CMS Expands Pharmacist's Role in LTC- Is it Enough?

The Center for Medicare and Medicaid Services (CMS) issued its final ruling in September on the requirements for long term care (LTC) facilities. Emphasizing the importance of pharmacological therapy oversight by the pharmacist, the final ruling requires LTC to provide a pharmacy services section in the resident's medical chart. and invite individual LTC facilities to utilize consultant pharmacy services as part of the healthcare team. While consultant pharmacist routinely (monthly) review resident's medication record and provide recommendations, CMS ruling did not mandate the consultant pharmacist participation in interdisciplinary team (IDT), but left it open to LTC to include or exclude pharmacist from the IDT. Furthermore, LTC facilities are asked (1) to incorporate  quality assurance and performance improvement (QAPI) programs with focus on systems of care, outcomes and quality of life, (2) develop infection control and prevention program that include antibiotic stewardship program and (3) take an active role in developing and implementing a baseline care plan for resident upon admission within 48 hours. All of which can have a significant role for the consultant pharmacist. 

However, when reading the ruling, it appears that most of the exclusions and the comments that CMS received on the role of pharmacist in LTC pivot on considering the pharmacist a health care provider under the Social Security Act, and the cost increase that LTC may incur secondary to the increase of responsibilities delineated to the consultant pharmacist. While the role of pharmacist has been somewhat expanded in the management of psychotropic medications, and infectious disease programs in LTC, the basic foundational role as a member of the health care team seems elusive. 

It is unfortunate that pharmacists continue to be envisioned as "dispenser of pharmaceutical products" and here lies their source of income. While today a large portion of pharmacists are involved in patient care and continue to show their value by increasing positive patient outcomes, some organizations continue to associate the cost of consultant pharmacist services to "products"; albeit hourly rates, or à la carte services, or in the form of indirect cost to state Medicaid and Medicare Part D programs. This subconscious approach to reimbursement undermine the several decades of advancement of the pharmacy profession. Disassociating pharmacy services from products is necessary for any inclusion of pharmacist in the health care team, and ultimately be considered as providers. 

While CMS places an important role on the pharmacy services that are provided to LTC, their remains a need for individual LTC to acknowledge the untapped resources made available to them through the consultant pharmacist, and on the consultant pharmacist to rise to the challenges by shedding the subconscious prejudice when it comes to financial gains.  

Trend Analysis in LTC why it is needed?

Today, basic foundational economic principles are being applied to medicine. Demands for affordable, and high-quality care is placed on physicians, nurses, pharmacists, administrators and institutions. The delivery of such quality of care at an affordable costs to an aging population residing in various settings has perhaps taken the back seat for more than we care to acknowledge.

Health economics, the term coined to couple two disciplines (health and economics) is build on two principles; cost-effectiveness and clinical-effectiveness.

To be able to measure any effectiveness, the inherent linchpin of health economics is health outcomes. And here lies the difficulties. It is not sufficient for example to claim that reduction in blood pressure (BP) or HbA1c by a certain percentage is an acceptable outcomes. Clinicians have to ask the ultimate question; for instance, if BP or HbA1c is reduced by a certain percentage, what does that mean in terms of long-term cardiovascular complications, survival of patients and quality of life (QoL). In other words, clinicians must be in-tune to the latest studies or even surveys addressing long-term effects and QoL. 

However, in controlled settings such as long-term care (LTC) or skilled nursing facilities (SNF), collecting data, and trending it ultimately improves patients outcomes and can be readily accessible. 

In 2010, the Center of Medicaid & Medicare Services (CMS) pursuant to the provision in the Affordable Care Act, launched best practices in nursing homes quality assurance performance indicator (QAPI). This program provides the framework for reviewing exciting policies and procedures redesigning new ones when needed, engaging the leadership team in the process, collecting data and feedbacks, designing a performance improvement and circling back with a systemic review and analysis. This structured approach to quality assurance and performance improvement must utilize established rules of engagement such as standardized care, enhancement of patient safety, management of chronic disease and preventive care. 

Trend analysis in SNF or LTC  is not the holly grail of patient outcomes, it is only a tool, when used in a systematic and comprehensive way, will certainly provide positive results in patient's care. Consultant pharmacists should be at the forefront of such endeavor by liaising and bridging the clinical-cost effectiveness of therapy. Hence bringing to the table clinicians and administrators. 

JC Rx Consulting and IO Solutions Call Center Joined Efforts

 JC Rx Consulting, LLC. is happy to announce a partnership with IO Solutions Call Center Inc. This partnership will provide customers of JC Rx Consulting access to a state of the art call center.

IO Solutions Call Center is a privately owned and operated Business Process Outsources (BPO) with years of experience. IO Solutions through JC Rx Consulting will be able to offer compliant turnkey specialized and dedicated healthcare business process solutions ranging from general billing inquiries, technical support, and related inquiries.

JC Rx Consulting’s expertise in healthcare combined with IO Solutions’ technology will allow healthcare customers to customize and scale needed services.

The services that would be provided to healthcare consumers as well as healthcare agencies range from the multi-channel communication, social media management, to direct customer care.

JC Rx Consulting and IO Solutions look forward to this joint partnership in providing streamlined, high quality, and exceptional outcomes to their clients’ healthcare needs. 

JC Rx Consulting LLC was founded on the principles held by the National Quality Strategy. We believe that the duty of every healthcare professional to develop the skills and provide a patient centric care that promote the national strategy put forth by the National Institute of Health (NIH), National Academy of Medicine (NAM, formerly Institute of Medicine), and other national health care organization. JC Rx services individually or collectively are geared to incorporate evidence-based medicine in line with the applicable clinical and regulatory guidelines. To ultimately serve the patients and their caregivers JC Rx provides the healthcare facility setting with consulting services, business solutions and medical communications.

IO Solutions Call Center, privately owned and in operation since 2007, is a Business Process Outsourcer head-quartered in Prince Edward Island. Years of experience in several fields have given IO Solutions flexibility in its delivery capabilities. IO Solutions offers compliant turnkey specialized dedicated business process solutions ranging from general billing inquiries, retail and technical support, financial solutions to healthcare related inquiries. IO Solutions technology is customizable and scalable to the needs of their clients and is secured and architected for stability. IO Solutions provide their clients with multilingual multitask delivery optimized by skill-based routing and analytics from onshore and offshore locations for Business to Business and Business to Consumer needs.

Significant increase in insulin use among nursing home residents

A presentation by Dr. Andrew Zullo et al. at American Diabetes Associations (ADA) 76th scientific sessions conference revealed a dramatic increase in the incident use of rapid-acting insulin and a modest increase in short-acting insulin between 2008 and 2010 in a national cohort of nursing home (NH) residents.

Data on medication use was assessed using Medicare Part D drug claims. Resident and facility characteristics were assessed prior to medication initiation using Medicare Part A, Minimum Data Set (MDS), and Online Survey, certification and Reporting (OSCAR) database. 

N= 11,531 (65 years or older, 90 days or more stay as NH residents)	2008	2010	% Change in 12 quarters
Sulfonylurea	25.4%	11.7%	13.7% ê
Metformin	12%	18.8%	6.8% é
Dipeptidyl peptidate-4 inhibitors	0.9	2.7	1.8% é
Thiazolidinedione	4.7	1.9	2.8% ê
Meglitinide	1.5%	0.3%	1.2% ê
Insulin	51.7%	68.3%	16.6% é
Rapid-acting insulin	11%	29.4%	18.4% é
Short-acting	22.6%	30.3%	7.7% é

Zullo AR, Dore DD, Daiello L, et al. National Trends in Treatment Initiation for Nursing Home Residents With Diabetes Mellitus, 2008 to 2010. J Am Med Dir Assoc. 2016 Jul 1;17(7):602-8.

Medication Adherence and Use of Technology

Medication adherence continues to be a major concern in health care. A growing body of evidence indicates that patients with chronic conditions have poor long-term adherence to therapy despite the positive safety profile and reduced risk of complications.  For instance, as many as 50% to 80% of patients treated for hypertension are non-adherence to their therapy. In addition, it should not come as a surprise that adherence to therapy carries an economic burden. The direct cost of non-adherence is estimated at $100 billion to $289 billion annually with a cost of $2000 per patient in physician visits annually.

In the recent March publication of JAMA Internal Medicine  a meta-analysis of randomized clinical trials to assess the effect of mobile telephone text messaging on medication adherence in chronic disease revealed that mobile phone text doubled the odds of medication adherence. Adherence rates improved from 50% to 67.8% an absolute increase of 17.8%.
While the studies reviewed were limited by a 12-week duration, and self-reporting as the most commonly used method to assess medication adherence, nevertheless, mobile text messaging can provide patients with yet another reminder tool.

The Medication Adherence Time Tool provided by American College of Preventive Medicine suggests in its use of the acronym SIMPLE (S-simplify the regimen, I-Impart knowledge, M-modify patient beliefs and behavior, P-provide communication and trust, L-leave the bias and E- evaluate adherence) the development of patient-centered communication style.

Who can benefit from these reminder? What text features and content is patients preferred? At what frequency should these text messages be sent out? In a smaller controlled population such as those in an assisted-living facility, or psychiatric therapy centers can benefit tremendously from such features.