Long-Term Care-Developing a Medication Management Program for Assisted Living (ALFs) and Long Term...

Long-Term Care-Developing a Medication Management Program for

Assisted Living (ALFs) and Long Term Care Facilities(LTCFs)

James W. Cooper, Jr, RPh, PhD, BCPS, CGP, FASCP, FASHP, Emeritus Albert W. Jowdy

Professor and Consultant Pharmacist, College of Pharmacy and Gerontology Faculty, University of

Georgia and formerly Clinical Assistant Professor of Family Medicine, Medical College of Georgia

Goal: Overview components of medication management systems

Objectives:• Discuss the importance of pharmacists

getting involved in providing consultative cognitive services to LTCFs/ALFs

• Describe the types of services a consultant pharmacist could and should be providing to LTCFs/ALFs

Objectives- cont’d

• List advantages and disadvantages of various medication packaging systems and services

• Discuss the differences between Medication Management and Pharmacy Wellness Programs

• Review ASCP’s (American Society of Consultant Pharmacist’s) ALF Model State Language

Objectives- cont’d

• Discuss how to better utilize the ASCP-approved Guidelines for Providing Consultant and Dispensing Services to ALF residents

• Illustrate how to handle problems/ obstacles/issues that are frequently encountered in, and systems and forms needed for developing Medication Management Programs for ALFs

Overview of LTCF and Assisted Living Industry

• Statistics : It is estimated that there are between 40,000 and 65,000 assisted living facilities (ALFs) in the USA, with between 3-4 million beds or twice the no. of LTCF nursing facility (NF) beds.The ALF industry is largely un-regulated

• At least one in 5 ambulatory older adults gets an inappropriate drug (JAMA 2002) and ADRs occur in 2/3 of LTC residents over a 4 -yr. Study ( Cooper JAGS, 1996); one in 7 results in hospitalization (Cooper SMJ, 1999) in ambulatory population

Assisted Living Types

• Please raise your hand if you have serviced an assisted living facility, nursing home or independent living facility!

• Assisted living has many types and names: Congregate housing independent living, assisted living, personal care homes, etc.

• Basic purpose of ALFs- delay or prevent nursing home placement!

Recognizing the Overall Challenges

• Lack of uniformity– Among ALFs– Within an ALF

• Pharmacy providers

• Type of resident

• Services provided

• Pay type

• Lack of understanding– By physicians – By administration,

residents, families

• Lack of communication– Between health care

providers, and with residents

• Lack of consistent regulations

• Lack of similarity between ALF/NFs

• Lack of ‘taking ownership’ of potential drug-related problems (Fosamax example)

Recognizing the Medication Use Challenges • Medications may be:

– Administered by staff (licensed, unlicensed)– Self-administered by resident; assisted by staff– “Set up” by family or friend or staff– Stored by the facility or in resident’s room or both

• Medication administration records and order changes may not be available

• Cognitive decline may occur over time• Typically, no traditional medication pass

occurs• Medical model versus social model

Medication Packaging Systems

• Long-Term Care Facilities (SNFs, ICFs, ICF-MR)-– “Bingo” cards– Vials, stock, etc.

• Assisted Living Facilities (ALFs)– Unit dose– Variation of bingo cards– Vials– Automated systems– Med reminders– Multiple packaging

Vials

Advantages and Disadvantages of Various Medication Packaging Systems

• Traditional vial systems – Advantages: cost, convenience– Disadvantages: safety, labor intensive for

staff, lack of accountability, difficult to monitor compliance, increased cost if many med changes occur, must designate someone to order refills, more responsibility for untrained staff

Advantages and Disadvantages of Various Medication Packaging Systems

• Unit-dose system– Advantages: reduces medication errors;

reduces cost if returns are allowed, convenient for staff, no reorder necessary if routine deliveries (ie. Cart exchange)

– Disadvantages: initially higher cost to patient, costly to pharmacy (carts, labor, inventory, third party payor, packaging equipment)

Unit Dose Medication Cart

Unit Dose Medication Cart

Alternative Unit Dose

Advantages and Disadvantages of Various Medication Packaging Systems

• Multiple medication packaging systems (loose meds in one package for one administration time)

– Advantages: reduces medication errors, particularly if using unlicensed staff; convenient for staff and residents who self-administer

– Disadvantages: potential for increased errors if filling is not accurate; labor intensive for pharmacy; cost

Automated Packaging

Advantages and Disadvantages of Various Medication Packaging Systems

• Automated systems-(ideally record MAR, inform prescriber, nurse or caregiver and pharmacist of patient compliance and drug counts)

• Advantages- cut med errors, provide documentation of drug administration and may record vital signs, other data

• Disadvantages- Cost, cost, cost

Advantages and Disadvantages of Various Medication Packaging Systems

• Multiple medication packaging systems (labeled meds in one package for one administration time)

– Advantages: reduces medication errors, particularly if using unlicensed staff; convenient for staff and residents who self-administer; cost

– Disadvantages: potential for increased errors if filling is not accurate; labor intensive for pharmacy; cost of system

Blister Pack Front

Blister Pack Back

Advantages and Disadvantages of Various Medication Packaging Systems

• Patient reminder systems (plastic containers to pager systems)

– Advantages: maintain resident’s independence; potential for med errors

– Disadvantages: dependent upon person filling container for accuracy; resident must be able to self-administer and able to understand and respond to pager

Considerations for Choosing a System• Safety• Convenience• Frequency of med

changes• Frequency of delivery • Storage space• Size of facility • Staff knowledge level• Ease of use• Timeliness of

packaging, delivery

• Cost – To facility

• Labor • Training• Liability

– To resident• Pay source

– To pharmacy• Equipment set up• Maintenance• Computer upgrade• Number of residents

using system• Labor

The “Real” Problem

Every resident may be using a different system, or combination

thereof….

Epidemiology of Medication Misadventures

• Up to one-third of hospital and one-half of nursing home admissions of older adults are associated with medication problems (Cooper AJHP 1977, Cons Pharm 1987)

• Half to two-thirds of these problems are due to drug misuse; one-third to one-half are due to adverse drug reactions or interactions (op cit.)

Key Factors in Medication Problems

• Drug misuse problems involve lack of patient understanding of their drugs, e.g. name , how to take and purpose of each, as well as improper use due to pre-existing conditions, e.g. aspirin-like drugs with a history of stomach or intestinal irritation or ulcers.

• Adverse drug reactions are associated with patients using too many drugs, seeing multiple prescribers and pharmacists and not taking personal responsibility for meds

ADR Concepts

• Up to 70-80% of adverse drug reactions (ADRs) are preventable by attention to patient history, cooperation between patients, prescribers and pharmacists

• Fewer than one-tenth of ADRs are ever reported per FDA Med Watch Estimate

• Some studies indicate that prescribers recognize or attribute ADRs less than one-fourth of the time when they occur

Drug Misuse Problems

• The main type of drug misuse problem is medication errors!

• There are three main categories of errors: prescribing, dispensing and administration errors

• The most common errors are in drug administration, whether by the patient themselves, their caregivers or licensed personnel

Factors in Administration Errors

Medication errors in administration can be classified as known or unknown. While 100 percent reporting of known errors may occur, this is only the tip of the iceberg. While up to one-fourth of doses may be given in error with traditional floor stock/individual prescription systems, this error rate may be reduced to 3 to 20 per cent of doses with unit dose systems that include pharmacist monitoring, and increased nurse or caregiver supervision of administration.

Factors in Administration Errors

• The application of Murphy’s Law:

• Anything that can go wrong, will go wrong is the key factor

• The best system minimized the chances for errors at the lowest cost!

• The Federal standard for serious medication error rate is zero tolerance!

Problem Areas in LTC & ALF Drug Use

• Multiple drug providers.• Incomplete, missing pharmacy

dispensing records or failure to supply pharmacy dispensing records to the consultant.

• Incomplete or incorrect medication administration records (MAR) and chart orders.

Problems with Med Use in LTC/ALFs

• Turnover of nursing or caregiver personnel.• Failure of all personnel to read, comprehend,

and adhere to any policy and procedures or lack of P&P

• Poor compliance with prior consultant recommendations.

• Failure to recognize that a problem exists.

Solutions to Drug System Problems

• A single provider who furnishes an efficient and cost-effective (automated?) distribution system that minimizes facility personnel time, provide adequate records, charges that are accurate, and MAR's that reflect actual usage, and feedback to caregivers and health care personnel when suspected med errors and adverse reactions occur!

Practical Unit-of-Use Systems

• In long-term care or ALFs a 3 to 30 day supply of unit-dose packaging or delivery system (solid dosage forms only) may be most feasible in current practice.

• In order to ensure the most economical use of all resources and minimize medication errors, an automated system should be considered for LTC & ALF drug distribution.

Automated Distribution Systems

• The ideal solution may involve an automated distribution system that provides all mentioned features and:– Reminder to take medication AND

documentation when doses are missed– Electronic interface with the pharmacist

and caregivers or nurses for purposes of refills, documentation of drug use and medication inventory

Existing or Proposed Automated Distribution Systems (websites)

• TabSafe- is the first system to provide both reminders, documentation and electronic interface with caregivers, nursing, pharmacist and physician (TabSafe.com)

• IMD2- Is a dosage cup dispenser filled by a caregiver with med reminder and announcement but no electronic interface (IMD2.com)

IMD2

Existing or Proposed Automated Distribution Systems (websites)

• Medisafe is a small storage container for meds designed for installation within a medicine cabinet. It has code and key entry and tamper light, but is not yet funded for the market (Medisafe.com)

Medisafe

Existing or Proposed Automated Distribution Systems (websites)

• Informedix is a portable telemedicine device that stores a one-month supply of up to 5 different medications. It reminds the user when to take meds, but can not deliver. It records information on health status, side effects and symptoms the patient may be experiencing. Patient must key in the data that is collected and electronically transmitted to the prescriber (InforMedix.com)

Informedix

Existing or Proposed Automated Distribution Systems (websites)

• Sure-Med cabinets (Omnicell.com) are locked, secure cabinets that store drugs and group dispense, provide record keeping, but require a nurse to administer the drug. A common system in nursing homes with a cart delivery system. Opus.com and Pyxis.com have similar systems. This is a throw back to the older Brewer system of dispensing cabinets.

Omnicell

Existing or Proposed Automated Distribution Systems (websites)

• (CompuMed.com) is a locked storage tray filled by a caregiver, with manual keypad setup by the caregiver and a simple button release for dispensing meds. No documentation nor electronic transfer.

• A review of med errors, distribution systems, error factors and solutions is presented-next lets consider patient contact activities!

CompuMed

Personal Pill Reminders

• The following sites provide personal medication organizers, reminders and other aides to safe med use:

• zelco.com

• medose.com

• epill.com

• medportinc.com

Drug Regimen Review (DRR)-Now Medication Regimen Review in LTCs & ALFs• DRR/MRR has been mandated in LTCs

since 1974- two types: retrospective (after Rx filled) and prospective (Fleetwood Model) as Rx is filled

• DRR/MRR is not currently mandated in ALFs, but preliminary evidence is that there are just as many med errors and ADRs in ALFs as in LTCs

MRR Purpose and Methods

• MRR is intended to verify drug administration as ordered, detect med errors and ADRs, and appropriate as well as inappropriate drug therapy that can lead to ADRs

• MRR methods vary: Simplest approach is to have as complete a list as possible of all patient problems to include diagnoses, conditions, past ADRs, and operations

MRR Methods

• Match all current drugs to the problem list, realizing that there will be duplications and omission, as well as drugs for which there may not be a problem

• For each problem are there patient signs and symptoms that can be assessed (S=subjective findings)

MRR Methods

• Next, are there drugs, physical or lab findings that assess drug effect? (O=objective findings)

• A=Assessment of S and O findings to determine if the problem is adequately treated and if there is any further information needed to complete the-->

• P=Plan for follow-up and recommendations

Case

• JT is a 84 yo female ALF resident with problems of GERD, PUD, and HBP - the SOAP of GERD/PUD/HBP is:

• S=pt. C/o occasional nausea and night-time awakenings with heartburn

• O=pt. Taking , ranitidine 150mg HS, celecoxib 200mg QAM, HCTZ 25mg and ASA 81mg/day.Diet ad lib.

SOAP of GERD/PUD/HBP

• O=Her stools are dark, lower eyelids pale , Hgb has dropped from 12->9 over past 3 months and her BPs have increased from 118/68->162/100 and has gained 11 lbs and has 1-2+ pedal edema since celecoxib started

• A= Celecoxib + ASA has caused gastric blood loss and pt. Has high risk of acute GI bleed. Ranitidine does not prevent and both BP and edema wt. gain increases attributable to Celebrex

Plan for GERD/PUD Problem

• Plan is to recommend stopping celecoxib and ranitidine, start APAP 650mg QID and rabeprazole 20mg daily. Weight and BP daily for two weeks; raise legs 2 ft. above heart for 1/2 hr daily. Restrict sodium to 2g diet. If BP not <130/85 & edema and 5-7 lb.wt. Loss does not occur within 2 weeks, change HCTZ to furosemide 10mg/day . Add FeSO4 325mg with 500mg Ascorbic acid daily for 30 days and re-ck. Hgb; if not >11, continue Fe for 30 more days.

Drug- Specific Questions for Patients to Ask Health Care Providers for High-Risk Meds:

• If you are taking NSAIDs such as ibuprofen, naproxen, Feldene, Daypro, Lodine, Relafen etc. on a regular basis, you may want to ask if Prilosec, Prevacid, Protonix, Aciphex or Nexium will lower your risk of GI problems.All the prior NSAIDs and Celebrex or Mobic may ALSO cause high blood pressure, heart failure or kidney problems!

Celebrex,Mobic or any NSAID Cautions

• Be sure to weigh daily when first taking either drug

• Report a 5 pound or more weight gain and watch for fluid retention in your legs and/or feet to your Dr. and pharmacist

• Check your blood pressure- if >130/85 or you are taking drugs for high blood pressure or heart failure, please check with your pharmacist and doctor

Drug- Specific Concerns for Patients Taking High-Risk Medications:

• DO NOT take low-dose aspirin without your prescriber’s approval and you should have a GI-protecting drug (PPI A). If you are taking Celebrex or Mobic you may have less risk of GI problems but still need aspirin protection for , heart, and brain problems as these drugs do NOT thin the blood!

NSAID Alternatives

• If you are taking NSAIDs you may ask if acetaminophen (APAP,Tylenol) may be safer for you, IF YOU DO NOT DRINK ALCOHOL as well as glucoseamine and chondroitin and/or topical ketoprofen gel for your osteoarthritis.

• If you are taking Fosamax, Boniva or Actonel- you especially need stomach protection with ASA or NSAIDs and you need to ask about weekly use!

NSAID Alternatives (cont’d)

• If you have a history or risk of heart attack-(MI)--or stroke (CVA) your primary care provider may recommend low-dose aspirin or prescribe drugs like Plavix to protect your heart and brain.

• Tylenol is safer for your arthritis than any NSAID, provided that you do not consume alcohol.

Fall Risk - Medication Risk Reduction Questions

If you/your care receiver are taking drugs such as Mellaril, Haldol, Risperdal, Seroquel , Geodon or Zyprexa, has your dose been reduced in the last 6 to 12 months or a tapering trial without the drug been attempted? Has a fall or fracture occurred?

Fall Related Questions Cont’d

If you are taking drugs for anxiety or sleep such as Valium, Tranxene, Librium, Doral, Paxipam, Xanax, Centrax more often than every week, ask your doctor for a shorter-acting version such as oxazepam or zolpidem (Ambien) for sleep or buspirone (Buspar) or Lexapro or Zoloft for anxiety.

Fall Related Questions Cont’d

Are you taking antidepressants such as amitryptyline (Elavil) or doxepin for

mood, sleep or pain ?

If so, have you fallen or had a fracture? Are there safer , newer drugs in this group ? (Zoloft, Paxil, Celexa, Lexapro in AM, or trazodone at bedtime only)

Cognition enhancing Drugs-Namenda, Aricept, Exelon and Razadyne

• If you are taking any of these medications, please be sure that you let your pharmacist or doctor know if you have any trouble sleeping, heartburn or GI upset to diarrhea, glaucoma, or leaking of urine

• Some medications may not work well with these drugs-keep a list of all prescribed and OTC drugs

Decongestants should be avoided!

• If you are taking anything with Sudafed and have high blood pressure, diabetes, heart attack or stroke or impaired kidney--- DO NOT TAKE THESE DRUGs!

• Some products that contain one of these decongestants include Acitfed, Allegra-D, Claritin-D, Afrinol-LA, and any cold or allergy drug that ends with a D-.Even topical decongestants (Afrin) may be dangerous!

Diabetes Drug Questions

If you are diabetic and using insulin or oral drugs, ask your Dr. about insulin “enhancers” such as Glucophage, Actos, Avandia or Precose or Glyset to lower your insulin needs. If you are diabetic and have a history or heart attack or stroke, you may need to take a beta blocking drug to protect your heart and/or brain. If you get low blood sugar you may not feel shaky or nervous-watch your fingerstick readings if you are taking one of these drugs and are under tight control (Cooper Diabetes Care 1998). You also need to get your lipids and thyroid checked!

Heart, High Blood Pressure and Circulation Questions• If you are taking any medication for your heart,

HBP or circulation, be sure you take your BP and pulse on a regular basis and report to your primary care provider (PCP) any consistent abnormal readings.-please DO NOT TAKE any drugs for arthritis e.g. ibuprofen, Celebrex or Mobic without checking with your pharmacist or doctor-If you are taking any blood thinners such as Coumadin or aspirin, Plavix or Ticlid you will need to have your blood checked on a regular basis- DO NOT consume alcohol or pain-medications without your PCP’s approval.

Heart failure drugs

• If your have congestive heart failure, you may be taking drugs such as Lanoxin, Lasix, Capoten, Diovan, Coreg and Aldactone.Please be sure to weigh daily and watch for any fluid weight gain of 5 pounds or more- this is of vital importance if you start on an arthritis drug such as Celebrex, Bextra or Vioxx or diabetes drug like Actos or Avandia

Cholesterol Check

• If you have not had your cholesterol checked, ask to have this test from your doctor or pharmacist-

• If you have chest or leg pain on walking, or blackout spells or have had a heart attack or stroke----->It is very important that you have your cholesterol not only checked, but lowered with a drug such as Vytorin, Lipitor, Pravacol, Zocor, Mevacor or Lescol if you have any of these problems-you may also need to be taking aspirin if your doctor recommends this drug.

Depression Check

• Do you feel “down” for more than a day or two at a time?

• Do you sleep too little or too much?• Do you not enjoy things that used to give you

joy? Has your appetite or weight changed much in the last 6 months to a year?

• Have you had any illnesses or loss of love ones that keeps you sad for more than two weeks?

• Do you have someone you can talk to about these losses?

Cancer Check

• Do you have any of the 7 warning signs?- change in bowel or bladder habits?

• A sore that does not heal?• Unusual bleeding or discharge?• Thickening or lump in breast, testicle or elsewhere?

Indigestion of difficulty swallowing?• Obvious change in a wart or mole?• Nagging cough or hoarseness?• Do you see a doctor at least yearly?-have a female

or male exam?• Men- PSA yearly?- Both Sexes Sigmoidoscopy

every 3 to 5 yrs. After 50

Cancer Check Cont’d

• Women- do you do a monthly breast exam, annual mammogram and pelvic with Pap test annually? This is critical when taking any estrogen or progestin product

• Both sexes-if fair-skinned, do you have a dermatologist inspect sun-affected areas every year?

Eyes, Ears and Throat Drugs

• Have your eyes checked at least yearly?• If you have glaucoma, be sure to check how

your drops are put in each eye and squint or squeeze the bridge of the nose for 30 seconds after each dose

• If you have dry eyes-or eye infections ask your pharmacist for a tear substitute eye drop (Liquifilm tears)

Eyes, Ears and Throat DrugsCont’d

• Have your ears checked by someone close to you- – If there is any excessive wax, ask for an

ear cleansing solution ( Debrox)

• If you have stuffy nose- do not use oral decongestants or nose sprays like Afrin if you have high blood pressure, angina, TIAs or Hx of heart attack or stroke

Throat and Breathing medications

• If you have a sore throat, check for fever and tenderness underneath your jaw- see your doctor if both are present

• If you have an ear ache-be sure to check your throat

• If you have asthma, bronchitis or emphysema, be sure you know which drugs you need to take to help your breathing

• Also be sure you know which drugs you can use for sudden shortness of breath

Osteoporosis

• Be sure that you are taking at least 1500 mg of calcium per day and 400 units of vitamin D

• Ask your doctor, nurse or pharmacist about drugs to preserve bone strength

• If you are taking hormones (Premarin, Estrace) for osteoporosis, be sure that you have a mammogram and female exam at least yearly or more often- you should stop by age 60.

• You can not take hormones past 60-ask about Fosamax, Boniva, Actonel, Micalcin or Evista

Other Hormones

• If you are taking thyroid, ask to have your tests checked yearly- if you did not have blood work before your thyroid was prescribed, ask for blood work after thyroid has been stopped for 4 to 6 weeks

• If you are taking cortisone-like medications such as prednisone, ask about bone and stomach protection

• Do not take alternative or herbal medications without medical advice

Wellness Medication Checklist

• If you are not taking a multiple vitamin and mineral supplement, consider or ask for a recommendation to decrease sick days due to infections. Have you had flu, Pneumonia, Tetanus/diphtheria shots?

• What is your support system- church, synagogue, temple ,mosque, friends, and loved ones?

• Is your diet adequate?

Wellness Checklist Cont’d

• Are you able to exercise daily?

• Do you have someone to talk with about things that bother you?

• Do you have a doctor and pharmacist who know all your medications?

Conclusions

• In the year elderly become progressively to severely disabled a large proportion are hospitalized for a small number of diagnoses, most of which relate to drug use. (Ferruci L, et al JAMA 1997;277:728-34)

• Adverse Drug Rxns (ADRs) are only 1/3 of drug-related admissions; other 2/3 are related to nonadherence to prescribed treatment (Cooper JW, et al. AJHP 1977; 34:738-42)

• How can medication management programs improve drug use among older adults in ALF and LTC facilities?

How can safe medication management programs decrease medication problems?

• Encourage patients to keep a personal record of all drugs prescribed or self-treated, and avoid alternative treatments or supplements unless they are approved by a primary care provider physician or pharmacist. (personal drug checklist)

• Show this medication record to every health care provider utilized- e.g. doctors, dentists, podiatrists, nurses, pharmacists etc.

• Expect each health care provider to review all current drugs and problems before adding another drug.

Pharmacists and Medication Management Systems

• Pharmacists should both develop the safest med management system and have a consultative practice that encourages both wellness and safe medication use!

• The best combination of distributive and clinical consultation activities is determined by the individual pharmacist and their patients needs!

Evaluating the Customer’s Needs

• Who is your customer?– Executive Director– Nursing staff– Resident– Family

• Services can be provided – to the facility– to an individual

Evaluating the Customer’s Needs

• Executive Director– What is the primary reason for residents

leaving your facility?– What is the approximate cost of filling an

empty bed?– What are your top 3 concerns in providing

quality and safety for your residents?– Do you have very many family complaints?

Evaluating the Customer’s Needs

• Be flexible!

• Be prepared to offer suggestions– Correlate medication management to fall

avoidance– Explore reasons for hospitalizations that

could be related to inappropriate med use– If the facility has a dementia unit, are

wandering residents a concern

Evaluating the Customer’s Needs

• Nursing/caregiver staff– Does the current medication management

system assure safety and accuracy of medication administration?

– Are there concerns about medication errors?

– Is drug information readily available?– Is proper documentation being done?

Evaluating the Customer’s Needs

• Resident/Family– What can I do to help you with your

medication concerns?– Are you wondering if your medications can

be reduced, changed, or eliminated?– Are you concerned about drug

interactions?– Are you worried about your medication

costs?

Evaluating the Customer’s Needs

• Resident/Family– Are you certain you are using your

medication correctly to receive maximum benefit? (e.g. proper inhaler technique)

– Would you like to make an appointment for me to meet with you and discuss your specific medications and concerns?

Meeting the Needs of the LTCF/ALF Customer

• After carefully listening to your customer, prepare a written proposal– be specific about services that you can

provide related to each area of concern– as additional information, provide your own

suggestions– include specific costs for services

Meeting the Needs of the LTCF/ALF Customer

• Incorporate outcomes measurement into proposal – Demonstration study in ALF over 6 months

• 23 dosage changes• 10 discontinuations of unnecessary meds• 13 discontinuations of duplicate meds• resulted in cost savings (for all residents) of

$743/monthCrutchfield D. Obstacles to medication monitoring in assisted living

facilities. Consult Pharm 1996;11:506-7.

Clinical Programs

• Asthma/COPD• Diabetes• Hypertension clinic• Lipid screening• Anticoagulant monitoring• Health Fair with other health care

professionals• Home infusion

BE CREATIVE!

“Out of the Box”

• Become involved in infection control plans– promote the importance of immunizations– provide immunizations (reimbursable!)– provide education

“Out of the Box”

• Provide– MMSE (mini-mental state exams), Global

deterioration scales– AIMS (abnormal involuntary movement

scale)– Depression assessments-Yesavaage &

Cornell– Psychoactive medication use assessment

“Out of the Box”

• Falls assessments– Medication related– Environmental causes– Osteoporosis screenings and

interventions- 70% of Fx in LTC are related to a fall

“Out of the Box”

• Visit residents– assess the need for assistive devices (e.g.

arthritis, PD)– ask for demonstration of inhalers, glucose

monitoring devices, application of patches, etc.

“Out of the Box”

• Pain Management– Outcomes based– Improve quality of life– Important to resident and family– Review meds for effectiveness, duplication– Become specialist in pain management

“Out of the Box”

• Expand customer base (caregivers)– Senior Directory– Senior Centers– Church Senior Groups– AARP– Disease Support Groups

• Use the internet– web page– contact caregivers who live out of state

“Out of the Box”

• Contract with HMO to be a case manager for medications– contact physicians to coordinate

medications– develop care plan, involve resident and

family; copy to physician and HMO

• How will the outpatient drug benefit impact these residents????

Sharpen Your Clinical Skills

• Become certified (CGP- go to ccgp.org for info)

• Participate in traineeships• Receive specialty certification

– lipid management– diabetes management – anticoagulation monitoring– immunization administration (ASCP 100%

immunization campaign)

ASCP Assisted Living Resources

• Guidelines for Providing Consulting and Dispensing Services to ALF

• Model State Language for ALF Regulations

• ALF: A Resource Manual for Pharmacists

• ASCP Statement on Admin of Meds in LTC by Unlicensed Personnel

• www.ascp.com/public/pr/assisted/

Websites and References

• www.n4a.org/- National Association of Areas on Aging.• www.agent.com/-AgeNet information and referral designed

to bridge aging parents and their children• www.ascp.com- Excellent source of senior care pharmacy

information, CE and CGP preparation. • www. Cooperconsultantpress.com- two books/courses on

LTC and Geriatric Medication Management .Get Coops Free 164 slide download on pharmacist side and 50 Safe Med slides on patient side and 84 slides on inappropriate meds for the older adult. and freebees under educational materials.

• See http://www.cop.ufl.edu/cpe/ for Coops 15 hour CPE on Lab and Physical Assessment of the Older Adult to Monitor Drug Therapy.

Websites and References

• www.alfa.org- Assisted Living Federation of America

• www.aahsa.org/- American Assoc. of Homes and Services for the Aging

• www.ahca.org/- American Health Care Association

• www.eldercare.com/assisted.html-Elder web is an on-line sourcebook with over 4,000 reviewed links to information.

Summary and Conclusions

• A review of LTC med systems and drug-related problems, as well as wellness screenings and pharmacists interventions has been presented.

• The safest, least expensive system that ensures reliable drug use and assessment is critical to effective senior care!