Editor’s Note: In this article we continue to examine how two of the industry’s leading challenges – staffing and rising acuity – combined with a resident’s right to choose their own pharmacy, fuel the possibility of a harmful med-pass mishap.
In today’s senior living communities, few issues are more pressing than building stronger workforces while wrestling with the myriad and mounting challenges of aging and long-term care.
The issues are inextricable. Look no further than the rising acuity in assisted living residents and the medication dangers they face in communities beset by high turnover and over-worked nurses.
The risks seem to come from all sides. More and more residents are on more prescription medicines from more diverse sources than ever before, while nurses and aides grapple with prescriptions from multiple pharmacies on morning rounds. Some see the scenario as a recipe for disaster.
“Introducing multiple pharmacies in any community is completely inefficient,” says Bill Deane, senior vice president of senior living for PharMerica, a leading senior living pharmacy services provider.
After visiting more than 100 communities since taking on his newest role, Deane has witnessed the chaos firsthand.
“If you think about the in-depth communication that has to occur within the pharmacy and community to ensure that a medication process is strictly followed, polypharmacy becomes a burden,” he adds. “Communicating with two or more pharmacies is a tremendous amount of redundancy – in many cases requiring double, triple, or more labor associated just around communication.”
In most cases, that translates to a medication reconciliation process that entails multiple calls about interactions and documentation, confirming physician orders, and more.
And then there is the confusing array of packaging.
“In addition, those medications are in multiple dispensing modalities, which creates confusion in the med carts,” he adds.
Consider this: if 20 residents utilize one pharmacy, another 20 use another, and yet another 20, a single community could have three different dispensing systems in their medication cart. Some could be in bottles. Some could be blister cards. Some in pouches.
“Just trying to keep up with that can be a nightmare if the systems aren’t utilizing one pharmacy,” Deane adds.
A look at labor
Today’s assisted living workforce faces mounting challenges. Here’s why:
The issues around polypharmacy have only recently become acute in assisted living, partly because the care gaps between skilled and assisted/independent living are narrowing. Much of it has to do with a healthier senior population that has held off moving to senior living, preferring to age in place. By the time most residents come to assisted living at an average age in the low 80s, many are suffering from numerous chronic health issues and complex medication management needs.
What have those trends led to?
According to data from the CDC and the National Center for Assisted Living, residents on average are taking up to 10 simultaneous medications. Assistance with medication management is a leading reason that many seniors choose the transition to assisted living. Seniors are also sicker than ever. Forty percent of them have Alzheimer’s or another dementia diagnosis requiring memory care, while 46% suffer from cardiovascular disease and 23% suffer from depression. More than 20% of assisted living residents arrive in a community having already suffered from a fall.
Low medication management expertise in assisted living compounds the issue. More than 80% of the assisted living caregiving workforce are aide-level employees who are prohibited from dispensing medications in some states. This issue leads to serious care coordination problems – everything from ordering and confusion among nurses about which pharmacy to call in an emergency to the lack of 24-hour services. Another problem is getting resident medical records updated.
Other polypharmacy risks include Adverse Drug Events (ADEs) from drug interactions and self-administration, which in turn lead to overdosing and drug interactions that can result in everything from respirator and cardiac failure to falls, elopement and incontinence.
Ironically, ADE issues in assisted living have been shown to create a “prescribing cascade,” a situation in which an adverse reaction to one drug that goes unrecognized or is misinterpreted, resulting in the prescriber inappropriately prescribing a subsequent drug to treat the signs/symptoms of the adverse reaction.
Adding to the risks of polypharmacy are over-the-counter (OTC) medications and supplements, which seniors consume at higher rates than any other demographic. More than 40% of all over-the-counter medications are purchased by seniors. Unless they are doing so under a physician’s consultation, these meds can and have led to a host of harmful – even lethal – interactions.
“If families bring in bottles of OTCs, especially without their names or a prescriber’s name on them, this injects yet additional risk into the med pass or the med management process,” says Deane.
Many senior living communities are moving to sole-source preferred pharmacy relationships to alleviate most, if not all, of these problems.
“Things vastly improve if the systems are uniform, which drives efficiencies, minimizes confusion and more importantly, minimizes the occurrence or chance for medication errors and all of the attendant risks,” says Deane.
“Risk causes two things – the obvious health risks such as a broken hip, and more than likely, a trip to the hospital. Neither one leads to a lot of positive things for many older seniors,” says Deane. There are also the attendant issues such as litigation and ongoing tracking and monitoring.
“We’ve designed clinical programs that proactively identify risk,” he adds. “We merge our data with the non-pharmacological data from the community to better predict which residents are at most risk for ADEs like falls.” As a result, he says, communities are able to adjust their care protocols that may include having extra staff on standby during times of the day a resident is more prone to falls than usual.
PharMerica’s ValueMed program also identifies psychoactive medications, opiate analgesics, BEERS criteria (which identifies meds deemed unsafe for the elderly), antibiotics and anti-depressants, as well as proactive drug utilization reviews done at the time of each new medication dispensing and any subsequent refills. “This means the med tech and med aides aren’t responsible for chasing down refill meds that have expired,” he adds.
Another key risk mitigation measure is medication reconciliation, a process that verifies all of a resident’s prescription and non-prescription medications.
Increases labor efficiencies.
There is growing evidence that a preferred pharmacy relationship can help senior living communities improve staff morale, free existing staff to focus on core responsibilities and do more with less. The net result: improved retention and lower turnover.
“Our senior living client base is very interested in how we can drive efficiencies from an operational standpoint in their communities,” says Deane. “Labor is a huge outlay for them. And many are still grappling with the medical component of the services their residents expect and need. And having to deal with these kinds of issues with less trained and capable staff members than those in higher acuity settings complicates matters tenfold.”
A key labor-saving benefit PharMerica’s ValueMed program provides is multi-dose packaging, which vastly increases the efficiency of the medication pass and reduces the chance of errors. PharMerica and ValueMed also integrate with more than 20 eMAR (Electronic Medical Administration Record) systems currently on the market, leveraging the technology to streamline med passes and allow for more accurate documentation. For those without an eMAR system, the company also offers its own system, EZ-MAR, at no cost.
Another benefit is a dispensing technique called “cycle fill,” which manages all of the oral solid medications and delivers up to a monthly supply at one time for each resident “so medication aides or med techs are not responsible for constantly keeping up with the number of tablets or capsules that are remaining and having to refill them manually,” he adds.
The business and medicine of healthcare is a constant revisiting of classic “make-buy” decisions. When human lives are at stake, those decisions take on added significance and consequences.
When it comes to medication management, assisted living owner-operators are realizing it’s better to leave little to chance. It comes down to letting the right people do their jobs.
“Prescribers prescribe. Pharmacists label and dispense. Nurses and aides administer,” Deane says. “This triple check system helps ensure everyone is doing their job appropriately to confirm the resident gets what, how and why they need it. By working with the ValueMed pharmacy and ValueMed’s OTC program, they can ensure meds are dispensed correctly, are labeled correctly, and are packaged in a system that’s utilized with the single preferred pharmacy to drive efficiencies safely and accurately.”
Rising acuity, older residents, more meds, fewer staff: multiple factors are combining into a perfect storm of polypharmacy risks in assisted living. Working with a single preferred pharmacy that has multiple safeguards in place, such as ValueMed, can reduce risk and increase care outcomes. Contact us at ValueMed@PharMerica.com or 866-628-2583 to learn more.