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Promontory Healthcare Companies, a Portland, OR-based provider of transitional care units in several U.S. markets, including skilled nursing facilities specializing in rehab and sub-acute care, acute care and psychiatric facilities, and home care operations
Comprehensive long term care pharmacy services from PharMerica, including TransitionRx, RxForecaster, and DischargeRx, as well as cost containment, compliance, and education products and services.
As one of the nation’s preeminent providers of transitional care, Promontory Healthcare Companies has earned a well-deserved reputation for ensuring residents move smoothly through the various care settings in the healthcare journey.
It is a passion embedded in its culture, and led by Chukk Neilson, BSN, clinical operations manager.
In his role, Neilson is involved in everything from budgets to staffing and education. When he’s not ensuring the nursing directors at Promontory’s facilities are trained, he’s busy writing policies and procedures for skilled facilities and managing vendors and ensuring all caregiver charting is in compliance.
Three major goals drive most of what Neilson does day-to-day and long-term.
One of them is ensuring discharge planning is “a moveable process. It has to be integral and multi-dimensional for every client of ours,” he says. “This begins at the point of entry and the social service involvement that occurs on day one of their experience here.” Neilson ensures his social service directors and their appointees meet with the client on the day of entry, and that the various disciplines across facilities are aware of the client’s needs, their environment, and their home and family structure. On top of this are all the myriad layers of services and therapies Promontory provides.
The process is made smoother by using PharMerica’s TransitionRx solution, which simplifies the handoffs when new residents are admitted to a Promontory facility. A pre-admission referral program that partners with hospital discharge planners and care coordinators, TransitionRx allows PharMerica to provide admission assessments, complete with medications and lower cost alternatives to review with the admitting physician, before or during the resident’s admission. When hospital discharge planners prepare a patient for discharge, PharMerica electronically receives the resident information and medications list from the hospital several days prior to discharge. PharMerica completes a Price Forecaster Assessment, providing pricing alternatives and coverage checks, then transmits it to a facility for review with the resident and the physician.
Each month, a PharMerica consultant visits a Promontory facility to conduct in-person medication regimen reviews, as well as making necessary recommendations to physicians and providers. Upon admission, a consultant pharmacist also will ensure all relevant tests and lab work are scheduled, check for drug interactions and side effects, and alert Promontory caregivers about any issues that could arise.
Nielson’s second major goal is family engagement. “This is a really important aspect of the total care our patients receive, particularly in skilled nursing settings,” he says. “The geriatric population tends to be on one end of the spectrum or the other – either a lot of family involvement or none. It deeply concerns us if we find our elderly patients return to the community without having access to the resources because of weak family involvement, or some type of care navigator. In that regard, we are passionate about advocating on behalf of our former residents in every way possible.”
The task can often be challenging. “It’s really unfortunate, especially for patients who are not alert and oriented, or they have some sort of dementia process,” he says. “And yes, it does become difficult, especially when you do have just enough family involvement to become dangerous.” Neilson doesn’t hesitate to marshal all available resources when family involvement is thin. Whether it’s contacting the Centers for Aging for advice and assistance, engaging the clergy and local churches or involving state and local health ombudsmen and area senior organizations, no resident leaves a Promontory facility without outreach plans in place.
Nielson’s most important goal, however, is continuity of care – beginning with discharge planning from higher acute care levels to one of Promontory’s facilities, all the way through managing transitions of patients back home or to other community settings.
With all he does, it may surprising to learn how much time Neilson and his caregivers devote to documentation. He applies the same passion to charting as he does his residents.
“What it boils down to is constant education, constant review of charts, and it’s unfortunate because it takes time away from bedside care,” he says. “I’m a huge proponent of positive charting because I know that my patient is being taken care of. I can follow that chart, those nursing notes, that medication administration record and it tells me a story. It tells me a story of what it looked like when my patient woke up to the time they went to bed, including all of the observations in between.”
Few challenges confound long-term caregivers more than medication management. The issues begin the moment an elderly person arrives by ambulance at the local hospital. Unless family members knowledgeable about all the myriad drugs the patient has been taking, it begins with the arduous task of connecting the dots.
In many cases, the patient arrives at the door of a nursing home or other post acute setting with even more medications, many from multiple pharmacies. That’s why medication management is the highest priority for Neilson and his staff.
“We find a lot of polypharmacy in our demographic. So we try to eliminate as many redundant medications or unneeded meds we can before the point of discharge,” he says. “We try to stabilize the medication regimens, and if a new medication was added, maybe the resident wasn’t used to taking it and we find they stopped or forgot to take it, and maybe that’s part of the reason they were admitted to us in the first place.”
Promontory’s commitment to medication management doesn’t end when a resident transitions to home or another setting. The process has been greatly facilitated with the help of PharMerica’s DischargeRx solution.
“The integration PharMerica brings to our continuity of care goals with each resident is paramount. Without including the entire health care spectrum, from physicians and nurses to therapists and other caregivers, we’re missing a piece of the link. And pharmacists have just as much to offer as anyone else does. In that way, PharMerica fills a big gap for us.”
Through DischargeRx, PharMerica handles all the details so residents can take home the medications they need at discharge. DischargeRx fits seamlessly into any discharge planning process, ensuring the resident’s current medications are properly ordered, packaged and sent promptly to their destination facility. PharMerica consulting pharmacists follow up directly with the resident to ensure they are taking medications and have a follow up appointments with their physician.
On the day a resident is discharged from a Promontory facility, DischargeRx allows the person to reenter the community with a 30 day supply of medication, which reduces risk and increases safety, he adds.
The engagement by PharMerica’s staff provides more than just peace of mind. “PharMerica partners with my facilities at a local level to ensure that all medications are warranted and needed.” Neilson says. “The medication reviews conducted by the consultant pharmacist allows my facilities the opportunity to discuss medication regimens with providers to ensure the client is receiving the highest quality of care. Medications that are not necessary can be discontinued, and patients told in plain English the reasons why.
“PharMerica’s consultant pharmacy services reduces the risk for my client by reducing polypharmacy, drug-to-drug interactions, and unnecessary medications,” he adds. “In addition, my compliance efforts are made easier through integration of our EMR with PharMerica through an electronic format. I am able to view black box warnings, which in turn allows me to educate my client. This also allows me to see potential interactions at the point of order entry, which could ultimately prevent harm from occurring.”
PharMerica’s DischargeRx solution can help Promontory achieve its primary goal of continuity of care and safe transitions.
“The implementation of split billing with DischargeRx has allowed my facilities to ensure clients have their medications at the point of discharge,” Neilson says. “Many clients are unable to afford physician follow up after discharge, and this can make it difficult for them to obtain needed medications and services. Secondly, my facilities can rely upon PharMerica to educate our clients and their families, and empower them on their medication regimens, which provides for a safer transition to a new environment. Finally, the drug regimen reviews, assessments, and recommendations PharMerica’s pharmacists provide allow for a dynamic process that aids my clients in their medical course.”
Over the past few years, Neilson has come to value the partnership PharMerica and its consultants have with Promontory.
“First of all, I’m not a pharmacist. I’m a nurse and I can tell you what a medication is supposed to do, but when it comes down to it, I need that pharmacist to be able to educate me so that I can educate my client,” he says. “That relationship allows me to have frank discussions about the level of care and why decisions and recommendations are made. I love having the ability to pick up the phone a pharmacist or even a pharmacy tech and have the level of responsiveness and proactiveness I’ve come to expect. The integration PharMerica brings to our continuity of care goals with each resident is paramount. Without including the entire health care spectrum, from physicians and nurses to therapists and other caregivers, we’re missing a piece of the link. And pharmacists have just as much to offer as anyone else does. In that way, PharMerica fills a big gap for us.
“The last thing I want to do is have a pharmacy dispense medication and never be able to get hold of them again, because then my client ends up in a deficit, and that I can’t tolerate,” he adds. “Having that backup, that support, 24 hours a day, seven days a week, and holidays, while ensuring my client is safe and taken care of, means a great deal.”
On a broader scale, Neilson values PharMerica’s business consulting services. The company conducts a quarterly business review (QBR) for Promontory to explore progress in medication management, as well as quality improvement. The process is far from being one-sided. In fact, PharMerica consultants typically work side-by-side with Promontory’s quality improvement interdisciplinary teams to discuss trends, or care delivery systems, or how medication delivery systems can be better managed. “Some of the information is even put through a quality assurance and performance improvement (QAPI) to discover possible ways of improving its care delivery systems on medication administration and management,” adds Nielson.
“With TransitionRX, it makes it really nice, at least with these patients when they go home. Whether it’s how they package the material, or the education that’s provided in layman’s terms, ultimately they’re able to advocate with the physician on that patient’s behalf. Having PharMerica acts as that advocate in addition to us is a double safeguard for my clients.”
During the quarterly meeting, the PharMerica representative will present his findings, discuss new medications coming to market, any high-cost medications, and possible cost saving opportunities each facility may have missed. “After a rather lengthy discussion, we have a chance to review their findings and recommendations,” he adds. “It’s so critical having a better handle on our pharmacy spend, which is second only to labor in terms of costs of doing business.”
“The QBRs allow me to see things from 10,000 feet above and right down to the actual facility,” he adds. “It allows me to view the programs PharMerica has in place to ensure I am implementing best practice to aid in client care,” Neilson says. “It also allows me to see the percentages of medication regimen recommendations that are being carried out by providers and the reasoning for the denial of some recommendations. Having this information empowers me to educate providers should the need arise.”
“Cost measures are always a great concern for the skilled nursing industry as margins are thin and becoming thinner,” he adds. “The QBR allows me to have a corporate overview that is capable of being drilled down to client specifics to ensure all cost containment measures are being utilized.”
As a result of the QBRs, as well as PharMerica’s RxForecaster and global authorization programs, Neilson has been able to document hard dollar savings of more than $353,000 during the first quarter of 2017. “While most of the savings were realized through the use of preferred drug formularies, global authorizations generally capture a large percentage of non-formulary medications, which allows the facilities the opportunity to change the order before first pass and ultimately saving money,” he adds. The quantity limits program within RxForecaster also reduces the number of high cost medications. Neilson said he hopes the reductions will save Promontory an additional $71,859 in 2017 alone.
Most of Promontory’s patients discharge back into the community, including home. For a full two months, Promontory maintains close contact with the former residents. Within 72 hours, a nurse follows up with the person to ensure they are feeling well, have what they need. If the resident is discharged to home health, the follow up is within 24 hours to ensure there is no gap in care. Weekly calls occur during the first month and every two weeks the second month.
Caregivers are ever vigilant to ensure medications are well documented and managed and physician appointments are honored. This is where DischargeRx shines. “Very seldom do we have to move them to a higher level of care than they were at previous to admission to our facilities,” says Neilson. “All those safeguards are in place so we don’t have a backslide and rehospitalizations, which negatively impacts our business in the long run. But ultimately, it impacts the patient in a negative manner we are determined to avoid.”
As a result, Promontory’s rehospitalization rates for chronic patients have plummeted from 9 percent to less than 6 percent.
“With TransitionRx, it makes it really nice, at least with these patients when they go home,” Nielson says. “And that they make themselves readily available to the patient. My pharmacy director has always been really good at answering phone calls from patients should they call PharMerica. But ultimately what it really boils down to is when PharMerica is getting ready for this discharge and they’re looking at the client going home and they’re making that cognizant effort to know that these regimens become complex for these individuals and that they’re set up for success. Whether it’s how they package the material, or the education that’s provided in layman’s terms, ultimately they’re able to advocate with the physician on that patient’s behalf. Having PharMerica acts as that advocate in addition to us is a double safeguard for my clients.”