Meeting Minutes

1. Meeting Minutes • October 14, 2013 I.  Congrats to our new liaisons Vivian Hong and Nhu Nguyen! II. Upcoming events a. Speaker event with Dr. Alan  Bell i.      Oct 24 ii.     6:00 – 7:30 PM b. Omnicare Tour i.      Nov 6 ii.     1:00 – 3:00 PM

2. Consultant Pharmacy Practice Mark Sey October 14, 2013

3. Definition - Who is a Consultant Pharmacist? • A pharmacist who is compensated to provide expert advice on the use of medications by individuals or within institutions, or on the provision of pharmacy services to institutions. • Originated in the nursing home environment • ASCP focus - defined by their common commitment to enhance the quality of care for all older persons through the appropriate use of medication and promotion of healthy aging.

4. The Right Answer YOU !

5. Today’s Discussion • Evolution of Consultant Pharmacy • American Society of Consultant Pharmacists • Senior care environments • Key long-term care professionals • Senior care pharmacy practice

6. Evolution of Consultant Pharmacy • 1965- Medicare/Medicaid • Drug regimen review required by charge nurse and prescribing MD working together • Consultant Pharmacist responsibilities for drug distribution • 1969 – ASCP Established • 1974 – DRR required by pharmacists in NF!

7. Evolution of Consultant Pharmacy • 1982 - Indicators developed to help surveyors assess DRR • 1980’s – Consultant pharmacists showed their stuff! • Practice roles more clearly defined • Consultant’s effectiveness documented • Decreased inappropriate drug use • Fewer ADR’s • MD’s accepted CP recommendations

8. Evolution of Consultant Pharmacy • “Success Breeds Success” Increased mandate for consultant’s services • 1987 - Pharmacist review mandated in ICF • 1988 - Pharmacist quarterly review mandated in ICF-MR • Pharmacists published their work in Consultant Pharmacist • People took increasing awareness of consultant pharmacists

9. American Society of Consultant Pharmacists (ASCP) • 8,000 members • Numerous State chapters • National meetings – May and November • Well-respected and informative web site • Website:www.ASCP.com • Website:www.seniorcarepharmacist.com • Embraces interdisciplinary initiatives • Supported development of Commission for Certification in Geriatric Pharmacy (CCGP)

10. The Continuum of Care Caregiver Skills High Low High High Hospital Subacute Nursing Facility Assisted Living Cost Acuity Home Health Care Low Low

11. The Senior Market 34.3 million individuals 65 years old and older Nursing homes 1.8 million residents Assisted living 1.8 million residents Other elderly 10.2 million residents Home care 3.5 million beneficiaries Community-based LTC 8.5 million individuals NORCs 8.5 million residents

12. Nursing Facilities • The traditional LTC environment in the U.S. • Provide care using a “medical model” that is somewhat analogous to hospitals • Approximately 2/3 of NFs are operated for-profit • ~1/2 are operated by chains – • 9% bed growth compared in 2010 compared to 2009 • HCR ManorCare, 38,000+ beds; 283 facilities • Golden Living, 33,000+ beds; 332 facilities • Life Care Centers of America, 31,000+ beds; 221 facilities • Kindred Healthcare, 29,000+ beds; 231 facilities

13. Nursing Facilities • Total number of beds 1,725,326 • Medicare 77,023 • Medicare/Medicaid 1,413,951 • Medicaid 186,086 • Noncertified 48,266 • Resident payer sources • Medicaid 65% • Private/other 22% • Medicare 13%

14. Nursing Facilities 200 beds or more 8% Fewer than 50 beds 12% 100 to 199 beds 41.8% 50 to 99 beds 38.7%

15. Typical NF Patient Flow • Patient seen in ER for work-up • Patient may be admitted to qualify for Medicare Part A • Patient worked up based on hospital criteria • Treated and stabilized • Set for discharge Hospital • To nursing facility after initial admission or • Return to nursing facility after brief hospitalization • Return to hospital for acute event, eg, fracture, symptomatic A-fib, etc RehabShort Stay LongStay • If needed, NF residents will usually need to visit the specialists Discharge to home or assisted living • NF attending physicians and selected geriatric specialists see residents in the facility Nursing Facility

16. Nurse Practitioners may see patients for the physician group • Nurses continually monitor resident’s health status through the plan of care Nurse Practitioner • Medical Directors need to make the best medication choices for their patients Nurse Medical Director RehabShort Stay RehabLongStay • Consultant Pharmacists regularly review medications Consultant Pharmacist Nursing Facility Focused View of NF Resident • LPNs need to know how to manage NF residents LPN

17. Assisted Living Facility Models Personal Care Model Hospitality Model NF Alternative/ Replacement Model

18. Assisted Living Target Market • 75-85 years of age • mostly female • $25,000 income (supports $1,600-1,750/month using 75-85% of resident’s income) • 2+ ADL support

19. Residents may come from the community or move back to the community for various reasons • Resident may visit Attending Physician, or Attending Physician may visit facility Community AttendingPhysician Assisted Living Facility Hospital Typical AL Patient Flow • Resident usually visits specialist. Specialists rarely visit assisted living facility. Resident would see specialist for monitoring of medications and therapies • If resident becomes less independent or needs short-term rehab Nursing Facility Specialist “The goal of assisted living is to keep them in assisted living.” Nursing Director National Assisted Living Provider • Patient seen in ER for work-up • Patient may be admitted • Patient worked up based on hospital criteria • Treated and stabilized • Set for discharge

20. Nursing Facilities Elderly population Multiple medical dx Multiple medications Federal regulations Skilled staff Mandated DRR Assisted Living Elderly population Multiple medical dx Multiple medications Regulated by State Less skilled staff DRR mandate varies Assisted Living vs. Nursing Facilities

21. Key LTC Professionals • Administrator • Medical Director • Attending Physician • Consulting Physician • Nurse Practitioner/ Physician’s Asst. • Nursing Staff • Director of Nursing (DON) • Charge Nurse, Head Nurse • Nursing Supervisor • MDS Nurse • Staff Nurse • Nurse Aides

22. Key LTC Professionals • Pharmacists – consultant and dispensing • Therapy Staff (physical and occupational therapy) • Dietitian • Activity Directory • Social Services • Geriatric Case/Care Managers • Staff development coordinator • Family members

23. LTC Pharmacy Landscape • OmniCare 1,400,000 NF/ALF beds • PharMerica Corp. 360,000 NF beds • Regional pharmacy providers • Green Tree, South Central Illinois • Smaller pharmacy providers • New, evolving provider and consultant companies, some specializing in AL • Independent consultant pharmacists

24. LTC Pharmacy Services Drug Distribution Services Consultant Pharmacy Services

25. Pharmacy Providers Services • Efficient and accurate distribution • Emergency kits • medication administration record • Standardized services between facilities • Improve pharmaceutical care • formulary • Pharmacy providers influence market share • Consultant pharmacists recommendations • Formulary preferred products • Disease management initiatives • Educational initiatives

26. What is a Consultant Pharmacist? • A patient advocate for best clinical care • Licensed by state to practice pharmacy • No degree requirement • No specific credentials required by most States • Typically involved in many activities

27. LTC Pharmacists Employment Model

28. LTC PharmacistsPractice Involvement

29. Consultant Pharmacist’s Domain • Pharmaceutical care • Medication-related problems • Appropriate use • Medication Regimen Review “MRR” • Anything drug-related • Side effects, dosage, switch to alternative products, monitoring, add drug for untreated indication, etc.

30. PharmacistsPractice Activities

31. Medication Regimen Review • Resident-specific • Pharmacist-conducted • Required in all NFs as a Medicare/Medicaid Condition of Participation and by OBRA ‘87 • Performed at least monthly • Retrospective or prospective • Encourage appropriate medication use • Provide optimal Pharmaceutical Care

32. Interdisciplinary Concise Accurate Neat Non judgmental Well documented Evidence-based Referenced when necessary Follow up included Components of Effective Medication Regimen Review

33. MRR Challenges for Pharmacists • Adequate training • Clinical skills and experience • Exploding knowledge base • Recognition/Cooperation • Adequate reimbursement • Work load

34. Thank-you!