Older adults residing in residential aged care facilities (RACFs) generally have complex co-morbidities and are prescribed a large number of different medications . Studies have reported that, on average, RACF residents take between 9 and 11 regular medications [2–4]. Polypharmacy increases the risk of medication-related problems and adverse drug events, including hospitalisations, placing a significant burden on residents and economic cost on the health care system [5–7]. Australian studies have shown that almost all RACF residents have at least one medication-related problem [4, 8–11] and between 30% and 73% of residents are prescribed at least one potentially inappropriate medication (PIM) [4, 12–18]. According to a recent meta-analysis of 33 international studies, the use of PIM is significantly associated with an increased risk of hospitalisation in the older population, and the risk was higher in those who took more than one PIM . Additionally, PIMs are associated with other potential adverse outcomes in older indivisuals, including fall, fracture, cognitive decline, delirium, stroke and cardiovascular events [20, 21].
Among PIMs, sedatives, antipsychotics and drugs with anticholinergic properties are particularly associated with greater risk of harm. A large Australian cohort study among 11,368 residents found that 61% were taking psychotropic medications, with the majority of these agents having sedative properties that can contribute to falls or confusion . The over-use of psychotropic medications has been recently highlighted in the interim report of the Australian Royal Commission into Aged Care Quality and Safety . Australian studies have reported that over 20% of RACF residents were taking antipsychotics regularly [22, 24] and the duration of antipsychotic use was longer than recommended [25–27]. Prolonged use of antipsychotics in older people is linked with increased risk of hospitalisation, hip fracture, peneumonia, stroke and death [28, 29]. Another large Australian study  of 17,000 RACF residents reported that 46% were taking drugs with moderate to strong anticholinergic effects; these drugs can contribute to cognitive and functional decline, delirium, worsening dementia, and increased mortality in older people .
Additionally, over-prescribing, using medicines longer than recommended, and drug interactions affect medication safety in aged care residents. The Australian 2018 Aged Care National Antimicrobial Prescribing Survey reported that 10% of residents were taking an antibiotic on the day of the survey and about two-thirds of these prescriptions were lacking relevant documentation of sign and symptoms to justify the need for antibiotic use . Another large Australian study reported that more than 50% of residents were prescribed proton pump inhibitors with a median duration of use of 360 days in the year, while the recommended duration of use is 8 weeks . Over-prescribing can also lead to unwanted drug interactions; a retrospective study of aged care resident’s medication records showed that 16% of residents were at high risk of drug-induced QT prolongation and potential arrhythmia due to polypharmacy . Overall, many published studies highlight the need to improve medication management in RACFs. It is an area where pharmacists, doctors and nurses can work together, ensuring improved medication safety and quality use of medicines for residents .
Amongst the factors affecting medication safety and quality use of medicines in RACFs, lack of accessibility to pharmacists and doctors, and poor interdisciplinary collaboration were highlighted in a recent systematic review of international studies . Consistent with these findings, the Australian Medical Association highlighted the “extremely urgent” need to increase the number of health care professionals in RACFs . General practitioners (GPs), nurses and pharmacists are the key health professionals involved in the prescribing, administration and supply of medicines. Since these health professionals are generally not co-located, there are significant limitations in access, communication  and coordination of medication management processes  for aged care residents.
In Australia, there are two government-funded pharmacist-led services in place that aim to improve medication management in RACFs: (i) residential medication management review (RMMR) program , and (ii) Quality Use of Medicine (QUM) service . The RMMR for RACF residents has been in place since 1997  and is similar to “clinical medication reviews” in the UK, “comprehensive medication reviews” in the United States and “MedsCheck LTC” in Canada [40–42]. The RMMR program enables GPs to refer RACF residents to accredited pharmacists to receive a medication review every 24 months or when there is a clinical need . Although the RMMR service has been shown to be an effective strategy to identify and resolve medication-related problems and improve quality use of medicines for RACF residents , the service has logistical limitations. These include physical separation of community pharmacies, RMMR pharmacists and RACFs which leads to lack of timely access to pharmacist services when residents need them most . Additionally, access to clinical pharmacists to conduct RMMRs for RACF residents is limited to periodic visits to the facility. Consequently, pharmacists performing RMMRs may not have a thorough understanding of the resident and may not be familiar with the facility staff and organisational structure, resulting in limited effectiveness of their activities within RACFs. The QUM service is intended to improve the medication management at the RACF level (e.g. through audits and staff education) [39, 44]; however, there has been little research to explore the effectiveness of this service .
Integrating an on-site pharmacist as part of the RACF health care team may address the gap in provision of medication management practices, policies and processes. The on-site pharmacist can assume overall responsibility for medication management, in collaboration with nurses, GPs, specialists and community pharmacists to ensure the quality use of medicines at the facility [45–48]. This new model can improve communication among the healthcare team and enhance resident and family’s involvement in medication management decisions for individuals , leading to improved person-centred care. At the facility level, the on-site pharmacist can develop and enhance RACF policies and procedures for overall medication management . These system improvement activities include reviewing and enhancing medication ordering, storage and administration processes, as well as conducting staff education, providing medication information, responding to medication utilisation reports, developing clinical referral pathways and contributing to staff and resident influenza vaccination.
A proposed model of integrated on-site pharmacist services into the RACF health care team was examined in a pilot study which was conducted by the lead author [45–50]. The conceptual foundation of the new model was to improve multi-disciplinary care, communication and collaboration in RACF’s healthcare team to enhance medication management [45, 46]. The findings of the pilot study indicated that the integration of a pharmacist into a RACF was feasible and acceptable to RACF staff, residents and GPs, and resulted in improved medication administration and clinical documentation , increased provision of education for nursing and carer staff to promote the quality use of medicines and prevent medication administration errors , and enhanced staff influenza vaccination rates . The positive findings of the pilot study informed the allocation of program funds from the Australian Department of Health to implement and evaluate this model in RACFs in the Australian Capital Territory (ACT).
The aim of this larger study is therefore to conduct a cluster randomised controlled trial (RCT) to evaluate if integrating pharmacists into RACFs, improves medication management in RACFs in the ACT, Australia. Objectives of the study include determining if this new integrated model (i) improves appropriateness of prescribing for RACF residents, as determined by the use of PIMs according to 2019 Beers Criteria , (ii) reduces RACF residents’ Emergency Department (ED) presentations and hospital admissions, (iii) improves other quality use of medicine indicators at the resident and facility levels, and (iv) is cost-effective.