Submission to the Joint Standing Committee on the National Disability Insurance Scheme

OCT

2021

Contents

• Purpose of this submission …………………………………………………………………………………………………….. 2
• About PSA………………………………………………………………………………………………………………………………. 2
  • Submission to the Disability Royal Commission …………………………………………………………………………. 2
• Executive summary ………………………………………………………………………………………………………………… 3
• Medicine safety in Australia …………………………………………………………………………………………………….. 5
  • Disability sector data on medicine safety ……………………………………………………………………………………. 5
• Person-centred care ……………………………………………………………………………………………………………….. 6
• Pharmacists delivering care to support people with disability ………………………………………………….. 7
  • The role of pharmacists and pharmacist-delivered services ………………………………………………………… 9
    • Safe and appropriate supply of medicines …………………………………………………………………………………. 9
    • Medication management review services ………………………………………………………………………………… 11
  • Collaborative care arrangements ………………………………………………………………………………………………. 14
  • Enhancing the contribution and capability of disability support workers ……………………………………. 15
  • Supporting access to vaccination services ……………………………………………………………………………….. 16
  • Supporting disability care facilities …………………………………………………………………………………………… 16
    • Medication management policies and procedures …………………………………………………………………….. 16
    • Quality use of medicines support service ………………………………………………………………………………… 16
  • Clinical governance framework and quality indicators ………………………………………………………………. 17
• Appendix 1: Framework of professional and ethical standards for pharmacists ………………………. 18

Purpose of this submission

The Pharmaceutical Society of Australia (PSA) is pleased to make this submission to the Parliament of Australia Joint Standing Committee on the National Disability Insurance Scheme (NDIS) inquiring into current scheme implementation and forecasting for the NDIS. PSA understands the focus is on how the NDIS is implemented and funded, and what supports are or should be available for people with disability.

About PSA

PSA is the only Australian Government-recognised peak national professional pharmacy organisation representing all of Australia’s 35,000 pharmacists working in all sectors and across all locations.

PSA is committed to supporting pharmacists in helping Australians to access quality, safe, equitable, efficient and effective health care. PSA believes the expertise of pharmacists can be better utilised to address the health care needs of all Australians.

PSA works to identify, unlock and advance opportunities for pharmacists to realise their full potential, to be appropriately recognised and fairly remunerated.

PSA has a strong and engaged membership base that provides high-quality health care and are the custodians for safe and effective medicine use for the Australian community.

PSA leads and supports innovative and evidence-based healthcare service delivery by pharmacists. PSA provides high-quality practitioner development and practice support to pharmacists and is the custodian of the professional practice standards and guidelines to ensure quality and integrity in the practice of pharmacy.

Submission to the Disability Royal Commission

PSA has previously made a submission1 to the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability (the ‘Royal Commission’) in response to the Issues paper on Health care for people with cognitive disability. This submission to the Joint Standing Committee reinforces many of the issues highlighted previously by pharmacists who work to support the health care needs of people with disability, particularly with regards to their medicines, medication management and health literacy.

1 Pharmaceutical Society of Australia. Submission to the Royal Commission into violence, abuse, neglect and exploitation of people with disability. 2020;Aug. At: www.psa.org.au/wp- content/uploads/2020/08/PSA_sub_DisabilityRC_050820_final.pdf

Executive summary

PSA acknowledges the substantial remit of the NDIS to provide the best support and care possible to meet the needs of people with disability and their carers. The issues that concern PSA and pharmacists arise from the apparent disconnect between health care and disability care as well as the somewhat rigid nature and mechanisms associated with the types of services and supports that can be accessed through the NDIS. In addition, not all people with disability access support through the NDIS.

While the NDIS must be contemporary and evidence-based, PSA suggests there is also a need to consider how best to connect a person with disability with mainstream health services through effective coordination and timely referral to provide holistic care. This may also mean that similar or existing health care-focussed services would not necessarily need to be established under the NDIS framework, thus reducing duplication, lessening the burden on the NDIS and potentially creating synergies across health care and disability care.

Medicines are the most common intervention in health care. While unfortunately there is a significant lack of data, we know people with disability rely on medicines for acute and chronic or complex health conditions. Additionally, many people with disability are dependent on medicines to facilitate their participation in the workforce and in the community.

We are also mindful that people with disability are vulnerable to medicine-related harm. It is concerning that pharmacists are substantially underutilised in the disability care sector and their expertise regularly only rate as an afterthought, if at all.

In order to improve future implementation and funding of the NDIS, PSA strongly suggests to the Joint Standing Committee it is critical that available services and support for people with disability must include seamless, regular and comprehensive access to the unique expertise of pharmacists in medicines and medication management.

It should be noted that ‘Management of Medication’ is a requirement of the NDIS Practice Standards, under Core Module 4: Provision of Supports Environment.2 As medicines experts, pharmacists can efficiently assist disability providers in meeting the NDIS medication management standard.

We strongly suggest the NDIS must be resourced adequately and appropriately so that the disability care sector can establish and promote better connections with pharmacists and, in partnership with PSA, deliver on activities, such as the following, to improve quality of care and impact of services for people with disability.

• Increase awareness and promote widely to people with disability, their carers, disability support workers and disability sector organisations about the role of pharmacists and pharmacist-delivered services. Based on the specific medication management needs of a person with disability, pharmacists are fundamental to: ensuring safe and optimal use of medicines and avoiding harm from medication misadventure; working as part of a multidisciplinary healthcare team to help resolve medicine-related problems; supporting independence and self-management, and improving quality of life for people with disability.

• Provide funding and support through the NDIS for regular pharmacist-delivered medication management services for people with disability who have chronic or complex medication needs. This is as important as other services that NDIS participants can access through their NDIS Plan to support their daily life. It will contribute to maximising benefits and outcomes of their medication therapy and preventing medication misadventure, maximise their participation and potential unplanned hospitalisations.

• Invest in the implementation of best practice collaborative care arrangements through the inclusion of pharmacists in healthcare teams for people with disability with chronic medicine needs to ensure medication safety and holistic therapeutic outcomes.

• Co-design, develop and deliver education and training to disability support workers to enhance medicine-related capabilities such as safe and appropriate medicine handling and administration of medicines to people with disability as intended by the prescriber.

• Implement mechanisms to ensure disability service providers and organisations include pharmacist input and expertise in the development, review and implementation of medication management policies and procedures.

• Provide arrangements and funding for pharmacists to deliver quality use of medicines (QUM) services to support disability service providers and organisations through implementation of an appropriate QUM plan.

• Assist with the implementation of a clinical governance framework and quality indicators for services delivered by pharmacists to people with disability and disability service organisations.

• Promote accessibility and availability of pharmacists delivering vaccination services in primary care settings, including schools, aged care facilities and group homes.

• To address current gaps in data around medicine use by people with disability, establish appropriate data collection and reporting requirements for disability service providers and organisations. This must also be supported and promoted through uptake of technology in disability settings to safeguard medication practices.

PSA as the national peak body for pharmacists requests collaborative opportunities to work with NDIS partners and disability sector organisations to assist in meeting core deliverables and objectives.

Medicine Safety in Australia

The use of medicines is the most common intervention made in health care and is steadily increasing. Safe and appropriate use of medicines can help improve people’s health and quality of life, treat infectious diseases, reduce likelihood of heart attacks or strokes, provide temporary relief from debilitating pain or ease the impacts of chronic diseases.

PSA published a report, Medicine Box 1 safety: Take care,3 which showed Medication-related hospital admissions staggering annual figures in Australia  250,000 admissions annually at a cost of $1.4 billion of 250,000 hospitalisations and an  50% of this harm is preventable additional 400,000 presentations to After hospital discharge emergency departments, as a result  Over 90% of patients have at least one medication-of medication errors, inappropriate related problem use, misadventure and interactions  3 in 5 discharge summaries prepared without pharmacist(see summary in Box 1). At least involvement have at least one medication errorhalf of these were preventable. The Residential aged careannual cost of these medicine- related problems reached close to  98% of residents have at least one medication-related $1.4 billion. problem  Over half are exposed to at least one potentially As part of PSA’s annual medicine inappropriate medicine safety series reports, in February Community 2020, the Medicine safety: Aged  1 in 5 people are suffering an adverse medication care4 report was published. PSA’s reaction at the time of a Home Medicines Review current schedule includes the  1.2 million Australians have experienced an adverse publication of a report focusing on medication event in the last 6 months medicine safety in disability care in 2022.

Disability Sector Data on Medicine Safety

In the course of research associated with previous submissions, PSA has encountered significant gaps in data on medicine use in disability care.

People with disability have a range of healthcare needs which may be met by accessing relevant healthcare practitioners or informal care through family members and friends. It is reported that 1 in 3 people with disability need help with health care.5 There is some insight into how these needs are fulfilled. The Survey of Disability Ageing and Carers (SDAC) reports6 on the use of mainstream health

Medicine Use in People With Disabilities

services which includes general practitioners, medical specialists and dentists. The survey,$ however, does not examine patient experience information on whether needs were met by other health professionals, including pharmacists. This is one example, but to PSA’s knowledge, the contribution of pharmacists’ care within the disability sector is not explicitly documented in any form.

The NDIS also publishes data and insights.$ However, we did not find any information on medicine use by people with disability. Thus, despite significant recent reforms in the disability sector, PSA does not believe there is adequate data to show the current state of play with regards to the care that people with disability receive through government-subsidised medicines (i.e. the Pharmaceutical Benefits Scheme) and pharmacist-delivered services which optimise the benefits of those medicines and prevent medicine-related harm.

It is generally known that psychotropic medicines can be used inappropriately in people with intellectual disability. This can include medicines such as antipsychotics, anti-anxiety medicines, antidepressants, medicines with mood stabilising properties and medicines used to treat seizures. Some of these medicines can also be used by people with other cognitive disabilities including autism, am acquired brain injury and dementia.

The extent of the problem of suboptimal use or inappropriate use of medicines in the disability sector is not well characterised; as referred earlier, PSA is not aware of contemporary data on medicine use in disability care. There is also complexity associated with the overlap in patient cohort receiving disability care and aged care, most significantly people with dementia.

Being acutely aware of the extent of inappropriate psychotropic medicine use in residential aged care as revealed$ by the Royal Commission into Aged Care Quality and Safety, PSA expressed grave concerns that similar trends could be occurring in the disability sector, particularly for people with cognitive disability who rely on medicines to maintain functionality and quality of life.

PSA suggests it is a priority to establish processes and accountabilities through appropriate data collection and reporting to gain an understanding of medicine use by people with disability. This will help to inform refinement of policies and deliver interventions in a timely manner to improve care for people with disability.

Person-centred care

The care, wellbeing and safety of the person are at the centre of all aspects of pharmacy practice. Pharmacists are committed to respecting and supporting the rights, choice and dignity of people and recognising diversity. Equity and timeliness of access to quality and safe care and delivering according to individual need and in a non-discriminatory manner are fundamentally important. Further details on the framework of professional and ethical standards that underpin pharmacists’ practice are outlined in Appendix 1.

Pharmacists’ Practice

Pharmacists’ practice is aligned with the Australian Charter of Healthcare Rights10 and supports the rights of people to receive safe, culturally responsive, high quality professional services. Pharmacists work to build mutual respect and rapport, engaging with people in an empathetic manner and considering issues such as mental health and physical or cognitive disabilities that may impact on their care needs.

Pharmacists’ practice also aligns with The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). Australia is a signatory to the UNCRPD which stipulates Australia’s obligation to tailor health care services to ensure people with disabilty receive the same “range, quality, and standard” of health care as the general population. This includes access to pharmacist-delivered medication management services.

Using their expertise in medicines, pharmacists optimise health outcomes and minimise medication misadventure. Consistent with the National Medicines Policy,11 pharmacists have a primary responsibility to contribute to the quality use of medicines (QUM),12 to support safe, appropriate, judicious and effective use of medicines. Pharmacists also have a key role in improving public health, investing in preventive health activities and services, and assisting patients, carers and other health practitioners with health and medicine related information and queries.

Pharmacists practise in a wide and diverse range of settings although the public and patients would generally be most familiar with pharmacists in community pharmacies. Australia has a well-distributed network of over 5,700 community pharmacies. Standards Australia’s Quality Care Community Pharmacy Standard (AS 85000:2017) forms the basis of the accreditation program for the practice of community pharmacy in Australia.

Community pharmacies are readily accessible and well placed to support NDIS participants. PSA is aware that some community pharmacies are registered providers under the NDIS primarily to supply assistive technology (aids and equipment). PSA understands that information resources and training are available to pharmacies seeking to become a registered provider but suggests more proactive provision of information to the profession could be beneficial. PSA can assist with communication and information dissemination to the pharmacy profession.

Pharmacists delivering care to support people with disability

Being aware of the extent of “neglect”13 that older Australians have endured in aged care, PSA stated previously that it would be a travesty if standards of care around medication management in the disability care sector was also found to be wanting. People with disability and their families and carers must have routine access to measures that help to ensure medication safety, support optimal and quality use of medicines and improve quality of life.

Pharmacists can support the disability sector in a number of ways, for example:

• In the majority of cases, pharmacists may provide pharmaceutical care and medication management support to people with disability in primary care, either directly (in person) or through their carers and support workers.

• Some pharmacists may provide support through QUM services to those in cared- accommodation (including, for example, hospitals, nursing homes, aged care hostels, cared components of retirement villages, psychiatric institutions) and other ‘homes’ such as group homes for people with disability.

• Pharmacists may also work with, or within, disability sector organisations to help implement best practice medication management policies and services.

As medicines experts, pharmacists can efficiently assist disability providers in meeting the NDIS medication management Practice Standard. This Practice Standard aims to ensure that NDIS participants feel confident that the provider administers, stores and monitors the effects of the medications being administered, and that providers work to prevent errors and incidents. QUM pharmacists are currently funded by the Government to ensure the aged care facility meets its medication management standards. Pharmacists should be similarly funded to support the disability sector.

PSA is aware that several jurisdictions have medication management frameworks for disability service providers. For example, one such framework stated the purpose is “to facilitate the best possible use of medications to improve health outcomes for people with disability and to promote the benefits of medications and minimise risk of inappropriate use and harm”. Given the priority of the NDIS is to safeguard its participants, protecting them from medication-related harm is paramount.

Although a broad range of medication management-related issues appear to be covered by such frameworks, PSA notes they appear largely to focus on the administration of medicines by support workers particularly when a person with disability does not, or cannot, self-manage their medicines.

It would seem therefore that, in implementing the framework, the role of pharmacists might only be considered in the context of dispensing prescriptions or packing dose administration aids and as a source of information about medications. The important role of pharmacists in ensuring medicines are handled safely and used/taken appropriately – as intended by the prescriber and to improve quality of life of the person – would not be apparent.

PSA believes the design and operation of the NDIS also suffer from a lack of understanding and recognition of the unique medicines expertise of pharmacists and the contributions they can make to the health and medication management of people with disability. PSA calls for the Joint Standing Committee to address this fundamental issue in considering recommendations on the future of the NDIS.

To assist the Joint Standing Committee Inquiry, PSA has outlined in the following sections, ways that pharmacists’ unique skills and knowledge on medicines could contribute to the NDIS aims and objectives of supporting people with disability through safe, appropriate and optimal use of medicines.

The role of pharmacists and pharmacist-delivered services

People with disability who require medicines for acute or chronic health conditions should have access to pharmacist care. PSA suggests that NDIS service providers can assist by referring people with disability to a pharmacist if they require assistance with medicine-related issues or information.

Figure 1 and the section following provide a summary of core pharmacist-delivered services or activities designed to improve medication safety, enhance optimal use of medicines and improve quality of life. PSA would be happy to expand on the details of any services, if required.

     Figure 1: Medication management services across the continuum of patient care

Safe and appropriate supply of medicines

Health care and medication management requirements can be more complex for vulnerable Australians including people with disability and the risk of adverse medication-related events may also be higher. In addition, the need for high-risk medicines is greater with certain conditions such as dementia, mental illness, behavioural conditions and depression.

Dispensing. Timely access to prescribed or over-the-counter medicines is facilitated by a well- distributed network of hospital and community pharmacies across Australia. Affordable access to most essential medicines for people with disability is provided through the Pharmaceutical Benefits Scheme. Universal access to affordable medicines is a foundation principle of Australia’s National Medicines Policy.

Being on medicines to manage chronic health conditions means regular visits to a pharmacy to have prescriptions dispensed and other health conditions attended to. The accessibility of community pharmacy staff also provides vulnerable people with a regular contact point socially and for non-health matters.

Medication adherence advice. A core tenet of pharmacy practice is to promote quality use of medicines. Pharmacists can support and tailor advice for people with disability on how to take or use their medicines (and therapeutic devices) safely and correctly so that they experience optimal

outcomes and minimise risks

of medication misadventure. People with disability may experience particular challenges with medication adherence due to factors such as14:

 impaired physical dexterity – difficulty opening medicine packaging, halving tablets, or operating therapeutic devices

 impaired sight, hearing and cognition – difficulty reading medicine labels and understanding or remembering dosing instructions; possible language challenges

 beliefs about the effectiveness of medicines, or concerns about adverse effects and cost leading to intentional non-adherence.

Advice from a pharmacist can help maintain and improve the health of people with disability on regular medicines, support their independence and self-management, and improve health literacy (individually, or through their carer).

Minimising harm and optimising benefits of medicines. Pharmacists can support people with disability and their carers who may be particularly vulnerable or feel challenged by daily medication management needs. Medicines can deliver benefits when used correctly and optimally, but harm can occur if medicines are not managed correctly or if the person’s condition has changed, including improvements in health. It is important that medicine use is continually monitored to ensure treatment expectations are being achieved. The health of an individual is a dynamic situation and therefore ongoing review of medication therapy (and adjustment, if necessary) can be helpful from a medication safety and quality care perspective.

Staged supply service. Staged supply is a clinically-indicated, structured pharmacist service involving the supply of a medicine to a patient in periodic instalments as requested by the prescriber or carer. The instalments are less than the originally prescribed quantity at agreed levels (e.g. daily or weekly). The balance of the prescribed quantity is held by the pharmacy to fulfil subsequent instalments.15 This service can assist people who may prefer or benefit from more frequent contact with and regular support from the pharmacist. It may apply when high-risk medicines are being used. It can also be helpful in situations where it is preferable to prevent inadvertent access to the medicines by others in the household (e.g. group homes).

Dose administration aid service. A dose administration aid (DAA) is a tamper-evident, well-sealed device or packaging system that allows organisation of doses of medicine according to the time of administration.16 Pharmacists provide holistic DAA services which encompass medication assessment and reconciliation, packing of DAAs and professional support to ensure the optimal use of DAAs. The service aims to support safe and effective administration of a person’s medication, improve adherence and reduce medication misadventure. It may particularly benefit those taking five or more medicines daily or with a complex regimen of medicines.17

Medication Management Review Services

Many people with disability rely on medicines. Despite there being established Australian Government-funded medication management programs (currently through the Seventh Community Pharmacy Agreement), it is disappointing that there does not appear to be regular pathways for people with disability to access these in a considered or structured manner. A streamlined pathway to pharmacist-led medication management review services could play a significant role in safeguarding NDIS participants from medication-related harm.

PSA has received feedback from pharmacists that sometimes a case manager of an NDIS participant or an allied health professional involved in their care is aware of services such as a Home Medicines Review and may be willing to arrange for a pharmacist to conduct a review; however, this appears to be very much an ad hoc approach. Case workers and allied health professionals lack the expertise to identify the clinical need to trigger a medication review via the prescriber. PSA strongly suggests it is unacceptable that this vulnerable population group may be missing out on a potentially beneficial medication management service, to ensure medication safety and support individuals to get the most out of their prescribed treatment.

The NDIS claims it can “provide all people with disability with information and connections to services in their communities”. PSA has seen little evidence that people with disability are being connected consistently to pharmacist-delivered services to support their needs around medication management.

The types of support that the NDIS funds18 are outlined to include “allied health and other therapy because of a person’s disability”, “personal care to assist with day to day care needed because of a person’s disability and development of skills to help a person become more independent”, “training of carers and informal supports to implement healthcare plans developed by health professionals” and “therapeutic and behavioural supports”. Medicine-taking is an everyday activity for people with disability who rely on their medication. The needs of these people are likely to relate to any or all of the types of support listed above.

Therefore, PSA sees direct scope and an obligation of the NDIS to support people with disability through access to pharmacist-delivered medication management services, if needed. Without this support, people with disability are significantly disadvantaged. This inequity in access to care must be addressed urgently.

As outlined in Figure 1, pharmacists deliver a range of more comprehensive medication management review services.

A MedsCheck service is a structured and collaborative clinical service conducted in the person’s preferred or regular community pharmacy. The primary aim of the service is to optimise the safe and quality use of medicines by the person. The service involves a review of the person’s medicines, a face-to-face consultation between the pharmacist and person, and the development of a medication profile and an action plan.19

A comprehensive medication management review is a structured, critical examination of a person’s medicines conducted by an appropriately trained and credentialed pharmacist (often referred to as an accredited pharmacist) in collaboration with the prescriber. These systematic review services are

Medication Management Reviews

Medication management reviews are aimed at identifying and resolving medication-related problems to optimise the impact of medicines on a person’s health outcomes. An example is a Home Medicines Review (HMR) which is government-funded for eligible patients living in a community setting.

There is significant acknowledgement of the value of medication management reviews in contributing to medication safety, quality use of medicines and better health outcomes. Pharmacist interventions were also found to be generally effective in improving quality use of medicines and health outcomes for people with dementia and/or cognitive impairment and their carers, and saved costs to the healthcare system.

Further to the above, a recent Australian study identified that age-standardised rates of potentially preventable hospitalisation are higher for people with intellectual disability than for the general population. With respect to acute conditions, people with intellectual disability are 5-8 times higher as for the general population. The difference is highest for epilepsy/convulsions and dental presentations. For vaccine-preventable conditions the difference is three times as high. Pharmacists are well positioned to ensure optimal management of epilepsy through medication management review services. Similarly, through medication review, medications that cause dry mouth and significantly worsen dental caries can be identified and strategies to address the issue can be developed.

Deprescribing aims to ensure a person’s medication regimen is aligned with their preferences and goals of care. It is a systematic process of identifying and discontinuing medicines where existing or potential harms outweigh existing or potential benefits within the context of the person’s care goals, current level of functioning, life expectancy, values and preferences. The process is undertaken in a person-centred, collaborative manner so that pharmacists can best support the understanding and expectations of patients, carers and prescribers and maximise the beneficial outcomes.

Opportunities to consider deprescribing for people with disability include:

• polypharmacy - people are generally at greater risk of adverse outcomes when using multiple medicines
• lack of efficacy of treatment - if the desired therapeutic effect is not evident, continuation of therapy should be re-considered
• change in treatment goals (which may relate to change in physical or mental health circumstances, degree of dementia, increased frailty, or comorbidities)
• adverse reactions to medicines - some health events such as falls or cognitive decline may be accepted as being part of the ageing process rather than treating it as an adverse consequence of medicine use.

Pharmacist-Led Deprescribing Interventions in Aged Care

Pharmacist-led deprescribing interventions have been shown to reduce polypharmacy and improve patient outcomes. 24,25,26,27 As was the key focus of the aged care Royal Commission interim report, 1 it is important that the use of high risk medicines by people with disability is closely monitored and reviewed in line with best practice guidelines to minimise risk of adverse effects.

The overuse and misuse of psychotropic medicines was highlighted during Hearing 6 of the Disability Royal Commission 28 and many similarities between problems in the aged care sector and the disability sector were revealed. The findings from the hearing identified that multidisciplinary collaboration is required to address this.

The hearing also identified that the power imbalance between people with cognitive disability and service providers, medical practitioners and family can lead to the administration of psychotropics without the person understanding what is happening or giving informed consent. Pharmacists are an important conduit in ensuring NDIS participants (and/or their decision maker) are provided with all the relevant information about medicines to provide informed consent.

To summarise this section, PSA suggests it will be helpful if the NDIS is appropriately resourced to increase awareness and promote widely to people with disability, their carers, disability support workers and disability sector organisations about the role of pharmacists and range of medication management services. Pharmacists ensure safe and optimal use of medicines and avoid harm from medication misadventure, work as part of a multidisciplinary healthcare team to help resolve medicine-related problems, support independence and self-management, and improve quality of life for people with disability.

PSA also suggests urgent consideration is required of arrangements through the NDIS to include pharmacists within the healthcare team to support people with disability, where support with their medicines is needed. Further, funding and support through the NDIS is needed for pharmacist-delivered medication management services for people with disability who have chronic or complex medication needs. This is as important as other services that NDIS participants can access through their NDIS Plan to support their daily life. It will contribute to maximising benefits and outcomes of their medication therapy and preventing medication misadventure and potential unplanned hospitalisations.

Collaborative Care Arrangements

PSA supports the development of workforce strategies to ensure people with disability have access to a collaborative health care workforce with capability to provide high quality care and support. PSA advocates for implementation and funding of practice models or care arrangements that enable pharmacists to provide clinical input through a multidisciplinary team arrangement with appropriate remuneration.

Despite recognition of the benefits of multidisciplinary healthcare teams, including pharmacists, such arrangements are still considered unique rather than routine due to structural or financial barriers – a point that was noted through the Aged Care Royal Commission.

Collaborative practice models being developed, trialled, refined or taken up include arrangements to formally integrate pharmacists into teams in general practices, residential aged care facilities, Aboriginal and Torres Strait Islander healthcare services, chronic disease clinics and Health Care Homes. Collaborative care is a cornerstone of best practice pharmacist care. The true value of pharmacists’ medication management expertise is realised when pharmacists and other healthcare professionals assume complementary roles, work cooperatively, share responsibility for problem solving, and together make decisions to formulate and implement a person’s health management plan.

PSA is aware of, and welcomes, the development of a South Australian model of care for delivery of health services for people with intellectual disability and complex health needs. One of the recommendations relating to pharmacists is as follows:

• Pharmacists should be integral to the new model of care using existing pathways to medication review. A pharmacist within the specialised service (SA Intellectual Disability Health Service) could provide staff/client education regarding medicines issues, undertake research/audits, develop medicine-related policies and undertake other clinical governance activities. The pharmacist could also have a coordination role with respect to linking the core team with pharmacists who are credentialled to conduct medication reviews in primary care.

There has reportedly been a delay in implementing this model of care as funding and resources were presumably reallocated due to the COVID-19 pandemic, despite there being a dedicated and passionate team of doctors and pharmacists involved in progressing the model.

Enhancing Medication Safety Through Collaborative Care

PSA is also aware of other innovative practices being developed by pharmacist practitioners. Some of PSA’s member pharmacists are part of a clinical group known as POMPIDA – Pharmacists Optimising Medicines for People with Intellectual Disability and Autism.

POMPIDA is a collective of independent accredited pharmacists who provide medication services to clients in the disability sector. POMPIDA was formed following collective recognition of the dearth of people with disability referred for Government funded medication-management service because of an apparent reluctance or lack of awareness of the value of these services in safeguarding these individuals from medication-related harm.

POMPIDA members are from a range of jurisdictions and their overarching goal is to increase awareness and uptake of medication management services to people with disability, especially cognitive disability. Some of these pharmacists are preferred providers for disability organisations or health services for people with disability. NDIS participants who are self-managed or plan managed are able to use funds from their NDIS plan (subject to Plan Manager approval) to receive a medication management service.

Through a collaboration with an NDIS-registered provider (I Can Jump Puddles), pharmacists (from POMPIDA) have commenced working with allied health practitioners (i.e., positive behaviour support practitioners) to conduct medication consults. The medication consult can be of a general nature or have a targeted approach to help identify potential restrictive practices (chemical restraints) in the client’s medication regimen. The pathway being developed is that this activity can lead to opportunities to conduct a comprehensive medication management review such as a Home Medicines Review if it is warranted.

PSA strongly believes that, as an insurance scheme, there must be investment by the NDS to enable implementation of best practice collaborative care arrangements through the inclusion of pharmacists in healthcare teams to ensure medication safety for people with disability as well as holistic therapeutic outcomes.

Enhancing the Contribution and Capability of Disability Support Workers

A core competency of pharmacists is to support the professional development of other members of the health care team. With regards to medication management practices, pharmacists can assist disability support workers to ensure safe medication handling and administration, and to facilitate optimal use of medicines for people with disability.

The types of contributions pharmacists can make through education and training of this workforce include the following:

• deliver education and training on principles of quality use of medicines generally and safe medication practices
• deliver education sessions (including new evidence, guidelines and therapies) on specific health issues or medicine/health topics
• provide education and guidance to support workers and complement the work of nurses in the identification of side effects of medicines (e.g., monitoring for signs of toxicity)
• support safe and appropriate medicine dosing and administration
• prevent medicine-related problems during transitions between care settings
• reduce/resolve medicine-related problems through collaboration with multidisciplinary healthcare team members

**Supporting access to vaccination services

Pharmacists have a key role in preventive health care and providing vaccination services is one such activity. Many people value the accessibility and availability of pharmacists delivering vaccination services in primary health care settings. Influenza vaccination services are commonly delivered by pharmacist immunisers and, as has been evident during the current pandemic, they have been fundamental to the COVID-19 vaccination rollout. Pharmacists have contributed to the rapid uptake of COVID-19 vaccines and helped to ease the health burden on Australians including vulnerable population groups.

To improve protection through immunisation more generally, PSA suggests it would be useful for NDIS participants to be able to access vaccinations through their care plan at a preferred vaccination site which may be their local pharmacy, regular doctor, group home or a dedicated vaccination clinic.

**Supporting disability care facilities

Medication management policies and procedures

Reviewing medication management policies and procedures in facilities is regularly undertaken by pharmacists, most commonly in residential aged care. From a medication safety perspective, it is essential to have pharmacist oversight in this type of activity where there is regular use of medicines, particularly by vulnerable people, irrespective of the care setting. As referred earlier, pharmacists are key to disability facilities and organisations meeting the NDIS medication management standard.

PSA also has experience working with a group of disability care homes to assist with the review of their overarching medication management-related policies and procedures.

PSA strongly believes there should be mechanisms to ensure NDIS service providers and organisations include pharmacist input and expertise in the development, review and implementation of medication management policies and procedures.

Quality use of medicines support service

Under the 7CPA, the QUM Program supports the delivery of services and activities by registered or accredited pharmacists aimed at supporting the quality use of medicines, including the safe use of medicines, within Australian Government-funded aged care facilities.35 The QUM Service is designed

Improving Procedures and Practices Related to Quality Use of Medicines

to improve procedures and practices related to QUM to ensure all aspects of medication use at a facility are judicious, appropriate, safe and efficacious.

A pharmacist may deliver QUM activities covering areas such as36:

• education and training (e.g. in-service sessions for residents, carers or nursing staff; provision of medicines information for medical practitioners and facility staff)

• clinical governance (e.g. participation in Medication Advisory Committees; assist in development of nurse-initiated medication lists; contribute to medication management policy and procedure development; assist facility to meet and maintain medication management accreditation standards, comply with regulatory requirements, and develop or report on quality indicators and other quality measures; conduct audits on medication supply and administration issues or clinical issues)

• resident-focussed (e.g. assess competency of residents to self-administer medicines; opportunistic advice to members of healthcare team on medication management issues; liaising services between all healthcare settings).

While the 7CPA-funded QUM services are specifically for eligible aged care facilities, PSA suggests a similar model should be considered for the disability care sector. Thus, PSA suggests NDIS arrangements and funding should provide for pharmacists to deliver QUM services to support relevant disability service providers / organisations through implementation of a QUM plan.

Clinical Governance Framework and Quality Indicators

Clinical governance is being progressively incorporated into health service sectors such as hospitals, commissioning bodies (e.g. Primary Health Networks), general practices, community pharmacies and Aboriginal Community Controlled Health Services. Building on the work of the Australian Commission on Safety and Quality in Health Care, PSA has developed Clinical governance principles for pharmacy services37 to support design and delivery of pharmacist services underpinned by safety and quality.

PSA believes measures should be included in the NDIS to support the implementation of a clinical governance framework and quality indicators for medication management and support services delivered by pharmacists for people with disability. PSA would welcome the opportunity to work with relevant agencies to assist in the development and implementation of an appropriate framework.

Appendix 1: Framework of professional and ethical standards for pharmacists

The practice of pharmacists is governed and supported by a comprehensive, hierarchical framework of legislation, and professional and ethical standards, as summarised in Figure A. The pharmacist workforce is fundamentally committed to person-centred care, evidence-based best practice, collaborative team care arrangements and quality improvement.

PSA is the pharmacy profession’s standards-setting body and custodian of the National competency standards framework for pharmacists in Australia38 (document type D in Figure A), and also develops, maintains and promulgates its own suite of documents, including: Code of ethics for pharmacists39 (C), Professional practice standards16 (E), Clinical governance principles for pharmacy services37 (E/F) and various guidelines (F) to support professional practice activities and pharmacist-delivered health services.

Figure A: Hierarchy of standards for pharmacists

• A. Commonwealth, state and territory legislation provides the legal framework governing pharmacy practice.
• B. The Pharmacy Board of Australia’s registration standards define requirements to be met to be registered as a pharmacist in Australia. The Board’s codes and guidelines may be used as evidence of what constitutes appropriate professional conduct or practice for pharmacists.
• C. Codes of ethics / conduct articulate the values of the pharmacy profession and expected standards of ethical behaviour of pharmacists towards individuals, the community and society.
• D. Competency standards describe the skills, attitudes and other attr butes (including values and beliefs) attained by an individual based on knowledge and experience which together enable the individual to practise effectively as a pharmacist.
• E. Professional practice standards (or quality standards) relate to the systems, procedures and information used by pharmacists to achieve a level of conformity and uniformity in their practice. Quality standards may be applicable to individuals or to organisations.
• F. Professional guidelines are generally service- or activity-specific and provide information on how best to deliver services consistent with expected professional standards.

38 National competency standards framework for pharmacists in Australia. Canberra: PSA; 2016. At: https://www.psa.org.au/wp-content/uploads/2018/06/National-Competency-Standards-Framework-for-Pharmacists- in-Australia-2016-PDF-2mb.pdf

39 Pharmaceutical Society of Australia. Code of ethics for pharmacists. Canberra: PSA; 2017. At: https://www.psa.org.au/wp- content/uploads/2018/07/PSA-Code-of-Ethics-2017.pdf

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G. Accredited Continuing Professional Development and practice support activities; these support continuous quality improvement by pharmacists and assist pharmacists to maintain and enhance their competence in current and possible future roles.

Note: Clinical governance principles are integral to E and F with regards to implementation of safety, quality and consistency of pharmacist-delivered care and services.

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