As adverse drug events and medication errors are more often linked as a major culprit for costly rehospitalizations, some inside long-term care are beginning to see their consultant pharmacist as a vital resource on broader issues.
In short, nursing home managers would do well to not only get closer to their pharmacist, but include them where the weightiest of policies are shaped.
After all, pharmacists serving long-term care figuratively spend sleepless nights worrying about many of the same things as nurses and their bosses.
Jennifer Hardesty, PharmD, chief clinical officer and corporate compliance officer for Remedi SeniorCare, admits her peers are obsessed year-round about customers’ survey readiness yet, sadly, only learn of a scheduled visit after the fact.
“We serve not only to improve medication management but to audit and improve pharmacy processes,” she says. “Often, we can intervene with surveyors, and dissolve a potential survey citation before it is even written.”
Many pharmacists also agonize as much over data as they do drugs. Managed well, both can be powerful antidotes.
Michael Boivin, president of Cubex MedBank Solutions, says that overall it would be better if consultant pharmacists worked more closely with nursing staff to reduce manual record keeping processes that are prone to error.
“While using manual e-kits and stat boxes, first dose documentation is reliant upon the nurse who removes the drugs and is a manual process that gets overlooked or can be inaccurate,” he says. “It also leaves room for error on finding which patient it was removed for and if that can’t be figured out, the drugs get charged back to the facility, which causes contention between the pharmacy and facility.”
Arguably, the one thing that nags pharmacists most is whether their recommendations are falling on deaf ears.
“All senior care pharmacists worry about the patient who is on one medication too many,” acknowledges Chad Worz, PharmD, executive director and CEO of the American Society of Consultant Pharmacists.
People such as Patricia
Howell, clinical support manager for McKesson Medical-Surgical, asserts too many nurses don’t pay attention to expiration or stop dates of drugs in med carts or narcotics in starter kits.
As Hardesty and Howell remind, facilities should have written policies for managing those recommendations, yet problems occur when nursing home staff don’t know or follow them.
“Facility staff often assist by relaying the pharmacist recommendations to the prescribers, and in transcribing the resulting orders from the prescribers,” says Hardesty. “When this process is delayed or incomplete, the effectiveness of the pharmacist is significantly reduced, which may impact patient care and regulatory compliance.”
This is how Boivin describes problems that occur when nursing home staff doesn’t have a complete picture of their medication needs: “Pharmacy has sent something but the facility says it’s not there. Facility calls pharmacy to order something without checking current inventory first. Facility calls pharmacy at last minute, creating a stat delivery.”
Another big one is being treated as an outsider.
“They often make it seem as if the pharmacist is just bothering them, that pharmacy issues are not important and/or they don’t have time for them,” laments T.J. Griffin, chief pharmacy officer for PharMerica. Worse, he adds, is too frequently “pharmacy is often an easy scapegoat — an easy target, particularly as it relates to med availability.”
Poor communication bristles pharmacists more than anything.
Hardesty calls it “the number one hurdle to overcome,” a missed opportunity to discuss the goals and expectations they have for reducing rehospitalizations, psychotropic medication use, antibiotic stewardship, and transitions of care.
Oddly, pharmacists are often the last to be consulted or notified about “changes in resident condition, new admissions, survey issues, customer service, and policy changes, [which] may result in a sizeable disconnect between the two partners,” says Erin Foti, director of consulting services for Remedi SeniorCare.
Often, pharmacists are the ones to take the initiative because regulations require it when they have concerns, says Alan Obringer, president of Guardian Pharmacy Orlando.
“Another way to assist communication efforts between nursing home staff members and consultants is ensuring a nurse is always present during the consultant’s review of medication carts, if their workload permits,” he says.
Pharmacists say the first step to opening strong communication ties is understanding the impediments.
Time is a big one. It’s sometimes difficult to get beyond routine questions about medication orders.
“It’s hard to find good quality time to discuss disease states and or specific patients,” says Griffin.
All pharmacists also must tiptoe around an 800-pound gorilla: constant staff turnover. That is agonizingly frustrating to people such as Kevin Coggin, PharmD, a consultant pharmacist for Turenne PharMedCo.
“We often get nurses who become the nursing director with limited experience in long-term care,” he says. “It takes months to get acclimated to their new role and, if they come from outside the facility, it may take longer.”
It’s when overworked nurses stop to seek help with things like passing meds and issues like polypharmacy when breakthroughs occur, as Howell has experienced. An effort on the nurse’s part to review the medication list with the consulting pharmacist can go far in reconciling and eliminating medications and reducing complicated dosing schedules, she adds. Unfortunately, “all this takes time and an act of responsibility that not all nurses are willing to take,” Howell says.
Another impediment comes from staff misconceptions about what the consultant pharmacist does. As Griffin explains: “Some facilities have the sense that consultant pharmacists operate like ‘pharmacy police’ and lump them into the category of a surveyor.”
To remedy this, Worz advises nursing home staff to “ask pharmacists to meet with them on a routine basis, invite them to care conferences, and involve them in weekly meetings. Ultimately, any clinician working in this setting needs to be integrated into the care plans of the residents to be most effective.”
Another misconception: “Pharmacists create more work for the facility by finding ‘problems’ instead of improving patient care and outcomes,” says Foti.
One insidious impediment is stifled communication, according to Michael Samarkos, director of clinical and consultant services at Guardian Pharmacy Orlando. It often happens when “large workloads and lack of time inhibit communications when a pharmacist is present.” This can be overcome when the pharmacist is regarded as a part of the team.
But one aspect pharmacists and nurses can agree upon: A crude or poorly integrated electronic medical records system can act as a veritable wall to accomplishing so much work that pharmacists and nurses bear in equal measure these days. Excess time is lost chasing paper trails in order to complete reconciliation reports, says Griffin.
Worse, even when a solid EMR is up and running, remote pharmacists often are hindered by poorly constructed security walls that impede the access they need.
Toward closer ties
Worz’s predecessor at ASCP, Frank Grosso, R.Ph., believes there are few greater investments on both sides than forging closer ties to tackle the costly problem of rehospitalizations.
“With over a million patients being discharged from skilled facilities to home, juxtaposed with the new reimbursement provider penalties for avoidable rehospitalizations, the value or ROI for pharmacist conducted medication reconciliation at the time of discharge has never been better,” says Grosso, who now works as an independent consultant with HealthCare Consults LLC.
Howell believes if nursing takes a proactive approach to better understanding consultant pharmacists’ role, adverse medication events will decline.
Others urge caregiving staff to exploit pharmacists’ greatest asset: consultation. Says Griffin, “When you have a prescriber involved in interdisciplinary meetings, good conversation takes place and orders can be written that result in positive outcomes.”
There’s never been a better time to partner with consultant pharmacists on best practices around the use of antibiotics, antipsychotics and opioids, as well as diversion issues, experts say.
“Just as the pharmacist has played a central role in the reduction of inappropriate antipsychotic use, they also can play a role in antibiotic use and opioid management,” says Worz.
While most nursing staff call upon a consultant pharmacist to explain thorny billing issues with resident families, few think to exploit their larger expertise in medication management. That, to many, is a huge lost opportunity, as senior care pharmacists exist to teach about medication use, Worz says.
“Having them address patients and families is an important step toward lower readmission rates and better outcomes, especially as residents transition home,” the ASCP leader explains. “In addition to routine in-services with staff on new medications and their proper administration and monitoring, pharmacists can play a vital role ensuring the medications we use are giving residents the best opportunity for success and the least risk of adverse consequences.”