Experience From Rural Practice

 Zaman Bhuiyan1, Ahmed Shrafif 2

  1. Ouse General   Practice, Ouse, Tasmania, Australia
  2. West Gippsland Medical  Clinics, Warragul, Victoria, Australia.

Introduction

The aim of Home Medicines Review (HMR) is for GPs and Pharamacists to work collaboratively to Review  the medicines management  needs of patients for whom quality use of medicines may be an issue.  Since its introduction in 2001, Home Medicines Review (HMR) received a mixed response from the Australian General Practitioners. Like many of our peers, it toolk us some time before contemplating our first HMR.

Settings:

Ouse General Practice:

Solo rural general practice in Tasmania, where  ‘ZB’ works, 90  km from Northwest of Hobart, 50 km From New Northfolk, town population 380, practice population 1500. Ouse General Practice is Dispensing Practice, the nearest pharamacist is in New Northfolk.

West Gippsland Medical Clinic:

A group pactice in Warragul, Victoria where ‘AS’ works 103 km southeast of Melbourne. Population 10,000.

Motivation:

Patients could be gettting where prescriptions/medicines from multiple sources including their GPs, Specialists and OTC. Their treating GPs could be unaware of it. This can increse likelihood  of drug Interaction and result s in appropriate  and unsafe prscription and poor outcome.

We came accross  and alarxming study stating nearely 96% of the patients were not taking exactly what their physicians thought they were. 2

Although we had similiar oberavations, initially we were secptical  about HMR. Concerned  that a lot of additional efforts were needed in terms of time , paper work and co-ordination.

Eventually we took up the task.  The motivation came from the need and from the potentional for improved outcome. Support and persuasion from local division of  General practice provided  the extra boost. We realised  it is not as laborious as we first thought.

Opportunities:

*Both practices are established  family practice  with stable clientele.

*Elderaly patients in these rural areas have long-term ongoing relationship with their GPs.

*The local division of General  Practice  (DGP)  very helpful & supportive. TGP & Pharmacists helped with the initiation of the process and continue to provide ongoing support to deal with difficulties.

*In Warragul, the pharmacies are very close to the practice, pharmacists are personnaly known the GPs. And it is easier for him to contact them in person.

*Patients are well known to their pharmacists and  already have estabished rapport (Warragul),

*In both practices, patients are bulk build for HMR, So no burden of any out of pocket expense.

Challenges:

*Initial ‘fear’ of someone (Pharmacist) intruding into out territory.

*Finding enough time in a busy practice.

*Some patients  appear suspicious for unsure  and needed  quiet a bit of persuasion.

*For Ouse , the pharmacist has to come from Hobart or New Northfolk. Travelling time is a big barrier, even from Ouse a pharmacist sometimes has to travel further 90 km to visit a particular patient at home.Co-ordinating suitable time with them often a problem.

*Regular follow up needed to monitor  the implementation  of recommendations. It involve several phonecalls, multiple consultations, going through various records .

Patients’ feedback:

“The Pharmacist told us about the side effect, how to take, went to take the medications. He also told us  that if we took any over the counter medication without doctor prescription, we shouldlet him (The Doctor) know”.

“It was difficult to remember medication as the docotor had advised. The Pharmacist told me to get a dosette box.”

“I did not learn anything new.”

“He (Pharmacist explained how to use my puffers”.

“It is really ex cellant that we get these services in rural areas.”

“I did not know that I had to tell you about what I take from the natuopath or from the supermarket.”

Pharmacist’s feedback.

“For years GPs and pharmacist have lead  fairly seprate lives, but  HMR not only help patients, they also open lines of communations between a GP and a Pharmacist”.

“HMR can be a exteamely  rewarding for a phaxrmacist”.

“Om average including travel. Patient interview , writin g a report,  the entire process may take up to 8-9 hours. And accredited pharmacist earns A$ 120.00/HMR. This equates to around A$15.00/hour. I do not believe it is cost effective for pharmacist at this point in time.”

“Each HMR brings  new and interesting  information, as well as ability to build a report  with aGP.”

“I look at an HMR as a means of maintaining  a sound clinical knowled ge outside of hospital and enviornment”.

Conculsion:

Although HMR is principally aimed at improving the qualities of the patient management,it is indeed three way learning experiencing for us  as GPs, our patients and  for the pharmacists alike. It was not merely a way of for formalising what we are doing, but a way of getting more understanding of patients medication uses so  that they are eaiser to work with.3

Patients feedback gerearlly  very positive . It improve the lines of communications among all three parties in world. We have noticed  a sense of ownership of the management plan and improved compliance among  our patients.

A concern has however been raised by some participating pharmacists about the inconvience of travelling long distances  in rural areas and about the inadequate re muneration for it . This issue may beat further exploration and  redressing .

Reference:

1.Commonwealth Department of Health and Aging. Fact Sheet Home Medicines review – Domilicilary medication Management.

2.Franck C et al. What drug are our frail elderly patients taking? Can Fam Physician 2001;47:1198-1204.

3.Bhuiyan AKMF. Home Medication  review. A personal Experience in Rural Tasmania, Aus Fam Physician 2004;33(8):644.