Clinical networks influencing policy and practice: the establishment of advanced practice pharmacist roles for specialist palliative care services in South Australia

South Australia (SA) has the highest proportion of older people per capita in the nation, with one in six people over 65 years of age.¹ In the next 15 years, that population will nearly double as the ‘baby boomer’ generation ages.¹ The SA Health Plan acknowledges the impact of an aging population on health service delivery and the need to expand palliative care services to make it easier for all people at the end of life to receive care in their preferred place. As part of the State’s health reform agenda, SA released its Statewide Services Plan–Palliative Care 2009–2016 (the Plan).² A key initiative of the Plan is to build the specialist palliative care workforce with the addition of advanced practice roles across disciplines not previously represented within the specialist palliative care team. As part of the implementation of the Plan, a working group from the Palliative Care Clinical Network was convened. A priority for this group was the development of a sustainable community pharmacy network, driven by the integration of new advanced practice pharmacists roles within the larger regionalised palliative care specialist services. This initiative required commitment and collaboration and, as such, key stakeholders from pharmacy and palliative care were brought together to advance this work. The two main objectives for this working group were:

1. To articulate the vision of advanced practice pharmacist roles.

2. To gain funding support for three advanced practice pharmacists positions and a project to develop a ‘statewide palliative care pharmacy network’.

Because the advanced practice palliative care pharmacist positions are new roles, it is important that careful consideration be given to how these roles fit with the new national framework for advanced practice in pharmacy and for such positions to align within the broader national Advanced Pharmacy Practice Framework (APPF).³ The APPF defines advanced practice as:

…practice that is so significantly different from that achieved at initial registration that it warrants recognition by professional peers and the public of the expertise of the practitioner and the education, training and experience from which that capability was derived.

There is compelling evidence that the number of therapeutic interventions and complexity of medicine use is increasing as a result of an aging population, increasing chronic disease and multimorbidity. Recognition of advanced practice is an important step in providing pharmacy services that meet the evolving needs of our society.

In July 2010, the Palliative Care Clinical Network Pharmacy Reference Group was convened with support from the Statewide Palliative Care Clinical Network Development Manager. The Committee Chair was the Palliative Care Service Director from a specialist palliative care service. Membership was selected to reflect both the specialist palliative care services and the pharmacy stakeholders from the community setting, as well as from the university, regulatory, workforce and health service planning settings. The first task for the reference group was to assist the discipline of pharmacy to consider the place of advanced practice roles in palliative care. These roles reflect a new direction for the discipline of pharmacy and have been embraced while being cognisant that registration for pharmacists in Australia currently does not have specific endorsement for advanced practice. There is strong commitment and collaboration between pharmacy and palliative care. These positions are community focused and do not duplicate or replace existing clinical pharmacy positions within tertiary hospitals. They have leadership responsibility across the metropolitan and country areas that are aligned with each Local Health Network in the domains of education, research, capacity building and clinical support.

The speciality of palliative care is grounded in a philosophy of total patient care to meet the needs that manifest across a range of domains. To meet these needs, a highly integrated team made up of diverse disciplines is necessary. Specialist services are best directed towards those people at end of life with complex care needs. These services also have an indirect or system-level role in supporting the end-of-life care provided by others through the provision of expert clinical advice, training and a range of other ‘capacity building’ measures.^4–6 A critical yet often overlooked member of the wider team of providers is the community pharmacist.

The importance of the pharmacist in community-based care of people at end of life is underscored by the fact that 70%–80% of patients receive some form of palliative care at home.⁷ For a variety of well-described reasons, this population is readily identifiable as being at high risk of medication-related problems and an increased likelihood of experiencing an adverse event.⁸ Although community pharmacists need to be informed as and when any patient’s health status changes significantly, the medication management issues associated with advanced and progressive life-limiting illness are particularly challenging. The accumulation of new and changing symptom burden profile, the use of complex drug regimens and invariable changes in the routes of administration can easily be compounded by simple access and supply issues. A close partnership approach can be fostered to improve the patient experience for those choosing to die at home. One such partnership has been described where the pharmaceutical society in Scotland set up a model in which selected pharmacies agreed to stock commonly used palliative care drugs and supply other pharmacies as needed in order to improve timely access for patients within the community setting.⁹

The role of the pharmacist is readily identified as a component of the inpatient interdisciplinary team, although it is not strongly represented in published descriptions of community-based services, even though the community pharmacist remains one of the most accessible professionals in that setting.¹⁰ The authors of a paper that surveyed palliative care service delivery by pharmacists in Australia and Canada cite the Oxford Textbook of Palliative Medicine as only having three sentences related to pharmacists in the chapter on the palliative care interdisciplinary team.¹¹ The role is often described as a resource and support for the physician rather than an independent contributor to the team.¹⁰

Hussainy et al. identify seven key areas where the pharmacist can contribute.⁷

1. Medication review

2. Education for patients and carers regarding specific medicines and modes of delivery

3. Ensuring ongoing access to medications

4. Information provision to team members, particularly regarding ‘off label’ medicines

5. Consultation and collaboration with team members regarding updating of medication chart

6. Liaison with other health care professionals to ensure continuity of patient care

7. Symptom management protocols

Pharmacy specialisation is recognised as a growing trend in many Organisation for Economic Cooperation Development (OECD) countries.¹² The American Society of Health–System Pharmacists states ‘pharmacists have a pivotal role in the provision of hospice and palliative care and that pharmacists should be integral members of all hospice interdisciplinary teams’.¹³

For services that have used a dedicated palliative care pharmacist, the feedback regarding the value of the role has been very positive.⁷ The areas identified include improved medication knowledge and the positive impact to change of practice as key outcomes.⁷ Despite positive findings from the introduction of this team member to the local service, funding has not been continued and the project pharmacist position not continued.⁷ The positive impact of optimal utilisation of the pharmacist has been reported within the palliative care outpatient clinic setting to provide counselling for new drug regimens and provision of a medication summary sheet along with a patient information leaflet.¹¹

While recognising that specialist palliative care roles have been identified (or mooted) for pharmacists, the use of the term ‘specialist’ is currently restricted under the national law to the dental and medical professions only.⁵ Currently no provision for use of this term applies to pharmacy. Importantly, the APPF distinguishes between specialisation and advanced practice. The APPF emphasises the depth and breadth of experience and the integration of this experience with training and education, but also importantly the contribution of advanced practice to the profession in the form of creating new knowledge as part of research and leadership.^3,5

At a national level, Australia’s National Medicines Policy and Palliative Care Strategy provide a framework for implementing improved access to, and quality use of, medicines in palliative care.¹² Within the national policy, a process to support the listing of medicines to manage symptom burden in palliative care through the Pharmaceutical Benefits Scheme (PBS) was established and continues to be expanded where efficacy, safety and cost-effectiveness criteria are met.¹²

The Palliative Care Pharmacy Working Group considered evidence from published research and reports and relevant position statements to inform the direction of the palliative care advanced practice pharmacist roles and the palliative care pharmacy network project.

A working group was established under the auspices of the Palliative Care Clinical Network to progress the development of advanced practice pharmacist roles for regionalised palliative care services.

A pharmacy stakeholder forum was conducted in December 2010. This provided an opportunity for wider participation in planning the role of the advanced practice pharmacist, with participation from 20 stakeholders reflecting regional and national professional organisations, practitioners from nursing, medicine, pharmacy, academia, regulatory, workforce and health service planning providers.

The Forum commenced with presentations to set the context for the participants before breaking into smaller groups to discuss and consider the advanced practice pharmacist role as it pertains to the following areas that reflect advanced practice competencies:

• Network links and partnerships

• Education

• Quality and Safety

• Research

• Policy

Each group was assigned a chair to lead the discussions, and the chairs shared the results with the rest of the participants. The combined group reviewed and discussed the list of priorities proposed; when there were differences in the priorities, the group discussed the alternatives and the prioritisation was decided by consensus. The final report was provided to the Palliative Care Clinical Network Steering Committee and the working group and informed the creation of the job and person specification of the advanced practice roles to ensure that all three positions commenced with a clear and shared vision and a strong foundation.

Advanced practice pharmacists entered the regional palliative care services of SA on 4 October 2011. South Australia has three metropolitan Local Health Networks based in the Centre, North and South of Adelaide. The three pharmacists commenced at the same time with a structured induction program to assist them to develop the strategic elements of their role. Part of the induction also included the establishment of professional links with local and national palliative care pharmacists and other pharmacy leaders.

The scope of the role is that of a leadership position that encompasses clinical practice, teaching, education, curriculum development, clinical research within the field of palliative care pharmacotherapeutics and contribution to relevant policy development.²

The working group identified the key outcomes for the Palliative Care Pharmacy Network to be supported through the advanced practice pharmacist roles:

• Facilitate a quality use of medicines approach across community, aged care, disability and acute care settings

• Expand the number and the capacity of community pharmacists across the state providing home medicine reviews for palliative care patients in the community

• Explore a systems approach to improve access to medicines around the clock to those who need them, and the safe disposal of those medicines when no longer required

• Explore and overcome barriers that inhibit greater contribution to the planning and delivery of coordinated multidisciplinary palliative care by community pharmacists in the community setting

• Bring together community pharmacists with an interest in palliative care to explore and develop opportunities for increased community pharmacy involvement in quality end-of-life care in the community

• Developing a quality and safety framework

• Establishing and maintaining networks, links and partnerships across the sector

• Identification of key performance indicators for evaluating the impact of this service

Collaboration between leaders in workforce reform, service planners, specialist palliative care providers and the pharmacy sector has been the key enabler to preparing services for the arrival of the advanced practice pharmacist positions. A report measuring the quality of death across the world has identified that, by increasing the proportion of community and home-based palliative care services, health spending is reduced by decreasing hospital stays and emergency presentations.¹⁴ The establishment of a palliative care community pharmacy network that can provide a crucial contact point for patients and families as they navigate their way through a changing illness course is considered fundamental for the timely and tangible provision of support. Crawford states that the pharmacist may often be the first point of contact about uncertain symptoms or questions about how to proceed with further assessment or investigation.¹⁵ Knowing that community pharmacists are crucial health care members for the patient living with an end-of-life illness is one thing; to engage with them and support them to support palliative care clients has been the challenge.

The introduction of the advanced practice pharmacist role serves as a vital bridge needed to build the relationship with the community pharmacy sector, academia, health policy planners and service providers. Having a dedicated team member with a strategic and policy focus on the enablers that actively support people to meet their wish of a home death brings us one step closer to providing a health system that can deliver on this promise.¹⁶