Closing the Gap with Pharmacy Connections

• Rapid uptake of service
• 16.40% reduction on unplanned presentations
• 13.95% increased engagement of planned care
• 28.23% of patients supported from rural and remote communities
• 66.02% reduction in Average Length of Stay (ALOS)

Patients recently discharged from hospital after an acute illness are at high risk for renewed hospitalisation, one major contributory fact is that as many as 44% of patients do not follow medication changes initiated in hospital.(1)

An estimated 250,000 hospital admissions that occur annually in Australia are medication related (2). Within the Cairns and Hinterland regions, First Peoples represent 11.6% of the population (Queensland 4.6%) and are a priority cohort due to high burden of chronic disease resulting in extensive use of medications (3). This high disease burden is demonstrated by the disproportionate hospital presentations with First People, representing approximately 22% of presentations to Cairns and Hinterland Hospital Health Service (CHHHS) in the 2024/2025 financial year (4).

Medicines are the most common tool used in healthcare and evidence suggests that poor control of chronic diseases subsequently results in high hospital admissions, morbidity and mortality for First Peoples. Barriers to medicines safety and access for First Peoples include finance, geographical locations, failed patient-clinician interactions and complex medication regimens as a result of complicated chronic disease/s. Additional complicating factors to First Peoples experiencing quality use of medicines, is poor health care delivery system which are compounded by cultural and language barriers, geographical challenges, restrictive funding arrangements, policies and difficulties with social, emotional and financial wellbeing (5).

Under federal government funding, remote communities access cares and medications at no cost, patients attend their primary healthcare clinic for all medical interventions and medication supplies. Typically to access medications patients are required to arrange; General Practitioner (GP) appointments, navigate to the practice, access a community pharmacy, arrange travel to and from their temporary accommodation, all of which are novel arrangements to remote patients increasing the risk of medication misadventure. Each activity may carry an added cost or barrier to accessing healthcare for patients, which the CHHHS pharmacy department has observed to contribute to disengagement with the health system.

CHHHS Pharmacy recognised that there was no formal pathway at primary/secondary interfaces of care, pharmacy services were ad hoc according to available resources, and health service data demonstrated less than 30% of First Peoples were receiving necessary clinical pharmacy services to prevent medication related harm (3).

Through funding from Connected Community Pathways program (CCP), CHHHS Pharmacy Department implemented an innovative First Peoples service consisting of a pharmacy team across five rural and regional hospital sites. The Communication of Medication Reconciliation at Admission and Discharge Events - Closing the Gap (CoMRADE-CTG) service enabled teams of pharmacists and pharmacy assistants to support First Peoples at the point post discharge follow-up and transitions of care between hospital and community by linking and facilitating medicines access, medication liaisons and Hospital Outreach Medication Reviews (HOMRs) across multiple healthcare systems. The CoMRADE-CTG team is not bound to the limits of CHHHS, with the team regularly connecting patients from Torres and Cape Hospital and Health Service (TCHHS) to provide extended support for safer transitions of care across Queensland that ensures appropriate medicines access and appropriate navigation of complex systems to optimize health outcomes to rural and remote populations.

Across five CHHHS hospital sites, this unique innovative service was established using the principles previously introduced in TOC programs and incorporating pharmacy skills in navigating various healthcare systems in public, community and federal domains. Service data extracted on referrals demonstrated that Queensland Health sites across CHHHS and TCHHS submitted (N=749), external providers (N=38) and self-referrals (N=70). Of these referrals, 28.23% of patients' primary place of residence was within a TCHHS community.

During the analysis period the patients presented to hospital for a total of 506 occasions pre-CoMRADE-CTG intervention and was observed to reduce to 423 presentations post intervention. These presentations represented unplanned care occasions. Patients who engaged with the CoMRADE-CTG service demonstrated a 16.40% decrease in hospital presentations. Conversely certain patient cohorts (particularly oncology planned care), patients FTA rate decreased. This cohort demonstrated a 13.95% increase in engagement with the health service (129 vs 149 respectively). It was noted that the Average Length of Stay (ALOS) for all admissions was 7.19 days pre intervention and 2.46 days post intervention representing a 65.79% reduction.

Funding provided by the CCP program enabled success of CoMRADE-CTG program. High acute workloads and unfamiliarity of referring to pharmacy across CHHHS posed risk to this service being deprioritized as a portion of the sites were funded to a 0.5FTE pharmacist and pharmacy assistant team providing limitations to the serviceability within CHHHS. Through dedicated education on how a referral to CoMRADE-CTG service complements acute and primary healthcare was required to mitigate the risk of being deprioritized. Other vital strategies that contributed to the success of the program were dedicated CoMRADE-CTG teams across regional and rural hospital sites within CHHHS.

The CoMRADE-CTG service has demonstrated that a dedicated pharmacy team that supports interventions which facilitate access and navigational services to support medication supplies, CTG registration, GP liaison and appointment management can have culturally safe positive outcomes that reduce medication misadventures. The introduction of a First People focused TOC stewardship with a dedicated referral pathway for intensive pharmacy support is demonstrating a reduction in the presentations and admission to the health service.

Increased funding into TOC programs focusing on First People's health may assist with further decreasing unplanned presentations and improve engagement with the health service. The introduction of First Peoples TOC program across Queensland Health would be beneficial to assist in addressing the difficulties surrounding medication management and navigation for all First Peoples.

Longer term evaluation and further research into the service and the clinical significance of interventions made will be required to determine the ongoing service impact.

1. Freeman CR, Scott IA, Hemming K, et al. Reducing Medical Admissions and Presentations Into Hospital through Optimising Medicines (REMAIN HOME): a stepped wedge, cluster randomised controlled trial. Medical Journal of Australia.

2. Lim R, Ellett LMK, Semple S, Roughead EE. The Extent of Medication-Related Hospital Admissions in Australia: A Review from 1988 to 2021. Drug Safety. 2022/03/01 2022;45(3):249-257. doi:10.1007/s40264-021-01144-1

3. Cairns and Hinterland Hospital and Health Service. Local Area Needs Assessment Service CaHHaH; 2022:18. 1. https://www.cairns-hinterland.health.qld.gov.au/__data/assets/pdf_file/0024/119634/LANA-Report-2022.pdf

4. Spinks JM, Kalisch Ellett LM, Spurling G, Theodoros T, Williamson D, Wheeler AJ. Adaptation of potentially preventable medication-related hospitalisation indicators for Indigenous populations in Australia using a modified Delphi technique. BMJ Open. 2019;9(11):e031369. doi:10.1136/bmjopen-2019-031369

5. Swain LS, Barclay L. Exploration of Aboriginal and Torres Strait Islander perspectives of Home Medicines Review. Rural Remote Health. 2015;15:3009.

6 Carins and Hinterland Hospital and Health Service. Casemix/DSS; CHHHS Presentations Indigenous/NonIndigenous FY 2024/2025.

7. Miller CJ, Smith, SN, Pugatch M. Experimental and quasi-experimental designs in implementation research. Pscychiatry Research. 2020;283:e112452. Doi: https://doi.org/10.1016/j.psychres

8. Valentelyte, G., Keegan, C. & Sorensen, J. A comparison of four quasi-experimental methods: an analysis of the introduction of activity-based funding in Ireland. BMC Health Serv Res. 2022;22:e1311 doi: https://doi.org/10.1186/s12913-022-08657-0