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.comwww.ASCP.com Website:www.seniorcarepharmacist.comwww.seniorcarepharmacist.com Embraces interdisciplinary initiatives Supported development of Commission for Certification in Geriatric Pharmacy (CCGP)

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

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

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

15. Typical NF Patient Flow Discharge to home or assisted living Return to hospital for acute event, eg, fracture, symptomatic A-fib, etc To nursing facility after initial admission or Return to nursing facility after brief hospitalization If needed, NF residents will usually need to visit the specialists NF attending physicians and selected geriatric specialists see residents in the facility Hospital Nursing Facility Rehab Short Stay Long Stay 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

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

17. Assisted Living Facility Models NF Alternative/ Replacement Model Hospitality Model Personal Care 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. Typical AL Patient Flow Assisted Living Facility Attending Physician Resident may visit Attending Physician, or Attending Physician may visit facility Specialist Resident usually visits specialist. Specialists rarely visit assisted living facility. Resident would see specialist for monitoring of medications and therapies Community Residents may come from the community or move back to the community for various reasons “The goal of assisted living is to keep them in assisted living.” Nursing Director National Assisted Living Provider “The goal of assisted living is to keep them in assisted living.” Nursing Director National Assisted Living Provider Hospital Nursing Facility If resident becomes less independent or needs short-term rehab 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. Assisted Living vs. Nursing Facilities 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

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

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

34. Thank-you!