Drugs are something the skilled/post-acute side seems to have a better-than-ever handle managing. Observers say rapidly growing SNF alternatives such as assisted living would do well to learn from their painful past.
Serious adverse drug events in nursing homes seem to have plateaued. Lengths of stay are even down. And efforts such as antibiotic stewardship have greater traction than ever before. But still, as Big Pharma continues cranking out powerful new drugs to treat maladies ranging from “nuisance” to “life-threatening” on the health scale, medication management remains a pressing matter.
“Expect 2017 to bring with it intense scrutiny of several classes of drugs, especially in the heavily regulated nursing home environment,” says William Vaughan RN, BSN, vice president of education and clinical affairs for Remedi SeniorCare. “While antipsychotics used for the treatment of behavioral and psychological symptoms of dementia will continue to be critically evaluated, antibiotics will also be high on the list of drugs attracting the attention of surveyors.” Vaughn also believes opioid prescribing “will also be put under the regulatory microscope as both federal and state governments create policies and enact legislation to address the related public health issues.”
Likely the biggest medication management challenge ahead is the so-called pharmacy “mega-rule” now underway in a three-phase rollout for long-term care that's designed to infuse greater accountability to stem drug-related hospital readmissions and more transparency in dosing, prescribing and administration practices.
In the face of all these challenges, innovation marches mightily along as many eyes turn toward pharmacogenetics as one compelling solution to ensuring seniors not only take fewer meds but also take those most likely to fix what ails them in a very custom, personalized way.
Feeling the strain
The pressures seem to be coming from all sides.
For one, providers increasingly will feel the heat on controlled substances after years of abuse and neglect among prescribers, caregivers and the residents themselves. For example, prescription drug monitoring programs are either under development or fully implemented in many states, as Jennifer L. Hardesty, PharmD, FASCP, chief clinical officer and corporate compliance officer for Remedi SeniorCare, observes. The concept behind PDMPs is to create a single database repository to tightly monitor how, where and when those drugs are used in long-term care.
“With the increasing focus on overprescribing and diversion of controlled substances, the future may hold increasing challenges and operational hurdles for providing controlled substances in long-term care and assisted living settings,” she adds.
For another, medication management and reconciliation is a virtual necessity to comply with new rules about preventing and penalizing drug-related readmissions, says Brandi Apple, PharmD, C-MTM, a clinical consultant pharmacist at Guardian Pharmacy of the Piedmont, a member of the Guardian Pharmacy family.
Moreover, the nature of assisted living is evolving and changing under our very noses, making medication management a slippery slope. Even federal regulators are stymied about how to define it. “The assisted living/residential care industry is rapidly growing, and the types of residents many of these providers accept are clinically complex and medically fragile,” Hardesty asserts. “With the increased acuity and complexity comes the need for a pharmacy that will provide a true medication management system that benefits both the patient and the facility.”
“It should be noted that many states do not require medication management in assisted living facilities and other alternative care settings,” says Alan Rosenbloom, president of the Senior Care Pharmacy Coalition. “Unless the contract between the LTC pharmacy and the facility requires medication management, it simply isn't provided.”
Many states also prohibit ALF staff from administering meds. And unlike their cousins on the skilled nursing side, ALFs aren't yet under the same scrutiny about where their drugs originate, Rosenbloom adds. Although many have contractual agreements with one or two preferred long-term care pharmacies, ALF residents are free to use them “or any other pharmacy source they want — retail pharmacies in the local community, mail order pharmacies, etc.,” he says. This causes the manner in which such pharmacies interact with patients to vary widely from state to state. Moreover, retail pharmacies also aren't under the same medication management rules as LTC pharmacies.
Meanwhile, more and more ALFs are reaping the benefits of evolving care and payment models such as accountable care organizations born under the Affordable Care Act. Doing so qualifies them to care for enrolled beneficiaries. Such partnerships also help ALFs at the expense of the SNFs because many patients bypass skilled facilities altogether, according to Rosenbloom. “Obviously, these trends create significant challenges for LTC pharmacies and also create opportunities,” he says. Still, “just because a patient who takes multiple prescriptions a day resides in an ALF rather than a SNF, that person still needs all of the consulting services LTC pharmacies provide.”
It remains unclear, however, that the ultimate payer will see the advantages of providing such services to patients in ALFs or other alternative settings and would be willing to provide “appropriate compensation to the pharmacies for those services,” he adds.
All told, these challenges are likely causing many ALF operators to lose sleep.
A complex challenge
Make no mistake: Medication management is as complex as any challenge senior living providers face today.
As recently as 2014, an inspector general report verified ADEs occur in 22% of all Medicare beneficiaries during their SNF stays; an additional 11% also experienced harm from those events. Meanwhile, nearly 60% of every one of those events were deemed “preventable.”
Other drug-related problems are lurking. The highly respected technology evaluator ECRI last November included two medication-related items in its top 10 list of healthcare's greatest hazards in 2017: undetected opioid-induced respiratory depression, and mishaps linked to faulty user setups of automated drug dispensing cabinets.
A recent Journal of the American Geriatrics Society study titled “Older adults who take many medications have a higher risk for becoming frail” set the bar low: just five different daily meds as the minimum in its study cohort.
According to Rosenbloom, the average nursing home resident takes eight to nine prescription medications each day and takes between 12 and 13 different prescription medications over the course of a month.
When he's not crisscrossing the country to consult with hospitals on physician management and staffing, Jerome Wilborn, M.D., national medical director of post acute care at Team Health (formerly IPC Healthcare), occasionally visits with patients. Weeks before this article was written, Wilborn visited with an 86-year-old hospitalized woman whose daily menu included a buffet of 28 different drugs.
“We treat our elderly with a very poor regimen of medications,” Wilborn says. “Part of the reason they're sick is because we make them sick.” He doesn't need any more confirmation that the industry suffers from a drug management problem. “I can go to any facility, and no matter how good my providers say they are, when I sit down with a director of nursing or unit clerk and ask them to give me five patients who are on more than 25 medications, every single time, one will quickly turn around and grab at least five charts,” he says. “You look at them and say, ‘Do you really think this makes a lot of sense? Let's walk through each one.' And in very short order, they will get rid of three to four meds on the first pass and feel comfortable. That's all I'm trying to get them to do. Then I say, ‘Now go back and do it again in a couple of weeks.' ”
As complex and challenging and interdisciplinary as medication management is, Wilborn can distill its parts down to one thing: medication optimization. It's not only about just ensuring that the most appropriate drugs are being prescribed, but also ensuring they get to the resident in the first place.
“It's not uncommon that medications you've prescribed aren't being given, especially in places like assisted living, where there's just a real paucity of caregivers, and sometimes those meds don't get passed,” he observes.