Contents
Key Points
  • Many members of the veteran community stand to benefit from a HMR.
  • Encourage veterans to receive a HMR by promoting its benefits and discussing what it involves for patients and/or their carers; for example:
    • providing education about the patient’s medicines
    • assisting medicine management at home
    • checking for duplicate medicines and interactions
    • compiling a medicine list from multiple prescribers.
  • To get the best out of a HMR, specify any particular medicine-related problems that need to be addressed in your referral.

Home Medicines Review – The benefits for you and your patients

Many members of the veteran community stand to benefit from a Home Medicines Review (HMR).1

From a patient’s perspective, HMRs improve knowledge, skills and confidence in using medicines.2 Patients also report a high satisfaction rate with the service.3, 4 Research conducted across Australia has consistently demonstrated that HMRs are an effective way to identify and resolve medicine-related problems and improve health outcomes.5-13

The majority of veterans who may benefit have not received a HMR. An analysis of the DVA health claims database found that of the 176,000 veterans living in the community who had one or more medicines dispensed in a 12-month period, only 4% received a HMR.1

Recent changes to the HMR service means increased flexibility for making HMR referrals, which may make it easier to deliver this service to patients in the veteran community. (Note: in the Medicare Benefits Schedule, a HMR is described as a Domiciliary Medication Management Review (DMMR) – item 900.)

Why refer for a HMR?

  • Are you, your patients or their carers confident that medicines are being taken as you have prescribed, and as you have intended?
  • Could your patients benefit from additional education about their medicines?
  • Are there additional medicines that your patients may benefit from taking?
  • Could your patients be taking a medicine or other product that you are unaware of?
  • Could your patients have adverse effects of medicines that have not come to your attention?
  • Are you confident that your patients are storing their medicines correctly, and are safely disposing of unwanted or expired medicines?
  • Would you like a pharmacist to review all drug doses and combinations for your patients?

All of the above issues are routinely addressed in the course of a HMR.

Australian studies have demonstrated that HMRs can resolve, manage or improve medicine-related problems in the majority of cases.11, 12 Additionally, HMRs have improved health outcomes in veterans.12-14 For example, in veterans receiving beta-blockers for heart failure, a HMR resulted in a 45% reduction in likelihood of hospitalisation for heart failure at any time.12 Another study found that a HMR in veterans taking warfarin resulted in a 79% reduced likelihood of bleeding-associated hospitalisation two to six months after the HMR.13

Besides the clinical benefits, HMRs help patients manage their medicines better. A study conducted in New South Wales on consumer perspectives of HMRs found that patients believed HMRs helped them gain information about their medicines, and made them feel reassured, valued and cared for.

HMRs also increased their willingness to discuss their medicines with their GP.3 The majority of patients in another Australian study who received HMRs became more confident in taking their medicines and felt they learnt something from the HMR.15

The following feedback received from Veterans’ MATES respondents highlights situations that can be addressed during a HMR:
  • 11% from a sample of 3,700 veterans with chronic obstructive pulmonary disease (COPD) were not confident that they were using their inhaler(s) correctly.
  • 40% from a sample of 2,000 veterans with acute coronary syndrome were unsure or not aware of the possible side effects of their heart medicines.
  • 12% from a sample of 6,700 veterans prescribed warfarin did not know how to recognise the early signs of bleeding.
  • 28% from a sample of 8,900 veterans with chronic heart failure did not ask their doctor or pharmacist before taking a non-prescription medicine.

Who is eligible for a HMR (item 900)?

There are three overarching criteria for a patient to be eligible for a Medicare funded HMR:

  1. the General Practitioner (GP) feels the patient would benefit from the HMR or is at risk of a medicine-related problem,
  2. the patient has consented, and
  3. the patient is living in the community (i.e. not a hospital in-patient or living in a residential aged care facility*).

There are no age restrictions or minimum medicine-related criteria.

For each eligible DVA patient, HMR referrals can be made every 12 months. If there is a significant change in the patient’s circumstances or medical conditions, consider the need for an earlier HMR referral.

*For those living in an aged care facility, there is a separate MBS item number (Item 903) for Residential Medication Management Reviews (RMMR).

A case study

Mr Jones is referred for a HMR because he is taking warfarin, has had difficulties with INR stabilisation and is on multiple medicines. During the HMR, Mr Jones describes his back pain as his major concern; he frequently purchases paracetamol 500 mg / codeine 10 mg tablets over the counter, which his GP is unaware of.

Regular paracetamol was discussed at the HMR, but Mr Jones said he found the number of medicines and timings of his medicines difficult. Mr Jones did not have information on him to identify that he was taking warfarin. The pharmacist suggested a Department of Veterans’ Affairs (DVA) Dose Administration Aid (DAA)**, a MedicAlert bracelet and regular pain management; his GP agreed that these might be helpful.

After a discussion with the pharmacist and Mr Jones, the GP organised a DVA DAA script and assisted Mr Jones to complete a MedicAlert form. Mr Jones was unaware that he was eligible for these and found the education and HMR service very helpful. With a greater consistency in taking his medicines, Mr Jones’s INR stabilised.

**DVA provides a DAA service that is free to eligible veterans.

Veterans who are likely to benefit from a HMR include:
  • those taking multiple medicines – Because the veteran population tends to be older, they use more medicines than the general Australian population, and they are more likely to have multiple chronic conditions. Managing multiple medicines can be difficult for some patients.
  • those with multiple prescribers – Some veterans may also visit multiple prescribers and pharmacies, which may result in duplicate medicines, or adverse effects and drug interactions being overlooked.
  • those prescribed a new medicine – The addition of a new medicine may cause confusion, particularly if the patient is using multiple medicines. Education and management advice about the new medicine can assist with adherence and reduce the risk of drug interactions.
  • those who have had recent hospitalisation – Hospitalisation usually results in changes to medicines and/or doses. This may generate patient confusion resulting in harm, because of potential medicine duplication, and continual use of discontinued medicines or doses.
  • those with cognitive, hearing, vision or dexterity problems – Such problems can result in patients not understanding or not being able to follow instructions on how to take their medicines. They can also cause difficulty in opening containers and handling medicines, or they may impact on their ability to use devices such as inhalers and DAAs.
  • those taking high-risk medicines – High-risk medicines generally require regular reviews because they have a narrow therapeutic window, a propensity for drug interactions, frequent or severe adverse effects, monitoring requirements, or a need for dosage adjustments in special conditions (e.g. renal impairment).

Referring a patient for a HMR

Only GPs can refer a patient for a HMR. Making a referral is simple. GPs can request HMRs for any patient living in the community setting who has a potential medicine-related problem.

Before referring patients for HMRs, it is necessary to get their consent. For some patients HMRs may seem confronting; however, if the benefits are explained, more patients are likely to be open to the service (see ‘Responding to patient concerns’).

Most prescribing software provide HMR referral templates. Some GPs use a computer print-off of the patient’s health summary as the basis of a referral.

From 1 October 2011 changes to HMR process means that the referral can be made to the patient’s preferred community pharmacy or an accredited pharmacist, as per the patient’s preference.

The HMR Referral Process

no-1Step 1

Identify patient living in the community who would benefit from a HMR. Discuss the benefits of HMR with the patient and obtain patient consent.

no-2Step 2

In consultation with the patient, initiate the referral to either the patient’s preferred community pharmacy or an accredited pharmacist. Include relevant clinical information, highlighting the reason for the HMR and any concerns that need particular attention.

no-3Step 3

After the pharmacist has conducted the HMR, discuss with the reviewing pharmacist the results of the HMR, including suggested medicine management strategies and generate a Medication Management Plan.

no-4Step 4

Discuss the HMR and the Medication Management Plan with the patient and consider creating a recall for a repeat HMR in 12 months. It is also considered best practice to provide a copy of the Medication Management Plan to the patient’s preferred community pharmacy.

no-5Step 5

Claim MBS item 900.

Responding to patient concerns

Some patients may be reluctant to take up this service, particularly if they do not understand the benefits, or what happens during a HMR (Box 1). Others may be concerned about upsetting their GP, losing their independence or dealing with an unknown pharmacist; and some may have privacy and safety issues given that the reviews are generally conducted in the home. However patients who have had the HMR service agree that the benefits makes this service worthwhile.3

When obtaining a patient’s consent, explain the benefits of the service:

  • HMRs exist only to help patients, by encouraging better and safe use of their medicines, thereby reducing the risk of side effects and improving disease management.
  • HMRs allow GPs and pharmacists to work closely together to deliver patients the best medical care possible.

For patients who are uncomfortable about having a HMR in their home, offer the HMR to be conducted in a neutral venue, such as the GP’s practice or at their pharmacy in a private room; it is not compulsory to perform HMRs in the patient’s home.

Box 1: During a HMR, an accredited pharmacist:
  • identifies all medicines used by the patient (both prescription and over-the-counter medicines)
  • compiles a comprehensive list of medicines prescribed by all the patient’s prescribers
  • identifies use of unnecessary, suboptimal or duplicate medicines and doses
  • determines the patient’s understanding of his/her medicines, including correct administration methods (e.g. eye drops, inhalers)
  • provides education on the patient’s medicines, including written information where appropriate and answers any questions the patient may have
  • assesses relevant drug–drug and drug–disease interactions, monitoring requirements and adverse effects
  • identifies adherence issues and assesses the need for compliance aids
  • addresses practical aspects of medicine management, including access, storage and disposal.

Further information

References

  1. DVA Health Claims Database, University of South Australia, QUMPRC. Accessed 2011.
  2. Gilbert AL et al. Collaborative medication management services: improving patient care. MJA 2002; 177: 189-192.
  3. White L et al. Consumer perspectives of the Australian Home Medicines Review Program: benefits and barriers. Res Social Adm Pharm 2011. Article in Press. Available online. http://www.sciencedirect.com/science/article/pii/S155174111000166X
  4. Campbell Research & Consulting. Home Medicines Review Program, Qualitative Research Project, Final Report. Department of Health and Aging; 2008. http://www.health.gov.au/internet/main/publishing.nsf/Content/hmr-qualitative-research-final-report [Accessed 6 Aug 2011].
  5. Castelino RL et al. Drug burden index and potentially inappropriate medications in community-dwelling older people. The impact of Home Medicines Review. Drugs Aging 2010; 27 (2): 135-148.
  6. Stafford L et al. Clinical outcomes of a collaborative, home-based postdischarge warfarin management service. Ann Pharmacother 2011; 45: 325-334.
  7. Sorenson L et al. Medication reviews in the community: results of a randomized, controlled effectiveness trial. Br J Clin Pharmacol 2004; 58: 648-664.
  8. Stafford AC et al. Drug-related problems identified in medication reviews by Australian pharmacists. Pharm World Sci 2009; 31: 216-223.
  9. Castelino RL et al. Retrospective evaluation of Home Medicines Review by pharmacists in older Australian patients using the medication appropriateness index. Ann Pharmacother 2010; 44: 1922-1929.
  10. Castelino RL et al. Are interventions recommended by pharmacists during Home Medicines Review evidence-based? J Eval Clin Pract 2011; 17: 104-110.
  11. Bennett A et al. A comparative study of two collaborative models for the provision of domiciliary-based medication reviews. Final report. Sydney, Australia: University of Sydney and St George Division of General Practice; 2000.
  12. Roughead, EE et al. The effectiveness of collaborative medicine reviews in delaying time to next hospitalization for patients with heart failure in the practice setting: results of a cohort study. Circ Heart Fail 2009; 2: 424-428.
  13. Roughead EE et al. Collaborative Home Medicines Review delays time to next hospitalization for warfarin associated bleeding in Australian war veterans. J Clin Pharm Ther 2011; 36: 27-32.
  14. Kalisch, LM et al. Improving heart failure outcomes with pharmacist-physician collaboration: how close are we? Future Cardiol 2010; 6: 255-268.
  15. Blennerhassett, JD et al. A novel medicines management pathway. JPPR 2006; 36: 175-179.

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Key Points
  • Many members of the veteran community stand to benefit from a HMR.
  • Encourage veterans to receive a HMR by promoting its benefits and discussing what it involves for patients and/or their carers; for example:
    • providing education about the patient’s medicines
    • assisting medicine management at home
    • checking for duplicate medicines and interactions
    • compiling a medicine list from multiple prescribers.
  • To get the best out of a HMR, specify any particular medicine-related problems that need to be addressed in your referral.