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Category 1 - PROFESSIONAL ATTENDANCES
Medical Practitioner Medication Management Reviews (Items 245 and 249)
Item 245 - Domiciliary Medication Management Review
A Domiciliary Medication Management Review (DMMR) (Item 245), also known as Home Medicines Review, is intended to maximise an individual patient's benefit from their medication regimen, and prevent medication-related problems through a team approach, involving the patient's medical practitioner and preferred community pharmacy or accredited pharmacist.
The item is available to people living in the community who meet the criteria for a DMMR.
The item is not available for in-patients of a hospital, or care recipients in residential aged care facilities.
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.
DMMR’s are targeted at patients who are:
- currently taking five or more regular medications;
- taking more than 12 doses of medication per day;
- have had significant changes made to 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 medical practitioners and specialists; and/or
- recently discharged from a facility / hospital (in the last four weeks).
In referring a patient for a DMMR, medical 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 medical 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.
In conducting a DMMR, a medical 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; 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; and
(e) provide the written medication management plan to a community pharmacy chosen by the patient.
For any particular patient - applicable not more than once in each 12 month period, except if there has been a significant change in the patient's condition or medication regimen requiring a new DMMR.
A DMMR includes all DMMR-related services provided by the medical practitioner from the time the patient is identified as potentially needing a medication management review to the preparation of a draft medication management plan, and discussion and agreement with the patient.
The benefit is not claimable until all the components of the item have been rendered.
Benefits for a DMMR service under item 245 are payable only 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 (e.g. diagnosis of a new condition or recent discharge from hospital involving significant 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.
Provision of a subsequent DMMR must not be made solely by reaching an anniversary date, and the service is not intended to be undertaken on an ongoing review cycle.
If the DMMR is initiated during the course of a consultation undertaken for another purpose, this consultation may also be claimed separately.
If the consultation at which the medication management review is initiated is only for the purposes of initiating the review, only item 245 may be claimed.
If the medical practitioner determines that a DMMR is not necessary, item 245 does not apply. In this case, normal consultation items should be used.
Where a DMMR cannot be completed due to circumstances beyond the control of the medical practitioner (e.g. because the patient decides to not proceed further with the DMMR, or because of a change in the circumstances of the patient), the relevant MBS attendance items should be used.
A DMMR should generally be undertaken by the patient's usual medical practitioner. This is the medical practitioner, or a medical practitioner working in the same medical practice, that has provided the majority of services to the patient over the previous 12 months and/or will be providing the majority of services to the patient over the coming 12 months.
The potential need for a DMMR may be identified either by the medical practitioner in the process of a consultation or by receipt of advice from the patient, a carer or another health professional including a pharmacist.
The process of referral to a community pharmacy or an accredited pharmacist includes:
- Obtaining consent from the patient, consistent with normal clinical practice, for a pharmacist to undertake the medication management review and for a charge to be incurred for the service for which a Medicare rebate is payable. The patient must be clearly informed of the purpose and possible outcomes of the DMMR, the process involved (including that the pharmacist will visit the patient at home, unless exceptional circumstances apply or they are an Aboriginal or Torres Strait Islander patient), what information will be provided to the pharmacist as part of the DMMR, and any additional costs that may be incurred; and
- Provision to the patient's preferred community pharmacy or accredited pharmacist, of relevant clinical information, by the medical practitioner for each individual patient, covering the patient's diagnosis, relevant test results and medication history, and current prescribed medications.
A DMMR referral form is available for this purpose. If this form is not used, the medical practitioner must provide patient details and relevant clinical information to the patient's preferred community pharmacy or accredited pharmacist.
The discussion of the review findings and report including suggested medication management strategies with the reviewing pharmacist includes:
- Receiving a written report from the reviewing pharmacist; and
- Discussing the relevant findings and suggested management strategies with the pharmacist (either by phone or face to face); and
- Developing a summary of the relevant review findings as part of the draft medication management plan.
Development of a written medication management plan following discussion with the patient includes:
- Developing a draft medication management plan and discussing this with the patient; and
- Once agreed, offering a copy of the written medication management plan to the patient and providing a copy to the community pharmacy or accredited pharmacist.
The agreed plan should identify the medication management goals and the proposed medication regimen for the patient.
Item 249 - Residential Medication Management Review
A Residential Medication Management Review (RMMR) is a collaborative service available to permanent residents of a Residential Aged Care facility (RACF) who are likely to benefit from such a review. This includes residents for whom quality use of medicines may be an issue or residents who are at risk of medication misadventure because of a significant change in their condition or medication regimen.
RMMRs are available to:
- new residents on admission into a RACF; and
- existing residents on an 'as required' basis, where in the opinion of the resident's medical practitioner, it is required because of a significant change in medical condition or medication regimen.
RMMRs are not available to people receiving respite care in a RACF. Domiciliary Medicines Reviews are available to these people when they are living in the community setting.
When conducting a RMMR, a medical practitioner must:
(a) discuss the proposed review with the resident and seek the resident's consent to the review; and
(b) collaborate with the reviewing pharmacist about the pharmacist's involvement in the review; and
(c) provide input from the resident's most recent comprehensive medical assessment or, if such an assessment has not been undertaken, provide relevant clinical information for the review and for the resident's records; and
(d) If recommended changes to the resident's medication management arise out of the review, participate in a post-review discussion (either face-to-face or by telephone) with the pharmacist to discuss the outcomes of the review including:
(i) the findings; and
(ii) medication management strategies; and
(iii) means to ensure that the strategies are implemented and reviewed, including any issues for implementation and follow-up; and
(iv) develop or revise the resident's medication management plan after discussion with the reviewing pharmacist; and
(v) finalise the plan after discussion with the resident.
A medical practitioner's involvement in a residential medication management review also includes:
(a) offering a copy of the medication management plan to the resident (or the resident's carer or representative if appropriate); and
(b) providing copies of the plan for the resident's records and for the nursing staff of the residential aged care facility; and
(c) discussing the plan with nursing staff if necessary.
A post-review discussion is not required if:
(a) there are no recommended changes to the resident's medication management arising out of the review; or
(b) any changes are minor in nature and do not require immediate discussion; or
(c) the pharmacist and medical practitioner agree that issues arising out of the review should be considered in a case conference.
A RMMR comprises all activities to be undertaken by the medical practitioner from the time the resident is identified as potentially needing a medication management review up to the development of a written medication management plan for the resident.
A maximum of one RMMR rebate is payable for each resident in any 12 month period, except where there has been a significant change in the resident's medical condition or medication regimen requiring a new RMMR.
Benefits are payable when all the activities of a RMMR have been completed. A RMMR service covers the consultation at which the results of the medication management review are discussed and the medication management plan agreed with the resident:
- any immediate action required to be done at the time of completing the RMMR, based on and as a direct result of information gathered in the RMMR, should be treated as part of the RMMR item;
- any subsequent follow up should be treated as a separate consultation item;
- an additional consultation in conjunction with completing the RMMR should not be undertaken unless it is clinically indicated that a problem must be treated immediately.
In some cases a RMMR may not be able to be completed due to circumstances beyond the control of the medical practitioner (e.g. because the resident decides not to proceed with the RMMR or because of a change in the circumstances of the resident). In these cases the relevant MBS attendance item should be used in relation to any consultation undertaken with the resident.
If the consultation at which the RMMR is initiated, including discussion with resident and obtaining consent for the RMMR, is only for the purposes of initiating the review, only the RMMR item should be claimed.
If the RMMR is initiated during the course of a consultation undertaken for another purpose, the other consultation may be claimed as a separate service and the RMMR service would also apply.
If the medical practitioner determines that an RMMR is not necessary, the RMMR item does not apply. In this case, relevant consultation items should be used.
A RMMR should generally be undertaken by the resident's 'usual medical practitioner'. This is the medical practitioner, or a medical practitioner working in the same medical practice, that has provided the majority of care to the resident over the previous 12 months and/or will be providing the majority of care to the resident over the next 12 months.
Medical practitioners who provide services on a facility-wide contract basis, and/or who are registered to provide services to RACFs as part of aged care panel arrangements, may also undertake RMMRs for residents as part of their services.
Generally, new residents should receive an RMMR as soon as possible after admission. Where a resident has a Comprehensive Medical Assessment (CMA), the RMMR should be undertaken preferably after the results of the CMA are available to inform the RMMR.
A RMMR service should be completed within a reasonable time-frame. As a general guide, it is expected that most RMMR services would be completed within four weeks of being initiated.
The resident's medical practitioner may identify the potential need for an 'as required' RMMR for existing residents, including in the course of a consultation for another purpose. The potential need for an RMMR may also be identified by the reviewing pharmacist, supply pharmacist, Residential Aged Care Facility staff, the resident, the resident's carer or other members of the resident's health care team.
The medical practitioner should assess the clinical need for an RMMR from a quality use of medicines perspective with the resident as the focus, and initiate an RMMR if appropriate, in collaboration with the reviewing pharmacist.
The medical practitioner and reviewing pharmacist should agree on a preferred means for communicating issues and information relating to the provision of an RMMR service. This should include the method(s) of initiating the RMMR, exceptions to the post review discussion, and the preferred method of communication. This can be done on a facility basis rather than on a case-by-case basis.
Where the provision of RMMR services involves consultation with a resident it should be read as including consultation with the resident and/or their carer or representative where appropriate.
RMMRs do not count for the purposes of derived fee arrangements that apply to other consultations in a Residential Aged Care Facility.
Category 1 - PROFESSIONAL ATTENDANCES
245 - Additional Information
Participation by a medical practitioner in a Domiciliary Medication Management Review (DMMR) for a patient living in a community setting, in which the medical practitioner, with the patient’s consent:
(a) assesses the patient as:
(i) having a chronic medical condition or a complex medication regimen; and
(ii) not having their therapeutic goals met; and
(b) following that assessment:
(i) refers the patient to a community pharmacy or an accredited pharmacist for the DMMR; and
(ii) provides relevant clinical information required for the DMMR; and
(c) discusses with the reviewing pharmacist the results of the DMMR including suggested medication management strategies; and
(d) develops a written medication management plan following discussion with the patient; and
(e) provides the written medication management plan to a community pharmacy chosen by the patient
For any particular patient—this item or item 900 is applicable not more than once in each 12 month period, except if there has been a significant change in the patient’s condition or medication regimen requiring a new DMMR
Fee: $130.95 Benefit: 100% = $130.95
(See para AN.7.1, AN.7.18 of explanatory notes to this Category)
Category 1 - PROFESSIONAL ATTENDANCES
249 - Additional Information
Participation by a medical practitioner in a residential medication management review (RMMR) for a patient who is a permanent resident of a residential aged care facility—other than an RMMR for a resident in relation to whom, in the preceding 12 months, this item or item 903 has applied, unless there has been a significant change in the resident’s medical condition or medication management plan requiring a new RMMR
Fee: $89.65 Benefit: 100% = $89.65
(See para AN.7.1, AN.7.18 of explanatory notes to this Category)
- Assist - Addition/Deletion of (Assist.)
- Amend - Amended Description
- Anaes - Anaesthetic Values Amended
- Emsn - EMSN Change
- Fee - Fee Amended
- Renum - Item Number Change (renumbered)
- New - New Item
- NewMin - New Item (previous Ministerial Determination)
- Qfe - QFE Change