1. Hospice Pharmaceutical Care 2015 and Beyond Mary Mihalyo, PharmD, CGP, BCPS, CDE Oregon-Washington Spring Intensive Vancouver, Washington 23 March 2015

2. Pharmaceutical Care The direct, responsible provision of medication- related care for the purpose of achieving definite outcomes that improve a patients quality of life. Medication related + Care related + Outcome related 7/2/2015 ASHP Statement on Pharmaceutical Care Am J Hosp Pharm 1993;50,1720-3 2

3. Medication related Includes decision to or not to use medications as well as judgements regarding medication selection, dose, route, frequency and method of administration plus patient education. 7/2/2015 ASHP Statement on Pharmaceutical Care Am J Hosp Pharm 1993;50,1720-3 3

4. Care related The pharmacist providing direct personal concern (i.e. care) for the well-being of another person just as nursing and medicine does. Integrated, collaborative and cooperative domains of care including medical care, nursing care and pharmaceutical care. ASHP Statement on Pharmaceutical Care Am J Hosp Pharm 1993;50,1720-3

5. Outcome related Identifying potential and actual medication- related problems Resolving actual medication-related problems Preventing potential medication-related problems 7/2/2015 ASHP Statement on Pharmaceutical Care Am J Hosp Pharm 1993;50,1720-3 5

6. Medication-related problems Untreated indication Improper medication selection Subtherapeutic dosage Failure to receive medication Overdosage Adverse drug reaction Drug–Drug and Drug-Food Interaction Medication use without an indication ASHP Statement on Pharmaceutical Care Am J Hosp Pharm 1993;50,1720-3 7/2/20156

7. Hospice CoPs 2008 Defined the role of the pharmacist for Hospice. As an industry, have we met the CoPs ? Let’s take a look at select sections… 7/2/20157

8. Medicare Part D & Hospice Was reform necessary? Has continuity improved? Have outcomes improved? Medicare Part D reform affirmed the right of hospices to use a formulary and resulted in approximately 25% increase in the cost of medications for the hospice industry. 7/2/20158

9. Medication Cost What is cost? Cost is defined by the buyer! Pharmacy Hospice Cost is NOT average wholesale price ! 7/2/20159

10. Are Medication Costs Rising? Yes, at rates never seen before…. Brand name medications: Generic medications: 7/2/201510

11. Why Medication Prices Are Rising Industry consolidation Drug shortages Raw material shortages Unanticipated demand Manufacturing difficulties Regulation Business and economic issues 7/2/201511

12. Medication Price Increases MedicationApproximate Hospice Cost 2013 Approxiate Hospice Cost 2014 Amitriptyline 100mg Tablet$4.00$91.00 Atropine Opth. Soln 1%-5$9.00$21.00 Erythromycin Estolate Susp 400 mg/5ml; 240 ml $25.00$350.00 Morphine 60 mg ER; #100$75.00$125.00 Morphine 20 mg/ml; 30ml$9.00$18.00 Nystatin Susp 100,000 U 240 ml $25.00$42.00 Oxycodone 20 mg/ml;30ml$57.00$284.00 Tetracycline 250 mg cap #100 $3.50$236.00 7/2/201512

13. Necessary Hospice Infrastructure Pharmacotherapeutic Support System 3 Essential Components: a. Pharm D b. Preferred Drug List c. Pharmacy & Therapeutics Committee 7/2/201513

14. PharmD “My Hospice can’t afford to hire a pharmacist!” Really? “Your Hospice can’t afford not to hire a pharmacist!” 7/2/201514

15. Hospice PDL Composed by symptom and by medication. Must be a dynamic document Patient specific! 7/2/201515

16. P & T Committee Multidisciplinary hospice stakeholders meet on a scheduled basis to oversee all issues relative to hospice medication use. Adding or deleting medications from PDL Adverse drug reaction reporting e-Prescribing protocol Medication diversion and error review Medication cost per patient day Patient education tools Pharmacy QA Symptom management algorhythms Therapeutic interchange 7/2/2015 16

17. Hospice Preferred Drug List Please see sample provided 7/2/201517

18. Adverse Drug Reaction Reporting Required by JCAHO! 7/2/201518

19. e-Prescribing Protocol e-Prescribing of controlled substances, including CII is now legal is 48 states. Regulations may vary, state by state. 7/2/201519

20. Medication Diversion & Error Review Individual states are now imposing new regulations aimed at preventing diversion of opioids from the home of hospice patients. – Example: State of Virginia now requires hospice to report patient death to the distributing pharmacy of record. 7/2/201520

21. Benchmark Medication Costs National PPD goal = $8.00 – Post Medicare Part D reform = $10.00 ? 7/2/201521

22. Patient Education Tools Hospice patient population medication specific written material left in the home for patient and care giver education. 7/2/201522

23. Pharmacy QA Pharmacy dispensing error reporting Patient satisfaction Nurse satisfaction 7/2/201523

24. Therapeutic Interchange Defined as the dispensing of a drug that is therapeutically equivalent to but chemically different from the drug originally prescribed by a physician or other authorized prescriber. Example: Substitution of ipratropium bromide inhalation solution(Atrovent)® for Spiriva® or Tudorza® Example: Substitution of oral prednisone 10 mg per day for Pulmicort® nebulization solution. 7/2/201524 ACCP Position Statement: Guideline for Therapeutic Interchange 2004

25. Therapeutic Interchange Although usually of the same pharmacologic class, drugs appropriate for therapeutic interchange may differ in chemistry or pharmacokinetic properties, and may possess different mechanism of action, adverse- reaction, toxicity, and drug interaction profiles. In most cases, the interchanged drugs have close similarity in efficacy and safety profiles. 7/2/2015 ACCP Position Statement: Guideline for Therapeutic Interchange 2004 25

26. Symptom Management Algorhythms Please see sample provided 7/2/201526

27. Remember: “It is neither immoral nor unethical to think about the cost of therapy!” - Methadone Mary, 1998 7/2/201527

28. Questions? mary.mihalyo@deltacarerx.com 7/2/201528