Referral for Domiciliary Medication Management - Home Medicines Review
Medical Benefits Schedule Item 900. Also known as DMMR or HMR

<<Miscellaneous:Date (long)>>

Patient | Community Pharmacy | General Practitioner

<<Patient Demographics:Full Name>>
<<Patient Demographics:Address>>
<<Patient Demographics:City>> <<Patient Demographics:State>> <<Patient Demographics:Postcode>>
Phone: <<Patient Demographics:Phone (Home)>>
DOB: <<Patient Demographics:DOB>> (Age: <<Patient Demographics:Age>>)
Medicare No: <<Patient Demographics:Medicare Number>>
DVA No: <<Patient Demographics:DVA Number>>

<<Addressee:Full Details>>
E-mail: <<Addressee:E-mail>>

<<Doctor:Name>>
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
E-mail: <<Doctor:E-mail>>
Provider No: <<Doctor:Provider Number>>
Prescriber No: <<Doctor:Prescriber Number>>

Timing for the Pharmacist to action this referral: <<Timing for the Pharmacist to action this Referral>>

Medical History
<<Clinical Details:History List>>

Current Medications
<<Clinical Details:Medication List>>

Allergies
<<Clinical Details:Allergies>>

Immunisations
<<Clinical Details:Immunisation List>>

Relevant Progress Notes
<<Summary:Progress Notes (Selected)>>

Relevant Pathology Results
<<Summary:Investigation Results (Selected)>>

Measurements
<<Clinical Details:Measurements>>

Social History | Occupation
<<Clinical Details:Social History>> | <<Patient Demographics:Occupation>>

Smoking status | Alcohol consumption

<<Clinical Details:Smoking>>
Quitting stage: <<Clinical Details:Smoking Quitting Stage>>

<<Clinical Details:Alcohol>>

Reason for referral for DMMR | Issues that may influence medication use

<<Reason for referral 1>>

<<Reason for referral 2>>

<<Reason for referral 3>>

To select any item - highlight its checkbox and type x

p poor vision
p hearing problems
p swallowing difficulties
p dexterity
p language and/or literacy problems
p cognition
p other: please specify...

Medication Administration

Medication usually administered by <<Medication usually administered by>>

Dosing Aids

p dosing aid device e.g. Dosett, Webster. Specify brand or type...

p other: please specify...

If a dosing aid is used, it is filled by <<Dosing aid, if used, filled by>>

Disease Monitoring Devices

p peak flow meter
p BP monitor
p blood glucose meter
p INR monitor
p other: please specify...

Medication Administration Devices

p spacer device for respiratory inhalers
p nebuliser pump for respiratory solutions
p other: please specify...

The patient <<Speaks enough English to do the interview>> English to do the interview.

An interpreter <<An interpreter (is/is not) required>> required. The patient's preferred language is <<The patients preferred language is>>.

I HAVE EXPLAINED TO THE PATIENT
x   the process in having a DMMR; and

THE PATIENT HAS CONSENTED:
x   to me releasing to you information about <<Patient Demographics:his/her>> medical history and medications; and

THE PATIENT UNDERSTANDS THAT:
x   the location of the DMMR is at <<Patient Demographics:his/her>> choice, but preferably in <<Patient Demographics:his/her>> own home; and
x   the pharmacist who will conduct the DMMR will communicate with me information arising from the DMMR; and

THE PATIENT <<Consent to release Medicare/ DVA  Number details>>:
x   to me releasing <<Patient Demographics:his/her>> Medicare no. or DVA no. to you for the pharmacist's payment purposes.

Signed......................................................................................................   Date................................................

<<Doctor:Name>>
<<Doctor:Qualifications>>

HOME MEDICINES REVIEW 
Information Sheet for patients

A home Medicines Review (HMR) can  help identify ways to get the best results from your medications.
 
A HMR involves your General Practitioner and community pharmacy.

It involves a pharmacist speaking with you, in your own home about the medicines you take.

   WHAT’S INVOLVED IN A HMR

•	Talk to your General Practitioner (GP) about organising a HMR.
•	Have your GP fax the referral to your  pharmacy,  who will then arrange an appointment with you.
•	A pharmacist will come and visit you in your own home to discuss your medicines and any concerns you may have.

During the home visit, the pharmacist will answer any questions and discuss ways that will improve the use of your medicines. The pharmacist will also ask about  any side effects or problems that you may be experiencing . The pharmacist will not change  any of your medications without your GP’s orders.   
          
•	Make a follow up appointment with your GP to discuss your home interview and the pharmacists report.

COST

The pharmacist’s fee is paid by the government and if your GP bulk bills it won’t cost you a cent. If you do need to pay your GP, you can claim most of the money back through medicare, so you will be out of pocket by less than $20.

For further information visit www.rdgp.com.au

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