1. Wireless Password: 9166703926

2. New Technology to Prevent Drug Diversion & Errors: Remote Automation in LTC Brad Savage, Senior Vice President

3. Long-Term Care Pharmacy Clinical Pharmacist Integrated Software e-Medication Cabinet Automated Dispensing Machine Service & Maintenance AlixaRx: Redefining Pharmacy Services 3

4. Post-Acute and Long-Term Care Today 4 Patients are released to post-acute and long-term care settings “sooner and sicker” Patients are discharged from hospitals 24/7; skilled nursing homes are experiencing a dramatic increase in Friday night and weekend admissions Many of these patients are medically unstable and require immediate access to medications Shorter stays are becoming more common (rehabilitation, completion of aggressive antibiotic therapy, etc.) Critical Need: A new model of pharmacy care

5. Traditional LTC Pharmacy 5 Punch-cards or Bingo-cards Emergency Kit Excessive Amount of Medications In Circulation

6. LTC Pharmacy with Remote Automation 6

7. Benefits of Remote Automation in the LTC 7 Enhances medication safety – simplifies the administration process Decreases drug diversion risks – fewer “loose” controlled substances in circulation “Returns Nurses to Nursing” - more time to focus on clinical tasks and less time spent sort medications and taking drug inventories With up to 95% of the most commonly prescribed oral solid medications available onsite 24/7 – greatly improves access Result: improving access to medications can reduce hospitalizations for acute and psychiatric care Daily dispensing model greatly reduces medication waste Reduces overall drug costs to all payors (governmental, third-party, private pay) with post-consumption billing Only pay for the medication used, not wasted or excess drug SAFETY * ACCESS * SAVINGS

8. Example of Controlled Drug Waste 8 Total Cost PerTotal DrugsFull CardsUnits Destroyed UnitCost Lorazepam tabs7 (x30)508 $ 0.45 $ 228.60 Morphine conc (ml)7 (x30)346 $ 2.03 $ 702.38 Lorazepam conc (ml)3 (x30)90 $ 3.20 $ 288.00 Oxycodone ER1 (x30)42 $ 3.00 $ 126.00 Hydrocodone/APAP1 (x30)114 $ 0.63 $ 71.82 Temazepam028 $ 0.50 $ 14.00 Oxycodone/APAP1 (x30)113 $ 0.63 $ 71.19 Modafinil012 $ 30.00 $ 360.00 Zolpidem027 $ 1.48 $ 39.91 Alprazolam08 $ 2.10 $ 16.80 1,288 units ------ $ 1,918.70 Census148 patients C ost/Resident/Month $ 12.96 Total Census32,000 patients $ 414,853.19 Narcotic Destruction for Facility #981 March 18, 2013 RPh Time = 2.0 hours

9. Support from Government Agencies and Professional Organizations 9 Drug Enforcement Administration (DEA) - To address the issue of excess controlled substances in LTC facilities, the DEA adopted regulations in June 2005 to permit remote automation in the LTC setting.  DEA acknowledged, “[s]tates will need to amend their laws and regulations to fully implement this change in the DEA regulations within their jurisdictions.” (Federal Register Vol. 70, No.92, 25463)

10. Support from Government Agencies and Professional Organizations 10 Centers for Medicare & Medicaid Services (CMS) – CMS recognizes remote automation is “likely the most efficient dispensing methodology and the most effective in reducing waste.” (Federal Register Vol. 75, No. 224, 71207)  Issued the “Short Cycle Dispensing Requirements “which mandate that pharmacies dispense Brand Name drugs in no more than a 14-day supply

11. Support from Government Agencies and Professional Organizations 11 National Association of Boards of Pharmacy (NABP) – NABP has been supportive of remote dispensing in the LTC setting.  In 2011 NABP’s Task Force on Pharmacy Practice Technology Systems recommended: o NABP should work with Boards of Pharmacy to recognize that technology can be utilized to improve patient outcomes…using laws and rules that are broadly written and place the responsibility on the pharmacist on duty and the pharmacy permit holder.  NABP’s Model Rules contain provisions for remote automated dispensing. o These rules serve as a great resource to state boards of pharmacy to promote uniform regulatory standards.

12. Support from Government Agencies and Professional Organizations 12 Institute for Safe Medication Practices (ISMP) - ISMP has stated that automated dispensing machines offer a variety of benefits to an organization (i.e., decrease delivery time, greater control of medications, support security measures)

13. CURRENT PERMISSIBILITY OF REMOTE AUTOMATION IN LTC 13

14. Remote Automation in the LTC Setting Moving Forward 14 Over ½ the states permit some form of remote automation in the LTC setting Given the numerous benefits with remote automation and problems with the traditional model, change is imminent…the industry must change. Challenges with Implementing Change to Permit Remote Automation Legislative Change vs. Agency Rule Change May affect multiple laws/rules (BoP, DoH, etc.) Rapid Development/Advancement of Technology If regulated and implement properly, remote automation is a great tool to reduce drug diversion and decrease drug administration errors.

15. 15 Thank You

16. Wireless Password: 9166703926