Medication Management Reviews

Domiciliary Medication Management Review (DMMR)

Questions and Answers

[General Information] [The Purpose of Domiciliary Medication Management Review] [Conducting a DMMR] [Eligibility Requirements] [Payment] [How Does a Domiciliary Medication Management Review Work?] [Domiciliary Medication Management Review and Other MBS Services] [Source of Assistance for Queries about the Item]

General information

Q: What is a Domiciliary Medication Management Review?

A: The Domiciliary Medication Management Review (DMMR – MBS Item 900) is a service to patients living at home in the community. It is sometimes referred to as a Home Medicines Review (HMR). However, this can be misleading as the term HMR strictly refers to the community pharmacist component of a GP initiated DMMR. The goal of a DMMR is to maximise an individual patient's benefit from their medication regimen, and prevent medication-related problems through a team approach, involving the patient's GP and preferred community pharmacy. It may also involve other relevant members of the healthcare team, such as nurses in community practice or carers. The DMMR process utilises the specific knowledge and expertise of each of the health care professionals involved. In collaboration with the GP, a pharmacist comprehensively reviews the patient's medication regimen in a home visit. After discussion of the visit findings and report with the pharmacist, the GP and patient agree on a medication management plan. The patient is central to the development and implementation of this plan with their GP.

The purpose of Domiciliary Medication Management Review

Q: What are the benefits of a collaborative approach to the medication management review?

A: Evidence from a number of collaborative studies conducted in Australia has found that programs similar to the DMMR may result in:

• improved patient satisfaction, understanding of and concordance with medication regimen;
• positive clinical benefits, in terms of the patient's health and quality of life;
• improved relationships between GP, patient and pharmacist; and
• a reduction in health care costs.

These studies have mainly involved the collaborative work of GPs, pharmacists and patients (and their carers where applicable). Pharmacists bring a pharmaceutical perspective to support the GP and patient in achieving the desired goals of therapy.

Studies have shown that some patients do not realise the potential importance of disclosing all medication consumption to their GP, or may choose not to do so.

A thorough review of a patient's entire medication regimen within the home environment lets the pharmacist and the GP understand all the medication currently or recently taken by the patient. The interview also makes it easier to improve the patient's understanding of their medications, and how they manage them, where this is necessary.

Conducting a DMMR

Q: Is there a referral form from GP to Pharmacist

A: Yes DMMR – HMR Referral Form (PDF 164 KB)

Q: Who can provide the medical component of a Domiciliary Medication Management Review?

A: A general practitioner, but not a specialist or consultant physician, can provide the medical component of a review. This should generally be the patient's usual medical practitioner, the one who has provided the majority of services to the patient over the previous 12 months and/or will provide the majority of services to the patient over the coming 12 months.

Q: Who can conduct a Domiciliary Medication Management Review?

A: Although anyone can suggest the need for a DMMR, it can only be initiated by a patient's GP after assessing the patient's need for the service. Providing they meet eligibility criteria, community pharmacies are able to coordinate the pharmacy component of a DMMR. Pharmacists have been advised that they need to contact Medicare Australia for advice on how to become registered as a HMR service provider in order to be able to coordinate DMMR services.

The pharmacist who conducts the clinical assessment of the information gathered during the patient interview and prepares the report for the GP, must be accredited to conduct medication management reviews. The accredited pharmacist is responsible for the review overall. The community pharmacist coordinating the service will either be an accredited pharmacist themself, or otherwise employ or contract an accredited pharmacist.

Q: Who can conduct the home interview component of a Domiciliary Medication Management Review?

A: Generally the home interview will be conducted by an accredited pharmacist. However, where the patient has a clear preference or where there is no reasonable access to an accredited pharmacist in a timeframe suitable to the patient, the patient's community pharmacist may conduct the interview with the patient and examine their medications, subject to agreement with the accredited pharmacist. Whether the patient's preferred community pharmacist or an accredited pharmacist conducts the home interview in these circumstances does not affect the claim for payment for the service.

Q: Who is an accredited pharmacist?

A: An accredited pharmacist is an experienced pharmacist who has undertaken specified education programs and examinations, and undertakes continuing professional education and re-accreditation as approved by the Australian Association of Consultant Pharmacy or an examination as approved by the Society of Hospital Pharmacists of Australia. The GP is not required to identify an accredited pharmacist to undertake the DMMR - this will be done by the community pharmacist.

Q. Who decides that there is "no reasonable access" to an accredited pharmacist?

A: This is primarily an issue for the patient. The home interview may be undertaken by the patient's preferred community pharmacist, either where the patient has a clear preference for that pharmacist to do the home interview, or where there is no reasonable access to an accredited pharmacist within a timeframe suitable to the patient. Note that in all cases the pharmacist who conducts the clinical assessment of the information gathered during the patient interview, and prepares the report for the GP, must be a pharmacist accredited to conduct medication management reviews. Which pharmacist undertakes the home interview for a DMMR service is not required to be communicated to Medicare Australia when the GP claims for the service.

Q: What is the role of other health professionals?

A: Much of the information required for the DMMR will be provided in the referral or obtained by the pharmacist during the patient interview. However, in order to acquire all relevant information it may be necessary to refer to other sources such as family members or carers, nurses in community practice or other members of the health care team. Before involving other health care professionals, the rationale for their involvement should be explained to the patient and patient consent obtained.

Q: Have confidentiality issues been considered?

A: Yes. The information from the patient's record can be passed on, only with the patient's consent, to the pharmacist conducting the review. All information will be treated as confidential. The same professional standards regarding consent and liability between consumers and pharmacists will apply with a review.

Input from each person involved in the process should be documented in the review report, its recommendations and the management plan, as applicable. The GP will hold a copy of the report and management plan and the consumer's pharmacy will keep full records for auditing purposes.

Q: How long should it take to complete a Domiciliary Medication Management Review?

A: The initial patient consent and basic information for the referral form can be achieved within a normal consultation. This may be a consultation for another purpose or a consultation undertaken specifically for the purposes of the DMMR. The timeframe for the subsequent stages of the DMMR needs to be negotiated with the patient and their preferred community pharmacy, and may vary. At the initial referral consultation, the GP should discuss the further stages of the process with the patient, ensuring the patient understands that the completion of the DMMR process requires a further consultation that is part of the overall DMMR service.

Any immediate action required at the time of completing the DMMR (eg writing prescriptions or making referrals) should be treated as part of the DMMR item. Any follow-up subsequent to the DMMR service should be treated as a normal consultation.

Eligibility requirements

Q: Can GPs offer a Domiciliary Medication Management Review to all their patients?

A: The review can be offered to any patient for whom the GP feels it is clinically necessary to ensure quality use of medicines or address patient's needs. Some examples of risk factors known to predispose people to medication-related problems include:

• Currently taking 5 or more regular medications;
• Taking more than 12 doses of medication/day;
• Significant changes made to the medication regimen in the last 3 months;
• Medication with a narrow therapeutic index or medications requiring therapeutic monitoring;
• Symptoms suggestive of an adverse drug reaction;
• Sub-therapeutic response to treatment with medicines;
• Suspected non-compliance or inability to manage medication related therapeutic devices;
• Patients having difficulty managing their own medicines because of literacy or language difficulties, dexterity problems or impaired sight, confusion/dementia or other cognitive difficulties;
• Patients attending a number of different doctors, both general practitioners and specialists; and/or
• Recent discharge from a facility/hospital (in the last 4 weeks).

Q: Is the review available for in-patients of a hospital or those in aged care facilities?

A: The review is available for eligible patients living in the community setting but is not available for in-patients of a hospital, day hospital facility or care recipients in residential aged care facilities.

Q: How often can a review be conducted?

A: A patient can have a DMMR once every 12 months or sooner if there has been a significant change in the patient's condition or medication requirements.

A.36.9 of the Medicare Benefits Schedule states:
Benefits for a DMMR service under this item are payable not more than once in each 12 month period, except where there has been a significant change in the patient's condition or medication regimen requiring a new DMMR. A significant change could be, for example, diagnosis of a new condition or discharge from hospital involving multiple or extensive changes in medication. In such cases the patient's invoice or Medicare voucher should be annotated to indicate that the DMMR service was required to be provided within 12 months of another DMMR service.

Payment

Q: Do pharmacists get paid?

A: Yes, a fee for service is paid through provisions made under the Fourth Community Pharmacy Agreement. This payment is made to the community pharmacy that coordinates the service, to cover all pharmacist elements of the DMMR service.

Q: What is the payment for a review service?

A: The Medicare Benefits Schedule (MBS) fee for completing a DMMR is $137.05 (with an MBS rebate of $137.05). This includes:

• the initial consultation and written referral to the patient's preferred community pharmacy, together with relevant clinical information;
• discussion with the pharmacist on the findings and recommendations from the review; and
• a second consultation with the patient to agree on a medication management plan.

Payment for the review under the MBS will not occur until after the second patient consultation. Once all components of the service have been completed, a GP can directly bill Medicare or provide the patient with an account, as with any other service.

How does the Domiciliary Medication Management Review work?

Q: How does the review process work?

A: There are four basic stages:
1. The identification of patients who may benefit from the review, for example patients:

• on multiple medications;
• who have recently been discharged from hospital;
• with recent and significant changes to their medications; or
• who are attending a number of different GPs and specialists.

While a review can only be instigated by a GP, the suggestion that a patient might benefit from a review can also come from other health professionals or the patient themself. The patient consults with their GP, allowing the GP to assess whether a DMMR is clinically necessary to ensure quality use of medicines or to address the patient's needs. The patient chooses the community pharmacy they would prefer to coordinate the review.

2. The community pharmacy coordinates the review, letting the GP know the arrangements for the review and the contact details of the accredited pharmacist. The pharmacist arranges a suitable time to interview the patient, preferably in the patient's own home. The review may be carried out at another location of the patient's choice, however their own home is preferable. The pharmacist conducts the review including an examination of all the patient's medications and related devices. The pharmacist also identifies any issues the patient may have with their medications, for example, compliance, storage and administration techniques. The accredited pharmacist conducts a clinical assessment of the information gathered during the patient interview and writes a report that includes their findings and recommendations.

3. The report will then be discussed with the GP, either face-to-face or by phone, who decides on a course of action.

4. The GP arranges a consultation with the patient to discuss the results and develop a written medication plan for agreement with the patient. The medication management plan identifies the GP, the patient and the patient’s community pharmacy. It shows the date of the review by the pharmacist, and the date of the patient’s follow-up consultation with the GP. The plan lists the patient’s current medical conditions and the medicines that have been prescribed for these conditions. It indicates what action has been proposed as a result of the review, who will be responsible for this action, and the expected outcomes. The plan provides space for confirmation that the patient agrees with the proposed action. The GP and the patient sign and date the plan to indicate their agreement to put the plan into practice.

If you have any difficulty accessing the PDF, please contact mbd.web@health.gov.au
Medication Management Plan Form (PDF 31 KB)
Medication Management Plan Form (Word 39 KB)

Q: What communication is required with the pharmacist?

A: To maximise the benefits of a DMMR, effective inter-professional communication is required.

During the medication review process there are several points of communication between the GP and the pharmacist, as outlined below:

• referring the patient to the patient's preferred community pharmacy, together with relevant information which the GP considers will assist the review;
• receiving a written report from the pharmacist;
• discussing the relevant findings and suggested management strategies with the pharmacist via telephone or face to face (as preferred);
• developing a medication management plan with the patient using the medication management review report as a basis; and,
• discussing the plan with the patient and once agreed, forwarding a copy to the preferred community pharmacist.

Q: Why does the GP need to provide laboratory results?

A: Providing information about laboratory results assists the pharmacist to assess the potential for changes in clearance of certain drug therapies, adverse effects that may be drug related, and monitoring of desired therapeutic outcomes. If laboratory results are made available initially, together with the therapeutic goals, the benefit of the medication management review is increased and potential inefficiencies minimised.

Biochemical tests useful for completion of a medication management review may include:

• serum electrolytes;
• INR for patients on warfarin;
• serum creatinine (allows calculation of creatinine clearance to help calculate dosage requirements);
• plasma lipids;
• plasma drug concentrations;
• liver function tests; and/or
• thyroid function tests.

Q: Is the review an assessment of prescribing patterns?

A: No. DMMR is designed to achieve safe, effective, and appropriate use of medications by detecting and addressing medication-related problem/s that interfere with desired patient outcomes. DMMR is not a mechanism for analysing prescribing patterns.

Q: What if the GP disagrees with the pharmacist's suggestions?

A: The care and treatment of the patient remains the responsibility of the GP. Discussion with the pharmacist should clarify why suggestions have been made or any concerns they may have regarding the patient's situation.

Q: What if the patient does not complete the Domiciliary Medication Management Review process?

A: In some situations a DMMR may not be able to be completed due to circumstances beyond the GP's control for example, because the patient decides to not proceed further with the DMMR, or because of a change in the circumstances of the patient. In such cases the GP may claim the relevant MBS attendance item for the work he/she has already undertaken.

Q: What if the GP identifies the need for a review as part of a consultation for another purpose?

A: If the patient sees the GP for another purpose and the GP identifies the need for a DMMR as part of this consultation, the GP may claim this consultation separately. Provided the GP completes the other stages of the DMMR, he/she may then claim for the DMMR.

Q: Does the patient have to sign the Medication Management Plan?

A: The MBS item does not require the patient to sign that they have received a DMMR - it does require as part of the last step that the GP develop a written medication management plan following discussion with the patient. The plan should be agreed with the patient as part of this process - evidence of this could be the patient signing the plan or the GP noting in the patient records that the plan has been agreed with the patient.

Q: Who are Medication Management Review (MMR) Facilitators?

A: Divisions of General Practice may employ MMR Facilitators whose role is to support the uptake of this collaborative model by both GPs and pharmacists. This will involve promoting the service to each professional group using personal visits, organising combined education and information sessions, and liaising between accredited pharmacists and pharmacist proprietors. They should assist in the implementation of DMMR services, and may be contacted through Division offices.

Q: Must the GP use a specific referral form?

A: The MBS item does not require GPs to use a specific form for the referral or the medication management plan. However, the item does require a GP to assess the patient's medication needs and following that assessment refer the patient to a community pharmacy for a medication management review and provide relevant clinical information (the first step in the GP's involvement) - the requirement is to provide the relevant information, not to use a specific form.

Domiiliary Medication Management Review and other MBS Services

Q: Can a GP refer a patient for a Domiciliary Medication Management Review as a result of an asthma 3+ plan or as part of diabetes treatment?

A: The GP may refer a patient for a DMMR, if as a result of an asthma 3+ plan, or as part of treatment for a patient with established diabetes mellitus, the GP assesses that a DMMR is clinically necessary to ensure quality use of medicines or address patients needs. A DMMR would meet the medication review requirement included as part of the annual cycle of care for a patient with established diabetes mellitus. As with other patients, patients with asthma or diabetes would need to meet the eligibility criteria for a DMMR and the GP would need to fulfil the MBS requirements for a DMMR service.

DMMRs are targeted at patients who are likely to benefit from such a review, and for whom quality use of medicines may be an issue or who are at risk of medication misadventure because of their co-morbidities, age or social circumstances, the characteristics of their medicines, the complexity of their medication treatment regimen, or because of a lack of knowledge and skills to use medicines to their best effect.

Q: How does a Domiciliary Medication Management Review relate to an Enhanced Primary Care (EPC) health assessment, care plan or case conference service?

A: A DMMR is a different service from a health assessment, care plan or case conference. There is no restriction on providing or initiating a DMMR on the same day as an EPC service. These services are distinct, however, and work undertaken for one service (eg a health assessment) cannot also be claimed for another service (such as a DMMR).

For example, medication review is a recommended component of an EPC health assessment. While this may include a review as part of a health assessment in the patient's home, it is likely to be a less comprehensive and less complex review than a DMMR service involving collaboration between GPs and pharmacists and a comprehensive home interview with the patient. As a result of a health assessment (or other EPC service such as a care plan or case conference) the need for a DMMR service may be identified and steps taken to initiate a service. To claim for the DMMR service, however, the GP requirements for the DMMR service must be met (i.e. consultation with patient, covering consent and provision of relevant clinical information to preferred community pharmacy, discussion with reviewing pharmacist, and consultation with patient to develop agreed management plan). Work undertaken and claimed for against another service cannot also be claimed to meet the DMMR requirements.

Q: If a DMMR assessment and subsequent discussion between the GP and pharmacist identifies the need for further assessment, eg a health assessment, care plan or case conference, can the GP claim for the DMMR item as well as the EPC item?

A: The final step in the DMMR process is for the GP to consult with the patient and develop an agreed medication management plan. If the DMMR identifies that another action is required, eg further consultations, or an EPC health assessment, care plan or case conference, these actions can be undertaken as part of necessary ongoing monitoring and follow up. A DMMR assessment may provide information which could be used in preparing a care plan, and a pharmacist who is providing an ongoing service or care to the patient may be appropriate as a member of a multidisciplinary care planning or case conferencing team.

It would not be appropriate, however, to hold a 'case conference' solely for the purpose of discussing the results of a DMMR review with the reviewing pharmacist. The DMMR pharmacy service payment and MBS rebate already make provision for this discussion, for pharmacists and GPs. An EPC care plan or case conference, as a multidisciplinary approach to coordinating the care of a patient with a chronic condition and complex needs, would also be expected to cover more than just medication management issues.

Sources of assistance for queries about the item

Copies of guidance for GPs on DMMR, including case studies, a patient information sheet, the DMMR Medicare item 900, a GP fact sheet, flow chart and check list have been distributed through Divisions of General Practice.

Other sources of information include:

• The Medicare Inquiry Line: 13 20 11
• Local Divisions of General Practice
• The Office of the Department of Health and Ageing in each State and Territory.