F425 Update
Medication Regimen Review (MRR)
for Short Term/Short Stay and
Residents who Experience
Significant Decline/Change in Condition
Presented by:
Dr. William C. Hallett, Pharm.D., MBA, CGP, C-MTM
President/CEO
Guardian Consulting Services, Inc.
whallett@guardianconsulting.com
F425 Update
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Presented by: Dr. William C. Hallett,
Pharm.D, MBA, CGP, C-MTM
Let’s get right into it….
Text of F425 Guidance
F425 requires that the facility work with the Consultant Pharmacist to:
 “Establish procedures that address medication regimen reviews for
residents who are anticipated to stay less than 30 days; or
 when the resident experiences an acute change of condition as
identified by facility staff.”
F425 Update
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Presented by: Dr. William C. Hallett,
Pharm.D, MBA, CGP, C-MTM
Text of F425 Guidance, continued…
“Facility procedures should address
 how and when the need for a consultation will be communicated,
 how the medication review will be handled if the pharmacist is offsite,
 how the results or report of their findings will be communicated to
the physician,
 expectations for the physician’s response and follow up, and
 how and where this information will be documented.”
Guidance issued: December, 2006
F425 Update
4
Presented by: Dr. William C. Hallett,
Pharm.D, MBA, CGP, C-MTM
Why the focus now on guidance that
was issued over 6 years ago?
CMS Memorandum S&C 13-02NH – Guidance Related to
Medication Errors and Pharmacy Services
 Issued to all State Survey Agency Directors on November 2nd, 2012
 Targets 7 specific areas in Pharmacy for increased survey focus
 Specifically cites Medication Regimen Reviews for Stays under 30
days and Changes in Condition:
“The requirement for the medication regimen review applies to
all residents, including residents receiving respite care, residents at
the end of life or who have elected the hospice benefit, residents
with an anticipated stay of less than 30 days, or residents who have
experienced a change in condition.”
F425 Update
5
Presented by: Dr. William C. Hallett,
Pharm.D, MBA, CGP, C-MTM
Why the focus now on guidance that
was issued over 6 years ago?
It all comes back to Preventable Hospitalizations.
The expectation of CMS is that, for New Admissions, the Consultant
Pharmacist can identify:
 Poorly or incorrectly written orders and other “reconciliation” issues
 Important Meds ordered with no monitoring parameters
 Incorrect dosing based on age, weight, renal function, etc.
For Change of Condition:
 The Consultant Pharmacist should evaluate for Medications that
may be inducing the change and recommend changes before the
resident gets expensive tests, consults, or ER visits!
F425 Update
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Presented by: Dr. William C. Hallett,
Pharm.D, MBA, CGP, C-MTM
New Admission Medication Regimen Review (MRR)
The Issue:
 Scenario 1: Resident admitted to Unit on the 1st, discharged on the 20th,
monthly MRR occurs on that Unit on the 23rd.
 Outcome: Resident missed, no MRR performed.
 Scenario 2: Resident admitted to Unit on the 1st, discharged on the 20th,
monthly MRR occurs on that Unit on the 17th.
 Little to no value to the MRR review!
CMS does not specify exactly when the MRR must be performed
during a short stay, just that it must be done.
Logic dictates the sooner the better.
F425 Update
7
Presented by: Dr. William C. Hallett,
Pharm.D, MBA, CGP, C-MTM
New Admission Medication Regimen Review (MRR)
Best Practice:
 Develop a system where the Consultant Pharmacist reviews
New Admission Orders within 1 to 3 days of admission.
 Leverage Technology:
 Log in to EMR or Pharmacy Vendor System remotely to access
Med Profile and perform Medication Regimen Review (MRR)
 Communicate Findings via email to DNS, cc the
ADNS/Supervisor, Medical Director and Administrator
 Understand the “Time Sensitive” nature of these MRR’s
 By nature, these require immediate attention
 Insist on 100% response rate within 24-48 hours of receipt!
F425 Update
8
Presented by: Dr. William C. Hallett,
Pharm.D, MBA, CGP, C-MTM
New Admission Medication Regimen Review (MRR)
Best Practice, continued….
 Understand the “cost” of failing to address these MRR’s
Promptly
 Survey Implications: A system was implemented, but it did not
meet the intent of F425, which calls for the following:
“….how the results or report of their findings will be
communicated to the physician, expectations for the
physician’s response and follow up, and how and where this
information will be documented.”
 Another Survey (and also Medical-Legal) Implication
 Failing to address promptly may result in actual, avoidable harm!
F425 Update
9
Presented by: Dr. William C. Hallett,
Pharm.D, MBA, CGP, C-MTM
New Admission Medication Regimen Review (MRR)
Best Practice, continued….
 Why send MRR findings and recommendations via email?
 Provides a time and date stamp of when the reviews were
performed
 Quickly and easily retrievable in the event it is questioned during
Survey
 Consider using a simple Cover Letter, and attach findings
 Cover letter should clearly indicate the purpose of the review, the
names of any residents for whom new reviews were performed,
and whether or not there were recommendations for that
resident.
F425 Update
Sample Email Cover Letter
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Presented by: Dr. William C. Hallett,
Pharm.D, MBA, CGP, C-MTM
F425 Update
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Presented by: Dr. William C. Hallett,
Pharm.D, MBA, CGP, C-MTM
New Admission Medication Regimen Review (MRR)
Common Findings of New Admission MRR’s
 Narrow Therapeutic Index Drugs ordered with no monitoring
(e.g., Coumadin, Dilantin, Digoxin, Carbamazepine)
 Inappropriate or poorly written insulin or sliding scale insulin
orders
 Inappropriate route of administration (e.g., a non-crushable
ordered via G-Tube)
 (Often expensive) medications for acute conditions written
without stop dates
 Drug-Disease State interactions or contraindications
 Medication Cost Issues
F425 Update
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Presented by: Dr. William C. Hallett,
Pharm.D, MBA, CGP, C-MTM
New Admission Medication Regimen Review (MRR)
The Unintended (GREAT) Benefit of New Admission MRR’s:
MEDICATION COST SAVINGS
 Most all short stay admissions (and in some facilities, most
every admission) comes in under Medicare Part A or an HMO
 This means that the facility is responsible for 100% of the drug costs
 New Admission MRR’s provide the perfect opportunity to quickly
and efficiently
 Identify and make Formulary Changes
 Discontinue Unnecessary Medications right away
 Our internal analysis: The cost savings FAR exceeds the cost of
performing the MRR’s!
 The F425 Requirement is for Short Term/Short Stay – can and
should facilities expand it to ALL admissions, regardless of
intended length of stay?
F425 Update
13
Presented by: Dr. William C. Hallett,
Pharm.D, MBA, CGP, C-MTM
New Admission Medication Regimen Review (MRR)
Best Practice, continued….
 The “Cost Savings” Element reinforces again how TIME
SENSITIVE these MRR’s are – MUST act on them right
away!
 Who can respond to New Admission MRR’s?





Nurse Practitioner
Physician’s Assistant
Medical Director
Attending Physician
Nursing Supervisor, via T/O from the Physician
F425 Update
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Presented by: Dr. William C. Hallett,
Pharm.D, MBA, CGP, C-MTM
New Admission Medication Regimen Review (MRR)
One final important note on New Admission MRR’s:
New Admission MRR’s can not and should not replace
normal monthly Medication Regimen Reviews
 Monthly MRR’s serve as an immediate QA on the New
Admission MRR’s
 Are the reviews being responded to PROMPTLY?
 Are the findings valid, relevant, and being accepted?
 Monthly MRR’s have the benefit of new and more
information, and often lead to additional changes.
F425 Update
15
Presented by: Dr. William C. Hallett,
Pharm.D, MBA, CGP, C-MTM
Supplemental MRR for Residents Experiencing Significant
Decline/Change in Condition
 What defines “Significant Decline”?
 Different than the MDS definition of Significant Change
 Consider a Supplemental MRR to rule out medications as a
cause for an UNEXPLAINED change in condition such as
those listed in F329:
 Recent/multiple Falls
 Weight Loss
 Seizure Activity
 Mood/behavior change
 Constipation/Impaction
 Sleep Disturbance
 Rash/Pruritus
And other unexplained changes
F425 Update
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Presented by: Dr. William C. Hallett,
Pharm.D, MBA, CGP, C-MTM
Supplemental MRR for Residents Experiencing Significant
Decline/Change in Condition
Best Practices
 Tie the process into Morning Report.
 Unexplained Change? Submit a request to your consultant Pharmacist
for review via Fax, email, phone.
 Consultant Pharmacist logs in remotely to your EMR or Pharmacy Vendor
System, performs review, and emails response.
 Look for a 1 business day turnaround on Supplemental MRR
Requests
 Request a response regardless of the outcome of the review.
Possible responses include:
 Highly likely to be caused by a medication, consider change
 Possibly likely to be caused by a medication, consider change
 Unlikely to be caused by a medication, consider other causes
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F425 Update
Presented by: Dr. William C. Hallett,
Pharm.D, MBA, CGP, C-MTM
Questions and Answers
Thank you!
Dr. William C. Hallett, Pharm.D., MBA, CGP,
C-MTM
whallett@guardianconsulting.com