Winning the drug war
F-Tag 329 (Unnecessary Drugs) is commonly cited by surveyors during skilled nursing facility inspections. Providers continue to struggle with residents receiving far too many medications from an assor
If medication management is not at the very top of Debbie Meade's list of most important issues, it is darn close.
“Safety is high on our list. Nutrition is a hot topic. Medication management leads to all of those,” says Meade, the CEO of Health Management, a management company in Georgia composed of three skilled facilities, one assisted living facility and one post sub-acute facility. “It can lead to skin and safety issues.”
Resident health issues notwithstanding, medication management continues to be a hot-button topic for long-term care providers, in part, because of one of the most common citation tags, F-Tag 329 — unnecessary drugs.
The tag, which has been on facilities' radars for decades, was developed at a time when the Centers for Medicare & Medicaid Services was honing in on overuse of or misuse of antipsychotic medications. Today, F-329 continues to vex providers because of a host of 21st century issues. Among them: older and sicker residents, new medications coming on the market at a rapid rate and the modern challenges related to transitions of care.
“With the increased frailty, increased number of co-morbidities and age of the average resident, medication regimes have also become more complicated to manage,” says Jayne Warwick, RN, HBScN, director of industry insight at PointClickCare. “F-329 is also reviewed in pain management, dementia care, diet management and behavior management tags, so it comes up in many areas of a survey. Medication appropriateness is also being highlighted in focused surveys such as the dementia-focused survey and industry trends such as reductions in opiate use.”
It's not that nursing homes are deliberately mismanaging medication, experts in this area say. In most cases, it is because they are not properly documenting the drugs residents are using, why they are using them, what efforts have been made to provide non-pharmacological interventions and attempt gradual dose reductions, and other important rationales required by CMS.
“It is imperative to document a comprehensive care plan outlining the condition, symptom, treatment measures supported by the physician, expected outcomes, side effects and trials to decrease or stop psychotropic medicines as clinically indicated,” notes Lisa Logan, RD, CNS, enteral program manager for McKesson Medical-Surgical.
Incomplete documentation tends to trip up providers.
“For example, all elements of the gradual dose reduction requirement may be present,” explains Sonja Quale, VP and chief clinical officer at PharMerica, “but the prescriber's rationale for refusing the gradual dose reduction — which may be entirely legitimate — is not documented, or the behaviors are not documented appropriately in the care plan or on the behavior monitoring sheet. Missing or incomplete documentation for pain assessment or lab monitoring … can also lead to F-329 citations.”
The new mega-rule for requirements of participation, parts of which went into effect at the end of November, clarifies aspects of F-329. For example, the new rule relays the importance of antibiotic stewardship.
“Helping and supporting the facility and making sure antibiotics are being used judiciously to help reduce the opportunity for antibiotic resistance is going to be a huge issue for us in the next couple of years,” says Todd King, senior director of pharmacy services for Omnicare.
Conveying proper use of antipsychotics is still a major component of the rule. Pat Howell, RD, CNS, clinical support manager with McKesson Medical-Surgical, says finding the root cause of behavior is primary in medication management. Many times, residents are acting out because of basic needs: “I'm hungry, lonely, tired. I have to go to the bathroom,” Howell offers. “Look at those things first, before giving them medication. If they are on medication, try to reduce it.”
Janelle Miller, director of content management with SigmaCare, and her colleague, Coral Lindahl, believe strongly in finding non-pharmacological interventions.
“We need to get a better handle on behaviors rather than just medicating people,” Lindahl says.
This often is easier said than done. Provider Meade points out that education could be better for nursing staff, particularly CNAs, to understand and deal with behaviors non-pharmacologically. “They are not trained to back up and figure out behavior,” she says.
Breaking habits hard
Another challenge is some of her short-term residents are on as many as 20 or 25 medications and may not be eager to give up their prescriptions. The willingness of doctors to prescribe these medications is yet another hurdle.
“One of the injustices is the specialists,” Meade says. “We have [some] patients going to 11 different doctors, and the lack of communication adds to the unnecessary medication list They are pretty set in their ways by the time they become patients of ours.”
She offers the example of the sleep medication Ambien: “They can't sleep without it. They demand it and the doctors don't want to take on the battle.”
Comprehensive documentation is providers' ammunition against surveyors' questions about proper use of medication. Providers can take the following steps to keep both residents and survey results healthy, according to Erin Marriott, RPh, consultant pharmacist at Southern Pharmacy Services, a member of the Guardian Pharmacy family:
• Always provide a diagnosis or reason for use for the medication so that staff can monitor its effectiveness.
• Establish protocols for the re-evaluation of new medication therapies or provide stop dates at the time of the initial order if intended for short-term use only.
• Put a medication reconciliation team in place to catch potentially unnecessary medications on admission and retrieve the additional information needed.
• Improve communication among the entire team, including from the hall nurse, MDS staff, consultant pharmacist, mid-level providers, attending doctor, resident and the resident's family or representative.
• Always keep the medical needs of the resident at the forefront of all prescribing. Do not be swayed by nursing facility staff, the resident's repeated requests or family requests/desires.
Electronic health records can make documentation simpler, says SigmaCare's Miller. The new mega-rule “is an opportunity to provide structure, and that's what we've taken to heart,” she says. “The altruistic view is it's good for the resident. But it's hard for facilities to comply with it. There is a host of reasons — nursing shortage and staff turnover among them. In their defense, they face a lot of hurdles, which is why you can provide the structure, at least in EHR, make collection simpler and avoid the F-tag.”
“EHRs are designed to ensure compliance in Orders Management and Electronic Medication Administration Records with the required elements of an order,” Warwick agrees. “Not only are all of the required elements and indications for use forced on every order, but monitoring requirements can be added to standard templates so that the right information is automated to the chart and flow to the EMAR so that it can be acted upon.”
Partnering with pharmacists
Long-term care consultant pharmacists are an important piece of the medication management puzzle.
“[F-Tag 329] is a primary focus of the consultant pharmacist,” says Frank Grosso, RPM, executive director of the American Society of Consultant Pharmacists. The consultant pharmacist's goal “is to find the most effective drug regimen possible, so this means as few drugs as possible.”
Along these lines, the consultant pharmacist strives to make sure there is an appropriate diagnosis, the drug is appropriate for the diagnosis and the dosage is appropriate, Grosso says. He or she also looks for redundancies and reports everything back to facilities to keep them on top of what is being used and to eliminate drugs that are unnecessary.
Bent Gay, RPh, the CEO of Gayco Healthcare, a long-term care pharmacy, agrees that the partnership is key.
“We work hand-in-hand with the facility and doctor to be their ears and eyes,” says Gay, who is the consultant pharmacist for Meade's facilities. “We'll say, ‘Let's do a dose reduction.' If a patient shows behaviors, you go back up [on the dosage]. It's the area I am there to help with. [Surveyors] want to know if the pharmacy is making sure every person is on the lowest possible dose of medication.”
Yet, even pharmacists' hands may be tied to a certain extent.
“True medication therapy management requires who is doing the management to have access to a patient's full medical record and be a participant in the care quality process, and neither of those are required by CMS regulations,” comments Alan Rosenbloom, leader of the Senior Care Pharmacy Coalition, a pharmacist advocacy group. “You've got to have full access to medical charts and be active on the care management team. So there are limitations imposed by the CMS regulation.”
The experts agree, however, that if providers keep their eye on the prize — residents' well-being — they should be in good standing, whatever comes their way.
“F-tags surround quality of care, particularly of residents,” Logan adds. “This all stems from giving patients the integrity, the respect they deserve and not treating them like a number.”