Download Long-Term Care-Developing a Medication Management Program

Long-Term Care-Developing a
Medication Management Program for
Assisted Living (ALFs) and Long Term
Care Facilities(LTCFs)
James W. Cooper, Jr, RPh, PhD, BCPS, CGP,
FASCP, FASHP, Emeritus Albert W. Jowdy
Professor and Consultant Pharmacist, College of
Pharmacy and Gerontology Faculty, University of
Georgia and formerly Clinical Assistant Professor of
Family Medicine, Medical College of Georgia
Goal: Overview components of
medication management systems
Objectives:
• Discuss the importance of pharmacists
getting involved in providing
consultative cognitive services to
LTCFs/ALFs
• Describe the types of services a
consultant pharmacist could and should
be providing to LTCFs/ALFs
Objectives- cont’d
• List advantages and disadvantages of various
medication packaging systems and services
• Discuss the differences between Medication
Management and Pharmacy Wellness
Programs
• Review ASCP’s (American Society of
Consultant Pharmacist’s) ALF Model State
Language
Objectives- cont’d
• Discuss how to better utilize the ASCPapproved Guidelines for Providing
Consultant and Dispensing Services to
ALF residents
• Illustrate how to handle problems/
obstacles/issues that are frequently
encountered in, and systems and forms
needed for developing Medication
Management Programs for ALFs
Overview of LTCF and Assisted Living
Industry
• Statistics : It is estimated that there are
between 40,000 and 65,000 assisted living
facilities (ALFs) in the USA, with between 3-4
million beds or twice the no. of LTCF nursing
facility (NF) beds.The ALF industry is largely
un-regulated
• At least one in 5 ambulatory older adults gets
an inappropriate drug (JAMA 2002) and
ADRs occur in 2/3 of LTC residents over a 4 yr. Study ( Cooper JAGS, 1996); one in 7
results in hospitalization (Cooper SMJ, 1999)
in ambulatory population
Assisted Living Types
• Please raise your hand if you have
serviced an assisted living facility,
nursing home or independent living
facility!
• Assisted living has many types and
names: Congregate housing
independent living, assisted living,
personal care homes, etc.
• Basic purpose of ALFs- delay or prevent
nursing home placement!
Recognizing the Overall Challenges
• Lack of uniformity
• Lack of communication
– Among ALFs
– Within an ALF
– Between health care
providers, and with
residents
•
•
•
•
Pharmacy providers
Type of resident
Services provided
Pay type
• Lack of understanding
– By physicians
– By administration,
residents, families
• Lack of consistent
regulations
• Lack of similarity
between ALF/NFs
• Lack of ‘taking
ownership’ of potential
drug-related problems
(Fosamax example)
Recognizing the Medication Use
Challenges
• Medications may be:
–
–
–
–
Administered by staff (licensed, unlicensed)
Self-administered by resident; assisted by staff
“Set up” by family or friend or staff
Stored by the facility or in resident’s room or both
• Medication administration records and order
changes may not be available
• Cognitive decline may occur over time
• Typically, no traditional medication pass
occurs
• Medical model versus social model
Medication Packaging Systems
• Long-Term Care Facilities (SNFs, ICFs, ICFMR)– “Bingo” cards
– Vials, stock, etc.
• Assisted Living Facilities (ALFs)
–
–
–
–
–
–
Unit dose
Variation of bingo cards
Vials
Automated systems
Med reminders
Multiple packaging
Vials
Advantages and Disadvantages of
Various Medication Packaging Systems
• Traditional vial systems
– Advantages: cost, convenience
– Disadvantages: safety, labor intensive for
staff, lack of accountability, difficult to
monitor compliance, increased cost if many
med changes occur, must designate
someone to order refills, more
responsibility for untrained staff
Advantages and Disadvantages of
Various Medication Packaging Systems
• Unit-dose system
– Advantages: reduces medication errors;
reduces cost if returns are allowed,
convenient for staff, no reorder necessary
if routine deliveries (ie. Cart exchange)
– Disadvantages: initially higher cost to
patient, costly to pharmacy (carts, labor,
inventory, third party payor, packaging
equipment)
Unit Dose Medication Cart
Unit Dose Medication Cart
Alternative Unit Dose
Advantages and Disadvantages of
Various Medication Packaging Systems
• Multiple medication packaging systems (loose
meds in one package for one administration time)
– Advantages: reduces medication errors,
particularly if using unlicensed staff;
convenient for staff and residents who selfadminister
– Disadvantages: potential for increased
errors if filling is not accurate; labor
intensive for pharmacy; cost
Automated Packaging
Advantages and Disadvantages of
Various Medication Packaging Systems
• Automated systems-(ideally record
MAR, inform prescriber, nurse or
caregiver and pharmacist of patient
compliance and drug counts)
• Advantages- cut med errors, provide
documentation of drug administration
and may record vital signs, other data
• Disadvantages- Cost, cost, cost
Advantages and Disadvantages of
Various Medication Packaging Systems
• Multiple medication packaging systems
(labeled meds in one package for one administration
time)
– Advantages: reduces medication errors,
particularly if using unlicensed staff;
convenient for staff and residents who selfadminister; cost
– Disadvantages: potential for increased
errors if filling is not accurate; labor
intensive for pharmacy; cost of system
Blister Pack Front
Blister Pack Back
Advantages and Disadvantages of
Various Medication Packaging Systems
• Patient reminder systems (plastic containers
to pager systems)
– Advantages: maintain resident’s
independence; potential for med errors
– Disadvantages: dependent upon person
filling container for accuracy; resident must
be able to self-administer and able to
understand and respond to pager
Considerations for Choosing a
System
• Safety
• Convenience
• Frequency of med
changes
• Frequency of delivery
• Storage space
• Size of facility
• Staff knowledge level
• Ease of use
• Timeliness of
packaging, delivery
• Cost
– To facility
• Labor
• Training
• Liability
– To resident
• Pay source
– To pharmacy
•
•
•
•
Equipment set up
Maintenance
Computer upgrade
Number of residents
using system
• Labor
The “Real” Problem
Every resident may be using a
different system, or combination
thereof….
Epidemiology of Medication
Misadventures
• Up to one-third of hospital and one-half of
nursing home admissions of older adults are
associated with medication problems (Cooper
AJHP 1977, Cons Pharm 1987)
• Half to two-thirds of these problems are due
to drug misuse; one-third to one-half are due
to adverse drug reactions or interactions (op
cit.)
Key Factors in Medication Problems
• Drug misuse problems involve lack of patient
understanding of their drugs, e.g. name , how
to take and purpose of each, as well as
improper use due to pre-existing conditions,
e.g. aspirin-like drugs with a history of
stomach or intestinal irritation or ulcers.
• Adverse drug reactions are associated with
patients using too many drugs, seeing
multiple prescribers and pharmacists and not
taking personal responsibility for meds
ADR Concepts
• Up to 70-80% of adverse drug reactions
(ADRs) are preventable by attention to
patient history, cooperation between patients,
prescribers and pharmacists
• Fewer than one-tenth of ADRs are ever
reported per FDA Med Watch Estimate
• Some studies indicate that prescribers
recognize or attribute ADRs less than onefourth of the time when they occur
Drug Misuse Problems
• The main type of drug misuse problem is
medication errors!
• There are three main categories of errors:
prescribing, dispensing and administration
errors
• The most common errors are in drug
administration, whether by the patient
themselves, their caregivers or licensed
personnel
Factors in Administration
Errors
Medication errors in administration can be
classified as known or unknown. While 100
percent reporting of known errors may occur,
this is only the tip of the iceberg. While up to
one-fourth of doses may be given in error with
traditional floor stock/individual prescription
systems, this error rate may be reduced to 3 to
20 per cent of doses with unit dose systems
that include pharmacist monitoring, and
increased nurse or caregiver supervision of
administration.
Factors in Administration Errors
• The application of Murphy’s Law:
• Anything that can go wrong, will go
wrong is the key factor
• The best system minimized the chances
for errors at the lowest cost!
• The Federal standard for serious
medication error rate is zero tolerance!
Problem Areas in LTC & ALF Drug
Use
• Multiple drug providers.
• Incomplete, missing pharmacy
dispensing records or failure to supply
pharmacy dispensing records to the
consultant.
• Incomplete or incorrect medication
administration records (MAR) and chart
orders.
Problems with Med Use in LTC/ALFs
• Turnover of nursing or caregiver personnel.
• Failure of all personnel to read, comprehend,
and adhere to any policy and procedures or
lack of P&P
• Poor compliance with prior consultant
recommendations.
• Failure to recognize that a problem exists.
Solutions to Drug System Problems
• A single provider who furnishes an efficient
and cost-effective (automated?) distribution
system that minimizes facility personnel time,
provide adequate records, charges that are
accurate, and MAR's that reflect actual
usage, and feedback to caregivers and
health care personnel when suspected med
errors and adverse reactions occur!
Practical Unit-of-Use Systems
• In long-term care or ALFs a 3 to 30 day
supply of unit-dose packaging or delivery
system (solid dosage forms only) may be
most feasible in current practice.
• In order to ensure the most economical use
of all resources and minimize medication
errors, an automated system should be
considered for LTC & ALF drug distribution.
Automated Distribution Systems
• The ideal solution may involve an
automated distribution system that
provides all mentioned features and:
– Reminder to take medication AND
documentation when doses are missed
– Electronic interface with the pharmacist
and caregivers or nurses for purposes of
refills, documentation of drug use and
medication inventory
Existing or Proposed Automated
Distribution Systems (websites)
• TabSafe- is the first system to provide both
reminders, documentation and electronic
interface with caregivers, nursing, pharmacist
and physician (TabSafe.com)
• IMD2- Is a dosage cup dispenser filled by a
caregiver with med reminder and
announcement but no electronic interface
(IMD2.com)
IMD2
Existing or Proposed Automated
Distribution Systems (websites)
• Medisafe is a small storage container
for meds designed for installation within
a medicine cabinet. It has code and key
entry and tamper light, but is not yet
funded for the market (Medisafe.com)
Medisafe
Existing or Proposed Automated
Distribution Systems (websites)
• Informedix is a portable telemedicine device
that stores a one-month supply of up to 5
different medications. It reminds the user
when to take meds, but can not deliver. It
records information on health status, side
effects and symptoms the patient may be
experiencing. Patient must key in the data
that is collected and electronically transmitted
to the prescriber (InforMedix.com)
Informedix
Existing or Proposed Automated
Distribution Systems (websites)
• Sure-Med cabinets (Omnicell.com) are
locked, secure cabinets that store drugs and
group dispense, provide record keeping, but
require a nurse to administer the drug. A
common system in nursing homes with a cart
delivery system. Opus.com and Pyxis.com
have similar systems. This is a throw back to
the older Brewer system of dispensing
cabinets.
Omnicell
Existing or Proposed Automated
Distribution Systems (websites)
• (CompuMed.com) is a locked storage tray
filled by a caregiver, with manual keypad
setup by the caregiver and a simple button
release for dispensing meds. No
documentation nor electronic transfer.
• A review of med errors, distribution systems,
error factors and solutions is presented-next
lets consider patient contact activities!
CompuMed
Personal Pill Reminders
• The following sites provide personal
medication organizers, reminders and
other aides to safe med use:
• zelco.com
• medose.com
• epill.com
• medportinc.com
Drug Regimen Review (DRR)-Now
Medication Regimen Review in
LTCs & ALFs
• DRR/MRR has been mandated in LTCs
since 1974- two types: retrospective
(after Rx filled) and prospective
(Fleetwood Model) as Rx is filled
• DRR/MRR is not currently mandated in
ALFs, but preliminary evidence is that
there are just as many med errors and
ADRs in ALFs as in LTCs
MRR Purpose and Methods
• MRR is intended to verify drug
administration as ordered, detect med
errors and ADRs, and appropriate as
well as inappropriate drug therapy that
can lead to ADRs
• MRR methods vary: Simplest approach
is to have as complete a list as possible
of all patient problems to include
diagnoses, conditions, past ADRs, and
operations
MRR Methods
• Match all current drugs to the problem
list, realizing that there will be
duplications and omission, as well as
drugs for which there may not be a
problem
• For each problem are there patient
signs and symptoms that can be
assessed (S=subjective findings)
MRR Methods
• Next, are there drugs, physical or lab findings
that assess drug effect? (O=objective
findings)
• A=Assessment of S and O findings to
determine if the problem is adequately
treated and if there is any further information
needed to complete the-->
• P=Plan for follow-up and recommendations
Case
• JT is a 84 yo female ALF resident with
problems of GERD, PUD, and HBP the SOAP of GERD/PUD/HBP is:
• S=pt. C/o occasional nausea and nighttime awakenings with heartburn
• O=pt. Taking , ranitidine 150mg HS,
celecoxib 200mg QAM, HCTZ 25mg
and ASA 81mg/day.Diet ad lib.
SOAP of GERD/PUD/HBP
• O=Her stools are dark, lower eyelids pale ,
Hgb has dropped from 12->9 over past 3
months and her BPs have increased from
118/68->162/100 and has gained 11 lbs and
has 1-2+ pedal edema since celecoxib
started
• A= Celecoxib + ASA has caused gastric
blood loss and pt. Has high risk of acute GI
bleed. Ranitidine does not prevent and both
BP and edema wt. gain increases attributable
to Celebrex
Plan for GERD/PUD Problem
• Plan is to recommend stopping celecoxib and
ranitidine, start APAP 650mg QID and
rabeprazole 20mg daily. Weight and BP daily
for two weeks; raise legs 2 ft. above heart for
1/2 hr daily. Restrict sodium to 2g diet. If BP
not <130/85 & edema and 5-7 lb.wt. Loss
does not occur within 2 weeks, change HCTZ
to furosemide 10mg/day . Add FeSO4 325mg
with 500mg Ascorbic acid daily for 30 days
and re-ck. Hgb; if not >11, continue Fe for 30
more days.
Drug- Specific Questions for Patients to Ask
Health Care Providers for High-Risk Meds:
• If you are taking NSAIDs such as
ibuprofen, naproxen, Feldene, Daypro,
Lodine, Relafen etc. on a regular basis,
you may want to ask if Prilosec,
Prevacid, Protonix, Aciphex or Nexium
will lower your risk of GI problems.All
the prior NSAIDs and Celebrex or Mobic
may ALSO cause high blood pressure,
heart failure or kidney problems!
Celebrex,Mobic or any NSAID
Cautions
• Be sure to weigh daily when first taking either
drug
• Report a 5 pound or more weight gain and
watch for fluid retention in your legs and/or
feet to your Dr. and pharmacist
• Check your blood pressure- if >130/85 or you
are taking drugs for high blood pressure or
heart failure, please check with your
pharmacist and doctor
Drug- Specific Concerns for Patients Taking HighRisk Medications:
• DO NOT take low-dose aspirin without
your prescriber’s approval and you
should have a GI-protecting drug (PPI
A). If you are taking Celebrex or Mobic
you may have less risk of GI problems
but still need aspirin protection for ,
heart, and brain problems as these
drugs do NOT thin the blood!
NSAID Alternatives
• If you are taking NSAIDs you may ask if
acetaminophen (APAP,Tylenol) may be safer
for you, IF YOU DO NOT DRINK ALCOHOL
as well as glucoseamine and chondroitin
and/or topical ketoprofen gel for your
osteoarthritis.
• If you are taking Fosamax, Boniva or Actonelyou especially need stomach protection with
ASA or NSAIDs and you need to ask about
weekly use!
NSAID Alternatives (cont’d)
• If you have a history or risk of heart
attack-(MI)--or stroke (CVA) your
primary care provider may recommend
low-dose aspirin or prescribe drugs like
Plavix to protect your heart and brain.
• Tylenol is safer for your arthritis than
any NSAID, provided that you do not
consume alcohol.
Fall Risk - Medication Risk Reduction
Questions
If you/your care receiver are taking
drugs such as Mellaril, Haldol,
Risperdal, Seroquel , Geodon or
Zyprexa, has your dose been reduced
in the last 6 to 12 months or a tapering
trial without the drug been attempted?
Has a fall or fracture occurred?
Fall Related Questions Cont’d
If you are taking drugs for anxiety or
sleep such as Valium, Tranxene,
Librium, Doral, Paxipam, Xanax,
Centrax more often than every week,
ask your doctor for a shorter-acting
version such as oxazepam or zolpidem
(Ambien) for sleep or buspirone
(Buspar) or Lexapro or Zoloft for
anxiety.
Fall Related Questions Cont’d
Are you taking antidepressants such as
amitryptyline (Elavil) or doxepin for
mood, sleep or pain ?
If so, have you fallen or had a fracture?
Are there safer , newer drugs in this
group ? (Zoloft, Paxil, Celexa, Lexapro
in AM, or trazodone at bedtime only)
Cognition enhancing Drugs-Namenda,
Aricept, Exelon and Razadyne
• If you are taking any of these medications,
please be sure that you let your pharmacist or
doctor know if you have any trouble sleeping,
heartburn or GI upset to diarrhea, glaucoma,
or leaking of urine
• Some medications may not work well with
these drugs-keep a list of all prescribed and
OTC drugs
Decongestants should be avoided!
• If you are taking anything with Sudafed
and have high blood pressure, diabetes,
heart attack or stroke or impaired kidney--DO NOT TAKE THESE DRUGs!
• Some products that contain one of these
decongestants include Acitfed, Allegra-D,
Claritin-D, Afrinol-LA, and any cold or
allergy drug that ends with a D-.Even
topical decongestants (Afrin) may be
dangerous!
Diabetes Drug Questions
If you are diabetic and using insulin or oral drugs,
ask your Dr. about insulin “enhancers” such as
Glucophage, Actos, Avandia or Precose or
Glyset to lower your insulin needs. If you are
diabetic and have a history or heart attack or
stroke, you may need to take a beta blocking
drug to protect your heart and/or brain. If you get
low blood sugar you may not feel shaky or
nervous-watch your fingerstick readings if you
are taking one of these drugs and are under tight
control (Cooper Diabetes Care 1998). You also
need to get your lipids and thyroid checked!
Heart, High Blood Pressure and
Circulation Questions
• If you are taking any medication for your heart,
HBP or circulation, be sure you take your BP and
pulse on a regular basis and report to your
primary care provider (PCP) any consistent
abnormal readings.-please DO NOT TAKE any
drugs for arthritis e.g. ibuprofen, Celebrex or
Mobic without checking with your pharmacist or
doctor-If you are taking any blood thinners such
as Coumadin or aspirin, Plavix or Ticlid you will
need to have your blood checked on a regular
basis- DO NOT consume alcohol or painmedications without your PCP’s approval.
Heart failure drugs
• If your have congestive heart failure,
you may be taking drugs such as
Lanoxin, Lasix, Capoten, Diovan, Coreg
and Aldactone.Please be sure to weigh
daily and watch for any fluid weight gain
of 5 pounds or more- this is of vital
importance if you start on an arthritis
drug such as Celebrex, Bextra or Vioxx
or diabetes drug like Actos or Avandia
Cholesterol Check
• If you have not had your cholesterol checked,
ask to have this test from your doctor or
pharmacist• If you have chest or leg pain on walking, or
blackout spells or have had a heart attack or
stroke----->It is very important that you have
your cholesterol not only checked, but
lowered with a drug such as Vytorin, Lipitor,
Pravacol, Zocor, Mevacor or Lescol if you
have any of these problems-you may also
need to be taking aspirin if your doctor
recommends this drug.
Depression Check
• Do you feel “down” for more than a day or
two at a time?
• Do you sleep too little or too much?
• Do you not enjoy things that used to give you
joy? Has your appetite or weight changed
much in the last 6 months to a year?
• Have you had any illnesses or loss of love
ones that keeps you sad for more than two
weeks?
• Do you have someone you can talk to about
these losses?
Cancer Check
• Do you have any of the 7 warning signs?- change
in bowel or bladder habits?
• A sore that does not heal?
• Unusual bleeding or discharge?
• Thickening or lump in breast, testicle or elsewhere?
Indigestion of difficulty swallowing?
• Obvious change in a wart or mole?
• Nagging cough or hoarseness?
• Do you see a doctor at least yearly?-have a female
or male exam?
• Men- PSA yearly?- Both Sexes Sigmoidoscopy
every 3 to 5 yrs. After 50
Cancer Check Cont’d
• Women- do you do a monthly breast
exam, annual mammogram and pelvic
with Pap test annually? This is critical
when taking any estrogen or progestin
product
• Both sexes-if fair-skinned, do you have
a dermatologist inspect sun-affected
areas every year?
Eyes, Ears and Throat Drugs
• Have your eyes checked at least yearly?
• If you have glaucoma, be sure to check how
your drops are put in each eye and squint or
squeeze the bridge of the nose for 30
seconds after each dose
• If you have dry eyes-or eye infections ask
your pharmacist for a tear substitute eye drop
(Liquifilm tears)
Eyes, Ears and Throat Drugs
Cont’d
• Have your ears checked by someone
close to you– If there is any excessive wax, ask for an
ear cleansing solution ( Debrox)
• If you have stuffy nose- do not use oral
decongestants or nose sprays like Afrin
if you have high blood pressure, angina,
TIAs or Hx of heart attack or stroke
Throat and Breathing medications
• If you have a sore throat, check for fever and
tenderness underneath your jaw- see your
doctor if both are present
• If you have an ear ache-be sure to check
your throat
• If you have asthma, bronchitis or
emphysema, be sure you know which drugs
you need to take to help your breathing
• Also be sure you know which drugs you can
use for sudden shortness of breath
Osteoporosis
• Be sure that you are taking at least 1500 mg
of calcium per day and 400 units of vitamin D
• Ask your doctor, nurse or pharmacist about
drugs to preserve bone strength
• If you are taking hormones (Premarin,
Estrace) for osteoporosis, be sure that you
have a mammogram and female exam at
least yearly or more often- you should stop by
age 60.
• You can not take hormones past 60-ask
about Fosamax, Boniva, Actonel, Micalcin or
Evista
Other Hormones
• If you are taking thyroid, ask to have your
tests checked yearly- if you did not have
blood work before your thyroid was
prescribed, ask for blood work after thyroid
has been stopped for 4 to 6 weeks
• If you are taking cortisone-like medications
such as prednisone, ask about bone and
stomach protection
• Do not take alternative or herbal medications
without medical advice
Wellness Medication Checklist
• If you are not taking a multiple vitamin and
mineral supplement, consider or ask for a
recommendation to decrease sick days due
to infections. Have you had flu, Pneumonia,
Tetanus/diphtheria shots?
• What is your support system- church,
synagogue, temple ,mosque, friends, and
loved ones?
• Is your diet adequate?
Wellness Checklist Cont’d
• Are you able to exercise daily?
• Do you have someone to talk with about
things that bother you?
• Do you have a doctor and pharmacist
who know all your medications?
Conclusions
• In the year elderly become progressively to
severely disabled a large proportion are
hospitalized for a small number of diagnoses,
most of which relate to drug use. (Ferruci L, et al JAMA
1997;277:728-34)
• Adverse Drug Rxns (ADRs) are only 1/3 of
drug-related admissions; other 2/3 are related
to nonadherence to prescribed treatment
(Cooper JW, et al. AJHP 1977; 34:738-42)
• How can medication management programs
improve drug use among older adults in ALF
and LTC facilities?
How can safe medication management programs
decrease medication problems?
• Encourage patients to keep a personal record
of all drugs prescribed or self-treated, and
avoid alternative treatments or supplements
unless they are approved by a primary care
provider physician or pharmacist. (personal
drug checklist)
• Show this medication record to every health
care provider utilized- e.g. doctors, dentists,
podiatrists, nurses, pharmacists etc.
• Expect each health care provider to review all
current drugs and problems before adding
another drug.
Pharmacists and Medication
Management Systems
• Pharmacists should
both develop the
safest med
management
system and have a
consultative practice
that encourages
both wellness and
safe medication use!
• The best
combination of
distributive and
clinical consultation
activities is
determined by the
individual
pharmacist and their
patients needs!
Evaluating the Customer’s Needs
• Who is your customer?
– Executive Director
– Nursing staff
– Resident
– Family
• Services can be provided
– to the facility
– to an individual
Evaluating the Customer’s Needs
• Executive Director
– What is the primary reason for residents
leaving your facility?
– What is the approximate cost of filling an
empty bed?
– What are your top 3 concerns in providing
quality and safety for your residents?
– Do you have very many family complaints?
Evaluating the Customer’s Needs
• Be flexible!
• Be prepared to offer suggestions
– Correlate medication management to fall
avoidance
– Explore reasons for hospitalizations that
could be related to inappropriate med use
– If the facility has a dementia unit, are
wandering residents a concern
Evaluating the Customer’s Needs
• Nursing/caregiver staff
– Does the current medication management
system assure safety and accuracy of
medication administration?
– Are there concerns about medication
errors?
– Is drug information readily available?
– Is proper documentation being done?
Evaluating the Customer’s Needs
• Resident/Family
– What can I do to help you with your
medication concerns?
– Are you wondering if your medications can
be reduced, changed, or eliminated?
– Are you concerned about drug
interactions?
– Are you worried about your medication
costs?
Evaluating the Customer’s Needs
• Resident/Family
– Are you certain you are using your
medication correctly to receive maximum
benefit? (e.g. proper inhaler technique)
– Would you like to make an appointment for
me to meet with you and discuss your
specific medications and concerns?
Meeting the Needs of the LTCF/ALF
Customer
• After carefully listening to your
customer, prepare a written proposal
– be specific about services that you can
provide related to each area of concern
– as additional information, provide your own
suggestions
– include specific costs for services
Meeting the Needs of the LTCF/ALF
Customer
• Incorporate outcomes measurement
into proposal
– Demonstration study in ALF over 6 months
•
•
•
•
23 dosage changes
10 discontinuations of unnecessary meds
13 discontinuations of duplicate meds
resulted in cost savings (for all residents) of
$743/month
Crutchfield D. Obstacles to medication monitoring in assisted living
facilities. Consult Pharm 1996;11:506-7.
Clinical Programs
•
•
•
•
•
•
Asthma/COPD
Diabetes
Hypertension clinic
Lipid screening
Anticoagulant monitoring
Health Fair with other health care
professionals
• Home infusion
BE CREATIVE!
“Out of the Box”
• Become involved in infection control
plans
– promote the importance of immunizations
– provide immunizations (reimbursable!)
– provide education
“Out of the Box”
• Provide
– MMSE (mini-mental state exams), Global
deterioration scales
– AIMS (abnormal involuntary movement
scale)
– Depression assessments-Yesavaage &
Cornell
– Psychoactive medication use assessment
“Out of the Box”
• Falls assessments
– Medication related
– Environmental causes
– Osteoporosis screenings and
interventions- 70% of Fx in LTC are related
to a fall
“Out of the Box”
• Visit residents
– assess the need for assistive devices (e.g.
arthritis, PD)
– ask for demonstration of inhalers, glucose
monitoring devices, application of patches,
etc.
“Out of the Box”
• Pain Management
– Outcomes based
– Improve quality of life
– Important to resident and family
– Review meds for effectiveness, duplication
– Become specialist in pain management
“Out of the Box”
• Expand customer base (caregivers)
– Senior Directory
– Senior Centers
– Church Senior Groups
– AARP
– Disease Support Groups
• Use the internet
– web page
– contact caregivers who live out of state
“Out of the Box”
• Contract with HMO to be a case
manager for medications
– contact physicians to coordinate
medications
– develop care plan, involve resident and
family; copy to physician and HMO
• How will the outpatient drug benefit
impact these residents????
Sharpen Your Clinical Skills
• Become certified (CGP- go to ccgp.org
for info)
• Participate in traineeships
• Receive specialty certification
– lipid management
– diabetes management
– anticoagulation monitoring
– immunization administration (ASCP 100%
immunization campaign)
ASCP Assisted Living Resources
• Guidelines for Providing Consulting and
Dispensing Services to ALF
• Model State Language for ALF
Regulations
• ALF: A Resource Manual for
Pharmacists
• ASCP Statement on Admin of Meds in
LTC by Unlicensed Personnel
• www.ascp.com/public/pr/assisted/
Websites and References
• www.n4a.org/- National Association of Areas on Aging.
• www.agent.com/-AgeNet information and referral
designed to bridge aging parents and their children
• www.ascp.com- Excellent source of senior care pharmacy
information, CE and CGP preparation.
• www. Cooperconsultantpress.com- two books/courses on
LTC and Geriatric Medication Management .Get Coops
Free 164 slide download on pharmacist side and 50 Safe
Med slides on patient side and 84 slides on inappropriate
meds for the older adult. and freebees under educational
materials.
• See http://www.cop.ufl.edu/cpe/ for Coops 15 hour CPE
on Lab and Physical Assessment of the Older Adult to
Monitor Drug Therapy.
Websites and References
• www.alfa.org- Assisted Living
Federation of America
• www.aahsa.org/- American Assoc. of
Homes and Services for the Aging
• www.ahca.org/- American Health Care
Association
• www.eldercare.com/assisted.html-Elder
web is an on-line sourcebook with over
4,000 reviewed links to information.
Summary and Conclusions
• A review of LTC med systems and drugrelated problems, as well as wellness
screenings and pharmacists
interventions has been presented.
• The safest, least expensive system that
ensures reliable drug use and
assessment is critical to effective senior
care!