Pharmacists are mainly reimbursed for dispensing and supplying medicines to RACFs through the Pharmaceutical Benefits Scheme (PBS). This does not apply for private prescriptions (i.e. medications not subsidized by the PBS), which are charged to patients. For reimbursement by the PBS, pharmacists currently need a paper prescription form for every medication dispensed, in accordance with the orders on the resident’s medication chart. The pharmacy then supplies medications to RACF residents, usually using Dose Administration Aids (DAA) or original packs depending on residents’ ability to administer medications or by arrangement with the RACF [1,4]. There may be situations where residents’ original prescriptions are not available for dispensing or repeat prescriptions run out. In these cases pharmacists are able to initiate or continue medication supply based on an ‘owing prescription’ system but the prescription must be received within seven days [5]. The ‘owing prescription’ system presents a number of important issues, notably considerable pharmacist time is consumed in following up prescriptions from GPs and delays in reimbursement whilst waiting for the prescription to be received from the GP.[5,6] Furthermore, in some cases GPs may then decide to discontinue the therapy hence leaving pharmacists without a prescription [6]. Delays in receiving prescriptions often renders the ‘owing prescription’ system in breach of the statutory requirements. Pharmacists can also supply medications based on the ‘emergency supply’ system. However, this system is associated with an increased cost burden for pharmacists due to the breaking of original packs of medicines and it also requires a high level of clerical organization for the health professionals involved [6]. The Healthcare Management Advisors (HMA) found that under the present system prescribers currently perceive the requirement of ordering medications on the medication chart as well as issuing paper prescriptions as a time consuming duplication of tasks [5].

The data were collected using focus groups. This qualitative method was chosen as it enabled exploratory work to be carried out in order to assess the views of study participants. Group discussion generated through interaction of study participants contribute to a more detailed, cost-effective and timely exploration of different perspectives [10]. Participants in focus groups were currently working with at least one RACF. Focus groups consisted of GPs, pharmacists and RNs/carers. Each focus group was homogenous in terms of professions. Homogenous groups were organized since they capitalize on common experiences [11]. Two focus groups were organized with GPs and two with pharmacists. To ensure a wide representation of ideas and saturation of themes, three focus group discussions with RNs and carers were organized since these groups, unlike pharmacists and GPs, contained both RNs and carers.

Focus groups with GPs were conducted in two metropolitan locations in Perth, namely Fremantle (main port south of Perth) and Osborne Park (northern suburb of Perth), Western Australia. These different areas in the metropolitan area were chosen to ensure a wide representation of GPs. Pharmacist participants came from different metropolitan areas and their focus groups were conducted in facilities of the Curtin University, School of Pharmacy. To avoid bias and ensure a wider representation of pharmacists each focus group had pharmacists who were not working in the same pharmacy. Focus groups with RNs/carers were conducted in respective RACF facilities located in different Perth metropolitan areas i.e. Bicton, Myaree and Belmont. RNs/carers were experienced in working at different RACFs. To further ensure a wider representation of participants, RACFs that were managed by different companies were chosen.

GP and pharmacist participants were contacted via telephone to seek agreement to participate and received an information letter and invitation to attend the focus group. GP participants were recruited through contacting their respective Divisions of General Practice aged care panels. Contacting pharmacists that worked with RACFs was a difficult task because there was no available official list of pharmacies that worked with RACFs. These pharmacies were identified by contacting pharmacies initially known to researchers to provide services to RACFs which then provided further information about other pharmacies that serviced RACFs. This was done until a sufficient number of pharmacists agreed to participate in the focus groups. A total of 20 GPs and 14 pharmacies working with RACFs were contacted. Participants for the RNs/carers focus groups were recruited by the RACF manager. The manager who invited RNs and carers to participate was informed about the approximate preferred number of participants in focus group meetings. All focus group participants received an information letter and invitation to attend the focus group and signed a consent form to participate.

A literature review aided the design of focus group questions and protocol [1-3,10-13]. A consultation meeting of researchers and the facilitator of the focus group also assisted in the review and finalization of this process. The final focus groups questionnaire consisted of an opening question (icebreaker), six transition questions and three key questions. The opening question was related to participants’ opinion on current medication supply systems in RACFs. Transition questions pertained to difficulties with current medication supply systems, potential improvements and potential new models of medication supply. Key questions related to model preference and additional training needed.

In order to ensure a degree of neutrality and avoid bias, the focus groups were conducted by a facilitator who was a staff member of School of Pharmacy but not part of the research team. One of the researchers was present at each focus group meeting managing the audio-recording and taking notes about contributions made by each participant. Focus group participants were reimbursed for their time. All focus groups were conducted during February 2009.

There were three main themes that emerged in focus groups discussions regarding the medication chart model. These themes pertained to: a) support for its use, b) reviewing the medication chart and c) potential difficulties with using the medication chart as a replacement prescription. Details of these are given below:

a) Support for using the medication chart as a replacement for prescriptions

Using a medication chart model as a replacement for prescriptions to supply medications to RACFs was generally supported by all professions. A RN suggested that medication charts clarify what is given to the resident by instantly knowing the medication the GP has authorized to give. Furthermore, it appeared that in some RACFs, medication charts were already the document by which the nursing staff were guided. The fact that medication charts were already superseding prescriptions was also highlighted by pharmacists. Centralization of medication supply and no variation in frequency of repeat prescriptions when medication charts are used were mentioned as reasons for pharmacists supporting this model. GPs also thought that the medication chart model enabled clarification of medication deliveries from pharmacies to RACFs and centralization of medication supply. According to GPs this model would allow them to maintain control over the type of medications their patients receive. Support statements for using the medication chart as a replacement for prescriptions are illustrated in Table1.

The use of an electronic version of the medication chart instead of a paper-based one emerged as an option in pharmacists’ focus groups. Some perceived advantages of electronic medication charts included: responding in real time when GPs change residents’ therapy electronically and automatic online claiming. Pharmacists also highlighted the advantage of this model allowing the pharmacist to see what stock would be required to be dispensed ahead of time. Comments of support for using an electronic version for medication charts are illustrated in Table2.

b) Reviewing the medication chart

The need for a regular review of medication charts was emphasized by all health professionals in focus groups. In the RNs and carers’ focus groups, this appeared to be a necessity based on their experience with the current use of medication charts. In order to assist GPs in reviewing the medication chart a pharmacist suggested an expiry date on medication charts so that it makes it necessary for GPs to review, whereas a GP proposed a review interval. This is illustrated in Table3.

c) Potential difficulties with using the medication chart model

Potential difficulties with using a centralized medication chart as a legal document were identified by all health professionals. Changes to residents’ therapy during weekends were identified by RNs and carers as a current difficulty with using medication charts and therefore urged caution in this regard for any future medication chart model. It was stressed that there may be cases where medication charts do not correspond with what the nursing staff actually administers to the residents as the GP may have not charted the medication. This may occur in cases where GP made the change over the phone and a new list of medications is not supplied by the pharmacy until the next working day. Another potential problem for RNs and carers with using medication charts as central documents was that it may not solve the problem of medications prescribed for short-term or PRN use. This is because the GP in those situations may not be available.

Legible writing with paper-based medication charts, especially when working with duplicates was highlighted by pharmacists as a potential problem. Additionally, claiming medications dispensed also appeared to be a concern with using paper-based medication charts. Potential technical computer problems affecting the process and GPs who may not be comfortable with using the electronic version of medications charts were also highlighted. The main concern GPs had with a prescription-less medication chart model was the potential lack of control over the amount of medications dispensed by the pharmacy. The above potential difficulties are illustrated in Table4.

Pharmacists’ support for an electronic version of the medication chart confirms findings of the HMA review who suggested that a paper-based medication chart should be only a transition to an electronic version. The electronic version of the medication chart was supported by stakeholders in the HMA review [5]. An electronic version may address some of the main potential difficulties that were raised by focus group participants in regards to using the medication chart model. These difficulties included: reimbursement of pharmacists, RNs/carers concerns with potential discrepancies between medication charts and medication administration when medications were prescribed during the weekend and GPs concern with the potential lack of control over the amount of medications dispensed by pharmacies (i.e. which the current prescription system maintains). Pharmacists also suggested that this model would allow real-time response to medication orders. The use of this model is likely to be confounded by potential technical problems and push back by some GPs who may feel uncomfortable in using an electronic version of the medication chart model.

Findings from this study could also apply to other countries where medication supply to nursing home residents is dependent upon the supply pharmacy receiving a prescription or medication order in order to continue supplying medicines and hence maintain residents’ therapy. For example, a prescription-less model of supplying medicines would be advantageous in the United Kingdom where currently continuation of supply is dependent on Registered Managers of nursing homes, in many cases, having to give GP surgeries 48 hour notice to produce repeat prescriptions which are then sent to the supply pharmacies [14]. A centralized medication supply system, especially an electronic one where stakeholders have direct access, would make this process unnecessary. Likewise, this system would overcome the potential administrative burden of having to pass written medication orders to the pharmacy by nursing homes’ medical staff (currently the case in the United States of America) therefore enabling more time to be focused on patient care [15].

Overall, the findings of this study suggested that the current use of paper prescriptions in RACFs may unnecessarily burden the supply of medications in this setting. In this regard there were signals that the current use of prescriptions is serving primarily as a means of pharmacists being reimbursed for medications dispensed, as well as GPs retaining control over the amount of medications dispensed by a pharmacy.

The main strength of this study is the representation of GPs, pharmacists as well as RNs and carers in focus group meetings. These health professionals were all experienced in dealing with medication supply to RACFs and all were currently working in at least one RACF. It should be noted that this study was only conducted in Western Australia and did not include participants from other Australian states and territories. This limitation may be considered minimal to the overall study results given the achievement of a saturation point in terms of new ideas and comments made by focus group participants as well as the similarity of medication supply systems to RACFs across the Australian states and territories. In this study no distinction was made between low-care and high-care RACFs as the medication supply system as the need for a prescription to facilitate continued supply is the same between the two categories. Diverse focus groups of health professionals may have facilitated exploration of different perspectives and this represents a potential advantage which may have been missed with the use of homogenous focus groups (i.e. same professionals) [9]. However, homogenous groups of participants in focus group meetings were used with the aim of capitalizing on common experiences of participants [11]. Segmentation of focus group participants also facilitates a comparative data analysis [12]. Additionally, the professional hierarchy of focus group participants (in this study consisting of RNs and carers) may have also affected the data [11]. GPs working in RACFs refer residents to a wide range of specialists including geriatricians and psychogeriatricians. These specialists were not invited to attend focus groups, as in Australia GPs carry the main burden of care for RACF residents.