‘A Joint Effort’: Stakeholders' Perspectives of Medication Management Reviews in Australian Residential Aged Care

ABSTRACT

Objective

Residential Medication Management Review (RMMR) is a government‐funded pharmacist‐led service to address medication‐related problems, such as polypharmacy, which are prevalent in aged care. Despite known benefits, concerns remain about the service's effective implementation to benefit residents. We aimed to explore stakeholders' perspectives of the service and identify challenges and improvement opportunities.

Method

A qualitative study was conducted using individual interviews and focus groups with 21 stakeholders, including general practitioners (GPs), a nurse practitioner, registered nurses, pharmacists and consumers. Audio transcripts of the discussions were thematically analysed using inductive coding.

Results

Seven interconnected themes were identified, highlighting complexities in RMMR implementation and its role in medication optimisation in aged care. Consumer participation was limited, with low awareness and engagement despite a strong desire for involvement. General practitioners played a central role, acting as both enablers and gatekeepers. Despite the recognised value of interdisciplinary collaboration, professional silos and communication gaps created tensions. Review quality varied, with resident‐centred and contextualised recommendations seen as more impactful. Improved integration of digital systems was viewed as a key enabler, though existing systems were often fragmented. Workforce and funding constraints limited provider motivation and service delivery. Finally, RMMRs were often reactive, highlighting opportunities to shift towards more proactive and transparent processes.

Conclusions

Overall, RMMRs are a complex system‐dependent process. Initiatives addressing identified challenges and strengthening consumer participation, improving interdisciplinary collaboration, integrating digital solutions and targeted policy reforms may enhance RMMR uptake and impact in Australian aged care.

Practice Impact

The study findings highlight opportunities for clinicians to improve Residential Medication Management Reviews by enhancing communication between stakeholders and involving residents in shared medication decisions. Service providers should adopt proactive, data‐driven approaches to reach residents who would benefit from medication reviews in aged care.

Policy Impact

Policy support is needed to improve digital integration, interprofessional collaboration and consumer engagement to strengthen medication reviews in aged care. A targeted policy initiative could enhance transparency through better reporting of Residential Medication Management Review uptake, implementation and outcomes.

1. Introduction

Medication management issues are prevalent in residential aged care. Almost all residents have at least one medication‐related problem [1, 2] with an average of 3–4 medication‐related problems per resident [3]. Polypharmacy (use of multiple medications) is highly prevalent with about one‐third of residents using nine or more medications [4] and nearly half exposed to potentially inappropriate medications [5]. These are associated with significant negative impacts on residents' health outcomes (such as cognitive decline, falls, frailty, constipation, urinary retention, bleeding and renal injury), psychological well‐being and overall quality of life, as well as increasing the risk of hospitalisation [6, 7].

Medication management reviews are one of the many strategies to optimise the quality use of medicines and reduce medication‐related harms through a systematic assessment of a person's medication regimen [8]. When well‐conducted and recommended changes actioned, medication management reviews can solve many medication‐related problems and prevent negative outcomes [9]. While international evidence on their overall impact in aged care is mixed, several Australian studies have shown that Residential Medication Management Reviews (RMMRs) can reduce unplanned hospitalisation and all‐cause mortality, as well as improve cost‐effectiveness of pharmacotherapy in residential aged care [3, 9, 10, 11, 12, 13].

Australia's RMMR program is a federally funded, pharmacist‐led service introduced in 1997 for aged care residents. Eligible residents can receive an RMMR every 12 months or more frequently if needed. The process involves an accredited pharmacist collaborating with the resident's general practitioner (GP) and, when relevant, specialists. Residential Medication Management Reviews are commonly triggered at admission, annually or when a resident's condition changes [14]. Once identified, the RMMR provider sends a referral request to the GP, usually via manual processes such as printed forms, email or fax, followed by obtaining resident or carer consent for the review. Pharmacists then visit the RAC home to gather information from multiple systems, interview residents and staff, and prepare recommendations to optimise medication use. As per the RMMR program rules, GPs then prepare a medication management plan in consultation with resident or carer and review pharmacist [14].

Despite evidence of benefits, there have been concerns about the overall impact of this service in improving medication management in Australia [3, 15]. For example, the uptake of the service remains low; a 2021 study found only 22% of new residents received an RMMR within 90 days of admission [16]. Furthermore, GP acceptance of pharmacists' recommendations varies widely, with as few as 45% of recommendations being actioned [3]. In addition, consumer involvement and person‐centredness within the process are poorly understood.

The objective of this study was to explore stakeholders' perspectives of the RMMR service as a system‐dependent process within complex residential aged care services, highlighting the challenges and opportunities for improvement. As part of a broader project aiming to optimise the pharmacist‐led medication management reviews, the context‐specific insights generated from this study will inform the development of an informatics‐supported model of medication management reviews in aged care.

2. Methods

This qualitative study used in‐person and online interviews and focus groups with RMMR stakeholders, identified by the project working group. Our study is reported in‐line with the consolidated criteria for reporting qualitative research (COREQ) (see Appendix S1 for checklist) [17]. Ethics approval was obtained from the Human Research Ethics Committee at Macquarie University (HREC: 15478) and informed consent was obtained from all participants.

Stakeholders, including accredited RMMR pharmacists, prescribers (GPs, nurse practitioners), registered nurses (RNs) and consumers, were invited to participate through researchers' networks, online advertisements and stakeholder organisation newsletters. Consumer participants were individuals with lived experience of a loved one living in aged care (carers or family members) and were recruited through online advertisements by the Consumers Health Forum Australia. A purposeful sampling strategy was used to ensure participation of relevant stakeholders. At recruitment, participants were offered a choice of a one‐on‐one interview or a focus group based on their preference and availability. Consumers who participated in focus groups were members of an advisory panel already known to the research team.

2.1. Data Collection and Analysis

Interviews and focus groups were conducted online (November 2023–February 2024) to support participation from stakeholders in different locations. Both formats used the same semi‐structured guide (Table 1) to explore participants' understanding, perceived roles, experiences with, and challenges and opportunities to improve RMMR uptake and impact. These discussions focussed exclusively on the RMMR services; other pharmacist‐led medication optimisation programs (e.g., aged care onsite pharmacist) were not examined. Although RMMR pharmacists are not considered ‘onsite pharmacists’, they are often involved in providing services such as Quality Use of Medicines to aged care providers and thus have existing relationships with RAC homes. As part of the broader project, participants were also asked brief exploratory questions about desired features of an informatics‐supported solution to enhance RMMRs. Findings related to the informatics‐supported solutions will be reported separately. Interviews were conducted by RG, LY and MO, and focus groups were moderated by AN and RG. Interviews continued until data saturation was reached, for instance when no new insights emerged, as judged by the interviewer and confirmed through team discussion. Interview durations ranged from 20 to 60 min, and focus groups lasted between 35 and 45 min. All sessions were audio‐recorded and professionally transcribed (Pacific Transcription, QLD Australia).

TABLE 1.

Semi structured interview/focus group guide.

Providers (pharmacists, nurses and GPs)

Consumers

Could you describe and/or demonstrate the RMMR process at your care home? What is your role in this process? What is your opinion of the RMMR process? Are there any challenges in this process? How have you managed these challenges? What can be improved? How does the electronic medication system available in aged care assist or hinder the RMMR? How could the electronic medication system be improved to better support RMMRs?

Could you describe your experience with medication management process for your loved ones in aged care? What do you know about the medication reviews for residents (called the RMMR) process? What do you understand your role is in this process? Can you recall any experience with RMMR? What did you like/dislike about the process? Are there any challenges in this process? How have you managed these challenges? What can be improved? How would you like to be involved in the process? What information would you like to receive after an RMMR is performed?

Abbreviations: GP, General Practitioner; RMMR, Residential Medication Management Review.

De‐identified verbatim transcripts of the interviews and focus groups were inductively coded and thematically analysed [18]. Following the thematic analysis approach, researchers (RG, AN, MO and RJ) initially familiarised themselves with the datasets by reviewing the transcripts and discussed example data points evident in the datasets. Pairs of researchers then inductively coded two transcripts each, compared coding decisions and resolved discrepancies to ensure consistency. All remaining transcripts were then individually coded by two reviewers (MO and RJ). Coding was reviewed by RG and AN to ensure coherence and completeness. After initial codes were generated, the team held a series of workshops to collate codes, identify patterns and develop preliminary themes. These themes were iteratively refined, defined and named through team discussions, and later reviewed by the broader project team.

3. Results

A total of 21 stakeholders (15 female, six male), including GPs, nurse practitioners, RMMR pharmacists and providers, RNs and consumers (family members or carers with lived experience of someone in aged care), participated in 15 individual interviews and three focus group discussions. Participants included seven consumers, four GPs, six pharmacists, three registered nurses (including two with quality manager roles) and one nurse practitioner (Table 2). All pharmacist participants were actively involved in providing RMMR services and worked within RMMR service provider organisations that had agreements with aged care homes to conduct reviews. All GPs and the nurse practitioner were also actively involved in residents' medical care within aged care.

TABLE 2.

Participant details.

Format	Participant	Role	Sex	State
Focus group discussion 1	Nurse practitioner‐1	Nurse practitioner	Female	New South Wales
	GP‐1	General practitioner	Female	New South Wales
Focus group discussion 2	Consumer‐1	Consumer a	Male	Victoria
	Consumer‐2	Consumer a	Male	Victoria
	Consumer‐3	Consumer a	Female	New South Wales
Focus group discussion 3	Consumer‐4	Consumer a	Female	South Australia
	Consumer‐5	Consumer a	Female	Victoria
Individual interviews	RN‐1	Registered Nurse	Male	New South Wales
	RN‐2	Registered Nurse and Quality Manager	Female	New South Wales
	Pharmacist‐1	RMMR Pharmacist	Female	New South Wales
	RN‐3	Registered Nurse and Quality Manager	Male	New South Wales
	Pharmacist‐2	RMMR Pharmacist	Female	New South Wales
	Pharmacist‐3	RMMR Pharmacist	Female	New South Wales
	Consumer‐6	Consumer a	Female	Tasmania
	GP 2	General practitioner	Female	New South Wales
	Pharmacist 4	RMMR Pharmacist	Male	New South Wales
	Pharmacist 5	RMMR Pharmacist	Female	Queensland
	GP‐3	General practitioner	Female	New South Wales
	Pharmacist‐6	RMMR Pharmacist	Female	New South Wales
	GP‐4	General practitioner	Male	New South Wales
	Consumer‐7	Consumer a	Female	Western Australia

Abbreviations: GP, General Practitioner; RMMR, Residential Medication Management Review.

^a Carer and/or family member of someone with lived experience in Australian aged care.

The seven interlinked themes and subthemes outlined below illustrate the complexities of RMMR services, including the challenges affecting their uptake and impact, as well as potential opportunities for improvement. The detailed definitions of these themes and subthemes together with representative participant quotes are presented in Table 3.

TABLE 3.

Themes, subthemes and participant quotes.

Themes	Subthemes	Definition	Example quotes
Consumer participation: low awareness and engagement amid a strong desire for involvement	Awareness and understanding	Consumers' limited knowledge of RMMRs, their purpose, and how to access them	‘My mother had a Webster Pack, yay thick. With her GP, we would sometimes, almost jokingly, say, look, does she really need all that? But he never said, could we have an RMMR’. (Consumer‐2)
	Depth of engagement	Depth of consumer involvement, moving beyond consent‐giving to genuine shared decision‐making during and after the review	‘I don't routinely chat with the consumer, with the client, or the next of kin unless I'm really going to change something’ (GP‐4)
	Information access and transparency	Challenges consumers face in accessing their medication information and RMMR reports	‘There's no reason why a resident or their family shouldn't have full access to what's on their chart, and what the person's taking and/or whether they're refusing their meds or how often they're taking something, then they certainly should have full open disclosure about that aspect of it’. (Pharmacist 4)
Gatekeeping and alignment: GPs as both enablers and constraints	GP identity and clinical authority	How GPs' professional identity influences their willingness to share decision‐making with pharmacists	‘My thoughts are that they're probably of an era where there was quite paternalistic medicine being practiced, which is yes, doctor, whatever you say, doctor, rather than being used to a conversation about the pros and cons of any particular thing’ (GP‐1)
	Perceived value of RMMRs	GPs' attitudes towards the usefulness of RMMRs	‘I don't always take it up, but, yeah, I mean if I feel that there's nothing more, if I feel like they're optimised, I won't take it up, but, yes, I'm very open, I think, to receiving that advice and suggestion’ (GP‐4)
	Competing workload demands	Time pressures, admin burden, and competing responsibilities affecting GP engagement	‘But for them to have access just to the report and not the conversations that were taken at the time, just [seems a hell of a lot] of extra work then to un‐explain it, or re‐explain it, or that that we probably don't have in aged care’ (GP‐2)
	Resistance to external input	GPs' reluctance to accept pharmacist recommendations	‘We may still have some GP with probably not open‐minded attitude, then they have issues in terms of like, don't tell me what I need to do’ (RN‐3)
Tension and potential: navigating professional silos in interdisciplinary practice	Team dynamics and collaboration	How trust, mutual respect, and ongoing relationships among RNs, GPs, pharmacists shape team functioning	‘If I made more of a personal effort to get to know the ‐ if there was one regular pharmacist that was coming to our aged care facility, there might be, I'm not sure, but if I had established that relationship with them, it might be easier to pick up the phone and chat with them’ (GP‐1)
	Role clarity and boundaries	Role perceptions influence collaboration and shared responsibility in medication reviews	‘Sometimes the recommendations are not always followed by the GPs, but it comes down to that person, or that care manager, or the RN to advocate to the patient – to advocate for the resident to make those recommendations happen’ (RN‐1)
	Low prioritisation of RMMRs	Competing clinical and administrative demands pushing RMMRs to the bottom of the task list	‘I find them really useful for managing polypharmacy, but unfortunately, I have to put it in the bottom list because – yeah, so I still have it in my bag, but I haven't touched and read it […] because of time—lack of time and competing demands’ (RN‐2)
	Communication and feedback processes	Quality, method, and timeliness of interprofessional communication and feedback on recommendations	‘I guess having that feedback and communication, so the method at the moment is via email, I don't feel like that communication channel is very clear, I'll send out the request, that's usually a print‐off of a digital document that I then write on and get scanned and emailed back’ (GP‐4)
Generic vs. meaningful: how review quality influence RMMR uptake and impact	Resident‐centred reviews	RMMRs considering the resident's context, rather than relying on just medication list	‘We were teaching our pharmacists to appreciate the whole patient, to get as good a medical history as they possibly could from the information available’ (Pharmacist‐3)
	Usability and actionability of reports	Clarity, relevance, and practicality of report content for driving clinical action	‘Sometimes we get other RMMR reports, it's a very academic transcript. It's delivered to the RN and giving them another task to do, which is actually decipher the meaning of that and then take that to the doctor’ (RN‐2)
Disconnected systems: inefficiencies of a fragmented digital ecosystem	Fragmented digital workflows	Multiple disconnected digital systems cause inefficiencies and duplication of effort	‘I have to keep records at my practice as well as what's kept at the nursing home’. (GP‐4)
	Need for integrated information access	Unified, up‐to‐date clinical and medication record to support shared care	‘If they had a one‐stop thing where it integrated with whatever system the facility was using, that would be a good thing’ (Pharmacist‐5)
Under‐resourced and undervalued: workforce and funding realities	Workforce shortages and turnover	Understaffing (mainly casual and agency nursing staff) impact medication management and RMMR processes	‘They often don't respond to emails, they often ‐ they're just short staffed again. It's the staffing, it's all about the staffing’ (Pharmacist‐5)
	Skill mix and preparedness	Gaps in training or capability affecting RNs' and pharmacists' roles in RMMRs	‘I think the lack of knowledge and understanding with RMMRs. I think some of my RNs –working in our nursing home, they are new grads and I think they're not quite well aware about medication reviews and what the process is yet’ (RN‐1)
	Mentorship and role transition support	Importance of structured support for pharmacists transitioning to aged care clinical work	‘We found it was best to show people the theory, so very quickly show them the process, just gently, and then take them straight to a facility. I never wanted any pharmacist to have the experience that I had of just being sent somewhere. They would go with an experienced person to show them around, introduce them to people, get that relationship going’ (Pharmacist‐3)
	Funding and system‐level incentives	Current funding models disincentivise sustained pharmacist and GP engagement	‘I still have to collaborate it with all and that's what takes time. We're still doing, I feel, twice as much work as other healthcare professionals for the remuneration’ (Pharmacist‐6) ‘GPs increasingly don't want to do aged care work. They've got to do something to attract or incentivise GPs to want to, I guess, prioritise longer term, because I mainly just do it because I feel like I'm serving the community. I would earn more money if I just sat in my room and saw patients face to face here’ (GP‐4)
Reactive processes and missed opportunities: the need for proactive, transparent RMMRs	Proactive review triggers and timing	Missed opportunities to use key events (e.g., falls, admission) to prompt timely RMMRs	‘But if they don't do the scheduled visits and if they don't track everyone, then there's probably a number of residents who's going to miss out’ (RN‐1)
	Lack of visibility and shared follow‐up	Gaps in communication post‐review, especially in sharing outcomes and revised care plans with key parties	‘We're lucky if we get response from the doctor’ (Pharmacist‐6)

Abbreviations: GP, General Practitioner; RMMR, Residential Medication Management Reviews; RN, Registered Nurse.

3.1. THEME 1: Consumer Participation: Low Awareness and Engagement Amid a Strong Desire for Involvement

Consumers expressed a strong desire to be involved in the medication management review process. However, they often faced challenges in understanding and engaging with RMMRs. All consumer participants were unaware of formal RMMRs, though some had participated in informal reviews. Healthcare providers also noted that families were not ‘always aware of the role of the pharmacist’ (RN‐2) and were reluctant to let pharmacists ‘interfere with the doctors' decisions.’ (Pharmacist‐4)

My mother had a Webster Pack, yay thick. With her GP, we would sometimes, almost jokingly, say, look, does she really need all that? But he never said, could we have an RMMR. (Consumer‐2)

Consumers reported a lack of transparency and access to information, particularly access to the RMMR report, leading to a sense of frustration:

This is an individual who has got the right to access their own medication review, but then they had to navigate a gauntlet of being stonewalled in order to access their own medication review. (Consumer‐6)

Moreover, residents and family members were reported to be largely limited to providing consent as required by the current process and were rarely invited to be involved during the review or any subsequent changes. Pharmacists engaged in RMMRs reported relying mostly on clinical and medication records and interviews with nursing staff for information about the resident. General practitioners tended to involve consumers only if there were significant medication changes after the review, limiting families' opportunities to be active participants throughout the process.

3.2. THEME 2: Gatekeeping and Alignment: GPs as Both Enablers and Constraints

All stakeholders, particularly RNs and pharmacists, discussed the importance of and challenges in engaging GPs in the RMMR process. Many ‘consumer‐focused GPs’ were supportive of RMMRs and recognised their value in improving care and promoting shared learning. Others often had limited engagement in the process due to several internal and external factors such as workloads, perceptions about their own and other's role in residents' clinical care and perceived value of the RMMR:

I've found that RMMRs are immensely helpful. As I said, it's opportunistic education as well and the pharmacists teach us just so much. (GP‐2)

Many GPs reported feeling overwhelmed by the volume of RMMR requests (‘bulk requests’ without justifications) and the time required to manage them alongside routine care pressures. Communication challenges and administrative tasks associated with RMMRs, such as handling emails or faxes and multiple digital systems, further added to GPs workloads:

You get a lot of requests and it's hard to stay on top of it. […] you've just got to try and work what you can and can't do realistically, with the amount of time you've got. (GP‐4)

The attitudes of GPs and low perceived value of RMMRs, potentially informed by their experiences, also minimised their engagement. Several participants noted that while many GPs were open to discussion, others were ‘just not interested’ (Pharmacist‐3) and saw RMMR as a ‘tick‐box’ exercise (GP‐1). Some participants also shared experiences of working with GPs who had narrow ‘paternalistic’ (GP‐2) perceptions of their roles, for example, ‘don't tell me what I need to do’ (RN‐2), and thus were resistant to pharmacists' recommendations.

3.3. THEME 3: Tension and Potential: Navigating Professional Silos in Interdisciplinary Practice

Stakeholders highlighted the value of teamwork between GPs, pharmacists and RNs (and care home management) in a multidisciplinary approach to foster mutual learning and better decision‐making. Such collaborations and teamwork were facilitated when healthcare providers ‘respected each other’ (RN‐3) and realised a common goal of improving resident care. A strong and continuing GP‐pharmacist relationship was perceived to be particularly important as GPs also found it easier to communicate with a consistent pharmacist (i.e., same pharmacist doing the review and communicating with them), saying ‘it might be easier to pick up the phone and chat with them’ (GP‐2). Some GPs and pharmacists preferred case conferences and roundtable discussions to enhance medication management plans, although these activities were beyond the current RMMR scope and funding arrangement.

Achieving effective interdisciplinary collaborations was not without challenges. Healthcare professionals reported being overwhelmed by ‘massive amount of admin’ tasks (GP‐4), competing priorities and workload pressures, leading to RMMRs being given low priority—often ending up at ‘the bottom of the list’ (RN‐1). Similarly, perceptions of roles and responsibilities interfered with the collaborative review process, as a nurse noted ‘This is my task, and this is my task and now it's your task to marry the two. It doesn't work for anyone with that’ (RN‐2). However, many healthcare professionals described going above and beyond their conventional roles and tasks to advocate for RMMRs and better medication management for their residents:

As a Care Manager, I would have to advocate to the doctor that this patient doesn't need it [medication], and we might need to cease all medications because that patient is actually receiving conservative management. (RN‐1)

Participants reported that printouts, emails and faxes used in the RMMR process were inefficient, causing delays and gaps in communication, and hindering effective collaboration and uptake of recommendations. One RN noted: ‘We receive [RMMR report] electronically, and then we print it out and put it in the GP's folder’ (RN‐1). Another aspect was suboptimal two‐way communication between pharmacist and GPs. Many GPs expressed frustration with RMMR requests that lacked contextual information and clinical reasoning. Several pharmacists also reported feeling demotivated with limited GP acknowledgement and feedback on their RMMR recommendations:

I'm wasting my time, don't go to any effort because [the RMMR report] is not going to be read. I don't think it's being read. (Pharmacist‐1)

3.4. THEME 4: Generic Versus Meaningful: How Review Quality Influence RMMR Uptake and Impact

Stakeholders had a shared positive perception on the impact of RMMRs on resident care and outcomes, as RN‐2 suggested: ‘The reviews are really effective. I find them really useful for managing polypharmacy’. However, they emphasised the need for RMMRs to be ‘holistic’ (Consumer‐4) to be effective, meaning they considered the resident's entire history, experiences and current preferences, not just their medications. They suggested that good quality RMMRs should be timely and collaborative, engage consumers and focus on a shared goal of resident well‐being:

I've seen a RMMR pharmacist who will go and talk to a consumer […] trying to understand how the falls married to the doses delivered, the administration of levodopa, et cetera. Then worked with the team to kind of bring that to the team's attention that this person may be falling after levodopa and what can we do around that to make a meaningful change to the consumer? That kind of pharmacy review is very meaningful to the service, and it becomes a joint effort. (RN‐2)

On the other hand, some stakeholders pointed out that generic reviews that lacked considerations to residents' unique and complex needs and contained ‘cut and paste’ recommendations can feel ‘judgemental’ (GP‐3), thus limiting recommendation uptake and impact. Additionally, reports that were not user‐friendly were more likely to be ignored as they may not provide actionable insights for healthcare teams and even increase their workload by requiring nursing staff to ‘decipher the meaning of [the report] and then take that to the doctor’ (RN‐2).

3.5. THEME 5: Disconnected Systems: Inefficiencies of Fragmented Digital Ecosystem

Many participants described in detail the lack of digital system integration in aged care as a major barrier to effective communication and care coordination. Professionals must navigate multiple disconnected platforms, including My Health Record, the clinical care software, the medication chart (electronic or hard copy) and pathology provider portals, leading to significant inefficiencies. Healthcare providers expressed frustration around ‘double handling’ (GP‐4) with manual data transfer across several systems and multiple email exchanges, increasing workload and error risk. Pharmacists echoed this, noting that while the electronic medication chart ‘was a big step forward [which] meant that the data was all available’ (Pharmacist‐3), many systems were difficult to access, have complicated layouts, and rely on a problematic mix of paper and electronic charts.

Stakeholders pointed out that integrating these systems could streamline processes, reduce workload, and improve care coordination, ‘If we had a central base that we could all access, it would make things easier’ (Pharmacist‐6). Participants stressed the importance of having up‐to‐date and easily accessible ‘one source of truth’ (RN‐2), for all medication and clinical information.

3.6. THEME 6: Under‐Resourced and Undervalued: Workforce and Funding Realities

Participants suggested that the uptake, delivery and impact of the RMMRs was influenced by organisational factors such as workforce shortages, staff training and professional support. A key concern was understaffing and reliance on agency nurses for care and medication management, which participants felt, due to the nurses' limited familiarity with residents, led to some eligible residents being ‘missed out’ from potential benefits of RMMRs. For pharmacists, transition from community or supply settings to RMMRs was challenging, ‘It takes a long time to get someone up there […] it's very hard to train a new staff member’ (Pharmacist‐1), and they emphasised the importance of professional support and mentoring around clinical reasoning, relationship management and RMMR report writing:

The external policy environment, particularly remuneration and funding, was a critical issue, mainly impacting pharmacists. Several pharmacists highlighted inadequate funding and financial disincentives associated with providing RMMR services, as one pharmacist commented, ‘We're still doing twice as much work as other healthcare professionals for the remuneration’ (Pharmacist‐6). Similarly, GPs discussed poor financial incentives as one of the reasons for limited interest to work in the aged care settings.

3.7. THEME 7: Reactive Processes and Missed Opportunities: The Need for Proactive, Transparent RMMRs

Participants reflected that the challenges discussed contributed to RMMRs being ‘a very reactive piece’ (RN‐2), leading to missed opportunities to review residents who could benefit. While RMMRs can be initiated by various events, participants noted that most are conducted annually, prompting calls for a shift towards a more proactive and structured approach focussed on clinically relevant triggers. These included admission, post‐hospitalisation, clinical deterioration or significant events such as falls or medication changes. GPs particularly advocated for clinical event‐driven RMMR initiation supported by embedded risk‐based prompts to enable earlier and more targeted identification:

Maybe triggering on admission, a flash up to remind you, and then just send it off straight away, would use it a lot more… Or a fall… that would be a common scenario… (GP‐3)

Many participants criticised the RMMR process for its poor visibility, noting that stakeholders often did not know where the process was at any given point. Consumers reported not having access to their loved one's RMMR reports, which limited their ability to follow up or remain involved. Pharmacists similarly reported that they were often kept out of loop of the medication management plans resulting from their reviews:

When I do those follow‐ups, I actually find that they have made a change, or they haven't made a change but that's about the extent of it. I don't think you actually see that formal medication management plan ‐ very few doctors will do it. (Pharmacist‐1)

4. Discussion

This study adds to the emerging evidence on stakeholder perspectives regarding RMMRs in aged care. While previous research has examined aspects of stakeholder views, often within specific contexts [15] or limited to healthcare professional groups [19], this study is among the first to explore the views of all key stakeholders, including consumers, on the RMMR process within the residential aged care setting. The findings highlight the complexities within the RMMR service, unearthing several challenges and opportunities for its improved uptake and impact. Our study shows that consumers have limited knowledge of and engagement opportunities throughout the process, despite a strong desire for involvement. While healthcare providers recognise the value of the service, they face barriers including gaps in communication and interdisciplinary collaboration, high workloads and ‘effort‐reward’ imbalances. Health information technology systems used in aged care are fragmented and inefficient, with limited interoperability across platforms, further hindering collaboration and information access and sharing. Potential opportunities to improve RMMR delivery include strengthening interprofessional collaboration, educating GPs on the value of RMMRs, supporting pharmacists in adopting holistic approaches, creating more opportunities for consumer engagement, and integrating health information technology systems for improved transparency and efficiency.

Medication optimisation strategies, such as RMMRs, emphasise consumer engagement in decision‐making [14, 20]. However, as identified in our study, such engagement is often limited by low consumer awareness of the service and its benefits. While there is little Australian literature on consumer awareness of RMMRs, our findings align with the currently available evidence suggesting low awareness of similar services such as home medicines reviews and medication reviews in other care settings [21, 22]. The current RMMR model, where off‐site pharmacists primarily rely on health records and interviews with aged care staff, also limits opportunities for direct consumer input [15]. This lack of involvement can result in reviews that are generic and less tailored to residents' individual needs and care goals. The extent to which medical practitioners involve consumers in decision‐making also varies, with consumers often being informed about medication changes only after decisions are made [20]. This contrasts with consumers' strong desire to be actively involved, request reviews, see the progress and understand their outcomes. In addition to initiatives to raise awareness, providing tools and resources, such as an electronic consumer medication portal [23] to enable residents and carers to initiate RMMRs, track progress and view outcomes could help enhance their active engagement.

General practitioners and pharmacists play key clinical roles in RMMR, yet both face significant individual and collaborative challenges. For GPs, high workloads, isolated views on roles and responsibilities, and scepticism about the value of RMMRs and pharmacists can result in their resistance to initiating RMMRs (by accepting referral requests) or adopting pharmacist recommendations [24]. Many GPs experience an ‘effort‐reward imbalance’ with aged care work being time consuming, poorly renumerated and administratively burdensome (e.g., cumbersome Medicare claim process for RMMRs), leading to de‐prioritisation of RMMRs, which are often perceived as peripheral to core clinical care [3, 12, 15, 25]. This is exacerbated by receiving bulk or poorly justified referral requests and generic RMMR reports lacking relevant or actionable recommendations, thus discouraging further collaboration. Pharmacists similarly face high workloads, fragmented information systems and limited compensation [15, 19, 26]. For example, while multidisciplinary care plans and case conferences are encouraged within the RMMR program, pharmacists are not remunerated for participation in these activities. In addition, effective interprofessional collaboration is often affected by communication gaps (e.g., limited GP feedback to pharmacists) and reliance on manual systems like email and fax, resulting in delays, inefficiencies and reduced engagement [1, 15, 19]. Similar to previous studies, our participants also reported variability in collaboration, with stronger communication where relationships were established and weaker engagement elsewhere [15, 19]. These relational differences, alongside structural constraints such as high workloads with limited compensations, can contribute to inconsistent review quality and weaken the collaborative foundations needed for effective RMMRs.

Addressing these challenges requires a multipronged multi‐level response. Improving collaboration and communication across all stakeholders is essential, but these relational efforts must also be supported by system‐level enablers. For medical practitioners, targeted education around the value of RMMRs and collaborative care may improve engagement [13]. Pharmacists would benefit from ongoing training on person‐centred reviews. Policy reforms, including expanding nurse practitioner roles to refer for reviews and aligning remuneration with RMMR complexity, may reduce burden and incentivise quality participation [15, 19]. Regular interdisciplinary meetings such as case conferences [15, 27] can support teamwork to ensure that RMMR recommendations are collaboratively reviewed and actioned [12]. Integrated digital systems can work in parallel by enhancing transparency, improving access to information such as past medical history and pathology results, reducing administrative burden (e.g., automated Medicare claiming for GPs) and streamlining communication (e.g., enabling GP feedback on recommendations to close the feedback loop with pharmacists). Models of care where GPs or nurse practitioners and pharmacists spend more time onsite could further enhance collaboration and person‐centred care for residents. The federal government funded aged care on‐site pharmacist model, launched in 2024 in Australian aged care, shows promise in supporting interprofessional collaboration and consumer engagement, ultimately improving medication management outcomes for residents [28]. However, careful implementation of the model of care is needed to ensure adequate resourcing and opportunity for on‐site pharmacists to undertake comprehensive medication management reviews. For example, if funding for on‐site pharmacists does not support their presence in aged care homes for sufficient time or does not support experienced pharmacists providing onsite pharmacist services, they may encounter similar challenges to the RMMR program. Furthermore, studies of the on‐site pharmacist program included the RMMR as an additional service [28, 29]; however, the current government funding arrangement precludes aged care providers availing both services simultaneously [14].

Rapid adoption of digital systems within Australian aged care in the past two decades has served to improve efficiency in administrative processes and the quality of care; however, interoperability of these systems remains an ongoing key concern [30]. Healthcare professionals navigate multiple platforms, requiring separate logins and workflows. This increases the risk of errors, inefficiencies, ‘double handling’ of data, and hinders interprofessional collaboration [31]. As consistently advocated by our participants, there is a need for these systems to be integrated and interoperable. Such integration could also enable RMMR uptake and impact to be monitored, potentially as an additional quality indicator within the National Aged Care Mandatory Quality Indicator Program. However, achieving interoperability between aged care digital systems would require addressing several technical, organisational and financial barriers such as resistance to change, large investment, lack of standardisation, data security and privacy concerns, and leadership and coordination factors [11, 30]. This can be facilitated by government‐led legislative and policy reforms mandating interoperability standards and compliance to ensure widespread industry uptake and use.

Our study findings also suggest a reactive nature of current RMMR services with ad hoc initiation of reviews. Studies have consistently stressed the importance of a proactive and systematic process for the early identification of at‐risk residents who can benefit from a medication review [3, 13]. Aged care residents often take multiple medications for various chronic and worsening conditions, requiring frequent (or need‐based) reviews [4, 32]. However, the current RMMR model allows for regular reviews only every 12–24 months, which may not meet residents' needs [14]. Although additional reviews can be requested when needed, they are often overlooked due to residents' complex care needs and workforce challenges. Enabling residents and their family members or carers to request reviews could help, as they are often the first to notice changes in their own or their loved one's condition [33]. Similarly, routinely collected data in aged care systems can be used to develop algorithms to identify, flag and prioritise residents who may need a medication review, such as those on medications with a high risk of falls or hospitalisation [34].

A key strength of this study was its use of qualitative methods to capture diverse perspectives from key stakeholders. Insights from consumers, GPs, pharmacists and nurses offered a comprehensive understanding of their unique needs and challenges, supporting the development of future interventions to address these issues. We acknowledge that one reviewer (MO) had extensive experience as an accredited RMMR pharmacist, which may have influenced aspects of data interpretation [35]. However, this clinical insight was balanced by the involvement of team members with limited first‐hand experience in RMMRs, whose outsider perspectives helped counter potential bias and strengthen the overall rigour of the analysis. However, a limitation was the absence of consumer participants residing in aged care homes and consumer participants who had previous RMMR experience, and this may have restricted the scope of consumer insights obtained. Additionally, the study did not examine the role of direct personal care workers in RMMRs, despite their close knowledge of residents and potential to identify early health changes and medication adverse effects.

5. Conclusions

Residential aged care consumers and healthcare providers share positive beliefs about the RMMR program and recognise its potential to improve medication safety and quality. However, the current model offers limited proactive identification of residents for a review, transparency and consumer engagement opportunities. Fragmented digital systems, ineffective collaborations and variable provider motivation can undermine effective RMMR delivery. Strengthening the program through policy reforms and targeted interventions, including consumer education, improved interdisciplinary collaborations and integrated digital systems, can enhance the reach and impact of RMMRs in aged care.

Funding

This work was supported by the Medical Research Future Fund Preventive and Public Health Initiative 2022 Quality, Safety and Effectiveness of Medicine Use and Medicine Intervention by Pharmacists Grant Opportunity (MRFMMIP000048).

Ethics Statement

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Human Research Ethics Committee at Macquarie University (HREC: 15478). Informed consent was obtained from all participants included in the study.

Conflicts of Interest

M.R. has received grant funding from the Australian Commission on Safety and Quality in Health Care. J.I.W. receives fees for teaching for Harvard University, as a Co‐Director of the Safety, Quality, Informatics and Leadership Program. R.S. is an associate editor of the Australasian Journal on Ageing.

Supporting information

File S1: COREQ checklist.

Data Availability Statement

Research data are not shared due to the sensitive nature of the qualitative interview material and the conditions of ethics approval.