Developing Medication Management Program for ALFs and LTCFs

1. Long-Term Care-Developing a Medication Management Program for Assisted Living (ALFs) and Long Term Care Facilities(LTCFs) James W. Cooper, Jr, RPh, PhD, BCPS, CGP, FASCP, FASHP, Emeritus Albert W. Jowdy Professor and Consultant Pharmacist, College of Pharmacy and Gerontology Faculty, University of Georgia and formerly Clinical Assistant Professor of Family Medicine, Medical College of Georgia

2. Goal: Overview components of medication management systems Objectives: • Discuss the importance of pharmacists getting involved in providing consultative cognitive services to LTCFs/ALFs • Describe the types of services a consultant pharmacist could and should be providing to LTCFs/ALFs

3. Objectives- cont’d • List advantages and disadvantages of various medication packaging systems and services • Discuss the differences between Medication Management and Pharmacy Wellness Programs • Review ASCP’s (American Society of Consultant Pharmacist’s) ALF Model State Language

4. Objectives- cont’d • Discuss how to better utilize the ASCP-approved Guidelines for Providing Consultant and Dispensing Services to ALF residents • Illustrate how to handle problems/ obstacles/issues that are frequently encountered in, and systems and forms needed for developing Medication Management Programs for ALFs

5. Overview of LTCF and Assisted Living Industry • Statistics : It is estimated that there are between 40,000 and 65,000 assisted living facilities (ALFs) in the USA, with between 3-4 million beds or twice the no. of LTCF nursing facility (NF) beds.The ALF industry is largely un-regulated • At least one in 5 ambulatory older adults gets an inappropriate drug (JAMA 2002) and ADRs occur in 2/3 of LTC residents over a 4 -yr. Study ( Cooper JAGS, 1996); one in 7 results in hospitalization (Cooper SMJ, 1999) in ambulatory population

6. Assisted Living Types • Please raise your hand if you have serviced an assisted living facility, nursing home or independent living facility! • Assisted living has many types and names: Congregate housing independent living, assisted living, personal care homes, etc. • Basic purpose of ALFs- delay or prevent nursing home placement!

7. Lack of uniformity Among ALFs Within an ALF Pharmacy providers Type of resident Services provided Pay type Lack of understanding By physicians By administration, residents, families Lack of communication Between health care providers, and with residents Lack of consistent regulations Lack of similarity between ALF/NFs Lack of ‘taking ownership’ of potential drug-related problems (Fosamax example) Recognizing the Overall Challenges

8. Recognizing the Medication Use Challenges • Medications may be: • Administered by staff (licensed, unlicensed) • Self-administered by resident; assisted by staff • “Set up” by family or friend or staff • Stored by the facility or in resident’s room or both • Medication administration records and order changes may not be available • Cognitive decline may occur over time • Typically, no traditional medication pass occurs • Medical model versus social model

9. Medication Packaging Systems • Long-Term Care Facilities (SNFs, ICFs, ICF-MR)- • “Bingo” cards • Vials, stock, etc. • Assisted Living Facilities (ALFs) • Unit dose • Variation of bingo cards • Vials • Automated systems • Med reminders • Multiple packaging

10. Vials

11. Advantages and Disadvantages of Various Medication Packaging Systems • Traditional vial systems • Advantages: cost, convenience • Disadvantages: safety, labor intensive for staff, lack of accountability, difficult to monitor compliance, increased cost if many med changes occur, must designate someone to order refills, more responsibility for untrained staff

12. Advantages and Disadvantages of Various Medication Packaging Systems • Unit-dose system • Advantages: reduces medication errors; reduces cost if returns are allowed, convenient for staff, no reorder necessary if routine deliveries (ie. Cart exchange) • Disadvantages: initially higher cost to patient, costly to pharmacy (carts, labor, inventory, third party payor, packaging equipment)

13. Unit Dose Medication Cart

14. Unit Dose Medication Cart

15. Alternative Unit Dose

16. Advantages and Disadvantages of Various Medication Packaging Systems • Multiple medication packaging systems (loose meds in one package for one administration time) • Advantages: reduces medication errors, particularly if using unlicensed staff; convenient for staff and residents who self-administer • Disadvantages: potential for increased errors if filling is not accurate; labor intensive for pharmacy; cost

17. Automated Packaging

18. Advantages and Disadvantages of Various Medication Packaging Systems • Automated systems-(ideally record MAR, inform prescriber, nurse or caregiver and pharmacist of patient compliance and drug counts) • Advantages- cut med errors, provide documentation of drug administration and may record vital signs, other data • Disadvantages- Cost, cost, cost

19. Advantages and Disadvantages of Various Medication Packaging Systems • Multiple medication packaging systems (labeled meds in one package for one administration time) • Advantages: reduces medication errors, particularly if using unlicensed staff; convenient for staff and residents who self-administer; cost • Disadvantages: potential for increased errors if filling is not accurate; labor intensive for pharmacy; cost of system

20. Blister Pack Front

21. Blister Pack Back

22. Advantages and Disadvantages of Various Medication Packaging Systems • Patient reminder systems (plastic containers to pager systems) • Advantages: maintain resident’s independence; potential for med errors • Disadvantages: dependent upon person filling container for accuracy; resident must be able to self-administer and able to understand and respond to pager

23. Safety Convenience Frequency of med changes Frequency of delivery Storage space Size of facility Staff knowledge level Ease of use Timeliness of packaging, delivery Cost To facility Labor Training Liability To resident Pay source To pharmacy Equipment set up Maintenance Computer upgrade Number of residents using system Labor Considerations for Choosing a System

24. The “Real” Problem Every resident may be using a different system, or combination thereof….

25. Epidemiology of Medication Misadventures • Up to one-third of hospital and one-half of nursing home admissions of older adults are associated with medication problems (Cooper AJHP 1977, Cons Pharm 1987) • Half to two-thirds of these problems are due to drug misuse; one-third to one-half are due to adverse drug reactions or interactions (op cit.)

26. Key Factors in Medication Problems • Drug misuse problems involve lack of patient understanding of their drugs, e.g. name , how to take and purpose of each, as well as improper use due to pre-existing conditions, e.g. aspirin-like drugs with a history of stomach or intestinal irritation or ulcers. • Adverse drug reactions are associated with patients using too many drugs, seeing multiple prescribers and pharmacists and not taking personal responsibility for meds

27. ADR Concepts • Up to 70-80% of adverse drug reactions (ADRs) are preventable by attention to patient history, cooperation between patients, prescribers and pharmacists • Fewer than one-tenth of ADRs are ever reported per FDA Med Watch Estimate • Some studies indicate that prescribers recognize or attribute ADRs less than one-fourth of the time when they occur

28. Drug Misuse Problems • The main type of drug misuse problem is medication errors! • There are three main categories of errors: prescribing, dispensing and administration errors • The most common errors are in drug administration, whether by the patient themselves, their caregivers or licensed personnel

29. Factors in Administration Errors Medication errors in administration can be classified as known or unknown. While 100 percent reporting of known errors may occur, this is only the tip of the iceberg. While up to one-fourth of doses may be given in error with traditional floor stock/individual prescription systems, this error rate may be reduced to 3 to 20 per cent of doses with unit dose systems that include pharmacist monitoring, and increased nurse or caregiver supervision of administration.

30. Factors in Administration Errors • The application of Murphy’s Law: • Anything that can go wrong, will go wrong is the key factor • The best system minimized the chances for errors at the lowest cost! • The Federal standard for serious medication error rate is zero tolerance!

31. Problem Areas in LTC & ALF Drug Use • Multiple drug providers. • Incomplete, missing pharmacy dispensing records or failure to supply pharmacy dispensing records to the consultant. • Incomplete or incorrect medication administration records (MAR) and chart orders.

32. Problems with Med Use in LTC/ALFs • Turnover of nursing or caregiver personnel. • Failure of all personnel to read, comprehend, and adhere to any policy and procedures or lack of P&P • Poor compliance with prior consultant recommendations. • Failure to recognize that a problem exists.

33. Solutions to Drug System Problems • A single provider who furnishes an efficient and cost-effective (automated?) distribution system that minimizes facility personnel time, provide adequate records, charges that are accurate, and MAR's that reflect actual usage, and feedback to caregivers and health care personnel when suspected med errors and adverse reactions occur!

34. Practical Unit-of-Use Systems • In long-term care or ALFs a 3 to 30 day supply of unit-dose packaging or delivery system (solid dosage forms only) may be most feasible in current practice. • In order to ensure the most economical use of all resources and minimize medication errors, an automated system should be considered for LTC & ALF drug distribution.

35. Automated Distribution Systems • The ideal solution may involve an automated distribution system that provides all mentioned features and: • Reminder to take medication AND documentation when doses are missed • Electronic interface with the pharmacist and caregivers or nurses for purposes of refills, documentation of drug use and medication inventory

36. Existing or Proposed Automated Distribution Systems (websites) • TabSafe- is the first system to provide both reminders, documentation and electronic interface with caregivers, nursing, pharmacist and physician (TabSafe.com) • IMD2- Is a dosage cup dispenser filled by a caregiver with med reminder and announcement but no electronic interface (IMD2.com)

37. IMD2

38. Existing or Proposed Automated Distribution Systems (websites) • Medisafe is a small storage container for meds designed for installation within a medicine cabinet. It has code and key entry and tamper light, but is not yet funded for the market (Medisafe.com)

39. Medisafe

40. Existing or Proposed Automated Distribution Systems (websites) • Informedix is a portable telemedicine device that stores a one-month supply of up to 5 different medications. It reminds the user when to take meds, but can not deliver. It records information on health status, side effects and symptoms the patient may be experiencing. Patient must key in the data that is collected and electronically transmitted to the prescriber (InforMedix.com)

41. Informedix

42. Existing or Proposed Automated Distribution Systems (websites) • Sure-Med cabinets (Omnicell.com) are locked, secure cabinets that store drugs and group dispense, provide record keeping, but require a nurse to administer the drug. A common system in nursing homes with a cart delivery system. Opus.com and Pyxis.com have similar systems. This is a throw back to the older Brewer system of dispensing cabinets.

43. Omnicell

44. Existing or Proposed Automated Distribution Systems (websites) • (CompuMed.com) is a locked storage tray filled by a caregiver, with manual keypad setup by the caregiver and a simple button release for dispensing meds. No documentation nor electronic transfer. • A review of med errors, distribution systems, error factors and solutions is presented-next lets consider patient contact activities!

45. CompuMed

46. Personal Pill Reminders • The following sites provide personal medication organizers, reminders and other aides to safe med use: • zelco.com • medose.com • epill.com • medportinc.com

47. Drug Regimen Review (DRR)-Now Medication Regimen Review in LTCs & ALFs • DRR/MRR has been mandated in LTCs since 1974- two types: retrospective (after Rx filled) and prospective (Fleetwood Model) as Rx is filled • DRR/MRR is not currently mandated in ALFs, but preliminary evidence is that there are just as many med errors and ADRs in ALFs as in LTCs

48. MRR Purpose and Methods • MRR is intended to verify drug administration as ordered, detect med errors and ADRs, and appropriate as well as inappropriate drug therapy that can lead to ADRs • MRR methods vary: Simplest approach is to have as complete a list as possible of all patient problems to include diagnoses, conditions, past ADRs, and operations

49. MRR Methods • Match all current drugs to the problem list, realizing that there will be duplications and omission, as well as drugs for which there may not be a problem • For each problem are there patient signs and symptoms that can be assessed (S=subjective findings)

50. MRR Methods • Next, are there drugs, physical or lab findings that assess drug effect? (O=objective findings) • A=Assessment of S and O findings to determine if the problem is adequately treated and if there is any further information needed to complete the--> • P=Plan for follow-up and recommendations