Integrating pharmacists into Aboriginal Community Controlled Health Services (IPAC project): Protocol for an interventional, non-randomised study to improve chronic disease outcomes

Enablers and barriers to non-dispensing pharmacist integration into the primary health care teams of Aboriginal community-controlled health services

BACKGROUND

The primary health care management of chronic disease affecting Aboriginal and Torres Strait Islander peoples requires healthcare quality and equity demands to be met, and systems that foster better team-based care. Non-dispensing pharmacists (NDPs) integrated within primary healthcare settings can enhance the quality of patient care, although factors that enable or challenge integration within these settings need to be better understood.

OBJECTIVES

To investigate enabling factors and barriers influencing integration of NDPs within Aboriginal community-controlled health services delivering primary health care. This was achieved through qualitative evaluation of the Integrating Pharmacists within Aboriginal Community Controlled Health Services (IPAC) Trial exploring the perceptions of NDPs, community pharmacists, healthcare staff, managers, and Aboriginal and Torres Strait Islander patients of these services.

METHODS

NDPs were employed across twenty urban, rural, and remote services in three Australian states and provided pre-defined medication-related roles to adult Aboriginal and Torres Strait Islander patients. Perceptions were elicited from online surveys, interviews, and focus groups. Transcripts were thematically analyzed using the constant comparison method to identify, compare, and refine emerging themes.

RESULTS

One hundred and four participants informed the findings, including 24 NDPs, 13 general practitioners, 12 service managers, 10 community pharmacists, 17 health service staff, and 17 patients. Enablers of integration included: personal (previous experience with Aboriginal and Torres Strait Islander peoples, cultural awareness, skills, individual attributes); health service-related (induction programs, Aboriginal Health Worker support, team-building initiatives); and community-related factors (engaged community elders, leaders, cultural mentors, community pharmacy champions). Barriers to NDP integration included a lack of systems supports for patients and staff to adapt to NDP roles, health service factors, travel requirements, a lack of community linkages, and time and budget constraints.

CONCLUSIONS

NDP integration within primary health care services has potential to enhance medication-related services to Aboriginal and Torres Strait Islander peoples if enabling factors are supported and health systems and adequate resources facilitate the integration of pharmacists within these settings.

The use of medication adherence guidelines in medication taking behaviour research

Medication nonadherence continues to be a serious issue in a range of long-term medical conditions and has been studied extensively over the past few decades. However, despite the plethora of research studies on medication adherence, poor methodological rigour in many studies has contributed to limited generalisability of the positive findings, limited impact on patients' medication adherence, and inability to compare between studies. This paper focuses on current guidelines designed specifically for research on medication adherence. It discusses key elements to consider during study design, selection of adherence measurements, and reporting on medication adherence research, to ensure a higher quality of research in medication adherence. Overall, there appears to be variations in adherence terminology reported in the literature despite improvements in defining medication taking behaviour and the availability of taxonomies. In addition, limited guidance exists on how best to measure adherence. Recommendations are provided on appropriate adherence measures for the adherence behaviour being investigated, including careful consideration of adherence concepts, validity of adherence instruments, appropriate instrument selection, definition of nonadherence threshold, and how to report medication adherence. Improving adherence research requires greater clarity and standardisation of descriptions of nonadherence behaviour, increased methodological rigour in study designs, better selection of adherence measurements, and comprehensive reporting.

Primary health care policy and vision for community pharmacy and pharmacists in Australia

There is evidence that the Australian Government is embracing a more integrated approach to health, with implementation of initiatives like primary health networks (PHNs) and the Government’s Health Care Homes program. However, integration of community pharmacy into primary health care faces challenges, including the lack of realistic integration in PHNs, and in service and remuneration models from government. Ideally, coordinated multidisciplinary teams working collaboratively in the community setting are needed, where expanding skills are embraced rather than resisted. It appears that community pharmacy is not sufficiently represented at a local level. Current service remuneration models encourage a volume approach. While more complex services and clinical roles, with associated remuneration structures (such as, accredited pharmacists, pharmacists embedded in general practice and residential aged care facilities) promote follow up, collaboration and integration into primary health care, they potentially marginalize community pharmacies. Community pharmacists’ roles have evolved and are being recognized as the medication management experts of the health care team at a less complex level with the delivery of MedChecks, clinical interventions and medication adherence services. More recently, vaccination services have greatly expanded through community pharmacy. Policy documents from professional bodies highlight the need to extend pharmacy services and enhance integration within primary care. The Pharmaceutical Society of Australia’s Pharmacists in 2023 report envisages pharmacists practising to full scope, driving greater efficiencies in the health system. The Pharmacy Guild of Australia’s future vision identifies community pharmacy as health hubs facilitating the provision of cost-effective and integrated health care services to patients. In 2019, the Australian Government announced the development of a Primary Health Care 10-Year Plan which will guide resource allocation for primary health care in Australia. At the same time, the Government has committed to conclude negotiations on the 7th Community Pharmacy Agreement (7CPA) with a focus on allowing pharmacists to practice to full scope and pledges to strengthen the role of primary care by better supporting pharmacists as primary health care providers. The 7CPA and the Government’s 10-year plan will largely shape the practice and viability of community pharmacy. It is essential that both provide a philosophical direction and prioritize integration, remuneration and resources which recognize the professional contribution and competencies of community pharmacy and community pharmacists, the financial implications of service roles and the retention of medicines-supply roles.