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Guest Editorial
The Medication Regimen Review
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Building Rapport with the Consultant Pharmacist
O
ver time, long-term care
(LTC) regulations have intensified to the point of surpassing the
regulations of nuclear power plants
(American Society of Consultant
Pharmacists, 2006). The medication
regimen review (MRR) is important
to provide safe and effective LTC
patient care. The MRR has undergone significant changes since the
first set of guidelines was developed
in 1967 and the founding father,
George F. Archambault, coined
the term consultant pharmacist
(American Society of Consultant
Pharmacists, 2007). The purpose of
this editorial is to review the goals
of the MRR and identify means to
strengthen the mandated process.
The main focus of the LTC
consultant pharmacist is to review
medication regimens for facility
residents. MRR is required every 30 days or more frequently,
as defined by federal regulations
(Centers for Medicare & Medicaid
Journal of Gerontological Nursing • Vol. 39, No. 10, 2013
Services [CMS], 2011). The MRR is
a retrospective review that provides
information and recommendations
to nurses, primary care providers,
and facility administration. Attention is concentrated on the identification of unnecessary medications,
potentially duplicate therapy, or
inappropriate medications (e.g.,
Beer’s Criteria [American Geriatrics
Society, 2012]), as well as necessary
monitoring parameters (e.g., laboratory tests, blood pressure, blood
sugar). Follow up for resultant actions from recommendations is also
required.
The MRR is complex and
requires communication with the
facility staff and ideally also with
the patient or family member(s) to
determine the appropriate medication regimen. One of the many
regulations, referred to as Tag F329,
requires interdisciplinary team
involvement and pertains to unnecessary drugs being taken by the
patient (CMS, 2006). An example of
F329 is as follows:
An LTC patient is admitted to the
hospital with an infection (e.g., pneumonia, septic urinary tract infection),
develops delirium, and is then placed
on an antipsychotic medication. The
infection is treated and resolves. The
patient returns to the facility on the
antipsychotic medication with an unknown or inappropriate indication.
Each LTC resident’s medication
must have a reason for use or diagnosis. The consultant pharmacist reviewing the medications and charts
for residents is especially vigilant for
an accurate diagnosis. If the diagnosis is not in the chart, collaboration with the nurse is necessary to
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determine whether the resident is
exhibiting signs and symptoms that
would support the medication. If
there is no supporting information
to continue the antipsychotic agent,
the consultant pharmacist should
communicate with the nurse and the
prescriber or primary care provider
to request a decrease or discontinuation of the medication. An interdisciplinary approach is usually
much more successful and helps
ensure that the team is aware of why
a change was requested. If communication is lacking, the recommendation may be unintentionally
confusing. In general, ambiguous
medication recommendations may
not be followed in a manner the
Several ways to improve
communication may be as
easy as being respectful,
building rapport and
professional relationships,
and treating others as you
would like to be treated.
consultant pharmacist intended or
may not be adhered to at all.
The consultant pharmacist can
assist in the regulatory process by
identifying variances and reporting
them to the director of nursing and
the administrator. If needed, the
identified issue should be placed on
the agenda for review by the LTC
facility’s quality assurance committee. By proactively raising awareness
and attending to the potential problem through quality assurance committees, facilities are better able to
answer the questions and concerns
of regulators and meet the intent of
the regulations—quality care. Other
areas in which the consultant pharmacist may participate in regard to
the MRR and quality are medication
cart audits (e.g., expired medica-
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tions, appropriate labeling and storage) and medication pass observations for safety and efficiency.
Effective communication regarding the MRR can increase
the quality of life of older adults
at an LTC facility; however, time
and workloads are challenges. For
nurses, the demands of patient care,
documentation, coordination of
care, delegation of care, administration of medication, provision of
treatment, and meeting attendance
may make the prospect of adding an
additional task to perform—including a recommendation made by a
consultant pharmacist—overwhelming, especially if there is no explanation or discussion with staff. For
the LTC consultant pharmacist, the
demands are intense as well, with
the need to review a large number
of charts per day; juggle regulations;
and complete emergent, mandated
medication reviews and generation
of reports for the director of nursing and administration. Although
computer programs and often stable
medication regimens may assist the
consultant pharmacist in completing the work, the volume can be
tremendous.
Several ways to improve communication may be as easy as being
respectful, building rapport and
professional relationships, and treating others as you would like to be
treated. For example, “When you
have a minute, would you please
review this? The number where I can
be reached is attached; please call me
if you have any questions.” Building
rapport and professional relationships with the staff does not take
much time and builds trust among
colleagues. Calling them by name,
asking how their day is going prior
to asking them to fax a request to
the physician, asking them if they
have any questions before you leave
for the day, or dropping off a bag
of candy or goodies occasionally is
a way to connect and are examples
of practical ways to work together.
Finally, it is important for the consul-
tant pharmacist and the nursing staff
to communicate the results of the
MRR. Outcomes that have a positive
effect on quality of life, function, and
care delivery processes help reinforce
the power of teamwork. There are
many demands on us as health care
providers. Working as a team will
help us achieve the end goal: striving to provide the best quality of life
possible for our patients while their
care is in our hands.
REFERENCES
American Geriatrics Society. (2012). American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of the
American Geriatric Society, 60, 616-631.
doi:10.1111/j.1532-5415.2012.03923.x
American Society of Consultant Pharmacists.
(2006). Unnecessary medications in the
elderly: A guide to improving therapeutic
outcomes. Miamisburg, OH: Med-Pass.
American Society of Consultant Pharmacists.
(2007). Consultant pharmacist handbook:
A guide for consulting to nursing facilities
(2nd ed.). Miamisburg, OH: Med-Pass.
Centers for Medicare & Medicaid Services.
(2006). CMS manual system. Retrieved
from http://www.cms.gov/Regulationsand-Guidance/Guidance/Transmittals/
downloads/r22soma.pdf
Centers for Medicare & Medicaid Services.
(2011). State operations manual. Appendix
PP—Guidance to surveyors for long term
care facilities. Retrieved from http://www.
cms.gov/manuals/Downloads/som107ap_
pp_guidelines_ltcf.pdf
Kimberlee J. Otto, RPH, FASCP
Owner
Senior Pharmacy Consulting, LLC
Consultant Pharmacist
Enhanced Care and Coordination Project
Council Bluffs, Iowa
Brenda Bergman-Evans, PhD, APRN-NP,
APRN-CNS
Chief Nurse Executive Advanced Practice
Program Director
Enhanced Care and Coordination Project
Alegent and Creighton Health
Omaha, Nebraska
The authors disclose grant support from
the Centers for Medicare & Medicaid
Services’ (CMS) Enhanced Care and
Coordination Project. Dr. Bergman-Evans
also discloses project support from the
CMS’ Continuing Care Transitions Project.
doi:10.3928/00989134-20130909-01
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