A team approach to medicines management
With rates of medicines prescribing increasing in Australia, especially among seniors, the risk of adverse events is ever present. Through observation and reporting, frontline care workers are important contributors to an effective medicines team, writes Dr Christine Beanland.
With rates of medicines prescribing increasing in Australia, especially among seniors, the risk of adverse events is ever-present. Through observation and reporting, frontline care workers are important contributors to an effective medicines team, writes Dr Christine Beanland.
There is an old riddle in healthcare circles: What is the most dangerous medicine you can take? The answer is: the fourth one.
This riddle highlights that the risk of an adverse medicines event increases with the number of medicines taken, regardless of what those medicines are. In our community about two thirds of people aged over 60 take four or more medicines. This number is likely to rise as the number of prescriptions written in Australia each year continues to increase. In the last financial year the Pharmaceutical Benefits Scheme (PBS) reported that prescription volumes increased 6.3 per cent to a total of 209.8 million items. The PBS accounts for about 82 per cent of prescriptions written in Australia each year.
There are a number of reasons for the increase in prescribing. The first is the development of new medicines. Our first medicines were used to ease symptoms, such as pain or fever. As our understanding of disease processes grew so did the development and use of new medicines to treat specific diseases or conditions – for example, antibiotics, anti-cancer drugs and antihypertensives.
Today, medicines are also commonly used to modify risk factors to decrease the likelihood of disease occurrence. In fact, the class of drugs most often prescribed in Australia today are the statins, which block cholesterol production leading to lower cholesterol levels. High cholesterol levels are a risk factor for cardiovascular disease, so the statins assist in reducing the risk of heart attack or stroke.
Another reason for the increase in prescribing is our ageing population. As we live longer, we each manage a greater number of chronic medical conditions, symptoms and risk factors. The prescribing of more medicines becomes an inevitable part of our medical management.
Therefore, the picture in the community is one of increasing complexity. At RDNS our staff support and provide care for many older people who are taking more than eight medicines to treat more than five conditions and they often have two or more prescribers.
The complexity of a person’s medicines regimen can increase the risk of an adverse event; this might be due to drug side effects, interactions between medicines or an error in medicines administration. An adverse event may present in many ways, from a worsening of current symptoms to the onset of new and serious conditions. For one in five older Australians this will result in hospitalisation.
The challenge for all of us in community care is to assist people to live well and remain as independent as possible.
Adopting a team approach
As healthcare service providers our aim is maintenance of good health and wellbeing, prevention of illness and to support the person to remain living in the community as independently as possible. To do this a team approach is required. The same is true in supporting older people to manage their medicines safely. Our research is currently implementing and evaluating new models of care for older people living in the community who are at high risk of adverse medicines events or errors. We have learned that an effective team requires engagement of all team members and clear communication pathways between the person, their family and/or informal carers or support network (such as friends or neighbours), all of their prescribers, their medical practitioner, community pharmacist, community nurses and community care workers. In complex situations, we also include the expertise of a consultant pharmacist.
The person is always the centre of the medicines team and their healthcare and treatment goals guide the actions of the team. Supporting them are their GP and other specialist medical practitioners, who are often also prescribers. Dentists, podiatrists and nurse practitioners also prescribe and medicines prescribed by them should always be included in the person’s medicines list or profile. The community pharmacist is a key member of the medicines team. Our research suggests that the health and wellbeing of older people is best supported by consistently using one community pharmacy where they are known and all their prescriptions are recorded and coordinated. The other important medicines team members are the health care team that support medicines administration. The community care worker is a valuable member of this team.
Role of community care worker
The role of the frontline community care worker in medicines support is limited by legislation, organisational governance and policy. As a community care workers you should always be aware of the organisational policies governing your scope of practice and work within them for your own and their client’s protection. This does not diminish your role in supporting safe and effective medicines use in any way. As frontline carers your skills in observation and reporting are important contributors to your client’s health and wellbeing and the clinical decisions made by other members of the medicines team.
There is a raft of ways in which the community care worker can help support clients in taking their medicines, from prompt reminders to monitoring their self-administration.
In a recent project, our research team implemented and evaluated a role for qualified community care workers, working under the supervision of registered nurses, to support older people assessed as low risk of an adverse medicines event or error. The role was demonstrated to be safe and effective and the response to the new role was very positive from the medicines team.
As one nurse said: “I visited someone today that the [community care worker has] been seeing regularly and it’s not a problem, and I have to say the documentation from the [worker] is brilliant, they’re terrific, and they always ring if there’s an issue.”
To me, this quote epitomises good teamwork and safe medicines management, helping people to live well.
Dr Christine Beanland is a senior research fellow in the RDNS Institute, where she leads the medicines support research program.
Things to watch
The principal risk factors for an adverse medicines event or error are if the person:
- is using four or more medicines
- has more than one prescriber or pharmacy
- has been discharged from hospital in the past month
- is experiencing possible side effects from their medicines
- has concerns about managing their medicines
- has experienced a recent medicines error/incident.
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