Maintaining healthy blood sugar levels among Skilled Nursing Facility residents is always a challenge. Long-term care pharmacy providers must consider a number of factors that can affect blood glucose management. Irregular nutritional intake, physiological changes, impaired renal function, or even variable physical activity can all cause significant swings in blood glucose levels. Trying to nail down the exact cause for the changes can be a daunting task. Some commonly overlooked factors that can contribute to blood glucose level variations include the resident’s skin condition, the technique used for injecting insulin, and how the injection site is treated. Read on for a look at some best practices for administering insulin injections recommended by long-term care pharmacy providers. [Tweet “Many seniors have #diabetes, making proper insulin injection a concern for #longtermcarepharmacy.”]
Long-term Care Pharmacy Injection BasicsWhen administering injectables of any kind to SNF residents, including insulin, always follow these basic precautions:
- Wash or disinfect hands before handling any injection materials.
- Clean and disinfect the injection site; be sure any alcohol is completely evaporated before giving injections.
- Insert needle at a 90 degree angle—or perpendicular to the surface of the skin.
- Do not give injections through clothing.
- Very thin residents may require injecting into a skin fold.
- Avoid giving injections into muscle tissue.
- Immediately dispose of all used materials.
Long-term Care Pharmacy Injection Best PracticesBe aware of the unique needs of each resident and his or her medication schedule. The following best practices recommended by post-acute care pharmacy providers will help you administer insulin injections with more sensitivity and less pain.
Rotate Injection SitesRotating injection sites will promote proper absorption and avoid the development of lipohypertrophy. Areas with lipohypertrophy can cause random and unpredictable blood sugar level changes.
Repeated injections into areas with lipohypertrophy or lipodystrophy can significantly slow the absorption of insulin. The resulting elevated blood glucose levels may then be attributed to another, erroneous cause instead of a flawed injection administration technique.
- Each injection should be given at least two inches from a previous injection, according to a planned and documented rotation schedule.
- Divide injection sites into quadrants or halves, and rotate one section a week in the same direction.
- Avoid aggravating lipohypertrophy by not injecting into areas that are firm, lumpy, or enlarged.
- For mealtime doses, choose the abdomen or upper arms for faster absorption.
- For a bedtime dose, choose the upper thigh or buttocks for slower absorption that lasts throughout the night.
Use the Correct NeedleStudies recorded in the Mayo Clinic Proceedings demonstrate that residents of any size benefit more from injections using a 4mm long needle. The 4-mm needle length for both injections and infusions works to get through the skin and access the subcutaneous fat where insulin needs to be delivered, even in obese persons.
Use the Correct Injection TechniqueInjecting insulin at the optimum depth is vital for proper absorption and maintaining healthy blood glucose levels. Long-term care pharmacy providers recommend injecting insulin in the subcutaneous fat, or the layer of fat beneath the skin. Injecting too deep can penetrate a muscle, which is painful. Also, the muscle tissue absorbs insulin faster so that the dosage doesn’t last for the necessary amount of time. If the injection isn’t deep enough, the insulin goes into the skin, which also affects the rate of absorption and effectiveness. A proper injection technique follows these protocols:
Our Grane Rx team works with your team to help ensure optimal care for residents. Learn more about our long-term care pharmacy services and how we can partner with you by calling (866) 824-MEDS (6337).]]>
- Pinch a few inches of skin between a thumb and two fingers, pulling it gently away from the muscle.
- Insert the needle into the skin fold at a 90-degree angle.
- Hold the pinched skin so the needle doesn’t go into the muscle.
- Press the plunger to inject the insulin.
- Release the grip on the skin fold.
- Remove the needle from the skin.
Skilled Nursing Facility pharmacy solutions. As science discovers more about how the human body functions and metabolizes medications, the potential to personally optimize medications for residents increases.
The topic of pharmacogenetics is increasing in popularity as we progress toward personalized medicine. We have learned a significant amount about how an individual’s genetic makeup impacts how medications are metabolized, which affects the efficacy and safety of a medication.
The missing link in most situations is understanding each resident’s genetic makeup so that can be related to the therapies he or she receives or may receive in the future.
That’s where post-acute care pharmacy must continue to grow and develop.
The Potential of Pharmacogenetics
Pharmacogenetics holds the potential of providing medical practitioners with specific genetic data that will allow us to tailor medications to individual residents. Providers could predict dangerous adverse reactions or identify therapies that would not be effective for individual residents if they could know a resident’s genetic makeup.
Routine pharmacogenetics is not normal practice at this time, but there are specific situations when it may benefit in current situations, including with anticoagulation and antiplatelet therapy.
Adverse drug events and medication nonadherence are a leading cause of hospitalization among residents. The majority of emergency hospitalizations caused by medication issues are linked to five specific types of medications: warfarin, insulin, oral antiplatelets, diabetic medications, and opioid pain medications.
In our efforts to reduce unnecessary hospitalizations, we must be willing to investigate newer, challenging avenues to find the root cause of medication-related issues.
Pharmacogenetics and Anticoagulant Therapy
Clopidogrel, otherwise known as the brand Plavix®, is a popular antiplatelet medication in long-term care pharmacy. Pharmacogenetics is a pertinent topic related to clopidogrel because clopidogrel is a prodrug, a type of medication that must be metabolized through the cytochrome P450 system before it becomes an active medication.
If a resident’s cytochrome P450 enzyme system is not functioning at its expected level, this will result in metabolism variations when processing clopidogrel, which ultimately means the medication may not be metabolized to the necessary active form.
Basically, we could be administering the medication to a resident exactly as ordered, but the body may not be reacting to it the way we expect. Pharmacogenetics would allow us to know if a resident’s cytochrome P450 system is functioning as expected prior to prescribing the medication.
Warfarin, popularly known as Coumadin®, is another key example.
Warfarin has a number of potential interactions with both foods and other medications. In addition, warfarin can also be very difficult to stabilize in some residents. The difficulty in stabilization could be caused by two different situations.
First, warfarin is metabolized significantly by the cytochrome P450 system, so variations in a resident’s cytochrome P450 system detected through pharmacogenetics could affect the plasma levels and processing of warfarin in the body.
Warfarin is also unique because of the VKORC1 enzyme, which controls the oxidation state of vitamin K. VKORC1 normally works to activate vitamin K as part of the normal process of blood clotting. Warfarin inhibits VKORC1, which reduces vitamin K oxidation and reduces clotting.
If a resident has lower levels of VKORC1, less warfarin will be needed to impact clotting. If this is not known and a resident receives a standard dose of warfarin, he or she may experience an increased risk of side effects, such as bruising and bleeding.
If pharmacogenetics were used, healthcare professionals would have cytochrome P450 and VKORC1 genetic information available to them when prescribing medications. This would allow for more appropriate doses of medication for the resident, tailored to his or her bodily processes, for more optimal results.
Pharmacogenetics and the Future
After using pharmacogenetics to gain a resident’s genetic information, it does not need to be repeated. The resulting data can be applied to the resident’s entire therapeutic regimen and taken into consideration before any future prescriptions to make his or her medication regimen specific and personalized.
Healthcare providers routinely encounter situations where things don’t work out as expected, or simply can’t be reconciled with medical training or experience. This is because of our unique human body, and factors we cannot detect.
Medical care of the future, armed with pharmacogenetics, will provide all that is needed to make optimal medication decisions for residents.
Pharmacy is always evolving, and Grane Rx works to stay ahead of the changes. We offer the Medication Insights™ program, powered by YouScript, to help identify potential interactions and offer alternative prescribing options. Visit our site to learn more or request a free analysis. ]]>
Rising medication costs are a significant concern nationwide and in skilled nursing. Today, prescription drug expenditures account for nearly 20 percent of healthcare costs, and prescription spending is growing faster than any other part of health care. Consider these facts:
This was the case at the Jewish Association on Aging, a network of senior care facilities in Pittsburgh, Pennsylvania. When they began working with Grane Rx several years ago, they felt like their pharmacy spend was out of control. Working with Grane Rx helped them regain control of their spending and cut costs significantly. [Tweet “The *right* #LTCpharmacyservices provider can help reduce pharmacy spend in #skillednursing.”]
- American spending on prescription drugs increased 13.1 percent in 2014—the largest annual increase since 2003.
- This uptick was largely driven by an unprecedented 30.9 percent increase in spending on specialty medications. In 2015, spending rose another 12.2 percent.
- Specialty drug pricing alone is far outpacing the Consumer Price Index, and specialty drugs increased to 44 percent of overall drug spending in 2017.
- Prescription spending in long-term care is approaching the $17 billion level with nearly 400 million prescriptions dispensed in 2016.
Making the Transition to Grane Rx LTC Pharmacy ServicesSeveral years ago, the decision was made at the Jewish Association on Aging to change providers to Grane Rx. As with any program, changing pharmacies is a huge undertaking. “Grane Rx staff were here throughout the transition, assisting with protocols, policies, procedures, and staff training,” says Mary Anne Foley, RN, MSN, Chief Operating Officer with the Jewish Association on Aging. “The transition and onboarding was very good. They had a team here that helped facilitate—they literally lived in the building.” While adapting to a new LTC pharmacy services provider can be difficult, often the problems come after the initial transition. That hasn’t been the case for the Jewish Association on Aging. “Over the years, Grane Rx has proven to be a true partner within our organization, providing ongoing support, education, and consultation to our staff, residents, and physicians,” Foley says. “Pharmacy staff have been incorporated into our Quality and Infection Control Committees and during this past year were instrumental in assisting with our organization-wide emergency management procedures.”
How Grane Rx LTC Pharmacy Services Made an ImpactThrough a combination of competitive Grane Rx pricing and cost-cutting measures, the Jewish Association on Aging, which provides both skilled nursing and assisted living, saw a 12 percent decrease in pharmacy spend. That’s substantial on its own, but the Grane Rx LTC pharmacy services team also impacted the Jewish Association on Aging facilities in other ways.
Cost ReductionGrane Rx did more than just offer lower prices on prescription medications. They also impacted positive change for the Jewish Association on Aging by helping them enact guidelines and procedures in-house. “We didn’t have a good process for the formulary,” Foley says. “Of course, our physicians, like most physicians, will just order anything, because they don’t really pay attention to costs.” Members of the Grane Rx team are regularly on site, brainstorming and helping with the process of reducing costs and realizing savings where appropriate. Because Grane Rx pharmacists were willing and able to sit and discuss the topic of formulary processes, they were able to explain the benefit of therapeutic interchanges to physicians. “When we transitioned to working with Grane Rx, our cost savings over the previous year were in the thousands,” Foley says. “They’ve worked with us on cost reduction and the creation of a formulary that our physicians buy into, which makes a tremendous difference.”
Clinical Support Beyond making a direct impact on pharmacy spend, Grane Rx also helps facilities prepare for surveys, compliance reviews, and continuing education. “They actually help prepare us for Department of Health surveys, for personal care and assisted living,” Foley says. “They do specific training—if we’ve identified specific issues, they’ll come work on those with us.” With the help of Grane Rx clinical staff, the Jewish Association on Aging nursing home achieved better than benchmark status on quality measures. In 23 out of 26 months, they earned a 5-star quality rating, and many of those measures are related to the use of medications, such as:
Beyond these measures, Grane Rx also provides medication-related counseling and guidance designed to help keep residents out of the hospital—an area of focus for long-term care.
- Percentage of residents who report moderate to severe pain, which is minimized by the timely delivery of meds by Grane Rx and access to medication cabinets.
- Antipsychotic medication use, which is monitored through weekly Grane Rx antipsychotic/antianxiety/anti-hypnotic monitoring reports and recommendations.
- Falls/Falls with major injury, which are limited through Grane reports and monitoring of anticholinergic/antipsychotics with reductions in these meds with high fall risk.
Emergency ManagementEmergency management is an important area for LTC pharmacy services to contribute expertise and training. A Grane Rx pharmacist participates in emergency management meetings to help the Jewish Association on Aging scope out pharmacy’s role in emergencies. That assistance has made a noticeable impact. “In our home health division, both of the survey teams said that our emergency management plans were the best they’ve ever seen,” Foley says. Competitive pricing and cost-cutting measures can help you gain control of pharmacy spending. Get started working with our team today by calling (866) 824-MEDS (6337) or filling out this quick form.]]>
Food, liquids, and medications are absorbed, distributed throughout the body, metabolized, and then eliminated. This is accomplished through a complex and complicated process involving a host of your body’s enzymes. Obviously, knowing how slow or how quickly a medication is metabolized and eliminated from the body is crucial when prescribing medications for health issues. When multiple medications are involved, as is the case with the average PACE participant, the issue becomes even more complicated. Let’s take a look at the role medication metabolism plays. [Tweet “When multiple meds are involved, medication metabolism becomes an important issue. #PACEpharmacy”]
Medication Metabolism & the PACE Participant
Most medication metabolism occurs in the liver, kidneys, and small intestine. Water-soluble, or hydrophilic medications, are more readily excreted by the body. Conversely, it is more difficult for fat-soluble, or lipophilic medications, to be eliminated without being changed.
Therefore, extremely water-soluble medications may bypass metabolism in the liver and be eliminated completely unchanged by the kidneys. And a largely lipid-soluble medication may undergo numerous phases of metabolism in order to provide a compound that can be excreted by the body. The basic understanding is:
- As lipid solubility increases, the need for metabolism also increases.
- As water solubility increases, the need for metabolism decreases.
It is commonly, and incorrectly, believed that all medications require extensive metabolism.
The human body is highly efficient, and only conducts those metabolic processes that are necessary. The amount and types of reactions depend on the individual’s body chemistry and the chemical structure of the medication.
Factors Affecting Medication Metabolism in the PACE Participant
A person’s genes dictate how the body functions. This affects the enzymes that metabolize medications.
A PACE participant may metabolize poorly, another about average, and yet another quite efficiently. This will affect how quickly a medication is used and eliminated from the body.
There are other factors that affect medication metabolism. There is some evidence in animals and humans that drug metabolism diminishes with age, although the effect has not been well studied.
A PACE participant of advanced years may have more difficulty metabolizing certain medications than younger participants.
Hereditary or genetic factors can play a part in how the PACE participant metabolizes medications—and especially certain combinations of medications. Some may enjoy a genetic predisposition to metabolize complex substances rather rapidly and without complications, while others may struggle to break them down for longer periods of time.
In humans, there have been a few reports of gender differences in metabolism. For instance, nicotine and aspirin seem to be metabolized differently in women and men.
On the other hand, gender differences can become significant in terms of drug-drug interactions based on the drug’s metabolism.
Pharmacy Solutions for the PACE Participant
In order to protect against unwanted adverse medication reactions, doctors and PACE pharmacy providers would want to choose a medication that is metabolized adequately by the individual. Clearly, knowing the health background and medical condition of each PACE participant is crucial to providing quality pharmacy solutions.
Want to learn more about the impact Grane Rx can have on your PACE center and your services to the PACE population? Start the conversation by calling (412) 449-0504 or emailing email@example.com.
Care transitions are one of the times when a resident’s risk of potential medication errors significantly increase. An estimated 80 percent of medical errors occur during the transition between medical providers. Of those errors, 40 percent involve medications, and 20 percent result in harm to the resident. The challenges to medication safety during care transitions must be identified and overcome for the sake of residents and their overall quality of care. The following are some primary areas in which to begin. [Tweet “Overcoming the challenges of #medicationsafety during care transitions. #longtermcarepharmacy”]
Better Communication for Medication SafetyCommunication breakdowns, or miscommunication, can be one of the biggest challenges that affect medication safety during care transitions. And yet, knowing this is true, extra care should be taken during this pivotal time to communicate everything necessary regarding medications to all involved parties. Healthcare providers must have a system of regular communication so that the needs of incoming SNF residents can be prepared for ahead of their transition. At least 24 hours is usually required to facilitate special equipment or monitoring needs. Moreover, every time the slightest change is made to a resident’s care plan, especially regarding medications, this change should be communicated to all involved parties, including the resident and his or her family support team. Ideally, a provider team member will be charged with the responsibility of managing medication safety and the communication of a resident’s care plan to all involved parties.
Current Information for Medication SafetyHealthcare providers and care facilities must strive to ensure each has up-to-date data on each resident for medication safety. Conflicting, outdated, or inaccurate information can result in serious harm to the resident, especially when concerning medications that have since been discontinued or replaced. Electronic data that is synchronized across every involved healthcare provider can go far to maintain up-to-date resident information that is immediately accessible. This can keep discrepancies from arising in resident care, as well as limit lost time when access to a provider is not immediately available.
Resident-centered Discharge Planning for Medication SafetySerious miscommunications during care transitions occur when the resident is unclear or confused about the decisions made for his or her health. Resident-centered discharge planning and education about medication safety that involves the entire patient support system will ensure that residents and families are informed and in agreement with medical decisions. This may necessitate performing a literary assessment with the resident to ascertain his or her level of understanding before communicating any medical information. Using terminology and phrasing that a resident understands breeds confidence in the medical team and their decisions for care.
Patient Support System Involvement for Medication SafetyA resident’s patient support system can be an invaluable asset to involve with care transitions, especially when striving to ensure medication safety. Family members who are actively involved are more likely to have a positive impact on the resident’s overall health outcomes. These family members must be taught their roles and the importance of their part in medication safety and overall care. Always try to provide printed resources for the patient support team to keep for later reference, especially concerning their loved one’s medications. Transitions of care can be confusing and difficult times for providers, staff, residents, and families, especially regarding medication safety. That’s why it is important to have effective communication, accurate information, patient-centered education, and patient support system involvement during transitions. A proactive approach to medication safety during transitions can help providers and staff facilitate safe and smooth care transitions. The Grane Rx team works with Skilled Nursing Facilities to design and implement medication safety and care transition processes. Could your SNF benefit? Call (866) 824-MEDS (6337) to find out more. ]]>
Many PACE participants have multiple disease states that require numerous medications. This leads to complex medication regimens consisting of multiple medications—what we in the industry refer to as polypharmacy. Without oversight, polypharmacy in seniors can be a significant problem, as taking multiple medications at one time increases the risk for adverse reactions. That’s why Medication Regimen Reviews (MRRs), provided by consultant pharmacists, are essential when administering medications to those in the PACE population. These reviews help prevent drug interactions and promote medication adherence among PACE participants.
Polypharmacy in PACE Participants Impacts Medication AdherenceWhen PACE participants take multiple medications, it’s not uncommon for medication adherence to decline. It can be difficult for anyone to keep up with numerous medications and instructions. Additionally, packaging that’s difficult to read, understand, or open for seniors can also lead to a lack of medication adherence. Regardless of why seniors fail to adhere to their medication regimens, the fact remains that with an increased number of medications comes an increased number of side effects, the potential for duplicate therapies, and the possibility of drug-drug interactions. Grane Rx partners with PACE centers to provide clinical consults, in which a specialty pharmacist reviews participant medications on a routine basis. These pharmacy consults serve two important purposes: promoting positive outcomes for PACE participants while helping PACE centers contain costs and make efficient decisions. Let’s take a look at the role of pharmacy consults—specifically, regular MRRs—in limiting polypharmacy in participants.
Polypharmacy in PACE Participants and the Role of Medication Regimen ReviewsA thorough MRR is necessary not only when participants are accepted but also throughout the duration of their medication therapy. In a nutshell, these reviews are one of the most important steps that PACE centers can take to help eliminate unnecessary medications, and ultimately, the incidence of adverse reactions. It’s important to determine why a participant is using a particular medication and to match each medication to an appropriate diagnosis. Often, medications are associated with one of three types of diagnoses:
In these cases, clinical judgment should be utilized to determine whether the off-label use is appropriately supported based upon the participant’s medical history and if the benefits of therapy outweigh the risks of adverse effects. Another important practice for preventing polypharmacy is optimizing medication regimens when more than one agent is being used to treat a condition. A common example of this is the use of multiple agents to manage hypertension in participants. It’s not uncommon to see as many as four or five antihypertensive medications ordered for the same participant. One of the fundamental guidelines in treating a disease state that may require more than one medication is to start with one medication and maximize the dose until either the maximum recommended dose is reached or the maximum dose without adverse effects is reached. Once the maximum dose has been reached, an additional agent can be used and titrated if better control is needed. PACE participants on multiple medications at suboptimal doses should have their regimen evaluated and, if clinically acceptable, have a medication discontinued while adjusting the doses of the other medications.
- a general diagnosis
- no diagnosis
- a diagnosis that is not an FDA-approved indication
Medication Regimen Reviews: Best Practices That Limit Polypharmacy in PACE ParticipantsMRRs are a major point of concern in recent years surrounding medication management in seniors. As part of CMS’ new Final Rule, for example, a major focus will now be on preventing or minimizing adverse consequences in skilled nursing residents related to medication therapy. While the new regulations don’t apply to PACE pharmacies, they can still apply the following best practices to help reduce the incidence of polypharmacy and adverse medication-related reactions in participants:
Acute status change reviews can be requested by completing and faxing the Medication Regimen Review Request Form to the pharmacy. Results of the review will be provided to the patient’s facility within three business days of the request.
- Having a licensed pharmacist review each participant’s medication regimen at least once a month—The consultant pharmacist’s review will include a review of the participant’s complete medical record/chart.
- Reviewing participant’s regimens more frequently, depending upon his or her condition and the risks or adverse consequences related to current medication(s)—A consultant pharmacist will review the medication regimen of a participant upon request by any member of an interdisciplinary care team, based upon a change in care status and/or the presence of an adverse consequence.
Any irregularities and/or clinically significant risks from medications will be documented in the participant’s medical record and recommendations related to the irregularity will be made to his or her physician. In addition, a separate report detailing all irregularities identified during the consultant pharmacist’s reviews for the month will be provided to the participant’s prescribing physician each month.
- Identifying and reporting irregularities to the participant’s prescribing physician—The consultant pharmacist will identify irregularities through a variety of resources and review specific information using any medical information available for the participant.
While polypharmacy in seniors itself isn’t a problem, the inherent risks are. That’s why it’s essential to review medication regimens to ensure participants are properly managing and taking their prescriptions. Want to learn more about the impact Grane Rx PACE pharmacy services can have on your PACE center? Start the conversation by calling (412) 449-0504 or emailing firstname.lastname@example.org.]]>
- Providing proof of action taken in response to the irregularities identified—Physicians may either accept and act upon the suggestions, or reject the suggestions and provide an explanation for disagreeing. All recommendations must be reviewed and responded to.
In 2016, the Centers for Medicare & Medicaid Services (CMS) introduced the Final Rule, a set of new regulations that significantly impact LTC pharmacy services. The most taxing phase of the Final Rule, Phase 2, went into effect just a couple months ago, in November 2017. While Phase 1 introduced a number of important medication-related changes that affect LTC pharmacy and residents, Phase 2 is far more complex, involving several pertinent medication-related topics. Before the implementation of Phase 2, we explored the implications of some of the coming medication-related changes concerning psychotropic medications in particular. But to ensure you’re prepared for the new year, we wanted offer an updated, in-depth review of some of the most fundamental medication-related changes. Let’s take a look.
Final Rule Phase 2’s Impact on LTC Pharmacy Services: New Regulations Regarding Crushed and Enteral Tube Medication AdministrationAs organizations have been preparing for Phase 2 changes, the administration of crushed and enteral tube medications has been a hot topic. Best practices indicate that crushed medications should not be combined and administered all at one time, either orally or via feeding tube. As such, the advanced copy of Appendix PP and Surveyor Guidance indicates that SNF staff members are to administer each crushed oral medication separately. So each medication being administered to residents would be delivered, for example, in a separate applesauce or pudding supply. While CMS believes this practice to be the standard, many in the industry hold that CMS’ approach may not be ideal for all residents. Because of this, failing to administer these medications separately will not be considered a medication error unless specific instructions about crushing and administering the medication are not followed. To stay in compliance with the new regulations, it’s important for Skilled Nursing Facilities to keep the following updates top-of-mind when administering crushed and enteral tube medications:
With that in mind, a facility is not required to flush between medications if there is a physician’s order that either specifies a different flush schedule due to fluid restriction or specifies the amount of water to be used for flushing due to fluid regulation. If the prescriber orders a medication to be crushed and the manufacturer states that the medication should not be crushed, the prescriber or pharmacist must explain in the resident’s clinical record why crushing the medication will not adversely affect the resident. Moreover, the pharmacist should inform the facility staff to observe the resident for adverse effects. This will be addressed through the Medication Regimen Review process, which we’ll cover momentarily. The new standards for the administration of these medications are to ensure the safety of the resident and prevent adverse effects from combining multiple medications. Because these updates focus on providing person-centered care, it’s encouraged, when possible, to separate crushed medications to provide the best resident care.
- Oral medications—As part of Phase 2 changes, the oral administration of crushed medications to residents will be person-centered and will not result in a medication error if medications are administered together. However, appropriately documenting residents’ desires related to medication administration is advisable.
- Enteral tube medications—Enteral tube administration requires flushing between each medication, or a medication error will be counted for each medication without a flush in between.
Final Rule Phase 2’s Impact on LTC Pharmacy Services: Medication Regimen Review Changes and Recommendations Follow-upMany long-term care residents have multiple disease states that require numerous medications. This leads to medication regimens that are complex and have the potential to increase residents’ risk for adverse reactions. One way to potentially minimize these adverse reactions is to use a Medication Regimen Review, provided by a consultant pharmacist. These reviews may help prevent drug interactions as well as help identify omissions, duplications of therapy, and miscommunication between care providers. There are two key focus points of Phase 2 changes to the Medication Regimen Review requirement:
To be compliant with these integral changes, facilities will need to provide the following:
- Helping residents maintain their highest level of function
- Preventing or minimizing adverse consequences related to medication therapy
All admissions, including residents not expected to be in the facility for more than 30 days, will be reviewed by the consulting pharmacist. Any findings for new admissions or re-admissions will be sent to the Director of Nursing within seven business days of admission.
- A licensed pharmacist’s review of each resident’s medication regimen at least once a month—The consultant pharmacist’s review will include a review of the resident’s complete medical record/chart.
Acute status change reviews can be requested by completing and faxing the Medication Regimen Review Request Form to the pharmacy. Results of the review will be provided to the facility within three business days of the request.
- More frequent reviews of medication regimens depending upon residents’ conditions and the risks or adverse consequences related to current medication(s)—A consultant pharmacist will review the medication regimen of a specific resident upon request by any member of the interdisciplinary team, based upon a change in resident status and/or the presence of an adverse consequence.
Any irregularities and/or clinically significant risks from medications will be documented in the resident’s medical record and recommendations related to the irregularity will be made to the resident’s attending physician, the nursing staff, or the pharmacy. A separate report detailing all irregularities identified during the consultant pharmacist’s reviews for the month will be provided to the resident’s attending physician, the facility Medical Director, and the Director of Nursing each month.
- Reports of irregularities to residents’ attending physicians and facility Medical Directors and Directors of Nursing—The consultant pharmacist will identify irregularities through a variety of resources and review specific resident information using any medical information available for the resident.
- Proof of action taken in response to the irregularities identified—Physicians may either accept and act upon the suggestions, or reject the suggestions and provide an explanation for disagreeing. All recommendations must be reviewed and responded to.
Final Rule Phase 2’s Impact on LTC Pharmacy Services: Guidelines for Psychotropic Medications A psychotropic medication is any medication that affects brain activities associated with mental processes and behavior. Antipsychotics, antidepressants, anxiolytics, sedatives, and hypnotics are some examples of the different categories that psychotropic medications can fall under. Until recently, CMS’ focus has primarily been centered around antipsychotic medications. However, with the new regulations in place, the focus will now shift to all psychotropic medication classes. The required provisions of the CMS Final Rule Phase 2 aim to reduce or eliminate the need for psychotropic medications, if not clinically contraindicated, to safeguard residents’ health. National prevalence of antipsychotic use for long-term care residents has fallen, but for providers that still have a high rate of use, CMS has identified a new goal of a 15-percent reduction in antipsychotic use by 2019. With this new focus on reducing antipsychotic medication rates, those in the industry will notice a marked shift toward the use of nonpharmacologic approaches and person-centered care practices. As such, according to the Final Rule, when prescribing psychotropic medications based on a comprehensive assessment of a resident, the facility must ensure that:
The Grane Rx team works hard to stay in-the-know on regulatory and guideline changes as they relate to LTC pharmacy services, and put that information into action. Could your SNF benefit from our services? Call (866) 824-MEDS (6337) to find out more. ]]>
- All residents who have not previously been prescribed psychotropic medications must have a specific condition requiring the use of the medication and have that condition or diagnosis documented in the resident’s clinical records.
- Residents already taking psychotropic medications should receive gradual dose reductions and nonpharmacologic interventions, unless clinically inappropriate, with the goal being to eventually discontinue the medication.
- Residents who require psychotropic medications on an as-needed (PRN) basis must have documentation in their clinical record of the specific condition that requires the use of the medication.
- PRN psychotropic medications are limited to 14 days. If extended therapy beyond 14 days is required, the prescriber must document the reasoning in the resident’s clinical record and indicate the new duration of use.
- All PRN antipsychotic medications are limited to 14 days. If there is a clinical reason to continue the order, the prescriber must evaluate the resident for appropriateness and write a new order that will be limited to another 14 days. This process must be repeated with each subsequent order.
Gastroesophageal reflux disease (GERD), which develops when stomach acid frequently flows back into the esophagus, is common in long-term care residents. Similar to other conditions, older adults are at a higher risk of complications from chronic GERD, making it important for long-term care providers—including LTC pharmacy services—to stay up to date on the condition. Some common medications used to treat GERD in residents include antacids, histamine 2-receptor antagonists, and proton pump inhibitors. While these medications are readily available and effective at relieving symptoms, there are a number of lifestyle modifications that can also help. Many of these modifications can be used in conjunction with medications to provide residents with optimal outcomes. [Tweet “#GERD is a common medical condition in older adults, including #SkilledNursing Facility residents.”]
LTC Pharmacy Notes: Lifestyle Changes for Treating GERDBefore resorting to pharmacologic treatment, it’s wise to see if certain lifestyle modifications help improve GERD symptoms in skilled nursing residents. There are two particular lifestyle modifications with the strongest amount of evidence: weight loss and head-of-bed elevation. Though weight loss may not be the answer for residents—who are at increased risk of nutritional deficiencies—long-term care providers can reduce GERD symptoms in residents by simply elevating the resident’s head using foam blocks or an extra pillow. In addition, a handful of other lifestyle changes that can help with GERD include:
- restricting food intake two to three hours before bed
- avoiding spicy foods
- limiting foods with high fat content
LTC Pharmacy Notes: Medications for Treating GERDPharmacologic options do have their place in the treatment of GERD. However, it’s important that they be used as a preventive measure, rather than a responsive one. GERD medications are designed to reduce the acidity of the stomach. There are three primary categories of medications for treating GERD:
Let’s take a closer look at each category and their implications for SNF residents. Antacids, such as Tums®, Rolaids®, and Maalox®, are designed to be given after symptoms present and provide symptomatic relief for up to an hour. Since they do not contribute to healing erosive esophagitis, they are not recommended as first-line treatment for GERD. Instead, antacids are a solid option for treating infrequent episodes of mild reflux. Additionally, antacids can be used for residents with identified triggers or for relief of breakthrough symptoms. H2RAs, like Pepcid® and Zantac®, are more effective than antacids. These medications are renally dosed and used as a maintenance option in residents who have milder forms of GERD or GERD symptoms without erosive esophagitis. Histamine 2-receptor antagonists may be given with or without food. However, to prevent GERD symptoms from occurring, it’s recommended that they be taken about a half hour prior to eating foods that can exacerbate symptoms. Additionally, if a resident still requires GERD therapy, H2RAs may be used concurrently with PPIs, as the efficacy of H2RAs may decrease after three to four weeks of use. Notably, there are some side effects associated with H2RAs, which include:
- histamine 2-receptor antagonists (H2RAs)
- proton pump inhibitors (PPIs)
PPIs, which include medications like Protonix® and Prilosec®, are the most potent acid-suppressing agent. Having shown greater efficacy than H2RAs, PPIs have become the standard of treatment for GERD. For maximum efficacy, this class of medications should be taken 30 to 60 minutes before the first meal of the day. If residents do not experience relief, 20mg of Prilosec may be administered twice daily for GERD. The recommended length of treatment is four to eight weeks. With PPIs’ potency also comes several long-term side effects. These include:
- CBC abnormalities
- liver function irregularities
In addition, it’s worth noting that some alternative agents may be effective in refractory residents. For example, though there’s limited supporting evidence, metoclopramide, baclofen, and melatonin are three off-label alternatives that are sometimes used to treat GERD in residents.
- Clostridium difficile-associated diarrhea
- bone fractures
- rebound hypersecretion
- vitamin B12 deficiency
- drug interactions
LTC Pharmacy Endnotes on GERD Treatment RecommendationsUltimately, it’s vitally important that residents have documented indications for all medications in their charts. Too often, medications for GERD are started in the hospital as prophylaxis and are continued once residents are back in a long-term care setting. This makes it essential to check a resident’s history and re-assess the need for GERD treatment. By working together and properly following treatment guidelines, we can alleviate symptoms of GERD in SNF residents, and, ultimately, improve their health outcomes. The Grane Rx team stays up-to-date on the latest information related to long-term care pharmacy—and passes that knowledge along to your team. Call (866) 824-MEDS (6337) or fill out this quick form to find out how your SNF could benefit.]]>
When it comes to the medication needs of those in the PACE environment, there are unique challenges to consider. A new study has determined that the number of older Americans who take three or more medications that affect their brains has more than doubled in just a decade. The sharpest rise occurred in seniors living in rural areas, where the rate of doctor visits by seniors taking combinations of such medications—opioids, antidepressants, sedative-hypnotics, and antipsychotics—more than tripled. This “polypharmacy” of medications that act on the central nervous system is concerning because of the special risks to older adults that come with combining multiple medications with overlapping effects. Falls—and the injuries that can result from them—are the chief concern, along with problems with driving, memory, and thinking.
A Look at the Impact on PACE Providers, Including PACE PharmacyCombining opioid painkillers with other medications such as benzodiazepines is of particular concern, recently receiving the strongest possible warning from the FDA due to an increased risk of death from combined use. Polypharmacy significantly increased for seniors with a pain diagnosis, occurring in the context of the overall growth in opioid prescribing, which has reached epidemic proportion. But visits without pain, insomnia, or other mental health diagnoses accounted for nearly half of CNS polypharmacy visits and grew significantly from 2004 to 2013. Ensuring that prescribing is evidence-based is one of the key challenges to achieving appropriate polypharmacy, particularly in the geriatric population, including PACE. It is well known that evidence to support prescribing decisions in the geriatric population is lacking because of the under-representation of this population in clinical trials. Additionally, prescribing guidelines typically focus on single disease states and often fail to provide guidance on how to prioritize treatment recommendations when compared to those with comorbidities. [Tweet “This type of #polypharmacy is having a particular impact on seniors, including #PACE participants”]
The PACE Pharmacy Provider’s Role in Combatting the IssueRecent developments have sought to address some of these issues. For example, an expert panel from the American Geriatrics Society has developed a set of guiding principles on the management of older patients with comorbidities. Prescribing assessment tools can play an important role in identifying and addressing potentially inappropriate prescribing. However, there are limitations associated with their clinical application in ensuring appropriate polypharmacy. For example, they do not provide guidance as to how treatment decisions should be prioritized—and in many cases, predictive validity has not been established. Deprescribing has become one of the important aspects of combatting polypharmacy, and is described as “a systematic process of identifying and discontinuing medications in instances in which existing or potential harms outweigh existing or potential benefits within the context of an individual’s care goals, current level of functioning, life expectancy, values, and preferences.” Though the main goal is to eliminate potentially harmful adverse drug events through the use of evidence-based stoppage of multiple medications, barriers exist that can impede the process of helping the PACE participant. Some of these barriers include: resistance from participants or family members, fear of losing participant-provider relationship, concern from clinicians to discontinue medications started by another provider, time expenditure, fear of medication withdrawal side effects, and lack of resources, such as a clinical pharmacist or database availability. Prescribers and PACE pharmacy providers must collaborate in collecting as much information as possible to answer the following questions:
Polypharmacy and deprescribing are the responsibility of the providers and pharmacists that interact with PACE participants on a regular basis. Some mental health conditions seen among PACE participants require taking a medication indefinitely. Ultimately, how long a person takes a psychotropic medication depends on his or her individual illness, responses to treatment, and personal situations. Some key factors must be taken into account when prescribing/deprescribing medications, especially considering their poor safety profile in the senior population. Fall risk is a major concern among the geriatric population, especially when taking medications that affect mental processes and behavior. In 2015, Medicare costs alone for falls totaled over $31 billion, landing fall injuries on the top 20 most expensive medical conditions. The use of non-pharmacological techniques is essential when attempting to discontinue a medication that may increase the risk of fall and injury to PACE participants in the home environment. A structured approach integrated with clinical judgement is required along with the full engagement of the participant, family, and caretakers. PACE participants have unique and specialized needs when it comes to medication usage. The Grane Rx PACE pharmacy team understands those challenges and works with PACE centers to overcome them. Partner with us today by calling (412) 449-0504.]]>
- Why and when was a therapy initiated?
- Was the diagnosis substantiated?
- Was the medication prescribed to counter adverse effects of another medication?
- Is the medication continuing to benefit the PACE participant?
- Are there alternative and equally effective nonpharmacological therapies available?