Evaluating good drugs

When a resident is on a high number of medications, the risk of errors and adverse reactions exponentially increases, according to a 2015 report from LeadingAge. Using multiple pharmacies also increas
When a resident is on a high number of medications, the risk of errors and adverse reactions exponentially increases, according to a 2015 report from LeadingAge. Using multiple pharmacies also increas

Nursing homes are awash in drugs. It's no wonder that managing their ebb and flow has become such a conundrum.

After all, nursing homes are the last stop for many people who typically arrive by car or ambulance with a bagful of medications collected from multiple doctors after multiple hospital visits involve multiple pharmacies. 

For certain, there are safeguards in place, but most facilities are charged with connecting all the dots — a challenge that is as confounding as any in long-term care.

There's never been a greater need for sound medication management practices.

Look no further than the escalating cases of diversion of highly addictive painkillers from nursing homes. Or the family of a Chicago suburban assisted living facility resident who died from an alleged morphine overdose. Or the West Coast nursing homes forced to settle Justice Department claims they overmedicated residents over a five-year period, allegedly leading to infection, sepsis, malnutrition, dehydration, falls, fractures, pressure ulcers and premature death.

Some say prescribing and dosing practices are part of the problem. According to the American Society of Consultant Pharmacists, seniors consume 40% of all prescription drugs and 35% of all over-the-counter drugs. Individuals 65 to 69 years old receive an average of 14 prescriptions a year — often from multiple doctors and pharmacies. 

According to the Centers for Disease Control and Prevention, three out of four orders for antibiotics are wrong and along with antipsychotics, are among the most over-prescribed drugs given to nursing home residents today. The problems of medication errors and adverse drug events are rampant because of over-dosing and drug interactions, most of which go undetected until it's too late.

“Antipsychotics are often used inappropriately and often are not monitored nearly as closely as they should be in this frail, fragile population,” says Jerome Wilborn, M.D., national medical director for post-acute service at IPC Healthcare, a TeamHealth company. “These meds can literally crush patients and lead to additional problems like immobility, worsening confusion and lethargy.” Wilborn says even when antipsychotics are used appropriately, they have to be dosed properly, and include a “robust, gradual dose-reduction plan.”

Top 5 threat

Meanwhile, the costs adverse medication events exact are enormous. Adverse drug events are culprits in nearly a one-third of all elderly hospitalizations and are among the top five health threats to nursing home residents, according to ASCP. Drug-related problems cost nursing homes more than $4 billion a year. In its 2015 report, “Medication Management Technologies for Long-Term and Post-Acute Care,” LeadingAge noted an estimated 800,000 preventable adverse drug events happen each year in nursing homes.

The enormous amount of medications thrown at the elderly also has led to profound pharmaceutical waste and its attendant disposal — issues only exacerbated by restrictive, complex and, in some cases, conflicting rules and regulations. Frank Grosso, RPh., ASCP's executive director and CEO, told McKnight's Long-Term Care News that the industry sorely needs “more government agency collaboration in the development of clear rules for drug disposal.”

The issue has forced many facilities to choose between Drug Enforcement Agency and Environmental Protection Agency rules, according to Bent Gay, RPh., CEO at Gayco Healthcare, a long-term care pharmacy. 

“The industry needs to sit down with both agencies and decide what's more important — keeping meds out of our water system or off the streets,” he told
McKnight's.

The sheer plethora of highly addictive opioids like hydrocodone and oxycontin has fed a nearly insatiable appetite in caregivers. A recent USA Today report found that more than 100,000 physicians, clinicians and aides now abuse or are dependent on these and other illicit drugs. Rates of diversion and theft are on the rise.

Following is a closer look at the three major medication management problems dogging long-term care, and what some experts believe are promising efforts to solve them.

Poorly monitored transitions

As if prescribing and dosing issues weren't enough, polypharmacy problems can compound medication errors tenfold, experts say.

As LeadingAge pointed out in its report, the higher the number of medications a patient takes, the higher the risk of medication errors, drug interactions and adverse reactions. It's made only more complicated when multiple pharmacies and doctors are involved because medical and medication histories might be fragmented or unknown. Polypharmacy is directly linked to higher incidences of falls, dementia and urinary incontinence.

“Polypharmacy is a big problem in the post-acute space,” IPC's Wilborn says. “All too often there are too many medications in patients who aren't going to benefit from them or any regimen of medication. Many don't need 10 or even five medications, and, unfortunately, we often see patients with more than 15.” The fewer the medications a resident is on improves the efficiency at which they are absorbed and dramatically lessens the likelihood of adverse events and waste, he adds.

The issue of polypharmacy is even more acute in assisted living settings, according to Steve Piepenbrink, president of Guardian Pharmacy of Indiana. 

“An assisted living facility may use four or five different pharmacies, so there can be a lot of duplication and overlap,” he tells McKnight's. The issue has prompted some communities to adopt a preferred pharmacy provider, he adds.

Compounding matters are risk evaluation and mitigation strategy (REMS) medications, which can cause delays in dispensing, as well as unwieldy and multiple formularies across hospitals, long term care, prescription drug plans and private insurance, says Jennifer L. Hardesty, PharmD, chief clinical officer and corporate compliance officer for Remedi SeniorCare. 

Many long-term care pharmacists point to poorly managed transitions as a leading culprit in medication errors and adverse reactions.

As seniors move from home to hospital to nursing home to other settings such as assisted living, a lot of information can, and does, fall through the cracks. Most critical among it are medication records and other vital data. Many blame poor care coordination, conflicting care plans, duplicative services and just plain confusion in pain-addled patients. Northwestern University researchers found last August, for example, that confusing and misunderstood discharge and medication instructions were direct causes for higher rates of hospitalization among seniors following outpatient procedures.

“Seniors living in the community with multiple doctors will go to the hospital, go to rehab, or move to a nursing home, take their drugs with them and no one knows about all the medications they've taken,” says Patricia Howell, RN, a member of McKesson's Clinical Resource Team. “The big bag they bring with them could contain dangerous interactions, or a redundancy in medications, have a different name from the med they were prescribed in the nursing home, and a post-acute care interdisciplinary drug regimen review is needed.”

Grosso blames the problems on glitches with the “interoperability of patient medication profile data from one care setting to the next.” Even established medication reconciliation processes can be stymied by the lack of accurate or timely data from one provider to the next.

The transition issue prompted PharMerica to recently launch sophisticated software decision-support tools to help providers, says Suresh Vishnubhatla, executive vice president of long-term care operations at PharMerica. 

“The root cause of these problems can be traced to the lack of medication reconciliation between transitions of care and these transitions are not very well managed,” he says. “The most likelihood of an error happens when there is some kind of change — in this case, from one setting to another. The patient leaves with a sheet of paper and nothing else, so how do you show that the transition has happened in a seamless fashion and every medication Mrs. Jones needs is on there?” A pharmacists' review of residents' medical charts is in order.

“There may be medications that were appropriate at one time but no longer,” Vishnubhatla adds. “The physician may not know that and no one has had an opportunity to review the chart. That's our job.”

With the problem of adverse drug events at critical mass in the industry's psyche, many “solutions” are popping up. Most prominent among them are data aggregators. In its recent report, LeadingAge identifies a number of “upstream technologies” such as electronic health records, e-prescribing, computerized physician order entry and clinical decision support systems, and “downstream technologies” such as electronic medication administration records, bar-coded point-of-care systems and remote pharmacy systems.

Howell said she believes EHR implementation “has really made a big difference in stemming adverse drug events now that we have providers typing in information instead of scribbling it out from telephone orders that can easily be misread.”

Ironically, clinicians gathered at a health information tech summit last August in Baltimore agreed that too many long-term care facilities are actually hurting themselves by limiting pharmacists' access to EHR records. The experts called for a greater role for consultant pharmacists in medication management.

Among those calling for an enhanced medication therapy management role for pharmacists is Alan Rosenbloom, CEO of the Senior Care Pharmacy Coalition. One of the hurdles is a conflict among multiple payors, he believes. Medicare Part D, the biggest among them, assigns medication therapy management to prescription drug plans, which in turn, assign the task to pharmacy benefit managers that administer formularies and process payments. Rosenbloom sees that as a problem because “medication therapy should not be managed by the people doing the paying.” A greater role for pharmacists, in fact, is consistent with the industry's move toward value-based purchasing, he adds.

Others are calling for streamlined dose kits for residents as they are transferred from one setting to another. Gayco's Gay believes the government should universally allow first dose stat kits with at least three days' supply of needed medications. Remedi's Hardesty said first dose availability is a problem in transitions, and supports efforts to ensure “the proper drugs are on site or quickly available as the acuity of residents increases.”

Drug waste concerns

Issues about the drugs that are never used and wasted are just as profound. Equally problematic is the matter of disposing of them.

A recent University of Chicago study estimated as much as $2 billion a year in drugs is being wasted in nursing homes alone, according to the website Marketplace Healthcare.

“Each year, long-term care organizations waste a lot of medications, throwing away partially used blister packs, expired medications and so on,” notes Jennifer Maniscalco, senior service line manager at Stericycle, in a recent McKnights.com blog. 

For years, providers have been baffled by confusing rules, and like consumers, have continued in frustration to toss pharmaceuticals, including narcotics, into the trash or toilet, where 6,400 tons of drugs end up each year. Agencies like the DEA and EPA (which recently revised its rules targeting some drugs as hazardous waste) have attempted to clarify matters in recent years, but confusion and frustration abound, observers say.

“Everyone wants to do the right thing, but it's a cost issue,” says Gay, whose hospice and assisted living customers sometimes ask him to pick up and destroy meds. Large retail pharmacies may tout their “free” drug takeback programs, but the task is costly and burdensome for so many independents, he adds.

Hardesty flatly says the industry is plagued by confusion. 

“There's no clear regulatory guidance; and what guidance exists — FDA, White House Office of National Drug Control Policy —  is geared more toward home use,” she says. Moreover, the Disposal Act amendment to the Controlled Substances Act permits collection receptacles in nursing homes, “but the stipulations are not practical and very few facilities or pharmacies have moved toward this option.”

Common disposal solutions today include reverse distributors and crushing and liquid dissolve kits that render drugs safe for solid waste streams. One of the most promising solutions to curb waste is short-cycle dispensing, many say. Gay says his business has gone to a three-day, four-day cycle for routine medications, in which three days are dispensed and three days later, a four-day cycle is dispensed.

Many facilities already are incentivized to dispense smaller drug quantities to Medicare Part A patients, says Albert Barber, PharmD, director of pharmacy services for AlixaRx. 

“Under per diem contracts, facilities bear the cost of medications for skilled patients and encourage pharmacies to dispense smaller quantities, especially for high-cost drugs,” Barber says. Moreover, Medicare rules require short-cycle dispensing for Part D residents. Even so, waste still happens, leading some facilities to adopt 24-hour cycle fills, he adds.

Piepenbrink says Guardian is one of the few organizations in the country that has long followed a seven-day dispensing cycle on many medications. He also noted that the federal government recently changed the rules requiring brand name drugs to be dispensed on 14-day cycles. Rosenbloom says he believes the industry may soon adopt short-cycle dispensing based on the success Part A is having in curbing waste. He also suggests pharmacies be allowed to switch to therapeutically equivalent drugs that need to be administered fewer times a day.

Diversion and theft

Researchers noted in a July 2012 issue of Mayo Clinic Proceedings that most drug diversions occur in the outpatient setting and the most commonly diverted drugs are opioids. 

In a given year, about one-third of all Medicare Part D enrollees use opioids, some of which may not be clinically appropriate, according to a MedPAC analysis on improper opioid use.

It's not surprising that many of the solutions that address waste and disposal — including short-cycle dispensing — can also help curb drug diversion and theft based on the notion that the fewer drugs there are to steal, the fewer that can be diverted. Observing a tight chain of custody on stored meds is another.

But they do nothing to address the larger issue of painkiller addiction. Experts say the systemic issue might best be addressed by improving staffing levels in nursing homes, but no one is holding their breath for this to happen. Efforts to legislate the issue, including recent Congressional bills designed to stem prescription drug abuse, have stalled.

Some legislative efforts have actually caused patients to be denied badly needed pain medications, as Rosenbloom describes one nightmare scenario: 

“Medicare Part D beneficiaries are able to get multiple scripts for the same drug, and so there's a Congressional effort afoot to give Part D plans the ability to determine certain beneficiaries are at risk for substance abuse and to limit them to one prescribing physician for all of their medications and to one pharmacy to pick up their meds. The problem is when a beneficiary goes to the hospital on a Part A stay, gets transferred to a nursing home and starts on a Part A stay which only applies to Part D, then transfers off the Part A stay and now their drugs are being paid for by Part D.”

Both the pharmacy that's contracted with the facility and the one that the plan has designated as a retail pharmacy can't provide the drug legally, he said, which means the patient can't receive medications. 

Rosenbloom said his group successfully lobbied Congress to exempt Part D from the program.

Additionally, addicted nurses and doctors work in settings some have described as a (sometimes inadvertent) “culture of silence.”

When Howell worked as a new nurse on an evening shift, one of her co-workers would give a patient pain meds on her days off. 

“I never gave them pain meds on my shift and so I thought I wasn't doing something right,” she recalls. 

As it turns out, the nurse was  actually taking the medications. 

“What nursing homes have to do is incorporate diversion awareness into their mandatory employee training and let people know if they see something that doesn't look right, report it,” Howell says. “You could save someone's life, or save someone's license.”

And go a long way toward improving medication management.