Your Custom Text Here
Elderly patients are more likely to experience polypharmacy, the utilization of five or more medications. Polypharmacy increases the risk of patient harm. Effectively deprescribing unnecessary medications and prescribing cascades can decrease medication burden while improving care outcomes. Resources are available to help providers safely identify and deprescribe unnecessary medications.
Drug Prescribing for Older Adults
Patients and caregivers that are knowledgeable about medication regimen are better equipped to participate in the care process. There is some basic information every patient and caregiver should know about drug therapy.
First, patients should have a complete list of their current medications including prescription medications, over-the-counter medications, and herbal supplements. A list can be provided by the dispensing pharmacy, skilled nursing facility, or prescriber.
Once patients and caregivers have the medication list, they should also know:
A Complete Medication Review is a great tool patients and caregivers can use to better understand medication therapy. A CMR is a patient-centered review of medication therapy that involves a one-on-one consultation designed to identify and address medication related problems and patient concerns.
The goal of a CMR is to improve the participant’s knowledge, understanding, and management of his/her medication therapies and health conditions. CMRs also help prescribers identify and bridge gaps in care. CMRs are required annually, and certain participants may be eligible for an additional CMR if he/she is recently discharged from the hospital.
Patients, caregivers, and clinicians should partner with a trained senior care pharmacist to provide a clinical review of medication therapy.
Diabetes is highly prevalent in older adults and in skilled nursing facilities. Poorly managed glycemic control increases the risk for hypoglycemia, the burden of care for residents, and the risk for facility regulatory non-compliance. Below are 4 F-Tags commonly associated with poor diabetic control.
1. F-686 Treatment Services to Prevent/Heal Pressure Ulcers
Diabetic patients are at a greater risk for developing pressure ulcers. In addition, uncontrolled hyperglycemia can delay wound healing.
2. F-690 Bowel/Bladder Incontinence
Uncontrolled hyperglycemia in diabetic patients may cause or exacerbate polyuria.
3. F-689 Free of Accident Hazards
Poorly managed glycemic control can cause hypoglycemia and increase the risk of falls. In addition, residents that experience polyuria, especially nocturia, may be at a greater risk of falling.
4. F-757 Unnecessary Medications
Sliding scale sole therapy for older adults is not appropriate for any care setting and can be considered an unnecessary medication.
Appropriate diabetic therapy can improve resident care and quality life. Doctors, pharmacists and nurses should work together to ensure that all diabetic patients receive the clinical monitoring necessary to achieve optimal medication therapy.
CMS requires that certain data be collected for residents in a long-term care facility. This information, known as the Minimum Data Set (MDS) is a collection of resident specific basic physical, functional, and psychosocial information. In addition to the MDS, the facility should also complete the Care Area Assessment (CAA) process. CAAs are triggered responses to items coded on the MDS specific to a resident’s possible problems, needs or strengths (1). There are currently 20 CAAs, 15 of which may be directly impacted by medication-related issues.
CAAs that can be Triggered by Medications
1. Activities
2. Activities of Daily Living
3. Behavioral Symptoms
4. Communication
5. Dehydration/Fluid Maintenance
6. Delirium
7. Dental Care
8. Falls
9. Mood State
10. Nutritional Status
11. Pressure Ulcers
12. Psychosocial Well Being
13. Psychotropic Medication Use
14. Urinary Incontinence and Indwelling Catheter
15. Visual Function
The consultant pharmacist has an instrumental role as a part of the interdisciplinary care team to help improve resident quality of care. A consultant pharmacist review of the MDS and CAA triggers can optimize the monthly medication regimen review. A consultant pharmacist can use the CAA triggers to identify residents that may require an additional review of medication therapy. For example, residents that have triggered for weight loss should receive a medication review for therapy that may suppress appetite. In addition, using the MDS and CAA information can also help improve the facility quality assurance assessment and improvement procedures. Identifying facility patterns can improve medication utilization.
1. Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Insturment3.0 User Manual. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-RAI-Manual-V113.pdf
2. Medication Management in the Elderly: A guide to Elimination Unnecessary Medications and Improving Therapeutic Outcomes © 1992-2016 Med-Pass, INC
Managing medication in older adults is multifaceted. Clinicians should work together to evaluate medications for appropriateness and effectiveness. The current standard is to provide patient-centered care. Patient-centered care is an approach that focuses on the individual person and his/her capacities and interest, in order to provide quality of life as defined by the individual. A team approach including the patient, healthcare providers, and family members is needed to achieve patient-centered care.
Families are an important part of the care team for residents in Long-Term Care facilities. Healthcare professionals need family insight when creating patient-centered care plans.
Family members can:
Working together to achieve patient-centered care improves patient outcomes while maintaining patient dignity. The patient–centered care approach is incomplete without family involvement.
Sliding scale insulin therapy is widely used in long-term care settings despite poor glycemic control, increased risk for hypoglycemia, and high burden of care. The Beer’s List has identified sliding scale insulin therapy to be a potentially high-risk therapy for patients 65 and older regardless of care settings, and the ADA determined that sole sliding scale insulin therapy should be avoided in LTCF. Although there is no current clinical guideline on how to convert residents from sliding scale insulin therapy to basal therapy, the ADA has provided several strategies depending on the current therapy.
Clinicians converting residents from sole sliding scale therapy to basal therapy can:
Non-insulin agents or fixed-dose mealtime insulin can be used for postprandial hyperglycemia. Basal insulin can be given in the morning to impact postprandial hyperglycemia and reduce the risk of early morning hypoglycemia. [1] For more information or strategies for managing diabetes in skilled nursing settings, view Management of diabetes in long-term care and skilled nursing facilities: a Position Statement of the American Diabetes Association at http://care.diabetesjournals.org/content/39/2/308.full [1]
According to the CDC, approximately 900,000 Americans develop pneumonia annually.Anyone can develop pneumonia. However, children under 2 and adults over 65 have been found to be most susceptible. There are currently two different pneumococcal vaccines. Prevnar (PCV 13) and Pneumovax (PPSV23). The CDC recommends that patients 65 and older receive both Prevnar and Pneumovax vaccines separated 1 year apart. Patients that have never been vaccinated, or if their history is unknown, should receive Prevnar first. The Pneumovax dose should be given at least 12 months later. If Pneumovax has been administered first, the Prevnar can be administered at least 12 months after the Pneumovax immunization. When indicated, Prevnar and Pneumovax should be administered if pneumococcal immunization history is incomplete or unknown. Consultant pharmacist can help facilities tract resident immunization history by reviewing immunization consents and administration records during the medication regimen review. Pharmacist can report omissions and make recommendations when appropriate. For complete immunization Schedule, or from more information please visit the CDC website.
According to HHS falls are the leading cause of accidental death in older adults in the United States. Often, resident falls result in injuries that lead to decreased mobility and functional ability. There are many risk factors that can increase the risk of falls. Facilities and healthcare providers should proactively identify and reduce resident fall risk factors.
Multiple factors can contribute to falls in older adults. Common risk factors include:
A thorough interdisciplinary clinical assessment of the resident and their environment is instrumental in identifying fall risk factors and developing a patient-centered care plan. Fall care plans should be periodically reviewed and modified as necessary. HHS Quality Monitoring Program has several evidence-based best practice resources available for fall risk management programs. See the link below for more information.
Pain is often undiagnosed in patients with cognitive impairment. Poorly managed pain in residents with dementia can lead to behaviors that may be misinterpreted and result in unnecessary psychoactive medication utilization. Here are common behaviors seen in cognitively impaired residents in pain.
Facial Expressions
Facial expressions are one behavior seen in cognitively impaired residents in pain. Frowning, grimacing, wrinkled forehead, closed or tightened eyes, rapid blinking, or any distorted expression are all facial expressions that may indicate pain.
Vocalizations
Vocalizations are another behavior often seen in cognitively impaired residents in pain. Sighing, moaning, groaning, grunting, chanting, calling out, noisy breathing, cries for help, or verbal abuse can be an indication of pain.
Body Movements
Body movements including rigid or tense body posture, guarding, fidgeting, increased pacing, rocking, restricted movement, gait or mobility changes can all be an indication of untreated pain in residents with cognitive impairment.
Changes in Interpersonal Interactions
Residents with cognitive impairment may show signs of aggression, or combativeness. At times, the resident may even resist care. Decreased social interactions, socially inappropriate behavior, or social withdrawal. All of these behavioral changes should prompt clinicians to assess a cognitively impaired resident for pain before initiating psychoactive therapy.
Changes in Activity Patterns or Routines
When undiagnosed pain is present in cognitively impaired residents, caregivers may notice changes in activity patterns or routines. Changes in appetite or rest patterns, even increased wandering are behaviors that can be associated with untreated pain.
Mental Status Changes
Lastly, crying, increased confusion, irritability or distress are all behavioral signs that can indicate undiagnosed pain in cognitively impaired residents.
Assessing pain in cognitively impaired residents may present certain challenges. Clinicians should monitor residents for these common behaviors and utilize a validated pain assessment tool to assure pain is addressed in cognitively impaired residents.
References
HHS Understanding Pain Communication Handout 04-01-14
Texas OASIS HCBS Dementia Training Academy Participant Manual
Appendix PP of the State Operations Manual defines Gradual Dose Reduction (GDR) as the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.
Why Should Medications be Gradually Reduced
Psychotropic medications should be tapered to determine if continued therapy is still beneficial to the resident, or to help find the optimal therapeutic dose. Tapering may be appropriate if the resident’s original target symptoms have resolved, non-pharmacological approaches have been effective, or if the resident’s clinical condition has improved or stabilized. The effectiveness of psychotropic medications should be evaluated during each prescriber assessment, consultant pharmacist MRR, and during the quarterly MDS review.
When to Gradually Reduce
Antipsychotic and psychopharmacological (anxiolytic, antidepressant, anticonvulsant) medications should undergo GDR within the first year of the resident being admitted on the medication or after the prescribing practitioner has initiated the medication. The facility must attempt a GDR in two separate quarters with at least one month between the attempts, unless clinically contraindicated. A GDR must be attempted annually thereafter, unless clinically contraindicated. Sedatives should undergo GDR every 3 months.
Clinical Rationale
A prescriber response is required for GDR recommendations. If the prescriber refuses the recommendation, clinical rationale for declining the attempted dose reduction is needed. GDR recommendations that are refused and do not have a clinical rationale, are considered to be an unnecessary medication.
Texas Health and Human Services reported that Pharmacy Services was the 3rd most cited deficiency for fiscal years 2015-2017, primarily dementia and unnecessary medications. An unnecessary medication is any medication when used in an excessive dose, for an excessive period of time, without adequate documentation or monitoring, in the presence of adverse effects, and or without a diagnosis. Here are 3 ways a consultant pharmacist can help improve pharmacy services in dementia care.
1. Confirm diagnosis for antipsychotic medication used in patients with dementia.
The consultant pharmacist should confirm that the resident has an approved diagnosis for antipsychotic therapy and that the diagnosis is appropriately documented in the resident's chart.
2. Review supportive documentation for antipsychotic medication used in patients with dementia.
The consultant pharmacist should confirm that additional documentation such as prescriber notes, psychiatric consultation, nursing notes, and PASSR forms are present and provide the supportive documentation necessary to substantiate an approved diagnosis and antipsychotic therapy.
3. Identify and discourage the use of medications that exhausterbate cognitive impairment.
Certain medications are known to to impair cognition and are not recommended in patients over 65. The consultant pharmacist should identify these medications and provide prescriber recommendations discouraging their continued use.
For more information subscribe to our monthly newsletter. March topic, Psychotropics and Dementia Care.
https://www.excelrxconsulting.com/
Medication therapy is one component of healthcare that can directly influence every other aspect of patient care. For residents in a skilled nursing facilities, the consultant pharmacist can be instrumental in identifying unnecessary medications and optimizing therapy. There are 3 types of medication reviews that a pharmacist can perform for LTCF residents.
The Medication Regimen Review (MRR) is a thorough evaluation of the medication regimen by a pharmacist, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication. The review includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities in collaboration with other members of the interdisciplinary team. Each facility resident should receive a MRR once a month. A MRR should also be performed for residents anticipated to stay less that 30 days.
The Interim Regimen Review (iMRR) is an evaluation of the medication regimen similar to a MRR, but it is performed more frequently. An iMRR should occur if a resident has experienced a change of status. The iMRR is designed to determine if the resident's change in status is medication related.
Lastly, the Complete Medication Review (CMR) is a patient-centered review and consultation of the current therapy regimen. The pharmacist reviews all current medications with the resident, and provides the resident a medication list with consultation points. Prescriber communications are sent as necessary. The CMR is a CMS requirement for Medicare Part-D participants. Eligible members should receive a CMR annually and after being discharged from the hospital.
To learn more, subscribe to our monthly newsletter.
Pharmacy services are a vital component of successful facility operations. The consultant pharmacist plays a key role in overseeing pharmacy services, ensuring regulatory compliance and optimal therapeutic outcomes. Here are 5 things to consider when selecting a consultant pharmacist.
1. Credentials
First, ensure that the consultant pharmacist has an active pharmacy license in the state. Also, search for a consultant that is a Doctor of Pharmacy and a Board Certified Geriatric Pharmacist. Working as a consultant pharmacist requires specialized clinical skills. Pharmacist with the additional clinical training and certifications have been trained to provide a different level of clinical service. Consultant pharmacists should carry a license card with them. License eligibility can also be verified on the Texas State Board on Pharmacy website at http://www.pharmacy.texas.gov/dbsearch/pht_search.asp. Facilities can also search for a Board Certified Geriatric Pharmacist on the Board of Pharmacy Specialties website at https://www.bpsweb.org/find-a-board-certified-pharmacist/.
2. Regulatory Knowledge
Facilities depend on the consultant pharmacist's report and recommendations to maintain or improve compliance. The consultant pharmacist should not only be a resource for clinical information, but for regulatory information as well. Look for a consultant pharmacist that can demonstrate an advanced knowledge of the CMS State Operations Manual and the Interpretive Guidelines. A facility can test a consultants knowledge by presenting regulatory questions and evaluating the consultants ability to provide an accurate and prompt response.
3. Strong Communication Skills
The consultant will need to communicate directly with administrators, physicians, nurses, medication aides, surveyors, and residents. Look for a consultant pharmacist that can demonstrate effective written and verbal communication. Consider scheduling a meeting with the consultant and request a service presentation. This will provide an opportunity to evaluate the consultants ability to clearly and concisely communicate.
4. Insured and Immunized
Consultant pharmacist are often contracted workers, and not facility employees. Ensure that the consultant pharmacist has active liability insurance. Since they have access to residents, also ensure the consultant pharmacist is current with his/her immunizations and has been screened for TB. Have the consultant present proof of insurance, an immunization record and TB screening results that can be filed accordingly.
5. Emotional Intelligence
A consultant pharmacist's clinical and regulatory knowledge is really only as useful as his or her ability to understand people and to collaborate with others. Self-awareness, motivation, and empathy are key components of emotional intelligence. Ask the consultant, who inspires you and why? What are your company's cores values? How would you work with the facility to understand or carry out a shift in needs? His/her response can help you determine if the consultant is self-motivated and if his/her priorities align with your facility.
Author, Adrienne Bridges Pharm. D, BCGP
Consultant pharmacist services are a CMS requirement. Often service contracts specify a 12-month duration with an option to automatically renew annually. The auto-renewal option is convenient for the consultant and the facilities. However, as a consultant pharmacist, I would strongly encourage facility executives and administrators to annually review the consultant pharmacist performance before renewing a service contract.
When I visit a facility for the first time I always ask for the pharmacy binder and review the previous consultant's summary and recommendations. Unfortunately, I often find an incomplete binder, vague reports or few recommendations. When I provide the corporate summary and recommendations for the facility, I often hear, "We did not know!"
Before renewing a service contract, ask the following questions.
1. Does the consultant pharmacist consistently review medication storage and administration?
The consultant pharmacist should be reviewing medication storage in the medication rooms and carts routinely. The consultant pharmacist should also perform medication pass observations to assess the medication pass error rates.
2. Does the consultant pharmacist perform a chart review for each resident every month?
According to CMS State Operations Manual Appendix PP, "The pharmacist performing the monthly MRR must also review the resident’s medical record to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated." With this in mind, generally speaking, most facility will have more that 15 recommendations per month. In addition, CMS has also indicated that it should take a consultant pharmacist approximately 20 minutes per MRR. Meaning, a facility with 100 resident should require about 33 hours of charting.
3. Are your reports submitted in a secured manner and in a timely fashion?
Effective November 28, 2017, each facility should have a policy and procedure that specifies the manner and timeframe in which MRR reports should be submitted. MRR reports include HIPAA secured information. These reports should be sent in a HIPAA secure manner, such as HIPAA secure faxing or encrypted emails. The timeframe for submitting these reports will help ensure timely responses to recommendations. The new interpretive guidelines also specifies that the consultant pharmacist should send the MRR recommendations to the medical director and attending physician directly. The facility must ensure that the medical director and attending physician contact information is readily available and current.
4. Are dangerous drugs and controlled substances being properly destroyed?
Dangerous drugs that are to be destroyed should be documented appropriately and stored in a secured bin for destruction. Controlled substances that are to be destroyed should be documented appropriately and secured separately from dangerous drugs in a doubled locked, permanently affixed storage compartment. The inventory sheets for destruction should include all legally required information. It is a good practice to destroy medications each month to avoid the risk of diversion and non-compliance.
5. Does your consultant provide training and development resources, and participate with QA meetings?
According to the CMS State Operations Manual Appendix PP the consultant pharmacist should identify the facility educational/informational needs about medications and provide credible information resources to the facility. The consultant pharmacist should also interact with the quality assessment and assurance committee to develop procedures and evaluate pharmaceutical services.
6. Did your facility have pharmacy service deficiencies on your last survey?
The consultant pharmacy should assist the facility in identifying and reducing the risk for pharmacy service deficiencies before the facility receives a tag. Please note, once a deficiency is identified, correcting the deficiency is a process and can take some time.
Facilities can evaluate their current consultant pharmacist services at any point during the service contract. If you determine that you are no longer satisfied with your consultant pharmacist services, consult your attorney for legal advice, most contracts have a 30 day written notice of termination option.
Several changes to the CMS Interpretive Guidelines became effective November 28th, 2017. Find out how these changes affect pharmacy services, and how to ensure that your facility is compliant.
Drug Regimen Reviews
The consultant pharmacist must perform a Drug Regimen Review for each resident each month. The DRR must be sent to the attending physician, director of nursing, and the medical director. The facility should have a policy that addresses procedures for DRR notifications, responses, and timeframe.
Psychotropic Drugs
Psychotropic drugs have been defined as any drug that affects brain activities associated with mental processes and behavior. PRN psychotropic medication orders should be limited to 14 days. There is an exception if the prescriber provides and documents a clinical rational for the extension, indicates the extension is medically appropriate, and specifies the duration of the extension. PRN antipsychotic medication orders should be limited to 14 days. These orders cannot be extended beyond 14 days. If continued therapy is needed, the resident must be seen by the prescriber and a new order must be written.
Infection Control Program
Facilities must establish an infection prevent and control programs, which should include an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. The CDC has developed implementation resources including "Core Elements for Antibiotic Stewardship in Nursing Homes". See the link below.
https://www.cdc.gov/longtermcare/pdfs/Factsheet-Core-Elements-Leading-Antibiotic-Stewardship.pdf
Revised F-Tags
The CMS revised F-Tags became effective November 28, 2018. The links below are two CMS resources to outline the changes.