Meeting Minutes
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October 14, 2013
I. Congrats to our new liaisons
Vivian Hong and Nhu Nguyen!
II. Upcoming events
a. Speaker event with Dr. Alan Bell
i. Oct 24
ii. 6:00 – 7:30 PM
b. Omnicare Tour
i. Nov 6
ii. 1:00 – 3:00 PM
Consultant Pharmacy Practice
Mark Sey
October 14, 2013
Definition - Who is a Consultant
Pharmacist?
A pharmacist who is compensated to provide
expert advice on the use of medications by
individuals or within institutions, or on the
provision of pharmacy services to institutions.
 Originated in the nursing home environment
 ASCP focus - defined by their common
commitment to enhance the quality of care for
all older persons through the appropriate use
of medication and promotion of healthy aging.
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The Right Answer
YOU !
Today’s Discussion
Evolution of Consultant Pharmacy
 American Society of Consultant
Pharmacists
 Senior care environments
 Key long-term care professionals
 Senior care pharmacy practice
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Evolution of Consultant Pharmacy
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1965- Medicare/Medicaid
– Drug regimen review required by charge nurse
and prescribing MD working together
– Consultant Pharmacist responsibilities for drug
distribution
1969 – ASCP Established
 1974 – DRR required by pharmacists in NF!
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Evolution of Consultant Pharmacy
1982 - Indicators developed to help
surveyors assess DRR
 1980’s – Consultant pharmacists showed
their stuff!
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– Practice roles more clearly defined
– Consultant’s effectiveness documented
Decreased inappropriate drug use
 Fewer ADR’s
 MD’s accepted CP recommendations
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Evolution of Consultant Pharmacy
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“Success Breeds Success” Increased mandate for
consultant’s services
1987 - Pharmacist review mandated in ICF
1988 - Pharmacist quarterly review mandated in
ICF-MR
Pharmacists published their work in Consultant
Pharmacist
People took increasing awareness of consultant
pharmacists
American Society of Consultant
Pharmacists (ASCP)
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8,000 members
Numerous State chapters
National meetings – May and November
Well-respected and informative web site
Website:www.ASCP.com
Website:www.seniorcarepharmacist.com
Embraces interdisciplinary initiatives
Supported development of Commission for
Certification in Geriatric Pharmacy (CCGP)
The Continuum of Care
Caregiver Skills
High
Low
High
High
Hospital
Nursing
Facility
Assisted
Living
Low
Acuity
Cost
Subacute
Home
Health
Care
Low
The Senior Market
34.3 million individuals 65 years old and older
Nursing homes
1.8 million residents Assisted living
1.8 million residents
Other elderly
10.2 million
residents
Home care
3.5 million beneficiaries
Community-based LTC
8.5 million individuals
NORCs
8.5 million residents
Nursing Facilities
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The traditional LTC environment in the U.S.
Provide care using a “medical model” that is
somewhat analogous to hospitals
Approximately 2/3 of NFs are operated for-profit
~1/2 are operated by chains –
9% bed growth compared in 2010 compared to
2009
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HCR ManorCare, 38,000+ beds; 283 facilities
Golden Living, 33,000+ beds; 332 facilities
Life Care Centers of America, 31,000+ beds; 221 facilities
Kindred Healthcare, 29,000+ beds; 231 facilities
Nursing Facilities
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Total number of beds 1,725,326
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Medicare 77,023
Medicare/Medicaid 1,413,951
Medicaid 186,086
Noncertified 48,266
Resident payer sources
– Medicaid 65%
– Private/other 22%
– Medicare 13%
Nursing Facilities
200 beds or more
8%
100 to 199 beds
41.8%
Fewer than 50 beds
12%
50 to 99 beds
38.7%
Typical NF Patient Flow
Hospital
• Patient seen in ER for work-up
• Patient may be admitted to qualify for Medicare
Part A
• Patient worked up based on hospital criteria
• Treated and stabilized
• Set for discharge
• To nursing facility after
initial admission or
• Return to nursing facility
after brief hospitalization
Discharge
to home or
assisted living
Rehab
Short
Stay
• Return to
hospital for
acute event,
eg, fracture,
symptomatic
A-fib, etc
Long
Stay
• If needed, NF residents
will usually need to visit the
specialists
• NF attending physicians and selected
geriatric specialists see residents in
the facility
Nursing Facility
Focused View of NF Resident
• Nurses continually
monitor resident’s
health status
through the plan of
care
• Nurse
Practitioners
may see
patients for the
physician group
Nurse
Nurse
Practitioner
Rehab
Short
Stay
Rehab
Long
Stay
• Medical Directors
need to make the
best medication
choices for their
patients
Medical
Director
• LPNs need to know
how to manage NF
residents
• Consultant
Pharmacists
regularly review
medications
Nursing Facility
Consultant
Pharmacist
LPN
Assisted Living Facility Models
Hospitality
Model
Personal Care
Model
NF Alternative/
Replacement Model
Assisted Living Target Market
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75-85 years of age
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mostly female
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$25,000 income (supports $1,6001,750/month using 75-85% of resident’s
income)
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2+ ADL support
Typical AL Patient Flow
• Residents may come
from the community
or move back to the
community for
various reasons
• Resident may visit
Attending Physician,
or Attending Physician
may visit facility
Community
Attending
Physician
• If resident
becomes less
independent
or needs
short-term rehab
Nursing
Facility
Hospital
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•
Assisted
Living Facility
Patient seen in ER for work-up
Patient may be admitted
Patient worked up based on hospital criteria
Treated and stabilized
Set for discharge
• Resident usually visits
specialist. Specialists
rarely visit assisted living
facility. Resident would
see specialist for
monitoring of medications
Specialist and therapies
“The goal of assisted living is
to keep them in assisted living.”
Nursing Director National
Assisted Living Provider
Assisted Living vs.
Nursing Facilities
 Nursing
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Facilities
Elderly population
Multiple medical dx
Multiple medications
Federal regulations
Skilled staff
Mandated DRR
 Assisted
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Living
Elderly population
Multiple medical dx
Multiple medications
Regulated by State
Less skilled staff
DRR mandate varies
Key LTC Professionals
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Administrator
Medical Director
Attending Physician
Consulting Physician
Nurse Practitioner/ Physician’s Asst.
Nursing Staff
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Director of Nursing (DON)
Charge Nurse, Head Nurse
Nursing Supervisor
MDS Nurse
Staff Nurse
Nurse Aides
Key LTC Professionals
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Pharmacists – consultant and dispensing
Therapy Staff (physical and occupational
therapy)
Dietitian
Activity Directory
Social Services
Geriatric Case/Care Managers
Staff development coordinator
Family members
LTC Pharmacy Landscape
OmniCare 1,400,000 NF/ALF beds
 PharMerica Corp. 360,000 NF beds
 Regional pharmacy providers
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– Green Tree, South Central Illinois
Smaller pharmacy providers
 New, evolving provider and consultant
companies, some specializing in AL
 Independent consultant pharmacists
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LTC Pharmacy Services
Drug Distribution
Services
Consultant Pharmacy
Services
Pharmacy Providers Services
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Efficient and accurate distribution
– Emergency kits
– medication administration record
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Standardized services between facilities
Improve pharmaceutical care
– formulary
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Pharmacy providers influence market share
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Consultant pharmacists recommendations
Formulary preferred products
Disease management initiatives
Educational initiatives
What is a Consultant
Pharmacist?
A patient advocate for best clinical care
 Licensed by state to practice pharmacy
 No degree requirement
 No specific credentials required by most
States
 Typically involved in many activities
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LTC Pharmacists
Employment Model
LTC Pharmacists
Practice Involvement
Consultant Pharmacist’s
Domain
Pharmaceutical care
 Medication-related problems
 Appropriate use
 Medication Regimen Review “MRR”
 Anything drug-related
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– Side effects, dosage, switch to alternative
products, monitoring, add drug for untreated
indication, etc.
Pharmacists
Practice Activities
Medication Regimen Review
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Resident-specific
Pharmacist-conducted
Required in all NFs as a Medicare/Medicaid
Condition of Participation and by OBRA ‘87
Performed at least monthly
Retrospective or prospective
Encourage appropriate medication use
Provide optimal Pharmaceutical Care
Components of Effective
Medication Regimen Review
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Interdisciplinary
Concise
Accurate
Neat
Non judgmental
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Well documented
Evidence-based
Referenced when
necessary
Follow up included
MRR Challenges for
Pharmacists
Adequate training
 Clinical skills and experience
 Exploding knowledge base
 Recognition/Cooperation
 Adequate reimbursement
 Work load
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Thank-you!