Feature: Prescribing Unity

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OIG: Nursing homes correctly reported 53% of abuse or neglect allegations in 2012
OIG: Nursing homes correctly reported 53% of abuse or neglect allegations in 2012

Proper preparation, dispensation, delivery and administration of medications to skilled nursing residents is a complex series of moving parts, requiring deft coordination among all clinical professionals involved. 

And while overall its success rate is high, the process isn't without its challenges.

Conflicting consultations, prescription disagreements, communication breakdowns and order confusion can all result during a sequence of handoffs from one clinician to another in the medication management process, specialists say. Ultimately, it comes down to ensuring consistency along all points in the delivery system, notes Milta Little, DO, secretary of the American Medical Directors Association Board of Directors and assistant professor of geriatric medicine at Saint Louis University.

“There is a great amount of variation in protocol that you see across the country,” she acknowledges. “One of the strengths as a whole is that consultant pharmacists must provide some kind of input in every facility. Having that kind of oversight here in the U.S. is significant. But the weakness is that we don't utilize them to their full potential.”

For example, a bad connection commonly exists between prescribing physicians and consultant pharmacists due to physical separation and poor communication, Little says.

“The pharmacist makes a recommendation that isn't followed up on or is ignored totally,” she says. “Historically in medication training, physicians are taught separately. That is changing so there is more integrated education. But as physicians we are used to being the ultimate decision maker, so it can be hard to have someone else in on the decision.”

Recommendations should be more meaningful so that the consultant pharmacist is more involved — perhaps at the bedside, Little says, adding that some long-term care facilities have formed a medication management committee to work toward building a strong team of clinicians.

Joan Baird, PharmD, director of clinical affairs for the American Society of Consultant Pharmacists, agrees that the consultant pharmacist needs to be better utilized.

“Consultant pharmacists have the advantage of usually seeing all medications and supplements listed in one place, which makes reviewing more efficient,” she says. “And prescribers in this setting are increasingly aware of the critical role a consultant pharmacist plays in ensuring medications are safe and effective for that particular resident. As seniors typically take more meds and may visit numerous clinical specialists, having a pharmacist review and weed out problematic combinations and redundancies is extremely important for optimal healthcare outcomes.”

By contrast, community pharmacists are clinically able to review medications. But there can be time constraints and in a community setting, the pharmacist must often rely on the patient to initiate contact, which is challenging, Baird says.

Access to the consultant pharmacist is a challenge, because typically one professional will cover several facilities and may not visit a facility more than once or twice a month, Baird says. Still, she points out that most consultants are on call with their facilities at all times in case of emergencies or questions during a surveyor visit.

“When I consulted, I would have liked more time in my busy schedule to meet with key clinical staff, and in some cases, to meet the residents whose charts I reviewed,” she says. “Time and other logistical issues can make this difficult. I always looked forward to attending quality assurance meetings because it allowed other clinical staff to consult with me directly rather than through chart notes.”

Sources of friction

One of the main issues in medication access concerns controlled medications, Baird says. As it stands, unless there is a specific nurse's agent contract in place with all nurses, all controlled medication orders must come directly from the prescriber. Orders may come over the phone from the prescriber in the case of CIII-V medications, but in the case of a CII narcotic, such as morphine or fentanyl, the prescription must be written. 

“Because the prescriber may not be at the facility when the medication is needed, the pharmacists and nurses must track down the prescriber and the prescriber must call or fax in the written prescription, depending on its classification,” she says. “The delay in reaching the prescriber — especially during transitions of care — can be onerous and can result in a delay in medication delivery. It is frustrating for all involved.”

Little acknowledges that the transition points — hospital discharge and SNF admission — can strain professional relations due to confusion over each resident's drug regimen, especially if that resident is prescribed a brand name when there is a generic equivalent.

“Reconciliation can be a challenging and difficult situation,” she says. “It is a critical point where errors can occur. It requires a lot of collaboration.”

Following guidelines is another sore spot that causes disagreements, Little says, because while consultant pharmacists are usually well versed in evidence-based guidelines on various medications, there are fewer guidelines on the geriatric scale.

“That means there are more variables that crop up,” she says, “which makes it more challenging in SNFs, where residents are typically excluded from drug trials.”

Technology hurdles

Outdated technology and manual process also contribute to a breakdown in medical team communication, adds Kasumi Oda, director of strategic marketing for Catalyst Healthcare.

“Working together is a challenge when clinicians are dependent on archaic systems that keep information contained in silos,” she says. “More and more organizations are implementing programs that allow for real-time collaboration and access to data across the spectrum of caregivers. Basing critical decisions based on partial or outdated information is quickly becoming a thing of the past.”

Because there are so many steps in medication delivery, there is a risk of errors, Oda says. Yet staying in constant contact with other caregivers through automation makes it possible to streamline the process. For instance, she says nurses can send physicians consults and include graphed vitals, physicians can provide sign-off using mobile devices, pharmacies can be notified in real-time and enter orders, nurses can verify new prescriptions, and automation packages medications accurately and efficiently.

Embracing the challenge

Even so, adopting the “latest and greatest” technology for medication management is beyond the financial and operational capabilities of many facilities, counters Mustafa Ahmed, senior sales executive of business development for InfoMax Technologies.

“In general, it is difficult for facilities and staff to take full advantage of the technology that's available,” he says. “The reason is the technology is often too complex, it does too many things and staff can only utilize a small percentage of it.”

Moreover, the time required to learn the system and to provide extensive training can take staff away from their core responsibility of caregiving, Ahmed says.

“This is the reason why a lot of technology projects in healthcare run such high risks and chance of missed benefits and ROIs when it's time to deploy,” he says. “In some cases, a simple technology that can be quickly utilized by more people provides more benefits than the technology that does it all but only a small percentage can learn to use or are willing to use it.”

Little adds that while technology like electronic medical records are tools to improve communications and reduce errors, it can also be “a double-edged sword” because of system glitches such as constant prompts that clinicians ignore or are not applicable to the patient.

“There needs to be a way of ensuring that the technology is used efficiently,” she says. 

To create this efficiency for their facility, one Remedi SeniorCare customer recently requested that a consultant pharmacist have direct access to the Remedi pharmacy interface and the facilities electronic health reports to complete reporting, according to Karsten Russell-Wood, the director of product management at Remedi.

“Pharmacy teams are being exposed to new requests for use of the medical record to complete inputs electronically,” he says. Technology also may allow physicians to share lab results that may drive medication dispensing.

Oda concedes reviewing the choices can be intimidating for administrators.

“With so many technology vendors on the market, it can be a challenge to sift through the features and functionality to find the product that will truly make a difference,” she says. “The good news is that vendors want to share what makes them unique.” 

Key Medication Management Issues

It can be convoluted: Prescribing, processing, delivering and administering medications is an intricate system with many shifting variables. The route from the source to the resident can be circuitous if not periodically reviewed and revamped.

Personality clashes: Opinions can vary about which medications are best in certain situations and because consultant pharmacists are not always onsite, they may feel left out of the loop. Organizing a medication management committee can bring professionals together and get them on the same page.

Trouble spots: Certain instances are prone to confusion and conflict, such as resident transitions in and out of the facility, a clear lack of evidence-based guidelines for geriatric patients and redundancies that can arise when numerous clinical specialists are involved with a resident's medication profile. Weeding out problematic combinations and “polypharmacy” orders can simplify the process.

Automating functions: Electronic medical records and computerized provider order entry systems can enable better, more timely communications between clinicians, ensuring faster and more accurate orders. Cost is definitely a factor, but facility operators should conduct a feasibility study to determine whether it is worth the investment.

Source: McKnight's Long-Term Care News interviews, 2013




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