Complex Medication Regimens Call for Help with Medication Management
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Complex Medication
Regimens Call for Help
with Medication
Management
Phillip Wizwer MS, FASCP and William Simonson, PharmD, FASCP, CGP
A ssisted living (AL) original-
ly was intended for indi-
viduals requiring assistance
with such activities of daily living
(ADL) as bathing, toileting, ambu-
lating, and self administration of
medications. What we have found,
however, is that one of the most
prevalent reasons for admission to
AL today is the need for assistance
with medication management be-
cause of the complexity of a resi-
dent’s medication regimen.
In fact, the use of medications
is higher in AL than it is in most
nursing homes. Often seniors, in-
cluding AL residents, receive med-
ications listed as potentially inap-
propriate for those aged 65 and
older as identified by the Beers
Criteria, which were adopted into
the Centers for Medicare and
Medicaid (CMS) Guidelines for chronic diseases that require mul- cific state regulations, although its
Potentially Inappropriate Medica- tiple medications, with many resi- summaries may not be entirely up-
tions in the elderly.1,2 It is not un- dents receiving more than 8 po- to-date. See www.ncal.org for addi-
common to see cognitive impair- tent medications daily.4 tional information.
ment or increased falls secondary As of December 2005, 27 states There is much evidence of the
to medications and/or sudden mentioned a medication review re- value of pharmacy interventions
changes in a senior’s medication quirement in their regulations and within the institutional environ-
regimen. This is especially true 22 of the 27 specified that a phar- ment, especially in the area of Med-
when medications such as benzo- macist be part of the review ication Therapy Management Serv-
diazepines, one of the most wide- process. Since regulations are con- ices (MTMS).5,6
ly used class of medication by stantly changing, it is important that To avoid nursing home type
seniors, have not been tapered state regulations be reviewed regu- regulations, many AL providers are
slowly.3 Clearly, AL residents are larly. The National Center for As- increasingly focusing their atten-
medically frail and have many sisted Living (NCAL) provides spe- tion on providing medication
26 Assisted Living Consult November/December 2006management programs. However,
this presents a potential dilemma Table 1.
How States Approach Medication Reviews
for many AL owners who may not
be interested in emulating a long-
term care medical model that may Number of states Medication review timeline By whom
result in further governmental reg-
ulations. On the other hand, with 3 not specified P
the increasing attention to the con- 1 change in resident’s P, MD
cept of aging in place and the condition
gradual evolution from a social
model of care to one resembling a 1 monthly CP, N
medical model, it may be neces- 1 monthly P
sary to rethink the best approach
to care for AL residents. 1 monthly and quarterly RN or P, CP
At present, most AL staff mem-
bers are unlicensed and may be 1 quarterly “pharm review”
less trained than licensed staff 2 quarterly P
members, but they are responsible
for distributing and administering 1 quarterly RN, P, MD
medication. Because of this, phar-
macists should be more involved in 1 quarterly MD, RN
training them to administer medica- 2 quarterly CP
tions. States such as Rhode Island
and New York are doing something 1 90 days & when change N, P, PCP
about this already; pharmacists in in resident’s condition
those states and others now train
unlicensed AL personnel to admin- 1 90 days & when change N, P, PCP
ister medications. Table 1 shows in resident’s condition
how states approach medication re-
1 62 days, with new RN
view in AL. medications, change in
In order to better position them- resident’s condition
selves, many AL facilities, with the
assistance of institutional pharma- 2 every other month, or P, RN, CP
cies, offer “pharmacy wellness” pro- every 3 months
grams and/or medication manage-
ment programs. 1 6 months P, MD, RN
A wellness program, similar to 1 6 months HC professional, P
what Health Maintenance Organiza-
tions (HMOs) offer, attempts to keep 1 at least annually CP, HC professional
individuals well before a major med-
ical problem develops. It often entails 1 at least annually MD, CP, HC professional
screening or monitoring programs, 1 periodically N, P, PCP
such as blood pressure screenings or
programs designed to improve resi- 1 “encouraged” review HC professional
dents’ compliance with their medica-
tion regimens, along with educational 2 not specified P
in-service programming. N-Nurse, P- Pharmacist, CP- Consultant Pharmacist, PCP- Primary care Provider,
A medication management pro- RN- Registered Nurse, HC – Healthcare, MD- Physician
gram (MMP) in AL is similar to Special conditions may apply. Refer to specific state regulations.
what is performed by pharmacists
in nursing facilities. With an MMP, a
consultant pharmacist or senior es. In addition, a dispensing phar- One such AL MMP program was
care pharmacist promotes optimal macy provides the drug product initiated in 1996 at the Cohen Flo-
drug therapy outcomes for residents and special services, many of which rence Levine Estates, a 69-unit facil-
and assumes responsibility for the are different than those provided in ity in Chelsea, MA (see Table 2),
entire spectrum of pharmacy servic- the community or retail setting. consisting of residents who are
November/December 2006 Assisted Living Consult 27fully independent as well as those
who have daily personal care needs Table 2.
due to a medical condition. This fa- Role of the Consultant Pharmacist in the Medication
cility was subsequently upgraded Management Program at Cohen Florence Levine Estates
with an additional building attached
to the existing one comprising 36 • Aid in ensuring that residents are taking medications correctly in
“special care” units designed for ad- accordance with physician instructions
vanced dementia and special needs • Check to see if all medications have a rational diagnosis or reason for
residents. On admission, all of the administration
residents are offered the services of • Check for appropriate dosages and be responsible for timely Drug Regimen
a consultant pharmacist who re- Reviews (DRRs) on all residents that become part of the Medication
views their medication regimens to Management Program
determine whether there are any • Aid in ensuring that residents understand the medications they are taking,
potential or current medication- and how and when to take them
related problems. (See Table 3) • Check for possible drug interactions and allergic reactions
Any medication-related problems • Keep track of pharmacy-related recommendations and/or concerns and
or issues noted are then communi- report outcomes to doctors and appropriate facility staff
cated to the resident’s physician
• Help educate home health care aides regarding medications and how to
and the appropriate facility staff. recognize adverse drug reactions ADRs
Subsequent MMP reviews are per-
formed as needed on an on-going
basis. Their frequency is determined
by the pharmacists, based on initial identifying, evaluating, and making
findings, the complexity of the med- recommendations to ensure resi-
ication regimen or potential compli- dents are receiving appropriate med-
ance issues noted. All residents are The routine availability ications along with improving med-
reviewed at least quarterly. ication compliance within a facility.
The pharmacist also is involved
of a consultant
with any resident who may be ex- pharmacist to AL What to Consider When
hibiting a significant change in residents increases Developing an MMP
physical, cognitive, or functional There are many things that need to
status. The pharmacist also pro-
revenue to the AL be addressed when developing an
vides recommendations for proper owner/operator, not to MMP for an AL facility. The admin-
medication storage for residents as mention enhancing the istrator needs to appreciate the val-
well as appropriate packaging op- ue of medication review and the
tions for medications sent to the fa-
reputation of the facility. positive impact that it can have on
cility and/or residents. the facility (marketing) and the resi-
dent (the most expensive bed for
Why It Is Important to the facility is the empty one).
Develop an MMP By keeping a more stable popu-
The elderly take more medications Such consultant pharmacists are lation, the facility benefits directly.
than younger people and often the best equipped to advise facili- It largely is the responsibility of
need special counseling. A large ties on medication management is- pharmacists to provide the evi-
number of elderly who are admit- sues and are in a very good posi- dence to administrators and other
ted annually to hospitals have had tion to participate in AL risk key decision-makers that the impact
adverse drug reactions (ADRs) management initiatives. of their medication reviews benefit
and/or inappropriate treatment of In addition, the routine availabili- the facility and its residents.
diseases. Many hospital admissions ty of a consultant pharmacist to AL Meanwhile, owners and adminis-
that result from drug related prob- residents increases revenue to the trators must understand the differ-
lems are costly and unnecessary. AL owner/operator, not to mention ences between MMP and pharmacy
Noted consultant pharmacist Diane enhancing the reputation of the fa- wellness programs. Unique forms
Crutchfield demonstrated the cost- cility with prospective residents, re- and/or systems will need to be de-
saving benefits of changing dos- ferral sources, and regulators.7 In veloped. Policy and procedures
ages, discontinuing unnecessary essence, within an MMP, the phar- specific to each facility must be de-
medications, and discontinuing du- macist is largely involved in educa- veloped. In addition, possible re-
plicate medications. tion programming for the staff; and sistance to medication monitoring
28 Assisted Living Consult November/December 2006that the facility’s administrator
Table 3. and/or owner understand the
Possible Medication-related Problems health benefits of such a program
to the residents and marketing ben-
• Medical conditions possibly needing/requiring new or additional drug efits to the facility itself, which will
therapy be able to inform all new residents
• Medical conditions possibly needing/requiring elimination or dose that such a medication review pro-
reductions gram is part of the services offered
• Resident taking unnecessary or inappropriate drugs by the facility.
• Wrong drug for resident’s medical condition
Explanation letters to family
members and residents need to be
• Correct drug but incorrect dose
developed and sent out on the facil-
• Adverse drug reaction not recognized ities’ stationary. Explanation letters
• Resident not taking medications correctly to MDs, explaining the program and
• Compliance issues the pharmacist’s role within the pro-
gram, also are necessary.
Once the MMP has been formal-
from families, residents, and staff a challenge. A formal method of ized, ongoing education for staff
who may not understand the value compensating the pharmacist for and residents will be necessary.
of an MMP performed by a phar- his or her cognitive services, sepa- It is important to develop a resi-
macist will have to be overcome. rate from the provision of medica- dent referral form for medication re-
Some staff members may not un- tions, is needed. It is important to view and management. The form
derstand the need for pharmacist realize that at the present time, should identify residents who have a
involvement in their facility. They MMPs in AL are not mandated by change in ambulation, continence,
may feel that existing staff can per- mental/memory status, or neurologi-
form medication review and super- cal status (eg, tremors, dexterity). A
vise administration of medications list of residents who may have be-
to residents without pharmacist come frail and/or have been hospi-
oversight. talized since the last visit of the
There is one unique problem, The pharmacist will need consultant pharmacist should be
however, in developing an MMP in to develop a means of obtained. Since typically there is
AL. Unlike residents of nursing fa- no formal medical chart for AL res-
communicating with
cilities who almost always are in idents, it will be necessary to de-
the facility and easily accessible, AL doctors and staff velop a means for accessing chart
residents frequently are not avail- regarding concerns information as well as resident in-
able when a pharmacist needs to formation. In addition, since there is
and/or findings that
meet with them, and, for the most no federal mandate for medication
part, there are no medical records result from the MMP. reviews within AL facilities, there is
to review. Medication reviews can- a need to develop and obtain resi-
not be performed just by reviewing dent consent, which would allow
medication profiles; it is very diffi- the pharmacist to be in compliance
cult to maintain an up-to-date pro- with Health Insurance Portability
file of prescription medications, the federal government. Assisted and Accountability Act (HIPAA) pri-
over-the-counter medications, and living regulations are the responsi- vacy-protection regulations.
herbal products that each resident bility of the respective states. The pharmacist also will need to
is taking. To perform an effective develop a means of communicating
medication review, the pharmacist Possible Strategies for with doctors and staff regarding
needs to meet personally with resi- Successful Implementation concerns and/or findings that result
dents in their own units in order to of an MMP from the MMP. It is suggested that a
assess medication usage and com- In spite of the above obstacles, letter on the facility’s letterhead be
pliance. Unlike in nursing facilities, performing MMPs in AL is a viable sent containing the date of the visit
charts and other information such concept. The following are possi- with resident, a reiteration of the
as progress notes and lab informa- ble strategies for their successful goals and purpose of MMP, infor-
tion often are not available or up- implementation. mation regarding the medication is-
to-date in AL facilities. First, a business plan is needed sues or concerns noted, and recom-
Payment for MMPs in AL also is and the pharmacist must make sure mendations.
November/December 2006 Assisted Living Consult 29tion review services from its market-
Table 4. ing budget. The facility realizes that
Forms/Records Needed for an MMP potential residents and their families
Census/Follow-up Record perceive the advantages of a quali-
fied senior care pharmacist and they
• Resident Concerns/Referral Form highlight the fact that all residents
• Consent to Obtain Information Form receive medication reviews as part
• Initial Assessment Form of their contract. In addition, the fa-
cility appreciates the fact that the
• Pharmacy Progress Record
medication reviews provided by the
• Pharmacy Concerns/Intervention pharmacist will reduce the likeli-
• MMP Appointment Record hood of residents experiencing med-
• Facility MMP Policy and Procedure Manuel ication-related problems such as
falls, which might cause them to
leave the facility for a nursing home.
Another way for the consultant care payment may become a reality In this case, the facility sees a signif-
pharmacist to become more in- in the future. icant financial benefit from the phar-
volved is to become part of an “in- Of course, private pay is one al- macist’s MMP. Another payment
fection control committee” at a fa- ternative for patients or their adult model is one that adds a fixed
cility. The pharmacist will need to children. Some pharmacists who amount of money to the resident’s
be kept abreast of residents who provide medication review have monthly unit cost to provide an
have developed or are being treat- found that many adult children will MMP. If this approach is utilized, it
ed for infections. That way, the gladly pay for a service that will must be disclosed upfront as one of
pharmacist will have to obtain up- the benefits and/or amenities of the
dates on residents who have, have facility. ALC
had, or are currently being treated
for any type of infection. Phillip Wizwer MS, FASCP is an Associ-
It is important that the pharma- ate Professor, Pharmacy Practice,
Developing an MMP may Massachusettes College of Pharmacy
cist develop a policy and procedure and Health Sciences in Boston, MA.
manual addressing how medica- produce many positive
William Simonson, PharmD, FASCP,
tions and medication issues will be outcomes, including CGP is an independent consultant
handled, and to consider the priva- pharmacist in Suffolk, VA.
fewer medications
cy issues of residents. A list of the
various forms and records that are per resident.
References
utilized within the MMP (see Table 1. Beers MH, Explicit criteria for determining
4) could be included, also. potentially inappropriate medication usage by
the elderly. Archives of Internal Medi-
cine.1997;1531-1536.
Impact and Outcomes of keep their parents from experienc-
2. Fick M et al. Updating the Beers criteria for
Developing an MMP ing preventable medication-related potentially inappropriate medication use in
Developing an MMP such as the one problems. One barrier that needs to older adults. Archives of Internal Medicine.
initiated at the Cohn Florence Levine be overcome is the tradition that 2003;163:2716-2724.
3. Curran HV, et al. Older adults and with-
Estates may produce many positive pharmacists are paid for the medi- drawal from benzodiazepine hypnotics in gen-
outcomes, including fewer medica- cines they dispense. In an MMP, the eral practice: effects on cognitive function,
tions per resident; improved medica- pharmacist is providing information sleep, mood, and quality of life. Psychological
Medicine. 2003;33:1223-1237.
tion management, a decrease in the and oversight instead of medicines.
4. Larrat E, et al. Medication utilization in
cost of medications to residents, in- However, it is important to note board and care facilities. Consultant
creased outcomes in resident and that a comprehensive medication Pharm.10:1263-77
staff education, and a better medica- review may identify numerous ways 5. Sound Medication Therapy Management
tion delivery system to residents. for AL residents to save money Programs;. 2006 Consensus Document. Journal
of Managed Care Pharmacy. April 3, 2006;vo1
through the use of generic medi- 12 (suppl).
How to Handle the Costs cines, and the elimination of dupli- 6. Weber R. Strategies for developing clinical
A big challenge for pharmacists in- cate therapies and unnecessary Services: advanced practice programs. Hospital
terested in providing an MMP is the medicines. Pharmacy. 2006;41:986-992.
7. Kahan B. Practice opportunities: providing
issue of payment. Although Medi- In a creative payment model used services in assisted living facilities. Geriatrics
care does not pay pharmacists for by at least one consultant pharma- “06.” ASCP 28th Midyear Conference and Exhi-
this intervention at present, Medi- cist, the AL facility pays for medica- bition. April 26, 2006. Las Vegas, NV.
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