A new age for long-term care pharmacies

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Jason Spears
Jason Spears

Forces of change are rapidly reshaping prescription drug practices in the long-term care (LTC) market. Pharmacies are rethinking the way they serve your industry, evolving to meet your patient-safety and quality of care standards—particularly in light of health legislation passed this year. New reform requirements have direct implications on the LTC industry. One of the biggest impacts is the mandate for LTC pharmacies to adopt dispensing techniques, “such as weekly, daily, or automated dosing” by Jan. 1, 2012, to reduce wasteful dispensing of prescription drugs.

As a result, many pharmacies are changing and modernizing their prescription delivery models to reduce, or even eliminate, medication waste in LTC facilities. Realizing this objective will undoubtedly affect nursing workflow and quality of care for residents. Because of these changes, it is vital for LTC facilities to understand their options, so they may select the most appropriate solution for their facilities, factoring in cost, workflow impacts, and resident benefits.  

There are two main categories of LTC medication distribution systems to consider: centralized dispensing and facility-based dispensing. Within each category there are several types of systems that support the new legislation language, which has come to be known as “seven-day or less” dispensing. Each category is analyzed based on several measures, including operational efficiency, capital requirements, and timeliness and accuracy of medications. 

Centralized dispensing

Centralized dispensing involves a local or regional pharmacy, typically located within two to four hours from the LTC facilities it services. These pharmacies package and label medications at their pharmacy, most often in 30-day supplies, and deliver them to the facility one or more times per day. Pharmacies that dispense centrally typically use one of two types of packaging: punch cards or multidose strip packaging.

Punch cards

The most widely adopted packaging used for distributing medications to LTC facilities is punch cards, which typically hold a 30-day supply of medications. Because a majority of LTC pharmacies use this type of packaging for delivering medications, most are exploring ways to reduce supplies from 30 days to seven days—or less.

Reducing supplies from 30 days to seven days has the potential to moderately reduce medication waste. However, it requires additional dispensing cycles per month. Pharmacies must dispense the same prescription more than four times as often as they currently do, resulting in significant increases in pharmacy dispensing costs. Consequently, LTC facilities must receive and handle four times the number of punch cards. This increase in volume would significantly raise facilities' costs for handling medications, adding to the expense and the potential for medication errors.  

While this model may not require investment in new technology, it would generate significant cost and labor increases for facilities and pharmacies and cost savings on the waste are not likely to cover the difference. This approach also comes with a potential to put residents at a higher risk of danger because of the additional opportunity for error. As a result, the Long Term Care Pharmacy Alliance (LTCPA) is opposed to it, outlining its issues in detail in its response to the medication waste provision.

Multidose strip packaging

Meanwhile, the past decade has seen an increase in adoption of automation technology that dispenses medications in multidose strip packaging (i.e. multiple medications in a single package). Multidose strip packaging can be easier to use when administering medications, making it preferred over traditional bingo cards for most nurses. Preliminary analysis of multidose packaging has shown a 50% reduction in the preparation and administration of medications, giving nurses more time to provide care to residents. It also has been shown to improve adherence and reduce medication errors.

Automated systems that package medications in multidose strips are easily capable of dispensing in quantities of seven days or less. In fact, most pharmacies that use this technology dispense in seven-day quantities, and some dispense in as little as two- and three-day supplies. For that reason, this technology has the potential to greatly reduce medication waste in long-term care. 

More than half of LTC pharmacies own or operate central fill packaging systems in their pharmacy. However, these systems are not well-suited in a high acuity environment, where medications are constantly changing. When a prescription is changed or discontinued, the remaining doses must be removed from the packaging, presenting a patient-safety risk and creating waste. Because of this, and the current economics behind Medicare Part D, actual use of these systems is limited. However, due to the many benefits of multidose strip packaging over traditional punch cards, these systems are well suited to service a large portion of LTC, especially more stable populations, such as independent and assisted living facilities. 

Facility-based dispensing

Many LTC pharmacies dispense medications in daily or unit-dose supplies on-site at the nursing facility. This is generally accomplished through the use of automated dispensing systems located at the facility. Some nursing facilities operate a licensed in-house pharmacy, employing a full or part-time pharmacist. However, most nursing facilities are not large enough to support an in-house pharmacy.

Facility-based dispensing provides two distinct benefits over a centralized model: elimination of medication waste and timely access to medications. Automated dispensing systems located at the nursing facility allow pharmacies to dispense only the medications that are needed, at the time they are needed.  Therefore, not only is waste virtually eliminated, medications are provided in a timely manner, which is often difficult when the pharmacy dispenses centrally.

EDKs and medication cabinets

Most state pharmacy boards permit the storage of controlled substances and other medications for emergency use at the LTC facility without special licensing. Therefore, a standard practice for LTC pharmacies is to provide Emergency Dispensing Kits (EDK) for immediate “STAT” and first doses. EDKs range from simple tackle boxes to more sophisticated automated medication cabinets, such as a Pyxis system. Automated medication cabinets typically include a limited formulary of unit-dose medications that the nursing staff can access in emergency situations. The inventory in the EDK or automated medication cabinet is monitored and regularly replenished by the pharmacy.   

Automated dispensing cabinets help prevent issues with diversion and improve dispensing accuracy over traditional EDKs.  As a result, they are a great, albeit costly, alternative to traditional EDKs, especially in light of the DEA's recent crackdown in LTC.  However, automated dispensing cabinets are not practical for handling the volume of all medications, especially in facilities with larger or more acute resident populations. Ongoing doses must be fulfilled via another distribution model. Therefore, several LTC pharmacies are beginning to combine the use of automated dispensing cabinets in the nursing facility with automated strip packaging in the pharmacy.

Drug-specific medication carts

Drug-specific medication carts are a relatively new concept. This technology combines an electronic medication cabinet, medication cart, and electronic Medication Administration Record (e-MAR) into one system. Medications are stored in the cart in drug-specific punch cards. During the medication pass, nurses use the e-MAR to identify the patient, and locate the medications with pick-to-light and barcode technologies. 

Given its recent introduction into the market, the system has not been widely adopted. Yet, in concept, it is very capable of eliminating medication waste while providing more timely access to medications than traditional centralized dispensing. A potential disadvantage is the lack of formulary items being stocked on-site, requiring some medications to be dispensed centrally. Further, these systems cost considerably more than traditional medication carts and they do not provide the same nurse time savings as systems that dispense multi-dose packaging.  However, because most medications are dispensed on-site in unit-dose quantities, waste is eliminated and medications are more available, improving the quality of care for residents. 

Remote dispensing systems

Remote dispensing systems are another recent innovation introduced to LTC. Secure, automated remote dispensing systems, similar to those used in centralized dispensing pharmacies, are located on-site at the LTC facilities. As with the other facility-based dispensing models, medications are immediately available to the nursing staff and their residents. However, medications are packaged in patient-specific, multidose packaging, which helps reduce medication errors and time spent on medication passes, providing nurses with more opportunities to spend time with residents. And, since the medications are dispensed only as needed, these systems essentially eliminate medication waste. Early analysis shows that remote dispensing systems are almost twice as effective as seven-day dispensing at reducing waste. In fact, in many cases, the savings provided directly to the facility on the Part A residents covers the entire cost of these systems.

As such, remote dispensing systems have the greatest potential to eliminate medication waste, while providing many benefits other solutions do not offer, such timeliness of medications and reduction in medication pass time. Unfortunately, regulations do not allow remote dispensing in all states, though many state boards of pharmacy are considering the adoption of remote dispensing language into their pharmacy regulations.  And, in August 2009, the National Association of Board of Pharmacy (NABP) introduced language into its model rules regarding “Remote Dispensing” and the use of “Automated Pharmacy Systems” in institutional facilities, including LTC facilities.  As market adoption increase, regulatory barriers are expected to lessen.

Impact on LTC

“Seven-day-or-less” dispensing will have an enormous impact on LTC facilities. Fortunately, there are many solutions that will have positive impacts, and many are already being effectively utilized across the nation. At this stage it is important to stay informed and be proactive in advocating for the solution that is right for your organization. Come prepared with a list of questions when you talk with your pharmacy partner about how they intend to achieve compliance by adopting “seven-day or less” dispensing. Reach out to LTC facilities already using new technologies and dispensing models to ask them about the benefits and challenges they have experienced. For those facilities leveraging automation, ask them about investments they have had to make in learning new technology and the return-on-investment (ROI) they have seen since implementation. Finally, evaluate new technologies by visiting vendor websites and booth exhibits at upcoming tradeshows.

Every new scenario will have its advantages and implementation considerations and may require investments in new technologies or learning curves. Just like most things in this world, no one solution is right for everyone.  The key is to get informed and remain in front of the decision making process.  You must advocate for a solution that is most representative of you and your residents' needs.

Jason Spears is the long term care market director for Talyst, which provides easy-to-use, automated medication management systems in acute-care hospitals and integrated healthcare companies.

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