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Many assisted living residents are there because they need help

managing their medications, and some senior living providers are moving

toward electronic recordkeeping for medication administration in an effort

to become more efficient and improve their care continuum partnership

profile.

PharmaCare “interfaces” with many eMAR software products and we

are able to download the medications into the facility’s database for the

assisted living residents. When asking our customers that have transferred

to using eMARs they agree that there are certainly considerations and

potential hurdles to face, but the outcome is ultimately “worth it”.

Healthcare reform goals include reducing paperwork, administrative

costs, and hospital readmissions. Using eMARs can help with this.

Electronic recordkeeping can also reduce medical errors and improve

quality of care. When assisted living providers begin partnering with

hospitals and other care providers along the continuum, it will become

more and more important to be able to provide data, or “actual,

quantitative evidence” to prove they’re providing quality care.

Electronic mediums to quantify and track what work is done in ALUs

are able to be shared with comprehensive

and cohesive reporting. The results desired

with electronic recordkeeping for medica-

tion management include decreased

medication errors and improved medica-

tion management and Quality Measures

monitoring. Each company considering a transition

into electronic recordkeeping needs to figure out what it is that they’re

looking for as they begin shopping around. Things to consider include:

Using eMARs requires having computers on each medication cart—

primary and backup. What are the community’s wireless capabilities, if choosing an Inter-

net-based (versus server-based) system? Are there “dead zones”? Is it possible to customize a program to fit a particular community? Who will provide both initial and ongoing training (for new hires or

software updates)? Does the facility want bi-directional information, pharmacy to facility

and facility to pharmacy?

When choosing an eMAR software, think about system reliability - how

long has it been in use? - along with how quickly it can be implemented,

the extent of its mobile access (for tablets or smartphones, for example)

and its remote reporting capabilities. Once a system is chosen, there are

still more things to consider and do in the days, weeks, and months prior

to implementation and roll-out. This includes meeting with the

pharmaceutical partner to confirm the process for entering orders into

eMAR database.

There needs to be ‘buy-in” from the administration down to those who

will use it on a daily basis. The eMAR is a tool, but if you’re not using it

properly it’s not going to do what it was intended to do. Tools are only as

good as the people using them, it’s important to make sure staff under-

stands the goals associated with implementing a system.

~ Jill Ashenfelter, RN, CPT, Assisted Living Account Manager

We are dedicated to serving your facility, its staff,

and its residents with the best pharmacy service possible.

If you have any questions or concerns, please contact us.

Skilled Nursing/Assisted Living Pharmacy

Skilled Nursing Pharmacy: Phone - 800.678.1773 (option 3) Fax - 800.272.7109

Assisted Living Pharmacy: Phone - 800.678.1773 (option 4) Fax - 877.445.1035 Steve Lowery, PharmD - Director of Institutional Pharmacy Services

Amy Sines, PharmD - Clinical Services Manager Karen Metcalfe, RN, BC, Quality Improvement Nurse

Jill Ashenfelter, RN, BC, CPhT - Assisted Living Nurse Mgr Krista Barry, CPhT - Nursing Home Accounts Manager

Infusion Pharmacy

Phone - 800.924.6497 Fax - 301.724.1135 Wendy Rice, PharmD - Infusion Pharmacy Manager

Marianne Valentine, RN, BSN, CRNI - Nurse Mgr

Home Medical Department Phone - 800.788.6693 Respiratory Care Team Phone - 301.723.2430

The PharmaCare Network

3 Commerce Drive

Cumberland, MD 21502

Visit us on the web at

www.pharmacarenetwork.com

Assisted Living and Electronic Record Keeping VOL 3 2ND QTR 2014 ISSUE 2

PharmaCare focus ADD R ESSI NG T H E N EED S O F LO NG T ER M C AR E O N E ST EP

AH EAD OF T H E R EST

Breaking a Costly Cycle – Rehospitalization of Skilled Nursing Patients

CLINICAL CORNER - Tramadol CIV The Drug Enforcement Agency and Department of Justice have decided to place Tramadol into schedule IV of the

Controlled Substances Act. The change will become effective for Maryland homes on August 18, 2014. It

is already in effect in West Virginia. This scheduling action requires the regulatory controls and administra-

tive, civil, and criminal sanctions applicable to schedule IV controlled substances on persons who handle

(manufacture, distribute, dispense, import, engage in research, conduct instructional activities with) or

possess or propose to handle tramadol. All LTCF and assisted living facilities will need to obtain an

authorized prescription from the physician as you would obtain for other CIV medications (ex: lorazepam,

alprazolam, etc). Any questions concerning this new change, please do not hesitate to call.

~ Amy Sines, PharmD, Clinical Services Manager

In This Issue

Rehospitalization 1

Clinical Corner 1

PharmaCarePRN 2

Rehosp. (con’t) 2

Hot Topics 3

Hand Washing 3

Ass’t. Living 4

The Patient Protection and Afford-able Care Act of 2010 introduced legislation to specifically address the problem of Medicare expenditures related to beneficiaries who were readmitted to a hospital within 30 days of being discharged. It is estimated that this cost to Medicare totals $17.4 billion annually, with a significant portion of this cost directly attributed to the readmission of patients residing in skilled nursing facilities (SNF). Today, many hospitals attempt to control these costs by focusing attention on reduc-ing the rate at which patients who are discharged into the community, are being readmitted to hospitals. However, many in the health care industry feel skilled nursing facilities may hold the real solutions to reducing readmission costs to Medicare.

Approximately 40% of Medicare patients who are discharged from hospitals are admitted to a skilled nursing or rehabilitation facility to continue care.

Studies suggest that nearly one-fourth of these patients were readmitted from the nursing home back to the hospital within 30 days. In addition, a new study published in the Journal of American Geriatric Society in 2014 found that 22% of patients discharged from a SNF to their home were readmitted back to the hospital within 30 days. These are two major challenges associated with skilled

nursing facility patients that pose one major economic burden to Medicare and for government policymakers and health care reform.

Because the costs associated with treating readmitted patients has escalated into the billions, it should be no surprise that more organizations such as the Office of the Inspector General (OIG) and the Centers for Medicare and Medicaid Services (CMS) are beginning to suggest that skilled nursing facilities “should be better monitored by the federal govern-ment when it comes to how frequently they send patients back to the hospital”. It has even been recommended by the OIG, that CMS develop quality measures to track and report hospitalization rate data and for state survey agencies to review the measure as part of the certification process. In a recent blog discussing the potential for readmission penalties to SNF’s, the author suggests that the

(continued on page 2)

In this edition of

PharmaCarePRN Tips &

Tricks, we will review the

Drug Information Module.

Are you tired of having to

thumb through thousands of

pages of your Nursing Drug

Handbook to find information

on the medications you are administering? Did you know that you can

have all of that information at your fingertips? Within the

PharmaCarePRN Drug Information Module, access to this data-including

administration techniques, potential interactions, precautions, side effects,

and storage - can be obtained simply by searching the drug name.

To access, log into the PRN Website and click on the Drug Info tab at

the bottom of the home page. Next, click on the Drug Monograph button

and search by the drug name you are looking for (Note: You can search

using both brand and generic names). A list of drugs will be displayed.

Select the drug you would like information on and the full monograph

will be displayed in the print preview window. **TIP** You can limit

the information you would like displayed and printed by using the drop

down box. Just choose the information you want displayed and print

certain sections of the monograph, such as potential side effects. Do you

have requests for information about a resident’s new medication? If so,

you can also batch print the drug monographs directly from the patient

profile instead of doing each one separately. From the patient profile,

select the patient specific report titled “Drug Monograph Report.” The

report will prompt you to select which medications you would like to have

a monograph printed. Once selected, simply click the print button. The

monographs will print and read in a format that is similar to the drug leaf-

lets you would receive at a retail pharmacy.

Also included in the Drug Information Module is a link to the

Medicare Part D Formulary Analysis Tool. This tool provides the

formulary status for the Top 200 prescribed LTC Medications. To use this

tool, first select the state in which you reside. Next, select the contract

name, the plan name, and the name of the drug you are researching. The

system will indicate if the medication is on the formulary. **TIP** In

addition to the Formulary Analysis Tool, if your facility has any

outstanding formulary issues, such as prior authorizations, there is a

link from the main page where you can manage these formulary issues.

Need a quick way to find out if something is stored in your Interim

Box? Simply click on the Drug Info Tab then click Search Facility Interim

box. Enter the name of the medication (Brand or Generic) you are

searching for and click search. The system will display the drug name,

the quantity, and the box the medication is located in. **TIP** Click on

Show All then click the Print button to print a complete listing of the

backup medications that are available.

Stay tuned for future issues as we will be detailing another section

providing tips on how to get the most from this portal. If you are not

currently subscribed to the website and would like a complimentary one

month access pass, please contact Chad Corwell, Director of Operations

at 301-723-2423 or ccorwell@3ipc.com.

~ Chad Corwell, MBA, Director of Operations

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Drug Information Part 3 - Helpful Hints and Tips

federal government will not surprisingly continue to look at post-acute care facilities as a cause for readmission. The rationale is that some factors that lead to preventable hospital readmissions are beyond the hospitals’ control. However, at this time the hospital is the only facility being penalized. The author also suggests that the Medicare Payment Advisory Commission (MedPAC) has already evaluated proposals to reduce Medicare payment rates for SNF’s failing to meet standards for read-mission rates by as early as 2017.

If we look at how skilled nursing facilities have contributed to this “revolving door”, the costly cycle associated with the rehospitalization of post-acute care patients, the answers seem to lie in the transformation of the SNF itself. Over the past decade the role of nursing homes has changed dramatically from primarily a residential setting for older adults with cognitive and functional impairments, to a post-acute care facility providing skilled care to medically complex patients or providing intensive rehabilitative services. Based on information obtained from the Minimum Data Set (MDS), CMS estimates that less than 30% of patients admitted to a SNF will now remain at the facility longer than 90 days. Providing care to more complex acute care patients inherently results in a greater risk for readmission to the hospital and with studies in the litera-ture suggesting that as many as two thirds of these readmissions may be preventable, this is sure to draw more attention from lawmakers in the near future.

There have already been strategies developed to reduce re-admission rates in SNF’s. Tools such as INTERACT II and LTC Trend Tracker, are already looking at systems and processes to reduce readmission rates. These tools tend to focus on the

continuum of care and the transition of care process. It is a known fact that a smooth and accurate transition in and out of, or between health care facilities reduces hospital readmissions. Other suggestions such as the use of nurse practitioners in nursing facilities to perform a higher level of patient assessments, access to specialists in the facility, and enhanced quality improvement programs are also being utilized. It will require facilities to begin to look differently at the specialty services they offer, the quality of their staff and the addition of skilled support staff to remain success-ful – and let us keep in mind; hospitals will be

watching very closely. They must learn to evaluate and partner with post-acute care facilities that effectively manage readmis-sions, to be successful.

By taking a proactive approach, and starting to look now at ways to improve the transition of care in and out of your facility, it will give you the opportunity to improve both patient care, and the relationship with the referring hospital. This will ensure that your facility will continue to be a trusted partner in the region’s healthcare.

~ Steve Lowery, PharmD, Director of Pharmacy

Breaking a Costly Cycle – Rehospitalization of Skilled Nursing Patients (con’t. from pg. 1)

Medicare spends ~$17.4

billion annually on

hospital readmissions

~25% of SNF residents

are readmitted back to

hospital within 30 days

22% of patients dis-

charged from SNF to

home are readmitted to

the hospital within 30

days

HOT TOPICS IN PHARMACY

ALTERNATIVE TO ALLERGY SHOTS: Grasitek, Oralair, Ragwitek

Allergy Coverage:

Grasstek: Timothy grass; the only

allergy agent approved for children

as young as 5 years old. Should be

started at least 12 weeks prior to

allergen season

Oralair: sweet vernal, orchard,

perennial rye, Timothy grass,

Kentucky Bluegrass; approved for

10-65 years old. Should be started

at least 16 weeks prior to allergen

season.

Ragwitek: short ragweed;

approved for 18-65 years old.

Should be started at least 12 weeks

prior to allergen season

Three sublingual tablets - Grastek, Oralair,

and Ragwitek - are a new alternative to allergy

shots against ragweed and common grass

allergens. Grastek is an extract of Timothy grass

pollen, the most common allergy-inducing grass

in North America, Oralair contains extracts from

five common grasses, and Ragwitek, the most

recently approved, contains extracts from short

ragweed pollen. They work much like allergy

shots to desensitize the immune system against

the target allergen and have been shown to be

almost as effective. The sublingual form has the

convenience of self-administration at home

rather than in a doctor’s office.

The most common side effects, which

occurred in about 25% of trial subjects, are oral

pruritis and throat irritation. Patients are also

required to have an epinephrine auto-injector at

home and be trained to use it, due to the small

risk of anaphylactic shock. The first tablet should

be taken in a doctor’s office in case of an allergic

reaction.

The main drawback to the new therapies is

that they only contain extracts from a few grass

and ragweed species and patients are allergic to

many other allergens. However, allergy shots can

be individualized for a specific patient to contain

extracts from a wide range of allergens.

Sublingual tablets with extracts of other allergens

are under development, but at the moment only

grass and ragweed are available.

Grastek is approved for ages 5-65, Oralair for

ages 10-65, and Ragwitek for ages 18-65. The

largest clinical trials did not include individuals

over the age 65, so the effectiveness and safety in

individuals over age 65 has not yet been shown.

Despite these limitations, the convenience and

safety of self-administered sublingual allergen

extracts makes them a useful alternative to

allergy shots for patients whose symptoms are

not well controlled by antihistamines.

~ Caitlin Hall, PharmD Candidate at

University of MD School of Pharmacy

The Importance of Hand Hygiene

According to the Centers for Disease Control and Prevention (2012), the national average for hand

hygiene compliance among healthcare employees is only approximately 40%. This is a very disturbing

statistic considering that hand washing is such a simple procedure to perform. The National Institute of

Health estimates that the annual cost of preventable medical errors is estimated at $17- $29 billion

dollars. Healthcare acquired infections (HAIs) are considered preventable medical errors. Every year 2

million patients acquire HAIs annually which is approximately 1 out of every 20 patients. Of these two

million patients – 90,000 will die!

Clean hands are the single most important factor in reducing the spread of many bacteria and anti-

biotic resistant organisms. Did you know that a single gram of human feces, which is about the weight of

a paperclip, can contain one trillion germs! The CDC recommends that healthcare providers should

practice hand hygiene at key points in time to disrupt the spread of microorganisms to patients including:

Before/after patient contact

After contact with blood, body fluids, or contaminated surfaces (even if gloves are worn)

Contact with a patient’s intact skin (i.e. taking a pulse or blood pressure, physical examinations,

lifting the patient in bed)

Contact with environmental surfaces in the immediate vicinity of patients

Before invasive procedures

After removing gloves

The CDC also states that hand washing education in the community:

Reduces the number of people who get sick with diarrhea by 31%

Reduces diarrheal illness in people with weakened immune systems by 58%

Reduces respiratory illnesses, like colds, in the general population by 21%

Hand hygiene is a simple thing and it's the best way to prevent infection and illness.

~ Karen Metcalfe, RN, BC, LTC Quality Improvement Nurse

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