A growing segment of the aging population is now utilizing services in the assisted living market. Consultant pharmacists are finding that the positive outcomes from drug regimen review in the long-term care setting can be applied to this population as well. However, the variety of state-to-state requirements in the assisted living market provide a myriad of challenges for the consultant pharmacist.
Consultants must convince the administrator that their services offered will benefit not only the individual resident, but the facility as well.
Simply defining and locating facilities can often be the initial challenge. Names of these facilities vary. Facilities may be called board and care homes, homes for the aged or domiciliary homes. The designations typically refer to provision of basic care, but some facilities now house residents with complex medical problems. They may provide complete nursing care, including oxygen therapy. If the facility is located in close proximity to a hospital or long-term care facility, even acute IV therapy may be provided.
Leaders in the assisted living market have indicated an interest in primarily retaining the identification of being residential care versus nursing care, in order to avoid the massive federal and state regulations with which nursing homes must comply. Nursing home regulations are seen as financially burdensome, and too heavily focused on regulations alone. The unique characteristics of individual facilities, however, may be largely responsible for the growing interest in the assisted living market. That is, a large segment of the aging population is keenly aware of the level of nursing care provided in the long-term care facility, and many of the elderly ambulatory only need minimal assistance with activities of daily living.
Once the facility is identified, the consultant pharmacist must convince the administrator that the services offered will benefit not only the individual resident, but the facility as well. By overseeing the medication regimen of the residents, the consultant is in a position to help prevent drug-related problems, including medication errors; weight loss and avoidable accidental falls; and monitor other medication related issues that could result in the discharge of the resident from their facility to an acute care setting or a long-term care setting. Clearly, this is a financial incentive for them. Education of administrators at this point can be crucial. Their background may not include health care, and demonstrating to them the importance of appropriate medication management will lead to a better understanding of the critical void the consultant pharmacist fills. Prior to initiation of services, it may be helpful to glean information (see TABLE 1) to establish basic knowledge and expertise about this particular care setting.
Questions to Ask Administrators or Nursing Supervisors
| What training or background do your nurses, assistants, and/or
mech techs have? Is continuing education mandatory?
What drug information resources are available to your staff for updating drug knowledge or answering their questions?
How do you document medication administration?
Is there any method to actually know what a resident has in their room? How often prn meds (pain Rx, inhalers, etc.) are being used?
If you have agency nurses who come into the facility to draw blood or give injections, do you have a paper trail to follow documentation?
What is the med pass procedure? written policies and procedures? Unit-dose system? bingo cards?
Are med errors reported? filed? Action taken?
How are level changes determined regarding self-adminis-tration? (e.g. a resident is admitted who has a good understanding of their medication and chooses to keep it at bedside and take as ordered by the physician without prompting or overseeing by the nurse. After 6 months, the residents condition has gradually declined. When is the decision made that the resident can no longer self-administer? (assuming no resident or care planning is done) Is there a written policy for this situation?)
What is your medication utilization rate? Psychoactive meds?
Are falls (with and without injuries) documented and being tracked?
In addition, consultant pharmacist services can be used by the facility as a marketing tool to assure residents and families that a pharmacist is available to answer drug-related questions from the staff and residents. The consultant pharmacist will also monitor for drug interactions and duplications (especially because many of these residents see multiple physicians), and interact with facility staff to provide the most cost-effective and therapeutically effective medication regimen.
Marketing as an independent consultant remains a challenge even with the advantages of the services as described above. Another option is to align oneself with a pharmacist interested in providing medication distribution services to the facility. This "package" may be more attractive, but the value of the consultant services should be billed separately. Another advantage of this method is to provide another means for monitoring and reduction of medication errors with the installation of a unit dose distribution system instead of a multiple vial system from numerous pharmacies.
The Medical History
Effective medication monitoring and performing drug regimen reviews in the assisted living setting can be difficult, at best. Unlike long-term care facilities where the consultant pharmacist has access to the residents medical chart, many assisted living facilities do not keep medical records for their residents. Frequently, there is a lack of a complete history and physical, lab work, routine vital signs, nursing summaries, etc. The consultant must also remember that they are literally working in the home of the residents. The residents leave the facility, in most cases, to visit their primary care physician, as well as specialists. Making recommendations under these circumstances must be done very carefully. Suddenly, physicians are seeing recommendations from a pharmacist regarding their patients medications. Physicians may not even be aware of the patients living environment, and there is even less chance that they are aware that a consultant pharmacist is reviewing medications on a regular basis. Certainly there is the potential for perceived interference with the care of their patients. An effective and close working relationship with the facility staff can help to alleviate, or reduce, these potential problems. Contacting physicians directly is the ideal solution. One problem, however, is that since the consultant is not on-site at the facility when the physician returns calls, even more frustration may result.
On a personal note, I have been providing consultant pharmacist services to a 100-bed assisted living facility since 1995. The residents are primarily suffering from Alzheimers. Because there are no current state requirements for drug regimen review, I have been reviewing each residents chart on a quarterly basis. Monthly visits are made to the facility and one-third of the charts are reviewed each month. This allows me to have a presence in the facility monthly to answer questions, check drug storage areas, and to provide educational programs.
The facility provides a progressive type of setting for Alzheimers patients, and the administration has been very supportive of my recommendations and interventions. This particular facility also keeps medical charts for each resident, making chart reviews much easier. We are currently working toward the goal of implementing the nursing home standards for drug regimen reviews.
Anticipated challenges with the use of nursing home standards in the assisted living setting include:
Lack of information, even if charts are available (e.g., copies of lab work that is done in the physicians office, but not sent to the facility);
Less staffing requirements and fewer licensed staff (making it difficult to obtain vital signs on routine basis);
Residents rights may interfere with therapeutic diets (e.g., a diabetic resident who refuses to adhere to their diet);
Numerous physicians and specialists to work with;
Resident refusal to change medications, even duplications;
Level of staff education;
Lack of policies and procedures for medication administration.
The challenges noted above provide an opportunity for the consultant pharmacist to play a major role in identifying potential problems, and helping the facility solve those problems for the benefit of the resident and the facility. In reality, the freedom to go beyond federal requirements and focus primarily on individual needs and outcomes may be considered an asset for the consultant. TABLE 2 lists some of the ongoing services that I provide.
Ongoing Services Provided in the Assisted Living Facility
| Quarterly drug
regimen review for each resident
Drug information and reviews of residents drug regimen between visits, as requested
Review of medication storage areas
Teaching the basic pharmacology section of the facility; required Alzheimers classes for all new employees
Revision of policies & procedures (pharmacy/nursing related)
Provision of educational programs can be an integral role of the consultant pharmacist. Although some states require a licensed nurse to administer medications, many others require only that the employee receive some training in medication administration. Some facilities that do not provide nursing care, but only room and board, still have personnel who oversee or provide minimal assistance to residents receiving medications. These individuals, in particular, benefit from inservices that provide basic drug knowledge, and help them to recognize potential adverse reactions so that a health care professional will be notified if necessary when problems are identified.
Residents may also choose, and have the right, to keep medications at bedside. The facility will need assistance with writing policies and procedures that do not interfere with the rights of the resident, but will also protect the health and safety of other residents. For example, a resident may wander into the wrong room and take the medicine belonging to someone else.
Dealing with family concerns in the long-term care or acute care settings can be quite frustrating for the staff and consultant. I recently encountered a family member that was upset because she was not called prior to initiation of a new medication order for her father. The order was for promethazine for a resident who was experiencing nausea. The nurse called the physician, received the order, gave the medication, then notified the daughter who was very upset that she was not called first. I have also had family members who insist on the utilization of psychoactive medications, even when the resident is lethargic or sedated. These remain challenges for the staff, but the consultant pharmacist can attempt to help educate families, too, on proper medication use.
One concern in many assisted living facilities is the frequency of resident falls. Medication utilization, i.e., number of medications administered to each resident, is at least as high in these settings as in the long-term care setting, and possibly higher, especially concerning the percentage of psychoactive medications dispensed. The incidence of drug-related problems, including falls, is significant. A closer look at the occurrence of falls and related medication use, and development of a tracking system for other related causes, is an added benefit that can be expected from using the skills of the consultant pharmacist.
The value of the consultant pharmacists interventions in this market has not been examined as closely as has been the case in the nursing home setting. However, as with all other types of pharmacist interventions, now is the time to document the value of what we do to help patients avoid drug-related problems, improve their quality of life, and save health care dollars.