health, the physio – we have physios on-site regularly too – and nursing home management, as well as our lifestyle team. I actually really enjoy working with them too. But during this clinical meeting, we go through and talk about some of our residents, and we look at residents that might be of concern. That could be things like their recent experiences and difficulties, issues, if they had a fall, if they’re becoming socially isolated, having pain issues.

We go through a list of residents like that and we kind of discuss care plans or care action plans for the next week or so with them. I really enjoy being part of these meetings. As a pharmacist there’s lots we can input in there, particularly things around recent medication changes or how their medications might be affecting their condition. And also, being able to liaise with the GPs about suggested plans and bring up queries. So that’s most mornings.

I also spend a bit of time with the visiting GPs. We’re quite lucky here, we have a GP visit most days. So once the GP is done with their rounds, I’ll generally catch up with them afterwards. We’ll have a bit of a chat about things they might have seen on their round, any queries that I might have come up with during the week or found during medication reviews. And I think the GPs have actually really started to embrace this. They come and find me now sometimes, which is a good thing to see. And I think something that they’ve really enjoyed during these rounds and talking is around deprescribing. Sometimes they just need someone to bounce some ideas off because it’s such a grey area sometimes. That’s some of the clinical regular work that we do. Also, we have regular case conferencing here at the home, and this is probably something that I’ve really enjoyed being on-site. So the case conference would involve the nursing staff, the GP and normally the resident and the resident’s family, and these are great opportunities to discuss residents’ care with them.

So we talk about all the patient-centric issues, so things they might be experiencing like pain, mobility issues, whatever is important to them. It’s a great opportunity for us to discuss things like deprescribing and getting their opinion and ideas and talking to them about how we can optimise care. You get some things that you would never have thought of. An example I have is, we had a resident who was just refusing to take medications, and these were analgesics because the resident had quite a bit of pain. We were kind of running out of tricks and ways to do it, and his wife came to one of these case conferences and said, oh, I used to give him apple juice at home with his medications and he did it fine. And after that, no issues at all, apple juice works a treat. It’s something we probably never would have stumbled upon, but keeping the family involved is really important there as well.

Hannah [00:04:45] It’s really amazing some of the solutions you can come up with that aren’t usually out of the textbook.

Julian [00:04:50] Yes, absolutely. So, yes, there’s a lot more things, a lot of things like audit work, looking at medications such as antipsychotics and analgesics, making sure, we’re trying to optimise the use of those.

Peter [00:05:06] What does the drug audit look like? It’s not something that maybe is familiar to all pharmacists.

Julian [00:05:08] I’ll use maybe antipsychotic audits as an example because it’s probably one that we do the most. But what we generally do is get a list of all the residents using these medications at the home, and then I like to go through, and fairly regularly, so I do it about every three months, I go through and look at why they’re using them, how effective they’ve been, and whether there’s any possibility that we could start looking at changing, reducing, and deprescribing, that sort of thing as well. And I’ll feed this data back to the GPs because the GPs are quite curious about this. And from there we can, sort of, make management plans for these residents and we’ve had really good success with these. We’ve reduced and started stopping a lot of antipsychotics, which had really good results for the residents.

Peter [00:05:52] That sounds really promising, particularly with the antipsychotics after the Royal Commission into Aged Care had some really quite shocking findings how they were being used.

Julian [00:06:01] Yes, I was quite fortunate that the home, before I came, had a fairly good low rate, I guess. A low number of residents on antipsychotics. But from there I’ve helped reduce by about 20% the amount of antipsychotics we use and we’re almost down to zero regular benzos.

Hannah [00:06:13] Brilliant job.

Julian [00:06:15] Yes. So it’s been really good. And I think the thing I’m probably most proud of is we’ve been able to sustain that. So a lot of residents haven’t jumped back on antipsychotics and we haven’t sort of seen an increased use after a big decrease. So yes, it’s been really good.

Hannah [00:06:28] So prior to your intervention, Julian, what was the trend for prescribing with antipsychotics in your facility?

Julian [00:06:35] Like I said, they actually weren’t too bad when we compared to other facilities, but we had a fairly regular and kind of increasing rate. And what we kind of found is some people would get started on antipsychotics and they would never get stopped, it would kind of get missed. They might be sitting on the PRN list for a couple of years before they get properly reviewed and taken off, and that kind of just added to that risk. So something, and some really low-hanging fruit, was to go find these residents, find a resident who hasn’t had any issues with their behaviour for, you know, sometimes it’s up to a year or two. And that was quite an easy way to reduce those numbers but reduce that risk. We’re not really treating numbers here, we’re treating people, reducing that risk for those residents.

Peter [00:07:13] Has taking the family on that journey been part of it as well in your role as a pharmacist? Because there’s often a great reluctance to take people off medicines where the family may feel that’s helped stabilise somebody.

Julian [00:07:22] Yes. And that could be quite difficult sometimes. So as pharmacists, I think we spend a lot of time speaking with patients, residents here, with families. So we kind of have a good understanding of how to communicate. And sometimes that pharmacist touch helps people to realise why we’re doing this process, what the benefits are, and helps them make better, more informed decisions rather than sort of being told, mum, dad, whoever has to stop these medications. From those conversations, it’s very, like you said, it’s very varied between people. Some people have come and said, yes, let’s just stop everything, why not, whereas others have said, no, no, no, you know, I understand that, but I still want dad or mum to be on the medications that they’re on now.

Hannah [00:08:04] Absolutely. And Julian, it sounds like you’ve become a real part of the team there at Tanunda, but I imagine things were quite different when you first started. What did going into the facility look like and actually establishing a new role?

Julian [00:08:18] It was interesting. It was difficult. The aged care home probably didn’t really understand what a pharmacist could do, aside from the usual chart review, recommendations to GPs. So it was a little bit of finding my feet and seeing where the gaps were. So I spent quite a bit of time shadowing the staff at the home, the nurses, and the management team, and kind of trying to pick up on what were their biggest gripes? What were some of the big issues they were facing every day?

Peter [00:08:46] What were the biggest gripes?

Julian [00:08:48] A lot of them were complaining about their medication rounds. They were very long; they were very complicated. So that’s something we kind of jumped on early. The home also wanted a little bit more information about what their medication use was like. They didn’t have very clear data and the data they had, they didn’t really know how to interpret, so I kind of went through that. Again, I’m not a huge data fan. I think, again, we’re treating the people, so it was a way around using that to help manage those. But then, yes, the other people were the GPs, too. So GPs are obviously not working for the home, but are obviously integral in the medication management side of things. Yes, talking to them and having some long conversations about what they want to see, what they think their problems are, and where to go.

Hannah [00:09:27] Julian, there’s quite a few different things that you’re now doing in the nursing home, and after engaging with management and the doctors and nurses, what were the big surprises of roles that they wanted you to do?

Julian [00:09:38] I mentioned to them that I had a bit of a passion for palliative care. In particular, I wanted to look at palliative care and how we use medicines. But they kind of took that as, oh, let’s just do everything palliative care for Julian. So I ended up with a role where I was looking at getting advance care directives, organising 7 Step Pathways, and that kind of thing. And there was a point there where I was a bit like, this is probably a bit beyond me at the moment, I definitely need some more training. So I’ve looked to upskill in that area, but also had to say, look, I need to maybe step back a bit and work on that. So there’s been quite a few examples of things that maybe we’ve tried that didn’t work as well and kind of had to go back to the drawing board. So being in a smaller home too, like a single home rather than a big corporate, was really good for that, because I was able to sort of implement things quite quickly. And then also, if they didn’t work that well, we could re-evaluate and learn from those experiences.

Hannah [00:10:26] And what were some of your key learnings from the projects that may not have gone so well?

Julian [00:10:31] Communication, I actually think, is probably one of the really important things. So, a lot of the projects we had involved nurses and things like medication rounds. So one of the things we looked at doing was simplifying the medication rounds a little bit, so reducing maybe the dose times and when the doses were given. Probably didn’t consult the nurses enough with that and changed dose times to when it was really inconvenient for the nurses and residents. So, yes, I kind of learned very quickly, let’s try to get everyone on board.

Hannah [00:10:57] I’ve learned that as a junior pharmacist as well. You’ve changed the dose and then realised it was in the middle of handover. And very quickly learned why that’s not good.

Julian [00:11:08] On paper it looked great. But, you know, we don’t live on paper. So, I’m glad I learned that early on and it wasn’t a big issue.

Hannah [00:11:17] Was there a particular experience that you’ve had as a pharmacist that made you so passionate about aged care and then palliative care?

Julian [00:11:22] I don’t know if there was a particular experience that really drew my attention. I started my aged care journey doing RMMRs with a group or a company in South Australia who did RMMRs, and I really enjoyed the work. I really loved, kind of, one of the pharmacists I work with said we’re kind of like detectives, we go in and find some evidence, put everything together and make a picture and then make a solution. I really enjoyed that clinical side of things. And then being at the aged care homes, I had a little bit of frustration, and I would see things that maybe were outside of my capacity to fix as sort of a visiting accredited pharmacist. Things like system issues and GPs not responding to advice and that kind of thing. So, that really sort of stirred my passion about, that there’s definitely more that we need to do in aged care to get things better for our residents.

Peter [00:12:10] It’s a really lovely point that you make about developing a passion and seeing the value of having a pharmacist that is embedded in aged care. PSA has partnered with a number of PHN’s around the country to really test the concept of the value of having pharmacists in the aged care facility and clearly, they see value in you. They’ve kept you on after the end of that project as an employed member of staff. You’ve already started doing some work as a senior pharmacist in palliative care with the SAHLN, and that’s a more recent thing in palliative care, what have you been able to do in that role and what does that role look like every day?

Julian [00:12:44] So, my role with this palliative care service, the Southern Adelaide Palliative Care Service, is around redeveloping and remodelling their community palliative care service. So we’re looking at implementing a 7-day service rather than the 5-day and then an on-call service they have, as well as making the teams of nurses and consultant doctors work more efficiently together. They were really keen to get a pharmacist in, particularly the head consultant was always aware that pharmacists had quite a good understanding of the system and how systems work, and he was quite keen to get a pharmacist in for that. And he’s had some experiences, some really good palliative care pharmacists too, so I think I got to ride on their coattails a little bit. But yes, it’s been a really rewarding and really enjoyable aspect and sort of seeing the inner workings of how the aged care home works and then also how the external specialist palliative care service works and starting to think about ways that they can connect better as well.

Peter [00:13:52] What makes a really good palliative care pharmacist?

Julian [00:13:56] A lot of compassion. A lot of compassion, a lot of empathy. It’s a really difficult time in someone’s life, so having that patience and compassion is really important. You’ll see a lot of things that might not necessarily fit in our black and white, this is what the guidelines say. Particularly at end of life, people will all want different things, so being adaptable and understanding and making sure the patient is always first and their decisions, or the carer, whoever is making the decisions, those things are met with when they’re needed.

Peter [00:14:26] Is there any advice that you have to say for community pharmacists that often sort of come into a palliative care arrangement quite suddenly when someone might present with prescriptions? Is there any tips and advice you can provide for them?

Julian [00:14:37] Yes, absolutely. So palliative care can be really tricky in the community, and talking to a lot of people, it seems that sometimes the pharmacy isn’t necessarily the issue. It’s the issue of the pharmacist finding out about the palliative care patient very late on in the journey and not being adequately supplied. So one thing that I think is really important is developing a good relationship with your GPs nearby. Having a great relationship where you can call a GP and you know, if it’s on their mobile and you’re avoiding the gatekeepers at the front desk, even better, get a DD script quickly for your palliative care patient. But also talking to the palliative care patient and finding out things like, what would they need? What are they going to require? When they come in, checking up and saying, do you have enough of XYZ medications at home? So that proactive planning is probably my best advice for community pharmacists, because if you don’t plan proactively, you’re going to end up with the notorious Saturday 10 minutes before closing, I need a huge supply of all these medications, situation.

Hannah [00:15:34] Yes. It’s always an issue that supply. Have you had any patients have issues with supply in pharmacies in South Australia with getting access to palliative care meds?

Julian [00:15:43] It’s actually an interesting question and it goes back to what did the nursing home want from me when I started. When I first started, they just recently had an issue with a resident who was prescribed some palliative care medications, but the medications just weren’t available, so they weren’t in the imprest at the home. The GP had come in on a weekend, so it was a locum GP on a Saturday night, I think. So the supply pharmacy wasn’t open and when they called the supply pharmacy, they couldn’t get the drugs. It’s one of those typical horror stories. And the big issue was that the GP and the nurses at the nursing home didn’t know what was on imprest. So the GP prescribed something that we didn’t keep at the home, when there were really good options available. So yes, that was actually one of the first things they said to me. They said, look, we had this issue, it was really bad, how do we stop it from happening? So something we did is, we went through and revamped how the imprest system works. So we sort of made a little expert advisory group for the imprest and that involved the GPs who prescribe at the home, the nursing staff and the supply pharmacy, and went through and made sure it was up to date to manage most of the end of life symptoms we’d expect, but also it supported the prescribers’ habits nearby as well.

Peter [00:16:30] And on the issue of, sort of, a minimum stock list, if memory serves correct, the South Australian branch led by Helen Stone has done some work with one of the PHNs on a minimum formulary list. Do you have any experience with that?

Julian [00:16:49] Yes. I think that was called the Palliative Care Access to Medicines Project. And it was essentially trying to establish a universal list of, I think it ends up with five medications that community pharmacies could keep on hand to support palliative care patients.

Peter [00:16:56] What are the medicines on that list?

Julian [00:17:00] Morphine ampoules, haloperidol ampoules, metoclopramide ampoules, there was midazolam ampoules and hyoscine hydrobromide.

Peter [00:17:10] So all in all, pretty low-cost things that wouldn’t be too difficult for most pharmacies to keep in stock.

Julian [00:17:14] Absolutely, quite low-cost things. But sometimes things are fairly rarely used or not commonly prescribed, but yes, definitely right, low-cost and potentially very important to someone’s care.

Hannah [00:17:26] Yes, we’ve had a similar program come out of Queensland called PaliPharm and the cost of all the drugs on the formulary was only about $100. So for the impact it can make on someone’s life and the access to care, it’s really not much at all.

Julian [00:17:45] Unfortunately though, as a pharmacist, I think we do this a lot, we end up shouldering that burden. So if there was a way that we could get supported to keep those medications in stock, and you know, almost like a palliative care doctor’s bag, something that we could keep in the pharmacy that would be one way to support pharmacists to keep those medications.

Peter [00:18:03] Back in August at PSA21 Virtual, Julian, you posted on Twitter that male incontinence in aged care is one of the most common issues that residents bring up when discussing their care in a residential aged care facility. I guess that’s a far cry from some of the more common things we hear about antipsychotic use, benzos, and some of those. What have those conversations been like, and how have you been able to help those residents?

Julian [00:18:23] Yes, absolutely. I think particularly male incontinence, I mean incontinence in general, if someone’s experiencing that, it’s always a priority, the top priority on their list. It causes a lot of anxiety, a lot of distress for them. So a lot of the time when I’ve gone to talk to residents about medications and not even brought that up, that’s been their number one issue. They’ve been, oh I’m struggling to go to the toilet, I have to go very quickly, or I can’t go, it causes me a lot of distress. So it’s been really interesting hearing and talking to them about that. Medications can play a role in that, and there can be medications to help. So a good medication review, are there any medications contributing to these issues? And there’s been a few opportunities where that has been the case. But then also, it’s something that we can flag with nursing staff and those multidisciplinary team meetings I was talking about, something that we can bring up there and go, let’s make sure we’ve got a good plan to help manage this person’s incontinence.

Peter [00:19:14] What are some of the red flag medicines that you’re looking out for in that situation?

Julian [00:19:18] So things that can increase incontinence, the things like your cholinesterase inhibitors, they are quite commonly prescribed, so things like donepezil, galantamine, and that kind of thing. Furosemide can be another one. We love a lot of furosemide and residents are on furosemide, so managing around that as well can be really, really interesting there.

Hannah [00:19:39] Is there any non-pharmacological intervention you look at implementing in the home while having those reviews?

Julian [00:19:44] The non-pharma stuff isn’t my expertise, so we generally refer to the physio team, the OT team and the nurses. But things I’ve seen are things like commodes next to the bed or urine bottles that the residents can use rather quickly. Even things like incontinence aids, so adult pads and that kind of thing, are all things that have had mixed success with some of our residents that help them to maintain their dignity and relieve them.

Hannah [00:20:11] It’s a really important issue. And before Pete was saying how something like that is not something that people typically associate with the role of the aged care pharmacist. What misconceptions do you think people have about the role of an aged care pharmacist?

Julian [00:20:24] There’s a few misconceptions actually, and having spoken to people, unfortunately, most of this role has been during COVID times that I haven’t got to meet people face to face, but, speaking to a few people, they’ve mentioned all the things of they just thought we would just sit there and review charts and talk to doctors about drug interactions and talk to nurses about don’t give this medication with food and that kind of thing. But to be honest, we do a lot of that, but it’s becoming a smaller and smaller part of the role. And like I said, I think a lot of the advantage of being on-site is a lot of those system-based changes we can make to help prevent any of these issues happening before they occur is something that has been really useful.

Hannah [00:21:03] Again, we were talking off-mic about one of the system implementations you did with the controlled drug book. Do you want to talk us through that?

Julian [00:21:12] Yes. And for anyone working with an aged care home, so community pharmacy, you would have experienced this, it happens very frequently. But I got a message from the care coordinator at one of the sites I was working at, and they said, oh no, the DD book, the count’s out again, but we don’t know what happened. So we went and had a look and it looked like there were some medications that weren’t counted in at the start of the week. And then that mistake had been followed through for the next 5 days. So it meant that 15 pairs of nurses had gone and counted those medications, because we count every shift, and none of them had picked up on it until right at the end. So talking to the facility, the care managers were like we need to do education, we need some sessions, this isn’t good enough. And if you think about it, like nurses know how to count, they can count to fifteen. It’s not, that probably wasn’t the issue. So talking to the nurses and having the time to be able to find the nurses, I already had some rapport with them

Hannah [00:22:02] There definitely is a thinking that education solves everything.

Julian [00:22:08] Right. So yes, having that opportunity to find out what was actually going on was really valuable. And we found that things like the stationery they were using was really complicated, and they were having to fill in two different books, and they didn’t have any really protected time to do it. So they were being interrupted during the count or they’re doing the count while they’re doing the handover. So we fixed all of those. Better stationery, change the way that they log it in, gave them some more protected time. And since that’s happened, we haven’t had any issues where we’ve had medications not being counted properly, and that’s either they’re just counting them really badly and haven’t found the mistakes or yes, it’s actually working.

Peter [00:22:40] You popped this in a poster for PSA21 Virtual called ‘Who Are You Going to Call?’, which really explored that behaviour change is more than simply having that knee jerk education response, but actually having a fairly structured approach to looking at some of those issues. How did you find that as an approach to try? Did that come naturally or is it something you really had to focus on?

Julian [00:23:02] I can’t claim too much credit for it. So, my partner, Deanna is doing a PhD at the moment on behaviour change, or it’s a big component of her PhD. So I’ve had it drilled into me at home about education isn’t always the key and look at the behaviours. So I’ve been really lucky in that aspect but it’s really something I think really rings true. Looking for the cause or what’s influencing these behaviours that we think are inappropriate and fixing the root cause rather than sort of slapping a band-aid on top. It’s actually really helped me with my work at the aged care home.

Hannah [00:23:33] So you’ve mentioned Deanna already, and we will be talking to her in an upcoming podcast. How do you find that your practice has changed by connecting with like-minded pharmacists?

Julian [00:23:44] I think mentorship is really important and it’s been really valuable for me. Having someone like Deanna who I can use as my sounding board, and she probably gets really sick of it, but to run ideas past and get a different perspective, and she’s always quite honest with me and would tell me, you know, that sound stupid. But I’ve also been really lucky to have some really good mentors throughout my career so far. So pharmacists like Natalie Soulsby, who’s quite well known in South Australia and has been in aged care for a long, long time. I started out and did my accreditation with her, and she mentored me through the whole process. And I got a really good insight into how to do a clinical review and how to do aged care reviews and a lot about the aged care industry from people like her. And she’s someone I can go and talk to now and say, hey, look, I’ve been noticing this. What do you think? What are some ideas we can do to improve it?

Peter [00:24:29] South Australia definitely has some superstar pharmacists and you being one of the first to work in an aged care facility on the ground in that kind of embedded role, have you become a mentor to other pharmacists in a similar role?

Julian [00:24:41] I’ve had quite a few people message and like I said, most of this has been during COVID time so I haven’t been able to meet too many people, but I get quite a few messages through Twitter and LinkedIn from pharmacists asking generally about the role, how they can be involved. A few people said, you know, what do you do? It sounds like something I’m interested in. And a lot of these have been early career pharmacists. The community pharmacy who supplies our drugs, they have an intern and she’s come and spent a day with me sort of shadowing and having a look at what we do. And we also had students on placement visiting that pharmacy come spend a few days up at the nursing home, and we kind of go through everything aged care and have appreciated the help as well that students can provide. But yes, I’m definitely also very open to, if anyone has questions or is looking for a way into aged care or some advice, I’m really open to having a chat with those people.

Peter [00:25:30] And some of your advice also probably features in PSA’s Residential Aged Care Pharmacist Foundation Training Program, which you were involved in reviewing. Is that a product that you would have liked, perhaps, before you’d gone into the aged care facility for the first time?

Julian [00:25:46] Yes, absolutely. I think it gives and it sort of worked on the experiences of a few of the pharmacists who are part of the PSA projects and have worked in aged care homes. But it gives you maybe a little bit of a framework of maybe where to start and some of the things that we can do. But it’s also a great way to build your confidence in, one, your clinical skills, but also in demonstrating and talking about what you can offer as a pharmacist. It sort of helps articulate a lot of those key responsibilities and skills.

Hannah [00:26:14] Yes and that’s a fantastic education program. Julian, when you’re starting in a new role, how do you go about finding resources and help available to help grow you as a practitioner?

Julian [00:26:24] I’m a very social person, so probably talking and asking people. But something I’ve done, and I encourage anyone else to do, is if you see someone doing something that you like, say working in a space that you think is really innovative or they have a job that you think, wow, I want that job, go, talk to them, reach out. People seem to be very generous with their time, particularly people working in this space. I think we all really feel that we’re making a really big contribution to aged care and when I say we, pharmacists, are a great way to help a lot of these aged care issues, so reaching out to these people and finding out from their experiences, but also any of the resources that they might use frequently is something I’ve had a lot of luck with.

Hannah [00:27:02] Some really great advice. And if you were talking to someone looking at sort of not sure where they’re at in their career and thinking aged care might be an option, what would you say is something that brings you the most satisfaction in your role?

Julian [00:27:15] Aged care, so far, for me has been almost all the great parts of working in a community pharmacy and all the great parts of working in a hospital setting. So the great parts of the community pharmacy for me were talking, building relationships and getting to know your patients or our residents here. So being in a fixed environment and getting to know these people over a period of time has been really rewarding, particularly being able to follow-up on things that we’ve done. We’ve made some medication changes and being able to see if there was a benefit to that person or even if there were consequences. I think that’s important. It’s something that you don’t always get, particularly in an RMMR role. But then also the benefits of that hospital pharmacy role is working as an integrated team, so working closely with other health professionals like nurses and doctors and the physio. So for me, it’s kind of almost a perfect marriage, and with all the really positive parts of those two types of traditional, I guess, pharmacy roles.

Peter [00:28:08] That’s really, really awesome that you’ve had the best of some of the other worlds that you had experience in. Where do you say the future goes for you next in terms of your career?

Julian [00:28:15] I don’t know. I’ve kind of stopped guessing because it’s changed, and there’s been so many opportunities recently, so I put the crystal ball away because it’s been wrong. But I really enjoy working here at Tanunda and I can’t really see myself moving from there too much. I have a really keen passion for education too. I’ve recently done a certificate in training, so that’s probably something I really want to delve into, the education side of things and hopefully getting some more pharmacists skilled and more pharmacists in aged care homes.

Hannah [00:28:42] That’d be fantastic, particularly if they can have the impact that you’ve had on your home. Julian, there’s a couple of questions we like to end on with our guests. Starting with, what’s the best piece of advice you’ve been given that has helped you in your career?

Julian [00:28:56] I think something that’s really helped me with my career has been to always be curious and always follow the why. One of my favourite phrases to hear, particularly in the corridor is, oh, ‘this is just how we’ve always done things’. Why? Why are we doing these things? Should we be doing these things? Can we do these things better? And I think that’s kind of led me to where I am now, you know, being in the community pharmacy, I’m going, it doesn’t seem right, how can we make it better? And you know, that’s kind of been my theme so far in my career.

Peter [00:29:26] So always ask why like the inquisitive five-year-old.

Julian [00:26:28] Exactly. Channel your inner, inquisitive five-year-old.

Peter [00:29:30] What are your top three tips for other pharmacists considering becoming an aged care pharmacist?

Julian [00:29:34] We touched on it before, but I really think mentorship is really important. Find some people who are working in the space, find some people you can build a network with. And for me, mentorship doesn’t necessarily have to mean the most senior, the most skilled, the most expert. It could even just be some friends who you can bounce some career advice off of, or maybe have a bit of a de-stress with, so a good strong network. I think there’s a lot of value in RMMR work. So working as an RMMR pharmacist for a couple of years, I got to see lots of different nursing homes, lots of different practice. Some not so good, some really fantastic. But it gave me a good level of experience and obviously, RMMR work will help build your clinical skills. And then the last bit of advice is probably, try and be as loud and advocate as much as you can for yourself. A lot of people don’t really know what we do and what we can offer. So you’ve kind of got to go out and tell people and demonstrate that as well. So, yes, make sure whenever you have a good win, celebrate it, make sure people realise that win, because it’s also a good learning opportunity as well.

Peter [00:30:33] Awesome. And what’s your best win that you’ve had?

Julian [00:30:36] One that really sticks with me was a resident at the facility when I first started. So like I mentioned, we did some medication audits and one of the ones we did was looking at antipsychotics, so we found everyone on antipsychotics. So this resident had been on that antipsychotic, quite a big dose of risperidone for a couple of years. When I went to go see him, he was kind of in a princess chair, didn’t really say anything, didn’t really move much. Looking at his progress notes, there was almost nothing. Nothing was happening. He wasn’t attending activities, but also wasn’t causing any disturbances. There didn’t seem to be any sort of those typical PTSD-type issues. Talking to his daughter, who was his next of kin, and his GP, I found out that he was started on those antipsychotics because he had some trouble adjusting to coming in the nursing home about 18 months earlier and displayed some aggression and was persistently agitated.

The antipsychotic stayed on the whole time. So we decided a good plan would be, let’s start reducing it, let’s get rid of the antipsychotic if we can. So we eventually managed to stop the antipsychotic for him, and the change was drastic. He started verbalising again. He was able to have conversations. He started smiling, which was just something really, really positive to see. And I ended up catching up with his daughter a couple of months later at a care plan meeting. And yes, she was like, he’s like a different person. He’s, you know, I can have conversations with him, and I can enjoy visiting him again, and he seems a lot happier. We hear about how important it is to reduce these medications, particularly the antipsychotics, but actually having seen it firsthand like that, it really sort of re-emphasises the important work that we can do.

Hannah [00:32:06] It’s a massive win and one that you should be really proud of, and clearly his family is quite thankful for you as well. And so we just wanted to say a big thank you for coming on the show today and sharing your experience in the aged care sector, Julian. It’s been really great having you and I think a very insightful discussion about the impact on patients, but also the role that pharmacists can have as soon as you integrate into the team.

Julian [00:32:29] Cool. Thank you, guys. I really enjoyed it.

Peter [00:32:34] Thanks, Julian, and thanks to everyone for listening. You can check out the show notes for links to everything we’ve spoken about today. And don’t forget to subscribe to get new episodes as soon as they’re released. And if you’re interested in learning more about becoming an embedded aged care pharmacist, PSA’s Aged Care Pharmacist: Foundation Training Program provides you with the knowledge and skills that you need.