A Day in the Life of an Onsite Aged Care Pharmacist
There was movement at the station, for the word had passed around…
No, I’m not referring to the opening line of the great Australian poem “The Man from Snowy River” first published by Banjo Paterson on this day, 26th April, in 1890. I’m envisaging what it must have been like in the nurse’s station when the staff at my aged care workplace first heard that they will be one of the first sites in Australia to receive their very own onsite pharmacist.
Hi, my name is Melissa and I’m a Choice Aged Care (CAC) onsite aged care pharmacist working at a New Hope Queensland (NHQ) facility in Brisbane. After finishing up at NPS MedicineWise (with the Program’s unfortunate de-funding), I was excited to find a role with CAC that was piloting the onsite aged care pharmacist model. As they say, “one door closes, another opens”. Coming from NPS MedicineWise, this aged care position really appealed to me due to the education and training delivery aspects of the role. The prospect of close patient relationships and multidisciplinary healthcare team interactions also felt like the role would deliver the best of both the retail pharmacy and hospital pharmacy worlds respectively.
The past few months have not disappointed! Let me recount to you ‘A Day in the Life’ of an Onsite Aged Care Pharmacist’.
Having successfully navigated school drop-off after the Anzac Day public holiday, I arrive at NHQ at around 9am. As I settle into my workstation, the morning routine begins as usual by being greeted by Smokey, the facility’s cuddly (and might I add portly) Labrador dog. NHQ observes The Eden Alternative philosophy of care, which means pets like Smokey are most welcome (and an overtly medical model of care is not). Residential Aged Care Facilities (RACFs) are designed to deliver a ‘home-like’ environment for care recipients. Unlike the pharmacy or hospital setting, my workplace here at NHQ is within my clients’ home and I am essentially their guest.
With Smokey satisfied after his morning scratch, I cast my eyes to my computer to peruse and prioritise the list of requests and tasks that will keep me busy today. NHQ’s Care Management System (LeeCare) collates the items and incidents that have been communicated for my attention. This is super handy given my role here is limited to a few shifts each week (NHQ and CAC’s pilot is seeking to replicate the reality of the future funding model, whereby the vast majority of RACFs will only have sufficient funding to engage an onsite pharmacist on a part-time basis).
I can see that since my last shift, the facility has welcomed 1 new permanent resident, 2 respite (temporary short-term) care recipients and another resident has returned from a hospitalisation. A carer has also communicated that Mrs Smith “wants to speak to the pharmacist about her blocked nose”. A nurse has also escalated to me a concern regarding Mr Tan’s self-medicating of analgesia. Apart from those items placed on my radar to action, today I have the routine monthly Falls Review committee meeting at 12noon and the daily Staff Handover at 2pm.
It’s a Transition of Care Stewardship kind of morning.
I visit our new permanent resident, Mr Peterson, who is a delightful gentleman of 87 years. He has come in from NHQ’s home care service, hence his medications and clinical state are quite stable (an unfortunately rare situation for a new resident). Mr Peterson’s move to residential aged care was related to progressing ‘acopia’ at home. Acopia is a term we use when someone is unable to ‘cope’ in their home setting and the risks of remaining at home are just far too great (e.g. recurring falls and injury). Bringing a care recipient in under 24-hour nursing care at an RACF (yet within the home-like environment at NHQ) provides the resident and their family with peace of mind. However, not all residents are happy about their transition to a RACF, and I can see that Mr Peterson is feeling pretty down in the dumps (despite trying to put on a brave face).
Back at my workstation (Smokey has moved on to the residents’ dining room), I make a note in LeeCare for staff to keep an eye on Mr Peterson’s mood as he continues to settle in here. Nurses will also conduct a Depression Scale assessment as part of his baseline Care Plan. I think he will be fine though, once he gets used to the routine. And is my informal process with other new residents, I’ll pop over to his room for a social hello a few times in the coming weeks. I’ve learnt that building trust and rapport with my residents is the most important thing that I can do in my role as NHQ’s Medication Safety Champion.
Our two new respite care recipients are a married couple, Mr and Mrs Denham. In fact, they have had a few respite stays at NHQ over the years. Their previous stay followed just after my commencement as the site’s onsite pharmacist and I was concerned with a few of their medication management habits (e.g. sharing each other’s medication from the same stock supply pack, even though they each had unique doses for that same drug). I coordinated a Home Medication Review (HMR) referral with the Denhams’ GP and one of CAC’s clinical pharmacists that conducts HMRs in the area. When chatting to the Denham’s this morning, I followed-up on some of those HMR recommendations and changes that were initiated following the pharmacist’s visit to their home. They both seemed very happy with the HMR service and outcomes, and I’d like to think that my previous ‘little’ intervention in co-coordinating their HMR will enable the Denham’s to continue safely living at their home for longer (with the occasional ‘as needed’ respite stay at NHQ).
Now onto my resident who has just come back from hospital this morning. Unfortunately, Mrs Rossi has experienced a significant decline in health (the hospital team has queried stroke) and several of her medications have been ceased in favour of a ‘conservative approach’. PRN orders for morphine and midazolam have also been charted by the hospital doctors. I visit Mrs Rossi and she is essentially unresponsive. Her decline is worse than I had expected after earlier reviewing her hospital discharge notes and. I confirm with care staff that this has been her presentation since returning from hospital. I also confirm with the supervising nurse that a discussion has already been had with Mrs Rossi’s family regarding her condition and that ‘comfort’ is now the priority of her care and medication management. Mrs Rossi’s family have also been advised by the supervising nurse that it may be time to com into the facility and say goodbye to their Nonna. I recall from reading Mrs Rossi’s life-history (important client case notes to perus in delivering person-centred care) that she is a mother to 8 children and her deceased husband was a businessman and leader within Brisbane’s Italian immigrant post-war community. It’s sad to see such amazing people with whom I have developed a close relationship with enter their final days. However, at these times, I take solace in the knowledge that residents like Mrs Rossi have lived a full and fruitful life and their final chapter was spent living with dignity and respect within a home-like setting.
All I can do now is double check our imprest/emergency supply stock and ensure all palliative medications are present and ready for use. I also give the Syringe Driver for non-oral administration a check-over to ensure it is in good working order. I confirm with Mrs Rossi’s GP, NHQ staff (via leaving a Progress Note in LeeCare) and her daughter that we are fully prepared to manage her comfort and final moments of care within the facility, without the need for re-hospitalisation (as per Mrs Rossi’s earlier documented wishes). This discussion afforded Mrs Rossi’s distraught daughter a huge measure of relief. Afterwards, I take a moment to reflect upon how much I have grown professionally (both in terms of scope and scale of clinical impact) during my short tenure as NHQ’s onsite pharmacist.
I have 20 minutes before the Falls Committee meeting, so pop in and see Mrs Smith about her blocked nose query. Mrs Smith describes experiencing bothersome allergic rhinitis type symptoms which are also contributing to a troublesome cough and difficulty swallowing. Mrs Smith told me that she previously hadNasonex and found the preparation to be excellent. However, she had to stop taking Nasonex several years ago due to it being very expensive and Mrs Smith advised that she has been putting up with the symptoms ever since. It may have taken my presence at NHQ as an onsite and accessible pharmacist for her to finally volunteer her concerns which were most certainly adversely impacting her daily quality of life.
I told Mrs Smith that the price of the same nasal spray type has become significantly more affordable since the generic brands have become available. Mrs Smith gave an audible sigh of relief, and a tremendous grin filled her face, a contagious grin I would say given the effect it had on myself. I told her I will speak to her GP about the option to chart a generic brand of Nasonexand communicated our discussion to her supply pharmacy. This simple scenario and many others like it have shown me how beneficial it is to have a medication expert available at the point of care for Australia’s 200,000+ aged care residents. A simple intervention (for a pharmacist) has now ensured that Mrs Smith can again enjoy her meals (taste and swallow) and not feel embarrassed about her cough when socialising with family and other residents.
The busy morning (with it’s highs and low) concludes with the 12noon Falls Committee meeting. Much of the focus in aged care is about continuous quality improvement. The facility’s management is involving me in many elements of care governance, and it’s tremendously satisfying to be able to apply my knowledge about health and medications to facility-wide Quality Indicators and continuous quality improvement activities. NHQ management team have asked me to a ‘deep dive’ into the site’s falls with serious injury Quality Indicator data and drug use evaluation. Benchmarking and comparing site data with that of NHQ’s multi-site organisational medication use and CAC’s broader 560 national RACFs has provided some informative data-analytics to drive quality. When I present the evolving figures, trends and proposed medication management interventions at these monthly Falls Committee meetings, I look around the room and see an incredible team of colleagues who all value the role I am playing in their team. It’s an amazing feeling to work in such a setting and have a positive facility-wide impact related to input that comes naturally to a pharmacist.
I take a (belated) lunch break with some colleagues in the staff-room. It’s good to switch off for a moment and get to better know the colleagues I work with (there are over 100 care staff at my NHQ facility, so I’m still meeting people). The care staff and nurses attracted to the aged care setting are remarkable folk – inherently caring, compassionate, and big-hearted people who I am so happy to now call my workmates. As with facility management, staff at the coalface of care are genuinely appreciative of the role I am having at NHQ. I sense that the staff know that pharmacists are also inherently compassionate people who also want the best for our vulnerable clients.
Winding up an enjoyable break, I rally myself for the next task on my list. Mr Tan is a complicated gentleman and his pain management regimen has been difficult to rationalise. The nurse’s LeeCare note to me suggests that Mr Tan’s analgesic self-medicating may have progressed to a stage that warrants another effort for me to get through to him. I’ve managed to develop a reasonable rapport with Mr Tan in the few months since I’ve known him. He remains fiercely independent with his medication management and prefers to do most things his ways. This is something his GP, NHQ nurses and I know we must respect, though we try to balance this with our duty of care obligations. The provision of quality clinical care and the person-centred approach involves facilitating a care recipient’s ‘dignity of risk’. I see it as an important role for me as NHQ’s onsite pharmacist to ensure that all clients are enabled such dignity, underpinned by a resident exerting genuine informed decision making and receiving accurate and timely communications about their medications.
Mr Tan is on a combination of strong opioid medications equalling 340 mg of oral morphine per day, as well as self-medicating ‘as required’ oxycodone and a medicinal cannabis preparation. I discuss with Mr Tan my (and his GP’s) concerns that this medication regimen runs the risk of serious breathing problems (respiratory depression). Specifically, I now emphasise this concern given it is late April and the risk to him of suffering from influenza or COVID-19 this winter may be catastrophic. I sense my 3 months of delicate rapport building with Mr Tan is finally paying off. He finally trusts me and understands that I am advocating for his best interests and not simply telling him what to do or undermining his independence. We spend some time ‘negotiating’ a mutually agreeable outcome (pharmacists, just like Mr Tan, are excellent negotiators). Mr Tan agrees to allow the nurses to manage his PRN as needed oxycodone doses (though I had no such luck with the medicinal cannabis item). We agree to re-assess this arrangement after 1 week and most certainly after winter once we are a little more comfortable with that risk of respiratory depression.
I conclude my “‘Day in the Life’ of an Onsite Aged Pharmacist” with our 2pm Handover at the nurse’s station involving with staff (the current shift of staff and the next shift) at the nurse’s station. The Handover is an intense 20 minute20-minute recap of my last 5 hours as NHQ’s Medication Safety Champion. I sit back and chime-in where relevant from a medication perspective when staff are discussing the day’s care of our residents. It certainly helps having the input of a medication expert at these Handovers when the average resident in aged care receives more thanclose to 10 regular medications.
We conclude Handover, and as two shifts of nurses and care staff shuffle away, once again, there was movement at the station.
Written by Michael Bonner after consolidating feedback from several onsite aged care pharmacists, facility staff and residents at those pilot sites. Clinical scenarios, events and workflows are real, though identifying details (RACF, pharmacist and residents’ names) have been necessarily altered.
This “Day in the Life” piece was submitted to the industry media for publishing on the morning of 26th April 2023. That same day, Minister Mark Butler announced an onsite aged care pharmacist policy change and departure from the Royal Commission recommendations and 25 years of clinical practice and evidence. The future for this amazing professional pathway for pharmacists is now uncertain.