A drug problem
Managing medications poses complex challenges in senior living
As more and more “Baby Boomers” transition to senior living settings, they're bringing many of the very challenges that have dogged the skilled nursing side for years. While assisted and independent living and CCRC operators spend countless hours building and outfitting facilities with creature comforts and amenities designed to attract boomers, they now find themselves wrestling more with issues of security, safety, health monitoring — and even emergency preparedness.
Few of these issues are more confounding than medication management. Although these operators' residents are generally less acutely ill and have fewer chronic conditions than those in nursing homes, the challenges that drug awareness pose are nearly as complex, and in some respects, even riskier.
When people enter nursing homes, they usually surrender the large bag of drugs they came with over to nurses charged with monitoring and dispensing them. But when people check into assisted living, many continue visiting multiple doctors and pharmacies, even managing their own dispensing. That level of independence and loose monitoring can pose keen challenges for caregivers.
As if prescribing and dosing issues aren't enough, the problem of polypharmacy can compound medication errors tenfold, experts say.
As Leading Age points out in its 2015 report, “Medication Management Technologies for Long-Term and Post-Acute Care,” the higher the number of medications a patient takes, the higher the risk of medication errors, drug interactions and adverse reactions.
The issue of polypharmacy is even more acute in assisted living settings, according to Steve Piepenbrink, president of Guardian Pharmacy of Indiana. Although more and more nursing home residents tend to use one doctor the longer their stay, the transient nature of assisted living often means many residents are swirling in multiple scripts from multiple places.
“An assisted living facility may use four or five different pharmacies, so there can be a lot of duplication and overlap,” prompting some communities to adopt a preferred pharmacy provider, he notes.
Reimbursement issues can be especially frustrating for assisted living residents when it comes to third-party insurance prior authorizations for non-covered drugs.
“Insurance companies may require test results, clinical information or additional rationale/documentation from prescribers for certain drugs prior to approving them for payment,” says Jennifer L. Hardesty, PharmD, chief clinical officer and corporate compliance officer for Remedi SeniorCare. “This becomes an operational, administrative, and financial burden to prescribers, pharmacies, facilities and patients of assisted living facilities.”
Consider even those medications assisted living residents buy off the shelves of their local store or corner pharmacy. It's not uncommon for them to expire under the radar or cause potentially dangerous interactions with prescription meds.
“Mismedication occurs even with OTC drugs,” says Laya Klein, quality control director of Geri-Care Pharmaceuticals. “Nursing staff are even more harried as Medicaid cost cutting results in a greater patient-to-staff ratio than ever before. Nurses complain that the labels and packaging of their OTCs are inconsistent since the supplier will send them whatever drug is cheapest. Pressed for time, nurses have difficulty choosing the correct OTC pain killer from their crowded OTC supply drawer.”
Many long-term care pharmacists pointed to poorly managed transitions as a leading culprit in medication errors and adverse reactions.
As seniors move from home to hospital to nursing home to other settings like assisted living, a lot of information can and does fall through the cracks.
“Seniors living in the community with multiple doctors will go to the hospital, go to rehab or move to a nursing home or assisted living facility, take their drugs with them and no one knows about all the medications they've taken,” says Patricia Howell, RN, a member of McKesson's Clinical Resource Team.
Now that the problem of ADEs has reached critical mass in the industry's psyche, solutions abound. Most prominent among them are data aggregators. In its recent report, LeadingAge identifies several “upstream technologies” like the electronic health record, e-Prescribing, computerized physician order entry and clinical decision support systems, and “downstream technologies” like electronic medication administration records, bar-coded point-of-care systems and remote pharmacy systems.
The very nature of how medications are stored in so many long-term care facilities has led to chronic waste.
Not realized by many, these costly medications quickly go bad if they aren't kept in tightly controlled, consistent and narrow temperature ranges, says Cynthia Fitton, product marketing manager, Follett Corp., which has long supplied medical grade refrigeration to the healthcare industry and recently began marketing to the long-term care community.
“A lot of providers don't have the same kind of awareness that a hospital pharmacy would for the tight temperature tolerance for some of these medications,” Fitton tells McKnight's Senior Living. “Everyone wants to do the right thing, but it's a cost issue,” says Bent Gay, R.Ph., chief executive officer of Gayco Healthcare, a long-term care pharmacy, whose hospice and assisted living customers have asked him to pick up and destroy meds. Large retail pharmacies may tout their “free” drug takeback programs, but the task is costly and burdensome for so many independents, he adds.
Some legislative efforts have actually caused patients to be denied badly needed pain medications. “Medicare Part D beneficiaries are able to get multiple scripts for the same drug, and so there's a congressional effort afoot to give Part D plans the ability to determine certain beneficiaries are at risk for substance abuse and to limit them to one prescribing physician for all of their medications and to one pharmacy to pick up their meds,” Pharmacy Operator's Association leader Alan Rosenbloom explains. The problem is when a beneficiary goes to the hospital on a Part A stay, gets transferred to a nursing home and starts on a Part A stay that only applies to Part D, then transfers off the Part A stay and now his or her drugs are being paid for by Part D. All of a sudden, both the pharmacy that's contracted with the facility and the one that the plan has designated as a retail pharmacy can't provide the drug legally. Now you have a patient who can't get any drugs.”