Short cycle dispense: A case study in implementation

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Carol Sirianni, R.PH.
Carol Sirianni, R.PH.
In April 2011, the Center for Medicare and Medicaid Services (CMS) released the final rule implementing Section 3310 of the Patient Protection and Affordable Care Act, stipulating that patients living in skilled nursing facilities, receiving coverage under Medicare Part D must receive their medications in supplies of 14-days-or-less. The ruling is slated to go into effect January 1, 2013. 

This rule promises to have a tremendous impact on how long-term care pharmacy (LTCP) providers serving skilled nursing facilities will operate their businesses and serve facility residents. As a result, there are a number of challenges that both LTC providers and skilled nursing facilities must anticipate and prepare for in advance, including:

1.     Increased Multi-Disciplinary Teamwork — Shorter dispensing cycles will require LTC pharmacies and skilled nursing facilities to work closely together to retool and create a smooth workflow that is both safe and efficient.

2.     Location of Patient for Administration — The acuity and mobility of skilled nursing facility residents has a dramatic impact on both workflow and the medication process because there are a variety of locations within a facility where a resident could be at any given time.

3.     Higher Medication Through-puts in Pharmacy — Shorter dispensing cycles will result in at least two times more volume at the pharmacy level. Current processes will need to be examined to determine if waste can be eliminated in waiting, motion, inventory, re-work/correction, overproduction, and information exchange.

4.     Need for Change Management — The multidisciplinary team will need to work with the pharmacy and nursing staff to communicate the new process/policy and ensure successful cooperation throughout the workflow.

5.     Making Technology Support Clinical Workflow — There is not a “one-size-fits-all” solution approach for every organization. Technology challenges will be compounded due to the additional volume of work, transactions and data requirements that will be taking place.

As the compliance date nears, LTC pharmacies and skilled nursing facilities must work together to overcome these challenges by:

  • Jointly determining the dispensing methodology (type of packaging and dispense quantity) for brand, generic and over-the-counter (OTC) medications
  • Retooling operations
  • Educating and training staff
  • Assessing current and future information systems and dispensing technology
  • Ensuring that reimbursement contracts and operational processes to support reimbursement changes are in place
  • Protecting the bottom line and profitability of both the pharmacy and skilled nursing facility

The following article is a testament to the successful implementation and sustainability of short cycle dispensing. It details key observations and experiences Brooklyn, NY-based Four Seasons Nursing & Rehabilitation Center noted since implementing short cycle dispense. The case study details best practices and recommendations for selecting a method and quantity of dispensing, adaptation of workflow and the training of nursing and pharmacy staff.  Operational and clinical results are discussed as are cost savings and enhanced compliance.

Four Seasons Nursing & Rehabilitation Center Transitions to Short Cycle Dispense

Brooklyn, NY-based Four Seasons Nursing & Rehabilitation Center implemented seven-day medication dispensing of brand and generic medications in 2006 with the intent to increase operational efficiency and enhance patient care. Since that time, the facility – which serves approximately 2,500 residents, including 300 long-term care patients – has expanded seven-day dispensing as an option for adult-day patients, outpatients, and facility employees. Because of this, the facility has already met and exceeded compliance with the CMS short cycle dispense requirement.

Since inception, Four Seasons had been served by an off-site vendor pharmacy. In 2006, with the goal of improving medication distribution for residents and expanding service to other populations, the management team established an on-site pharmacy. This coincided with the enactment of Medicare Part D, which stipulated that reimbursed medications were no longer returnable to the pharmacy for reuse in the State of New York. As a result, Four Seasons needed to designate one full time equivalent (FTE) employee, to collect, log, and destroy the unused medications in order to comply with the new requirement.

Since medication waste and the resulting staff time diverted for handling unused medications presented significant workflow challenges, Four Seasons wanted to implement an alternate method of medication distribution to ensure efficient, effective medication delivery. It evaluated and selected an automated system of multi-dose packaging based on a seven-day fill cycle – a significant transition away from the 28-day cycle “bingo card” system, on which it was operating at the time.

Because the process of transforming medication processes must start at the highest level of any organization, Four Seasons engaged senior administration and nursing representatives at the beginning of the process. Early buy-in from senior level executives and the use of multidisciplinary teams — including representatives from management, pharmacy and nursing — not only helped to ensure a smooth transition process, but also worked to boost efficiency and adoption rates.

Once the plan was in place, the pharmacy set out to identify and acquire the technology to help improve operational efficiency. This efficiency would free up pharmacists to spend more time on patient care. In addition to eliminating medication waste and staff time associated with handling unused medications, Four Seasons needed to ensure its electronic medical record (EMR) system was well-coordinated for expansion across the facility. After an in-depth research process, the pharmacy selected the AmerisourceBergen FastPak EXP to handle all medication dispensing using compliance packaging.  The FastPak EXP provided user-friendly, reliable software that boasted high accuracy rates and cost efficiency.

With any system change – especially related to automation – comes change to both overall workflow and individual tasks. Though pharmacy technicians were expected to be responsible for more than 90 percent of technology operations, Four Seasons set out to train and develop both pharmacy and nursing teams to ensure that all users were comfortable with workflow and process changes. To ensure an increase in efficiency and an improvement in patient service, each change was explained and reinforced. For example, because the automated system eliminated the need for traditional medication carts, nursing day-to-day systems changed radically. As a result, both nursing administration and nursing staff needed to undergo in-depth training to become familiar with the look and feel of the new system and ensure comprehension of each streamlined process for handling medication.

Enhancements to Workflow

At the pharmacy level, since implementing short cycle dispense and automated dispensing technology, Four Seasons has seen an 80 percent reduction in pharmacy packaging time – from five hours to one hour for a 40-bed unit and an average of ten to 12 medications per patient.  Efficiency has improved, enabling the pharmacy to commit more time to their clinical work.

On the nursing side, Four Seasons had originally estimated a 40% reduction in medication administration time. Coupled with the savings realized from the commingling of prescription medications using compliance packaging, Four Seasons was able to meet – and exceed – this goal. Approximately one year after the system went live, regular, standing orders for all over-the-counter (OTC) medications were incorporated into multi-dose packaging. This has cut medication administration time even further to 50 percent of the time required when Four Seasons was using unit-dose blister packs.

In addition, Four Seasons is meeting the CMS mandate to pass medications within one hour of the prescribed time. This reduction in medication pass time enables nurses to complete CMS-regulated documentation during their shifts – cutting down on overtime and associated costs.

Four Seasons Nursing and Rehabilitation Center frequently dispenses medication for residents who leave the facility on pass. Fulfilling out-on-pass prescriptions for residents who leave the facility for a period of hours or days has also been streamlined by the automated system and compliance packaging. Historically, these types of fulfillment requests were a pain point for both pharmacy and nursing teams, as they were generally sudden and last minute in nature. With commingled, compliance packaged medications, the need to prepare out-on-pass medications is eliminated since they are already labeled according to time of administration. If a resident wishes to temporarily leave the facility, the nurse simply tears off the needed medication based on the time of the planned absence and provides an instruction document, containing medication background, and any recommended precautions. This also helps ensure compliance with caretakers while the resident is in their care.

As a result of enhancements and efficiencies achieved through pharmacy and nursing workflows, patient medication errors have been reduced. This means better quality care, an increase in patient safety, and higher patient satisfaction rates, overall. Seven-day dispensing has also helped Four Seasons streamline the process of reimbursement and claims submission – generating additional labor and cost savings.

Generating ROI and Cost Savings

For many LTC pharmacies and skilled nursing facilities, the cost to implement short cycle dispense might seem to outweigh the intended benefits. It's important, however, to look beyond the initial investment, as long-term benefits are significant and vital to patient safety and future success in the continually evolving healthcare marketplace. Initially, Four Seasons saved about $110,000 per year in labor costs – including salary and benefits for one FTE pharmacy technician and one FTE registered pharmacist. As the pharmacy has grown and expanded its patient population, labor cost savings have continued to increase over time. In addition, using an automated dispensing system has required the pharmacy to switch from purchasing unit-dose packaged medications to bulk medications (100-, 500- or 1,000-count bottles).  This switch has resulted in a significant cost savings, as unit-dose medications cost typically three to five times more than bulk.

Other cost savings included the cost associated with nurses “borrowing medications,” or using medication from another patient on the same prescription.  Borrowing medications has virtually been eliminated through the use of patient specific compliance packaged medications.  Savings are estimated at $500 per month and elimination of missing medications by commingling of medications is also estimated at $500 per month. 

Beyond cost savings and enhancements to patient safety, short cycle dispense and automation helped Four Seasons expand patient populations and generate additional revenue streams. With a robust short-term rehabilitation program, Four Seasons discharges approximately 400 patients into the community each year. These patients can choose to receive their 30-day discharge medications in either vial or compliance packaging. Multi-dose compliance packaging is also available for adult day patients.

Conclusion

Since transitioning to short cycle dispense and automated fulfillment techniques, Four Seasons pharmacy management and facility administration have experienced significant operational, financial and clinical benefits that have contributed to its overall success. Four Seasons is compliant well in advance of the January 2013 deadline for short cycle dispense implementation. Though LTC pharmacies and skilled nursing facilities might feel overwhelmed with the impending short cycle dispense implementation date, the change will bring significant efficiencies and cost savings that will improve patient safety and quality of care.

Jonathan Shaatal, R.PH., MS, is the director of pharmacy at Four Seasons Nursing & Rehabilitation Center. Carol Sirianni, R.PH., is the vice president of customer programs and solutions at AmerisourceBergen Drug Corporation.

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