An exploration and evaluation of the work processes of accredited pharmacists performing Home Medicines Reviews in the Australian communityMarea Patounas BPharm MPS AACPA

IF49 PhD Student

UHREC Ethics Approval 1400000561

Supervisors:

Prof Lisa NissenDr Esther LauProf Greg KyleMs Debbie RigbyDr Vincent Chan

Outline

• Background

• Significance of PhD project

• Research aims

• Research design & methods

• Results – interviews, national survey

• Research dissemination

2

Learning Objectives

3

After completing this activity pharmacists should be able to:

• Describe a recent systematic review of clinical medication reviews in

Australia

• Explain issues and problems reported by patients about pharmacists

performing Home Medicines Reviews in Australia

• Describe a human factors framework for studying and improving the work

of healthcare professionals and patients – SEIPS 2.0 Model

Superpolypharmacy and the complexity of healthcare

4

Photo courtesy of M Patounas

The term “medication review” encompasses a continuum of processes in

various formats and complexities

5

From: PSA Guidelines to providing Home Medicine Review (HMR) Services. 2011.http://www.psa.org.au/downloads/practice-guidelines/home-medicines-review-services.pdf

Types and locations of Medication Reviews in Australia

Community:

Home Medicines Review

Hospital

Approved Aged Care Facilities

(RMMR)

Community:

MedsCheck, Diabetes

MedsCheck

6

PhD project –

accredited

pharmacists

(APs)

Jokanovic N, Tan EC, van den Bosch D, Kirkpatrick CM, Dooley MJ, Bell JS. Clinical medication review in Australia: A

systematic review. Res Social Adm Pharm. 2016;12(3):384-418. https://www.ncbi.nlm.nih.gov/pubmed/26250049

7

Medication Reviews – what does the literature say?

Problems with HMR pharmacist work processes

• Failure to :

– clearly identify themselves at the start of the home interview

– clearly set the scene with the main purpose of the interview

– have structure within the home interview process

– engage in discussion & address patient needs

– inform the patient of the fact that the HMR Report would be sent to the GP

• Laptop in home interview may not be well perceived by patients Carter SR, Moles R, White L, Chen TF. The impact of patients’ perceptions of the listening skills of the pharmacist on their

willingness to re-use Home Medicines Reviews: a structural equation model. Research in Social and Administrative Pharmacy.

2015;11(2):163-75. https://www.ncbi.nlm.nih.gov/pubmed/?term=The+impact+of+patients%E2%80%99+perceptions+of+the+listening+skills+of+the+pharmacist+on+their+willingness+to+re-use+Home+Medicines+Reviews

8

Ahn J, Park JE, Anthony C, Burke M. Understanding, benefits and difficulties of home medicines review. Australian

Family Physician. 2015;44(4):249-53. https://www.ncbi.nlm.nih.gov/pubmed/?term=Understanding%2C+benefits+and+difficulties+of+home+medicines+review

Extract:

• “Participants who received the shortest reviews felt their HMR was 'a complete waste of time.' (P:3) In their

limited time they felt they simply received no information.

– 'She [the pharmacist] came here, she sat right where you're sitting...and said that's all, have a good day.

And off she went.' (P:3)

• They engaged in no discussion and were given dismissive responses to their questions.

– 'I didn't get any answers. Everything was fine.' (P:4)

• In addition to these pharmacists being brief, they were also described as being inattentive, which added to

the participants' dissatisfaction.

– 'She [the pharmacist] was a bit blasé. Her person was there but like nothing inside. She was empty. Like

a shell...

– It was like she had other places to be and she wanted to get it over and done with.' (P:4) .”

9

Ahn J, Park JE, Anthony C, Burke M. Understanding, benefits and difficulties of home medicines review Australian Family

Physician. 2015;44(4):249-53.

Problems with HMR pharmacist work processes

Problems with HMR Reports

• Majority of HMR Reports unexceptional in format & content

– 13 / 110 (11.8%) particularly good layout, 3 / 110 (2.7%) poor layout

– 7 / 110 (6.4%) remarkably good content, 11 / 110 (10%) poor content

• No mandated guidelines on HMR Report structure

– APs may choose to subscribe to software companies

– E.g. Medscope, MediFlags

10

Sorensen L, Stokes JA, Purdie DM, Woodward M, Elliott R, Roberts MS. Medication reviews in the community: results of a randomized,

controlled effectiveness trial. British Journal of Clinical Pharmacology. 2004;58(6):648-64.

Data analysis techniques

11Ickowicz E, Amer Geriatrics Soc Expert P. Patient‐Centered Care for Older Adults with Multiple Chronic Conditions: A Stepwise

Approach from the American Geriatrics Society. Journal of the American Geriatrics Society. 2012;60(10):1957-68.

A Stepwise Approach from the American Geriatrics Society

Pharmacists in society - changing paradigm (Mossialos et al. Health Policy 2013)

Lim

ite

d fu

nctio

ns Retailing of

productsDispensing

Compounding

Retailing

Ad

ditio

na

l fu

nctio

ns Safety Monitoring

Focus on medication-related adverse events

Co

mp

reh

en

siv

e r

ole Public Health

Role Promotion, Prevention and Disease Management

12

Significance of research

Research Aims

1. What are AP’s work processes in the 3 stages of HMR work system:

I. Pre-interview (preparation)

II. Home interview stage (with the patient)

III. Post-interview stage (collation of findings & recommendations into

a HMR report for the patient’s GP)

2. What time is required to complete a HMR?

– What time is required for the 3 stages of HMR?

13

The stages of HMR process for this research project (Steps 1, 2 and 3)

14

GP

Initiates HMR Referral; &

receives completed HMR

Report; Management Plan

back to APStage 1:

Pre-Interview(Information

gathering)

Stage 2:

Home Interview

Stage 3: Post

Interview (Clinical decision making & HMR

Report preparation)

Collaboration with patient and/or

carer and others linked with

patient's care such as community

pharmacist

Home Medicines Reviews – 3 “Stages”

What do accredited pharmacists do when performing HMRs?

How much time is involved with their HMR work?

How to gather information to answer the research question/s?

1. Perspectives

– Focus Groups, Interviews, Surveys

2. Examine artefacts

– HMR reports, other documents of practice

3. Observe HMR practice in real time

– Non-participatory observation

– Time and motion studies

– Audio recording of patient-pharmacist conversation15

Triangulation

of research

methods

PhD extended Project – multiphase study

Focus Groups

• 2 Focus Groups – uncover broad themes

• 10 accredited pharmacist participants

Interviews

• Semi-structured Interviews – in-depth

• 15 accredited pharmacist participants

Survey

• National e-survey via QUT Key Survey

• 255 accredited pharmacist participants

Artefacts

• Examination of accredited pharmacist artefacts

• HMR Reports

Observation

• Non-participatory observation & audio recording of in-home patient-pharmacist conversation

16

Participants, recruitment & sample size

17

Study Recruitment

Method

Data collection

method

Number of AP

Participants

HMR Practice Location

Focus

Group 1

Purposive,

professional

networks

Face-to-face:

Audio recording &

live scribe

6 Brisbane & North/South

Coast areas

Focus

Group 2

Purposive,

professional

networks

Face-to-face:

Audio recording &

live scribe

4 Brisbane

Semi-

structured

Interviews

Purposive,

professional

networks,

snowball

sampling

Face-to-face (1) &

via phone (14),

with audio recording –

average time 90

mins

15 Brisbane, south-east,

regional & far north

Queensland; &

Regional & remote NSW

Survey Convenience

sampling

Electronic –

QUT Key Survey255 ACT 1% SA 11%

NSW 36% Tas 4%

NT 1% Vic 20%

Qld 17% WA 10%

Data Analysis

18

19

Holden RJ, Carayon P, Gurses AP, Hoonakker P, Hundt AS, Ozok AA, et al. SEIPS 2.0: a human factors framework for studying

and improving the work of healthcare professionals and patients. Ergonomics. 2013;56(11):1669-86.

https://www.ncbi.nlm.nih.gov/pubmed/24088063

What do

accredited

pharmacists

DO?

PhD project –

accredited

pharmacists

(APs)

RESULTS: Quotes: TIME

20

It just depends on how hard

your - how long is a piece of

string?

How hard do you want to look at

the pathology reports? Just from my own personal point of

view, that interests me, so I will sit

there a bit longer.

I probably spent an hour and a half

this afternoon looking and

background medical reading as

well about the patient’s condition,

yeah.

How long is a piece of string?

sometimes it can really blow out,

especially if they have got a lot of

medicines and you have got trouble

getting them back on track

And it is longer if you have got a

carer. The interview takes longer

when there is a carer there.

In some ways what is happening in the

rest of their life can be relevant to what

is happening for them. Hearing about

their social situation --

may be keys to

something else as well.

Quotes – ‘Grouping via Disease vs Working Down the List”

Researcher:

“Do you have a particular order or process by which you interview the patients about

each medicine?

I know you said you mainly go by disease groups. Is there a particular order that you

interview them about each one?”

Participant:

“Not really. I'd probably pick the top guys first, so I'd do diabetes,

cardiovascular and pain. Then I would add in GORD, GIT - but yes, the top three for me would

be cardiovascular, diabetes and pain. That's what - they would be my targets first and then bring the other

two in and see what trickles out.

It depends on the patient. Like if I'm dealing with an MS patient, I'm probably more talking about

continence and that. But I do do a lot of work with recommending other practitioners for things

like continence management and that too. So some patients I will say to them you could visit a

physiotherapist who specialises in continence management or a physiotherapist who specialises in pain

management, I've told her, or whatever. I touch on that with the patient, but I tend to dress that more

firmly in my report to the GP.”21

“GROUPING VIA DISEASE vs WORKING DOWN THE LIST”

Quotes – PERSONAL SAFETY• “There might be weird pictures of guns or horrible stuff and you're kind of like, oh my gosh, and

you're thinking, how the hell am I going to get out of here if I have to? I've had a few things like that.”

• “The Aboriginals, they're always a totally different ballgame for millions of different reasons. It's a miracle that you can do an HMR if they're at home if they turn up, because they can even ring up and do that sort of thing. Generally the home environments are catastrophic, they're distracted, some of them are cognitive impaired, they've got a million people in the house, they're selling drugs in the house. I've been attacked by dogs, all sorts of funny things. You've got somebody else with you as well. Generally I tend not to hear much back from the patient, or the doctor for that reason. There's probably less - whether that's because often you do the HMR and they don't even go back to see the doctor.”

• “A lot of people are bit embarrassed about their house and certainly I've had the cockroaches crawl across me. I've watched mice run across the floor. I've had cats and dogs doing all sorts of -animals jumping on me. So you know and just houses full of smoke and grot, but it's a lot nicer sometimes to actually sit outside. But it can get a bit awkward when they haven't actually got all their medicines out and they're just slowly traipsing back in and out of the house to get the [puffers] and get the extra things out. So you don't get that same thing of being sitting in the kitchen or wherever where you can actually see where the medications are stored.”

22

Quotes: PERSONAL SAFETY

Quotes – MOTIVATION TO BECOME ACCREDITED• “I think it is more the contact with people and the ability to use a lot of those clinical skills that

you learned at uni that you wouldn’t necessarily use in a pharmacy working day-to-day so more

chance to actually use your clinical knowledge.”

• “It seemed like an exciting opportunity. I think I was taken up in the - as P5 said, it was an

exciting time that the role of a pharmacist was potentially going to change. There was an

opportunity and you needed to grab that and do that extra bit of work in order to become

accredited, in order to ride the wave, more or less.

It was get on - you had to take the step to get in there. I think it was just exciting and it is good

when you feel that you are going to be part of that team and striving for really great

outcomes for the patient. Yeah, yeah.”

• “To be challenged clinically and just apply - seeing patients - because I was in a role where I

wasn’t seeing patients. I was working part-time in the community just casually and kept that up.

When I first started at the practice the principal said, ‘P2, I am really enjoying seeing patients. I love

that’. He said, ‘It is good for the soul’, and I thought, it sure is so that’s why I did it. It sounds a bit

idealistic, doesn’t it? “23

Quotes: MOTIVATION TO BECOME ACCREDITED

PERSONAL

SAFETY

COGNITIVE

FRAMEWORK

Concept map – emergent themes Study 1 & 2

PROVIDING

VALUE TO

PATIENT

CARE

PRE-INTERVIEW

HOME

INTERVIEW

POST-

INTERVIEW:

HMR REPORT

TIME

TIME

FEELING

SUCCESSFUL

DESPITE

BARRIERS

“FRAME A

PATIENT

PICTURE”

“PLAYING

SHERLOCK”

PERSON/S

TASKS

TOOLS &

TECHNOLOGY

ORGANISATION

INTERNAL & EXTERNAL

ENVIRONMENT

“GROUPING VIA

DISEASE vs

WORKING

DOWN THE

LIST”

TIMERUM

PROFESSIONAL

FRUSTRATION

Rapport &

trust

GP

MANAGEMENT

PLANFOLLOW-

UP

DRPs

Adherence

Med

Recon

Holden RJ et al. SEIPS 2.0: a human factors

framework for studying and improving the

work of healthcare professionals and

patients. Ergonomics. 2013;56(11):1669-86.

National Survey 2016 (n=255) Respondents’ Demographics

25

24

77

56

67

31

Age of Respondents

20-29 30-39 40-49 50-59 60+

181

74

0Gender of Respondents

Female Male x

26

Decade of Graduation

1950-59 2

1960-69 6

1970-79 35

1980-89 62

1990-99 51

2000-09 84

2010-2015 15

2

6

35

62

51

84

15

0

10

20

30

40

50

60

70

80

90

Nu

mb

er

of

Res

po

nd

ents

Year of BPharm Graduation

National Survey 2016 (n=255) Respondents’ Demographics

27

3

93

3

4529

10

53

26

Location of HMR practice in last year

ACT NSW NT Qld SA Tas Vic WA

National Survey 2016 – Respondents’ Demographics

132

70

69

8

Location of HMR practice in last year

Urban Rural

Regional Remote

Average time required to prepare for HMR:

PRE-INTERVIEW STAGEQUT National Survey - M Patounas n=255

28

119

72

41

15

6

2

0 20 40 60 80 100 120

0-30 mins

30-45 mins

45-60 mins

60-90 mins

90-120 mins

120 mins+

Number of Responses

Tim

e t

o p

rep

are

fo

r a

HM

R

0-30 mins 30-45 mins 45-60 mins 60-90 mins 90-120 mins 120 mins+

119 72 41 15 6 2

Survey Results: TIME to perform HMR

Average time required to perform

HOME INTERVIEW STAGE QUT National Survey - M Patounas n=255

29

5

59

120

65

6

0

0 20 40 60 80 100 120

0-30 mins

30-45 mins

45-60 mins

60-90 mins

90-120 mins

120 mins+

Number of Responses

Tim

e t

o in

terv

iew

pati

en

t d

uri

ng

HM

R

0-30 mins 30-45 mins 45-60 mins 60-90 mins 90-120 mins 120 mins+

5 59 120 65 6 0

Survey Results: TIME to perform HMR

Average time required:

POST-INTERVIEW STAGE

HMR Report preparation & provisionQUT National Survey – M Patounas n=255

30

4

42

102

69

31

7

0 20 40 60 80 100

15-30mins

30-60 mins

1-2 hrs

2-3 hrs

3-6 hrs

6+ hrs

Number of Responses

Tim

e to

pe

rfo

rm P

ost-

Inte

rvie

w S

tag

e o

f H

MR

15-30mins 30-60 mins 1-2 hrs 2-3 hrs 3-6 hrs 6+ hrs

4 42 102 69 31 7

Survey Results: TIME to perform HMR

Survey Responses – Personal Safetyn=255 QUT National Survey – M Patounas

31

Survey Responses –

Signing of Patient Privacy Notification Formn=255 QUT National Survey – M Patounas

32

Survey Responses – Technology and Toolsn=255 QUT National Survey – M Patounas

33

HMR practice: other health professionals contacted apart from doctors255 respondents, 507 responses; Source: QUT National Survey – M Patounas

34

65

18

43

14

166

36

21

92

117

34

0

20

40

60

80

100

120

140

160

180

I don't contactother HPs

Aboriginal andTorres StraitIslander HP

Dietitian Exercisephysiologist

Pharmacist Physiotherapist Podiatrist Practice Nurse Psychologist Social worker Other

Nu

mb

er

or

Re

so

ns

es

Other Health Professionals mainly contacted as part of HMR practice

Expected outcomes of extended PhD project

• Key contributions in knowledge:

– Accounting for HMR work processes from an AP perspective

– Describing thematic domains of APs’ HMR work processes

– Enumerating APs’ time required for the 3 stages of HMR

– Examination of APs’ “artefacts” – HMR Reports

– Observational analysis of home interview

• Essentially:

– Highlighting the contribution & significance of APs’ HMR work processes in healthcare

– Research in pharmacy practice is important for observing pharmacists’ effectiveness

and their contribution to the healthcare system and to patient health outcomes (PSA

Careers Guide 2015)

– “We must be prepared to critically review our practices, to meet changing

service provision contexts, respond to increased public expectations & health

policy directions” (Felicity J Smith. Conducting Your Pharmacy Practice Research Project 2nd ed)

35

Research Dissemination 2017 APSA-ASCEPT

https://eprints.qut.edu.au/115428/

36

APSA Conference 2017Home Medicines Reviews – exploring accredited pharmacists’ work processes

Marea Patounas1, Esther Lau1, Greg Kyle1, Debbie Rigby1, Lisa Nissen1, Vincent Chan2. Faculty of Health, School of Clinical Sciences, QUT1, Brisbane, QLD, Australia; RMIT University2, Melbourne, VIC, Australia.

Introduction. In healthcare, work processes shape patient, professional and organisational outcomes. Little is known about the specific tasks and activities that form the work processes of accredited pharmacists (APs) performing Home Medicines Reviews (HMRs) in Australia.

Aims. To explore APs’ work processes and the time taken to conduct the three stages of HMR: pre-interview (preparation phase); home interview (with the patient); and post-interview (collation of findings and recommendations into a HMR Report for the patient’s General Practitioner).

Methods. Focus groups and semi-structured interviews were conducted with Australian APs. Participants were recruited via professional pharmacy networks and organisations. The sessions were transcribed verbatim and thematically analysed using Leximancer and NVivo 11 software.

Results. There were 10 APs in the focus groups and 15 APs who participated in the semi-structured interviews. Participants for the two focus groups were from southeast Queensland, and interview participants ranged from urban, regional and far north Queensland, to northern regional and western regional New South Wales. The configural work system processes for each stage of HMR were categorised as: person, task, technology, organisation, and internal and external environment factors. The APs focussed on establishing rapport and trust with the patient as a top priority. The majority of APs spent an estimated 4 hours performing a HMR from beginning to end, with the majority of pre-interview, home interview and post-interview stages taking 30-60 minutes, 45-60 minutes and 1.5-2 hours respectively. Most HMR reports were 2-4 pages in length, although this varied depending on whether the AP worked from a home office or if they were a practice pharmacist (integrated into a clinic/practice setting).

Discussion. A detailed account of APs’ HMR tasks and work processes may be of practical value to medical home decision makers, funding bodies, professional organisations, educators and health professionals involved in medication reviews. Further investigation of APs’ work processes and the time taken to conduct HMRs is warranted.

APSA-ASCEPT Conference 2017 Abstract

https://eprints.qut.edu.au/115428/

Lifelong Learning in Pharmacy 2018 Abstract

38

Research Dissemination 2018 LLLP

39

FIP 2018 – HMRs and ADR reporting

FIP 2018 – HMRs and RUM

40

41

APSA Conference Abstract 2016

No of Pages

HMR Report

Response %

1 2%

2 40%

3 36%

4 19%

5 3%

6 <1%

https://eprints.qut.edu.au/101815/

What does HMR success look like to you?

QUT National Survey 2016 (n= 250) – M Patounas

42

Thank You to all the accredited pharmacists and AACP, PSA & SHPA who made this research possible!

marea.patounas@qut.edu.au

https://eprints.qut.edu.au/view/person/Patounas,_Marea.html

Acknowledgments to Tony Hall, Hung Tran & QUT colleagues