Need a pill? A physician prescribes it, a pharmacist dispenses it and a nurse administers it. But for long-term care (LTC) businesses, this medication chain is far too simple and can lead to dangerous consequences for senior resident populations, especially for residents with multiple illnesses.
Let’s say “Mary,” age 87, is discharged from a hospital to a local skilled nursing facility (SNF) after a hip replacement. When she arrives at the SNF, her chart says she’s been prescribed an inhalant steroid, a cholesterol-lowering drug, a beta-blocker, a multivitamin and five other drugs—all duly noted on her discharge chart. The SNF continues to give Mary all the medications noted on the hospital’s discharge summary, since no directions say otherwise—not realizing that the steroid was only meant as a short-term relief for the pneumonia she developed while in acute care and is no longer needed.
Enter the LTC facility’s care team pharmacist, whose job includes doing a thorough medication review, examining every medication Mary is taking and why. The pharmacist sends a note to the physician questioning the continued (now unneeded?) steroid use. Then, during a one-on-one medication review conversation between Mary and the pharmacist, Mary also reveals that she’s been skipping her beta-blocker heart medication because it upsets her stomach—until the pharmacist wonders if the real culprit may be the multivitamin she is taking concurrently and alerts the physician to that possibility.
THE RISE OF GERIATRIC PHARMACY
Current national statistics are shocking: Most older adults take an average of 9 to 15 different medications during a single year. Add a few hospital visits, and that pill-count can rise astronomically. In addition, many seniors have trouble juggling all their medications, leading to nonadherence and drug-interaction side effects that inadvertently can lead to the prescribing of even more drugs.
“We’re realizing that medications are an integral part of the care we’re delivering, but we need to be monitoring them. And one of the best ways to ensure monitoring appropriate drug use and minimizing the risk of adverse drug interactions is the pharmacist,” explains Nicole Brandt, PharmD, CGP, BCPP, of the University of Maryland School of Pharmacy.
Specifically within senior care, pharmacists play an important roles in combatting pseudodementia—a situation where medication side effects mimic symptoms of dementia. Cholesterol-fighting statins, anti-inflammatory drugs and antianxiety drugs all can cause confusion, memory loss and/or behavior changes in older adults—along with many other drugs listed in the Beers Criteria as being high-risk for the elderly. Without a full pharmacist’s chart review, Mary could end up with an inaccurate diagnosis of early cognition loss, possibly adding another pill or two.
The LTC pharmacist’s job includes reviewing medications and alerting the attending physician to possible drug reactions, unneeded drugs and possible alternative drugs. Another huge part of the job is talking personally with the residents, to make sure they understand what medications they’re taking, how to take them and why they’re important. This latter role is something many overtaxed physicians may not have time to do during their normal rounds at a SNF.
The complexity of medication regulations and the higher education of today’s pharmacists (many are now earning PharmD degrees and/or Certified Geriatric Pharmacist credentials) both have contributed to the rise of the geriatric pharmacist, explains Courtney Oland, RPh, MBA, FASCP, director of pharmacy operations, Waltz Long Term Care Pharmacy, Brunswick, Maine, part of the Guardian Pharmacy network.
“Pharmacists are now increasingly serving as resource people for the direct-care staff who may not have extensive clinical knowledge of how to deal with medications,” she says. “Nurses and medical directors are looking for a partner in care delivery and see one right across the table in the pharmacist.”
THE BUSINESS CASE FOR CARE TEAMS
Last year, the Centers for Medicare & Medicaid Services (CMS) mandated a 15-percent reduction in the off-label use of antipsychotics. The goal, although specific to a certain class of drugs, spurred LTC organizations to take a fresh look at how all prescription drugs were being used and monitored—and along with it, created a new focus on the role of pharmacists within the care team.
As national mandates often reverberate throughout the LTC industry, some early-adopting LTC organizations are now welcoming geriatric-certified pharmacists as valuable participants in their resident care teams, recognizing their unique skill set. To the same end, some SNFs (especially not-for-profits) are upping the ante, seeking LTC pharmacists who are trained in geriatrics and/or who have completed geriatric-based residencies.
One of the strongest cases for integrating pharmacists on care teams may be hospice and palliative care, notes Betsy Rothley, MSN, FNP, Chief Development Officer at Enclara Health, a hospice pharmacy services provider. Few medical and nursing schools teach pain management specifically, she says, “so a lot of clinicians just don’t know what best practice is for pain management. This is where the pharmacists can put on the consulting hat.”
For many in the nursing home industry, the culture change is clear: The pharmacist is in. Exploring ways in which to use their skill sets, geriatric expertise and knowledge of medicatrion management could improve resident care, reduce risk and add a valuable member to the person-centered care team.