Home Medication Review or Domiciliary Medication Management Review (DMMR) is one of the least used items by GPs. There are reasons for that. Firstly, DMMR is perceived as a cumbersome labour-intensive item. Secondly, there are some misconceptions about eligibility for DMMR. In fact, DMMR (HMR) is a very useful and reasonably easy to complete item.
Eligibility
If you ask any GP in Australia what is the eligibility for DMMR, the answer is almost invariably the same – ‘a patient must have 5 or more medications’. That is not correct.
DMMRs are targeted at patients who are likely to benefit from such a review: patients for whom quality use of medicines may be an issue or; patients who are at risk of medication misadventure because of factors such as their co-morbidities, age or social circumstances, the characteristics of their medicines, the complexity of their medication treatment regimen, or a lack of knowledge and skills to use medicines to their best effect.
You can see from the passage above (adopted from MBS Schedule) that the eligibility for DMMR is about managing and preventing issues related to medications. That may be:
· currently taking five or more regular medications;
· taking more than 12 doses of medication per day;
· have had significant changes made to the medication treatment regimen in the last three months;
· taking medication with a narrow therapeutic index or medications requiring therapeutic monitoring;
· experiencing symptoms suggestive of an adverse drug reaction;
· displaying sub-optimal response to treatment with medicines;
· suspected of non-compliance or inability to manage medication-related therapeutic devices;
· having difficulty managing their own medicines because of literacy or language difficulties, dexterity problems or impaired sight, confusion/dementia or other cognitive difficulties;
· attending a number of different doctors, both general practitioners and specialists; and/or
· recently discharged from a facility/hospital (in the last four weeks).
Other reasons for DMMR may be:
- The patient is taking multiple over-the-counter medications that may interfere with prescribed medications.
Recently, there was an addition to the eligibility criteria:
In referring a patient for a DMMR, general practitioners should note that only patients meeting the following criteria will have the pharmacist portion funded through a Community Pharmacy Agreement program:
· Is a Medicare and/or Department of Veterans’ Affairs (DVA) cardholder or a person who is eligible for a Medicare card;
· Is subject to a chronic condition and/or complex medication regimen; and
· Is failing to respond to treatment in the expected manner.
If the patient does not meet these criteria, the general practitioner can still issue a referral under this item. However, the remainder of the service will be on a “user pays” basis as determined by the accredited pharmacist.
Practice point.
We can see now that the eligibility for DMMR goes well beyond “having 5 medications or more”.
Completing the item.
In conducting a DMMR, a general practitioner must, with the patient’s consent:
(a) assess a patient is subject to a chronic medical condition and/or complex medication regimen but their therapeutic goals are not being met; and
(b) following that assessment, refer the patient to a community pharmacy or an accredited pharmacist for a DMMR and provide the relevant clinical information required for the review; The referral template is available with any clinical software; and
(c) discuss with the reviewing pharmacist the result of that review including suggested medication management strategies; and
(d) develop a written medication management plan following discussion with the patient; The plan may be written over the report provided by the pharmacist. That is less labour-intensive; and
(e) provide the written medication management plan to a community pharmacy chosen by the patient.
DMMR can be billed every 12 months.
Always consult Medicare schedule descriptors at MBS Online.
DMMR is conducted by an Accredited Pharmacist. An accredited Pharmacist is specially trained in medications management. An Accredited Pharmacist is, usually, not a dispensing pharmacist. In other words, normally, an Accredited Pharmacist does not sell medications or “belongs” to any particular pharmacy.
Practice points.
- Build your DMMR team. Talk to your local pharmacist. Find out about Accredited Pharmacists in the area. Your local pharmacist would, normally, know who they are.
- Look at the Referral and the Plan templates for DMMR. It is worrhtwhile to adjust them to your liking.
Correlation between DMMR and Care Plans
Study of perceptions of Home Medication Review (HMR, Medicare item 900) by patients with Chronic illness
● Patients with and without chronic illnesses were offered an anonymous questionnaire based on eligibility for HMR
● Over 40% of patients with chronic illness who received Care Plans self-identified themselves as eligible / in need of
HMR
● Compared with 5% of patients without chronic illness, who have self-identified themselves as eligible / in need of
HMR
Presentation on the connection between DMMR / HMR and Care Plans can be downloaded here.
Engaging patients for DMMR service
Engaging patients for DMMR service has proven to be difficult. The reason for that is poor understanding of the benefits of DMMR by the patients.
Your practice may use some engagement tools to assist the enrolment. One is the newsletter that can be distributed to the patients via email or in print or both. Please, find this free newsletter template HERE.
Another great tool is the questionnaire that is based on YES/NO answers. If the patient answered YES to any of the questions, he/she is likely to be eligible and agree to enrol. Please, find the questionnaire HERE.
