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For PACE participants, the challenges are even more pronounced, as they try to navigate medication usage in their own homes. The goal of post-acute care pharmacy services in the PACE environment, then, is to ensure the highest level of safety in medication management. To achieve that goal, Grane Rx uses an innovative three-part approach called Precision Medication Management that meets the unique medication needs of PACE participants in a cost-effective way.

Part 1 of Medication Management in PACE: Clinical Consults

Polypharmacy, or the regular use of more than four medications, is significant among the PACE population. In fact, the American Society of Consultant Pharmacists reports that people between ages 65 and 69 take an average of 14 prescriptions per year, while those age 70 or older take an average of 18. With an increased number of medications—which are often prescribed by multiple physicians, including specialists—comes an increased number of side effects, the potential for duplicate therapies, and the possibility of drug-drug interactions. Grane Rx partners with PACE centers to provide clinical consults, in which a geriatric-specialized pharmacist reviews participant medications on a regular basis. During a clinical consult, pharmacists implement a number of safety checks, including:

Clinical consults serve a dual purpose: They help promote positive outcomes for PACE participants while helping PACE centers contain costs and make efficient decisions.

Part 2 of Medication Management in PACE: A Preferred Medication Program

In health care, including post-acute care, it’s imperative to optimize patients outcomes while containing costs whenever possible. The Grane Rx Preferred Medication program helps PACE centers tackle that balancing act when it comes to medication management. When partnering with a PACE center, Grane Rx implements a clinically appropriate preferred medication program—specific to that PACE center—to minimize medication costs. When formulating this list, the Grane Rx team works collaboratively with the PACE center team to find medications that will meet the therapeutic treatment needs of participants and prescribers while containing costs. The facility-specific preferred medication program is reviewed and tweaked regularly to ensure it contains the most clinically relevant and cost-effective medications. An automatic therapeutic interchange program is also included as part of the program. [Tweet “Here’s what you should know about #medicationmanagement in the #PACE environment”]

Part 3 of Medication Management in PACE: Pharmacogenetic Testing

Pharmacogenetics, which is defined as variations in response to medications based on a person’s genetic makeup, represents the future of medicine. In the past—and in fact, often today—prescribers were left with questions when trying to determine why a patient didn’t respond to a specific medication.

The use of pharmacogenetic testing more broadly in the future may change that.

In short, different PACE participants metabolize medications differently. Participant A may be impacted more profoundly by a medication or may have a more limited response than Participant B. That’s where taking a look inside a person’s genetic makeup and how he or she will metabolize medicine can make a difference.

Grane Rx has established partnerships with some of the industry’s leading providers of pharmacogenetic testing providers that provide state-of-the-art genetic testing and clinical decision support software.

This risk assessment tool helps providers determine the most appropriate dose of medication for each participant—whether that’s a higher or lower dose than standard, the normal dose, or an alternative medication. It also has the potential to reduce the use of unnecessary medications that were prescribed based on an adverse reaction to another medication.

Using pharmacogenetics can help reduce the risk of adverse drug events among PACE participants—and, as a result, limit the number of hospitalizations.

The Grane Rx Medication Insights program can help make prescribing easier.

Want to learn about the impact Grane Rx services can have on your PACE center? Get started by calling (412) 449-0504 or emailing paceteam@granerx.com.

long-term care pharmacy. As researchers uncover more about how the body works and metabolizes medications, the potential to personalize those medications—and optimize results—grows. The topic of pharmacogenetics is increasing in popularity as we progress toward personalized medicine. We have learned a significant amount about how an individual’s genetic makeup impacts how medications are metabolized, which affects the efficacy and safety of a medication. The missing link in most situations is knowing and understanding each Skilled Nursing Facility’s resident’s genetic makeup so that we can relate that to the therapies that a resident is receiving or may be receiving in the future. That’s where post-acute care pharmacy will continue to evolve.

The Potential Role of Pharmacogenetic Testing in Post-acute Care Pharmacy

Pharmacogenetic testing has the ability to provide healthcare practitioners with this valuable piece of information. Knowing a resident’s genetic makeup gives providers the potential to be able to predict potentially dangerous adverse reactions, identify therapies that may not be effective, and prevent unnecessary hospitalizations caused by these ill effects. While pharmacogenetic testing is far from routine practice at this time, there are specific situations when it may want to be considered, including with anticoagulation and antiplatelet therapy. Adverse drug events and medication nonadherence are a leading cause of hospitalization among seniors. The majority of emergency hospitalizations caused by drug events are associated with five specific types of medications: warfarin, insulin, oral antiplatelets, diabetic medications, and opioid pain medications. As we work to reduce unnecessary hospitalizations, we are finding ourselves having to look outside of the box more and more to find the root cause of medication-related issues. [Tweet “The potential role of #pharmacogenetics in #postacutecarepharmacy”]

How Pharmacogenetics Could Benefit Anticoagulant Therapy in Post-acute Care Pharmacy

Clopidogrel, known by its brand name Plavix®, is a widely used antiplatelet medication in long-term care pharmacy. Pharmacogenetics is a pertinent topic related to clopidogrel because clopidogrel is a prodrug, a type of medication which must be metabolized through the cytochrome P450 system before it becomes an active medication. If a resident’s cytochrome P450 enzyme system is not functioning as expected, this will result in variability in the metabolism of clopidogrel, which ultimately means the medication may not be metabolized to the active form.

In short, we could be administering the medication to the resident exactly as ordered, but the body may not be reacting to it the way we expect. Pharmacogenetic testing would allow us to know if an resident’s cytochrome P450 system is functioning as expected prior to prescribing the medication.

Warfarin, or Coumadin®, is another key example. Warfarin has a number of potential interactions with both foods and other medications. In addition, warfarin can also be very difficult to stabilize in some residents.

The difficulty in stabilization could be caused by two different situations. First, warfarin is significantly metabolized by the cytochrome P450 system, so variations in a resident’s cytochrome P450 system detected through pharmacogenetic testing could impact the plasma levels and clearance of warfarin in the body.

Warfarin is also unique because of the VKORC1 enzyme, which controls the oxidation state of vitamin K. VKORC1 normally works to activate vitamin K as part of the normal clotting cascade. Warfarin inhibits VKORC1, which reduces vitamin K oxidation and reduces clotting. If a resident has lower levels of VKORC1, less warfarin will be needed to affect the clotting cascade. If this is not known and a resident receives a standard dose of warfarin, he or she may experience an increased risk of side effects, such as bruising and bleeding.

If pharmacogenetic testing was used, clinicians would have cytochrome P450 and VKORC1 genetic information available to them at the time of prescribing. This would allow them more appropriately prescribe a dose of medication to the resident that will be best suited for his or her body to optimize effectiveness and minimize adverse effects.

As mentioned earlier, pharmacogenetic testing is not standard of care at this point in time. However, there are valid reasons, such as with antiplatelet and anticoagulation therapy, which could make this type of testing more common.

Once a person has pharmacogenetic testing conducted, it does not need to be done repeatedly. The results of the testing can be applied to the resident’s entire therapeutic regimen and taken into consideration prior to future prescribing to make his or her medication regimen more targeted and personalized.

As healthcare providers, we encounter many situations that just don’t make sense or where we can’t figure out why something isn’t working as expected. This is because of the human body and factors that we cannot see with the naked eye. In the future, with pharmacogenetics, we’ll be armed with the extra tools we need to make optimal decisions for our residents.\

Pharmacy is always evolving, and we work to stay ahead of the changes. Grane Rx offers the Medication Insights™ program, powered by YouScript, to help identify potential interactions and offer alternative prescribing options. To learn more or request a free analysis, visit www.MedicationInsights.com.

Heart failure is a condition that’s more common among the elderly population, making it vitally important for long-term care providers, including LTC pharmacy services, to stay up-to-date on the condition and management strategies.

The Long-term Care Providers’ Guide to Heart Failure: Defining the Conditionm

Heart failure is a syndrome that presents with structural abnormalities of the heart and symptoms including fluid retention, shortness of breath, fatigue, or exercise intolerance. It is a progressive state beginning from decreased function of the cardiac muscle, developing into difficulty with circulation of blood and delivery of oxygen to the tissues.

Types of Heart Failure

There are two types of heart failure distributed in relatively equal proportions throughout the population. Heart failure with preserved left ventricular ejection fraction (HFpEF) includes residents who have abnormal relaxation of the cardiac muscle, abnormal filling, or stiffness of the ventricle. This results in a heart that can expel most of its blood with each contraction but does not fill to the same maximum capacity as a normal heart would. Heart failure with reduced left ventricular ejection fraction (HFrEF) includes residents who have damage to the cardiac muscle usually due to coronary artery disease. These residents’ hearts cannot contract hard enough to eject a normal amount of blood. Both of these etiologies result in residents with less ability to supply the body with oxygen and keep fluids from accumulating in the periphery and the lungs.

Acute Decompensated Heart Failure

Residents who have heart failure with significant volume overload, congestion, and fatigue make up the majority of hospitalized heart failure residents. Progression of these symptoms commonly in conjunction with worsening cardiac function may result in a diagnosis of acute decompensated heart failure, indicating a time when the resident is at especially high risk of death and rehospitalization. Due to poor resident outcomes after progression to this stage of heart failure, the most important goal for long-term care providers is to prevent it. A frequent cause of this occurrence is the failure to adhere to medications or dietary restrictions. Comorbid conditions also play a large role.

The Long-term Care Providers’ Guide to Heart Failure: Current Management Recommendations

The type of heart failure is the first variable for long-term care providers to account for in treatment considerations. In heart failure with preserved ejection fraction, comorbidities play a much larger role in therapy considerations. Therapies may also affect these residents in a slightly different way with preserved ejection fraction residents being more sensitive to diuresis. Controlling symptoms is a main goal of therapy for heart failure, which will, in turn, improve quality of life. Functional capacity includes residents’ ability to carry out everyday activities and the amount to which they are limited by heart failure related shortness of breath. A resident presenting with lower functional status may need additional medications and have a lower baseline quality of life. Volume status is an important consideration for optimizing diuretic therapy to reduce edema in the periphery and in the lungs, if present. Comorbidities must also be taken into account when assessing a resident for appropriate therapies. Other disease states may define a resident’s risk for certain adverse effects related to heart failure medications. Comorbidities such as angina, sleep apnea, or syncope may indicate the need for additional treatments that will in turn help to control heart failure.

Nonpharmacologic Management

Sodium restriction is recommended in all residents with heart failure to help reduce volume overload and subsequent edema. Goal sodium intake should be 2–3g daily—and further reduced in residents with more severe disease. Fluid restriction should only be considered in residents who are experiencing fluid retention despite high-dose diuretic therapy and adequate sodium restriction. This should be monitored by obtaining weight daily to observe gain or loss of water weight. Smoking cessation is important in the setting of heart failure to improve hemodynamic symptoms. Nicotine’s role as a vasoconstrictor can contribute to these residents’ difficulty with circulation of blood and oxygen. Transdermal nicotine replacement therapy is acceptable for use with appropriate physician monitoring.

Heart Failure Medications

The table below details the medication classes commonly used for the treatment of heart failure, when they are used, and potential side effects. Common heart failure medications.  

The Long-term Care Providers’ Guide to Heart Failure: Management in the Long-term Care Setting

Residents with heart failure in long-term care come with their own set of complications and difficulties. The age and complexity of residents in long-term care are frequently elevated, making the population more prone to complications and difficulties with management. Cognitive issues in this population also make for more challenging residents who may be harder to involve in their own care. Having nursing staff as the key caretakers among long-term care providers comes with many benefits, such as skilled care, increased monitoring and supervision, and improved medication compliance. In addition to more robust clinical support, residents with heart failure also require additional social support, which is an important factor for residents managing chronic conditions. All of these aspects contribute to long-term care residents as a unique population who require specific care to manage heart failure. [Tweet “Making sense of #heartfailure management in #skillednursing. #longtermcarepharmacy”]

Transitions of Care

Residents in long-term care settings are frequently transitioning between acute and long-term care settings and back again, especially with a progressive condition like heart failure. In these circumstances, it can be difficult for long-term care providers to create the appropriate continuity of care to prevent readmissions. The most important thing to consider when transitioning a resident in or out of a care setting is communication. Follow-ups should become commonplace to assist with understanding past medical history if a resident is new to the staff or helping to educate those who are receiving the resident. Telephone calls can be utilized as a means of confirming recent changes in care or status due to a transition. Putting into place protocols for heart failure in a long-term care facility can also help to create a smooth transition from acute care. Maintaining a consistent care procedure allows for less variability in care and more guideline-based implementation of procedures for residents affected with heart failure. Residents are more likely to receive care that is standardized to other settings if protocols are in place. Transitions to lower care settings may also occur as residents are transferred home or to personal care. In these circumstances, resident and caretaker education play an important role, ensuring the resident’s ability to be more independent in managing his or her own disease state and the medications that go along with it. Understanding signs of changes in condition or even a decline will help to prevent a rehospitalization because the resident will be able to initiate early action such as contacting a physician.

Team-based Approach

The long-term care setting includes nursing staff as well as many other specialized professionals that can help improve outcomes for residents with all disease states. Those with heart failure especially benefit from the inclusion of dietitians and therapists to their care team. Having access to multiple disciplines increases the ability of staff to work as a team engaged in all resident care. Involving the resident’s cardiologist is another way to expand the care team for a heart failure resident. The off-site physician should be kept updated on the resident’s care and changes in status. The resident’s in-person appointments with the physician are also important and should be maintained every four to six months. A physician who is better informed may be in a better place for proactive intervention that keeps residents out of the hospital with better quality of life.

Resident Education

Residents’ involvement in their own care allows them to take initiative and be more invested in the outcomes their healthcare providers are also interested in. Heart failure is both chronic and progressive, meaning residents will need to do their part in managing the disease state for the remainder of their life. Without the appropriate education, they are less likely to be able to carry out self-care activities such as monitoring for fluid retention and medication adherence. Diet is a specific area where residents have a large role, which they may need help understanding. Sodium restriction to the degree recommended for heart failure residents can be difficult and requires a lot of consideration at mealtimes. Often times, the foods that are easiest for an older adult to prepare or consume are those that contain the highest amounts of sodium. Better-educated residents can be better involved with their healthcare team in preventing exacerbations and maintaining their health.

Staff Education

A lot of monitoring is required on a daily basis to optimally manage heart failure. The staff in a long-term care setting must be active in this area. Helping to monitor for medication-related changes and diuresis needs are key roles in disease management. Dietary restriction assistance is also important to keep in mind to assist residents in their compliance with sodium or fluid restricted diets. Implementation of protocols also requires in-depth and ongoing staff education because compliance cannot occur without understanding. When staff members understand the expectations, they are better able to carry out protocol requirements and improve the consistency of care in the long-term care facility.

Medication Management

Medication regimens in heart failure residents are frequently long and complicated. These regimens help to decrease exacerbations and maintain quality of life, but they also require a good deal of monitoring. Diuretics frequently need resident-based day-by-day titration to maintain fluid balance. Nursing staff should know how to intervene with diuretic medications when a resident is showing signs of increased water weight or edema and in turn when they have been restored to equilibrium. Weight needs to be obtained for heart failure residents at as close to the same time as possible on a daily basis to monitor fluid load. This can be best achieved by assigning this role to one nurse’s aide. Side effects such as hyperkalemia and hypotension are common with many heart failure medications and require careful daily monitoring. Blood pressure should be taken daily, and symptoms of dizziness, nausea, blurred vision, or lightheadedness should be noted for residents who may be at increased risk of falls and in need of medication adjustment. If possible, serum electrolytes should also be observed frequently, especially while titrating diuretics to detect low levels of potassium before symptoms appear. Kidney function can be monitored less frequently but still consistently. Frequent medication reconciliation is the final aspect of proper medication management in this population of residents. Any care transition should initiate a review of the resident’s medications and any discharge orders to ensure the most recent and accurate regimen is being used. Lack of compliance to the most current medication regimen could be a reason for worsening condition and hospitalization of a resident. As discussed, the management of heart failure in long-term care is a complex topic, which requires a multidisciplinary approach in order to optimize resident outcomes, improve care transitions, and minimize rehospitalizations. Although heart failure can be challenging, the potential for improved outcomes is plentiful through communication, collaboration, and standardization. It’s difficult to stay up-to-date on the latest in pharmacy best practices. Our Grane Rx long-term care pharmacy services team is here to advise your SNF on all aspects of medication usage. Discover the Grane Rx difference today by calling (866) 824-MEDS (6337).]]>

By definition, a medication error is a preventable event that may cause or lead to inappropriate medication use or patient harm. Medication errors may occur at any point in time from prescribing to the PACE pharmacy dispensing the medication to administration. The Institute of Safe Medication Practices (ISMP) estimates that 7,000 deaths occur annually in the United States from preventable medication errors. The reality of medication errors is that they are possible in all care settings, including the home. Two of the most challenging aspects of medication errors in the home setting—and faced by PACE pharmacy services providers—are detection and prevention. Medication errors are an important topic in PACE pharmacy because of the Level 1 reporting guidelines, which require quarterly reporting of medication administration errors.  Reportable errors are errors without an adverse effect that occur due to a violation of a physician’s order. This includes errors made by the PACE organization, an individual or entity that is contracted with the PACE organization, or a participant or caregiver. Reporting includes the date, location, type, contributing factors, and actions taken.

PACE Pharmacy Services: Common Risks for Medication Errors

In the following paragraphs, we will review common risks for medication errors, focus areas for medication error prevention, and specific considerations for medication administration error prevention in the at home setting. As mentioned previously, medication errors can occur at any point in time from prescribing through administration of a medication. There are several common risks that have been shown to increase the potential for medication errors: Polypharmacy is potentially the strongest risk factor for medication errors. Nearly one-third of adults in the United States take five or more medications. This number increases as we age. The larger the number of medications that a patient is prescribed, the higher the potential for medication errors. Avoiding overprescribing and controlling the duration of therapy are two important considerations for keeping medication totals at an acceptable level. Health literacy is another common risk factor. It’s imperative for participants to have an understanding of what medications they’re taking, why the medications are being prescribed, and when and how the medications should be taken. Medication adherence and proper administration are less likely when participants don’t understand what they are taking and why it’s important for their health and well-being. High risk medications are an identified list of medications that can cause significant harm if used in error. This includes medications that may have dangerous adverse effects; look-alike/sound-alike medication that could be interchanged during the ordering, transcribing, or dispensing process; or Beers list medications, which may be potentially inappropriate for use in the geriatric population. Minimizing the use of medications in this group unless absolutely necessary can potentially reduce the risk for medication errors.

PACE Pharmacy Services: Focus Areas for Medication Error Prevention

There are five basic focus areas for medication error prevention, including:
  1. Prescribing/Ordering, which includes the prescriber selecting and dosing the medication appropriately for the participant
  2. Transcribing, which is getting the original order accurately to the pharmacy either verbally, in writing, or electronically. As we move to a more electronic and automated world, there are new considerations for accurate transcribing to consider.
  3. Dispensing, which is the PACE pharmacy interpreting and filling the order accurately and as written by the prescriber
  4. Administration, which could involve a nurse, participant, or caregiver. This includes taking the medication in the manner in which it was prescribed.  
  5. Monitoring and Reporting, which is appropriately following up with the participant to check on progress and using skills to determine if medications are being taken properly. Early detection is important for preventing more severe issues.
While prescribing and transcribing have historically been areas where the majority of errors occur, errors with administration are increasing both in the inpatient and at-home settings. It is estimated that one out of every three medication errors is caused by lack of knowledge of either the medication or the patient. [Tweet “Learn 5 keys to preventing #medicationerrors among #PACE participants in the home environment.”]

PACE Pharmacy Services: Prevention of Medication Errors in the At-home Setting

The following considerations may provide assistance with reducing medication errors in the at- home setting:

Improved Care Coordination

Improving care coordination includes improving communication channels and opportunities between players of the healthcare team, such as doctors, nurses, and pharmacists.  Coordinated and enhanced communication is essential to optimal healthcare management.

Patient/Caregiver Engagement

Patient and caregiver engagement is centered on finding the most effective ways possible to interest a participant and include his or her caregiver support system. Tap into the participant’s interests and skill levels. Think outside of the box as it is definitely not one size fits all.

Focus on Transition of Care

Two-thirds of medication errors are believed to occur during transitions of care. When a patient is transitioning between care settings, this is a special opportunity for enhanced care coordination, communication, and patient/caregiver engagement to ensure all parties are on the same page and working from the same plan.

Health Literacy Education

Health literacy education is designed to ensure the participant understands his or her therapies, taking into consideration hearing, vision, or physical impairments, language barriers, and/or the ability to understand written text.

Labeling

Labeling can provide medication and educational materials in a manner that is clear and easily understood by the participant. In addition to words, consider pictures, symbols, or colors to help create an easily understood administration plan.

Embracing and Incorporating Technology

Technology does not have to be complicated. Consider assistive devices such as phone calls, text messages, or machines to remind participants when to take medications and to confirm which medications need to be taken. This can also be used as follow-up confirmation for the care team or family support team. Medication errors can be overwhelming at times. As medication errors occur, thorough documentation and root cause analysis of when, where, and how a breakdown occurred will help develop a manageable solution that will reduce the risk of the same error occurring in the future. ISMP and the Agency for Healthcare Research and Quality are great resources for additional information and ideas about medication error awareness and reduction strategies. Grane Rx offers innovative PACE pharmacy solutions designed to prevent medication errors and improve adherence. Put our PACE pharmacy services to work for your PACE center today by calling (412) 449-0504 or emailing paceteam@granerx.com.]]>

Medication nonadherence is a common issue in the United States, contributing to as much as $300 billion in avoidable health-related costs each year. Because seniors often take multiple medications, they are at high risk for nonadherence and hospital readmissions, making this an area of emphasis for both PACE pharmacy and long-term care pharmacy. While residents are cared for in a Skilled Nursing Facility, their medication needs are overseen by medical and pharmacy providers. However, issues can arise during care transition, as these residents are transitioned to the home environment. Fortunately, there is a solution. Grane Rx offers a program called Meds2Home™ that dispenses and ships patients’ medications to their homes. Meds2Home is offered for both SNF residents following discharge and PACE participants. Let’s take a look at five ways that Meds2Home can benefit your long-term care organization.

Meds2Home Benefit 1: Increases Referral Opportunities From Hospitals

The Centers for Medicare & Medicaid Services is placing particular emphasis on reducing rehospitalizations among long-term care residents. This emphasis can be clearly seen in the inclusion of multiple quality standards related to hospitalization. Hospitals are also dinged when patients are rehospitalized. Because of this, hospitals are increasingly looking to refer patients to long-term care organizations with clear plans for keeping patients out of the hospital. Meds2Home helps to improve medication adherence among these patients, which in turn, lowers the risk of rehospitalization. This would make facilities using Meds2Home more attractive to hospitals for patient referral.

Meds2Home Benefit 2: Provides an Additional Layer of Care for Patients

While in a Skilled Nursing Facility, residents aren’t responsible for managing their own medication regimens. Due to the complexity of those regimens, many find them easily confusing after discharge. Meds2Home can help ease the transition for these patients—and also provides PACE participants with access to their medications without needing to leave their homes. [Tweet “5 ways the Grane Rx Meds2Home program positively impacts #longtermcare providers”]

Meds2Home Benefit 3: Improves Patient Satisfaction

More than anything, patients want to feel valued and like their needs are understood. Meds2Home helps bridge the gap when it comes to prescription medications. Medications are delivered to a patient’s home in organized packaging, with easy-to-understand labels that identify exactly when medications should be taken. This helps give peace of mind to patients, which improves their satisfaction with the services they’ve received.

Meds2Home Benefit 4: Offers a Smoother Care Transition

Beyond the benefits for SNF residents as they transition to home, the Skilled Nursing Facility also benefits from a smoother care transition. SNF staff can feel assured that their discharged residents will receive the medications they need—and that they’ll understand how and why to take them. In addition, a Grane Rx care coordinator provides an extra layer of support, checking in with patients about their medications on a regular basis and then reporting back to the long-term care provider.

Meds2Home Benefit 5: Provides an Adherence Tool for Patients

In addition to clearly labeled medication packaging, patients also receive educational information about each medication they take. Patients who understand what their medications are for are more likely to continue taking them as prescribed. The Grane Rx EasyRead Pharmacy Solution provides them with this information by including an image of each medication along with the medication name, a description of the tablet or capsule, and the indication for use of the medication. The Grane Rx Meds2Home program is only one facet of what makes our post-acute care pharmacy services different. To get started, call (866) 824-MEDS (6337). ]]>

medications for PACE participants. Anticoagulation therapy is commonly utilized in PACE participants who:

Under normal circumstances, blood clotting is essential to one’s well-being to prevent excessive bleeding when we are cut or injured. Blood clots that form outside of this situation can be very detrimental as they can become dislodged and travel to the brain, heart, or lungs, resulting in stroke, heart attack, or pulmonary embolism.

Medications for PACE Participants: Understanding the Role of Anticoagulants

Individuals who are at a higher risk for blood clots include those who have atherosclerosis, diabetes, heart failure, irregular heart rates, immobility, obesity, and malignancy. Each year 900,000 Americans are affected by either a deep vein thrombosis or pulmonary embolism, resulting in 100,000 deaths annually. Half of blood clots occur during or soon after surgery or a hospital stay. Approximately 25 percent of individuals with pulmonary embolism die without warning.  Anticoagulation therapy following an initial incident is important considering 30 percent of people who have a blood clot will have another clotting incident within ten years. While it is known that medications are one of the leading causes of emergency room visits and rehospitalizations, anticoagulation therapy leads the pack of medications that can be attributed to these incidents. [Tweet “PACE participants & anticoagulation therapy: What you should know. #PACEpharmacy”]

How Anticoagulants Work for PACE Participants

Anticoagulation therapy can be used to either dissolve a clot that has already formed in the body or as prophylaxis to either prevent additional clots from forming or to prevent an initial clotting incident in at-risk participants. While anticoagulant medications are commonly referred to as blood thinners, they do not make the blood thinner.

Anticoagulants function to reduce the ability of the blood to form a clot either by inhibiting vitamin K in the body or by directly inhibiting the formation of clotting factors. By affecting the body’s ability to form a clot, anticoagulants can effectively prevent unwanted clots, but unfortunately, can also place a participant at risk for prolonged bleeding, which is the primary unwanted effect of anticoagulation therapy.

Anticoagulant medications are available as either injectable or oral products. Injectable products are generally utilized more at the start of therapy, especially for the treatment of an active clot.  Oral medications are generally utilized for ongoing prophylaxis in the outpatient setting for easier administration.

Over the past several years, there have been several new oral anticoagulation therapies approved by the FDA—Eliquis® (apixaban), Pradaxa® (dabigatran), Savaysa® (endoxaban), and Xarelto® (rivaroxaban). These therapies function by inhibiting thrombin (Pradaxa) or factor Xa (Eliquis, Savaysa, and Xarelto), thereby altering clot formation.

While one benefit of the new oral therapies is they do not require routine blood monitoring, there are several other considerations that need to be kept in mind with these medications for PACE participants.
All four of these therapies are short-acting compared to warfarin (Coumadin), therefore, if therapy is missed, interrupted, or not consistent, there is a risk for breakthrough strokes. If adherence is a concern, these medications may not be the best option for the participant, and warfarin therapy may need to be considered.

As mentioned previously, while prolonging the time to form a clot is the primary intent of anticoagulation therapy, the less-than-desirable side effect to this is an increased risk for bleeding, which may be possible with all anticoagulant therapies.

Warfarin has a reversal agent (vitamin K), which can be administered if the blood becomes too thin. Pradaxa has a reversal agent (praxbind) that was recently approved by the FDA; however, its availability is primarily limited to the hospital setting at this time. The other three oral medications—Elquis, Savaysa, and Xarelto—do not currently have a reversal agent on the market. There is an interest in developing reversal agents for these medications, but there are none that are commercially available at this time.

When switching to warfarin from Eliquis, Pradaxa, Savysa, or Xarelto, the participant will need to continue his or her current anticoagulant therapy in addition to the warfarin until his or her INR reaches a therapeutic level. It will normally take about five days for warfarin to reach appropriate levels in the body. With Pradaxa, it is recommended to stop therapy after one to two days on warfarin for participants with normal renal function. If the participant has impaired renal function, wait until day 3 to stop Pradaxa therapy.

Put our knowledge about the latest in PACE pharmacy solutions to work for your PACE center. Get started today by calling (412) 449-0504 or emailing paceteam@granerx.com.]]>

Staff at long-term care facilities, including providers of LTC pharmacy services, may be exposed to hazardous medications at various points throughout the day. It is likely that staff will be involved in activities that have the potential for contact with uncontained medications. Exposure to these medications in the workplace has been associated with acute and short-term reactions (such as nausea, rash, and mucosal irritation), as well as long-term effects (such as congenital abnormalities). Staff safety is paramount, and it’s important for long-term care pharmacy providers to inform other staff of the risk and how to avoid or reduce risk. While hazardous medications are most commonly thought of in association with chemotherapy (antineoplastic agents), there are many other medications that are officially classified as hazardous. Hazardous medications are organized into three groups—antineoplastic agents, non-antineoplastic agents that meet one or more NIOSH criteria, and medications with reproductive risk for those who are pregnant, breastfeeding or actively trying to conceive.  Examples of non-antineoplastic hazardous medications include hormonal products, antibiotics, and immunosuppressant medications. A complete list of medications that are considered to be hazardous can be located in the Grane Rx Policy and Procedure Manual.

How to Handle Hazardous Medications

When handling hazardous medications, good work practice includes: Hazardous medications should be prepared by post-acute care pharmacy providers, not by nurses or physicians without proper PPE and engineering controls. The risk of exposure to hazardous medication through inhalation or direct skin contact is present in procedures such as: [Tweet “Understanding the risks of hazardous medications in #LTCpharmacyservices”]

How Long-term Care Pharmacy Can Mitigate the Risks of Hazardous Medications During Administration

Exposure to a hazardous medication is potentially likely during administration. Good work practices include:

How Long-term Care Pharmacy Can Mitigate the Risks of Hazardous Medications During Caregiving

Exposure to hazardous medications during care giving can occur when dealing with excreta that may contain high concentrates of hazardous medications. Special precaution need to be taken by personnel while caring for a resident who has been taking hazardous medications. These include: While it’s important to use appropriate precautions when coming into direct contact with hazardous medications and body fluids, it’s also important to keep in mind there is potential for there to be particulate matter on the outer container of the hazardous medication products. It’s difficult to stay up-to-date on the latest in pharmacy best practices. Our Grane Rx long-term care pharmacy services team is here to advise your SNF on all aspects of medication usage. Discover the Grane Rx difference today by calling (866) 824-MEDS (6337).]]>

In a recent blog, we took a look at medications that increase fall risk—and the role long-term care pharmacy providers play in mitigating that risk. Let’s take a deeper dive into that topic and look at why effective medication management is essential. Medication management plays a vital role in improving resident outcomes and reducing resident fall risk. In the long-term care setting, the incidence of falls is nearly 50 percent. As residents age, this number rises. The incidence rate of falls (number of falls per 100 person years) increases from 47 in older adults ages 70–74 to 121 in those age 80. It has been well documented that medication can contribute to falls, especially in older adults. Seventy-two percent of people ages 55 and older use at least one medication, with 20.3 percent of that group using four or more medications. The high rate of medication usage in this population has led to a rise in adverse drug reactions (ADRs), a particular concern for post-acute care pharmacy. Two-thirds of all ADR-related hospitalizations occur in those age 60 and older. ADR-related hospitalizations account for approximately 3.4–16.6 percent of all hospital admissions in older people. Unfortunately, the exact number of falls caused by medication is not known because falls are not officially recognized as an ADR. With a growing aging population and increased prescribing of medication to older adults, proper medication management and education is vital. Pharmacists are uniquely equipped to lend their medication expertise to improve resident outcomes. Each day, 74 older adults die from fall-related injuries, which equates to 27,000 deaths per year. Most startling is that one out of five falls result in a serious outcome such as a fracture or a head injury. In fact, more than 95 percent of hip fractures are caused by falls. These statistics help paint a picture of how serious falls are, especially in older adults, but don’t show us how to prevent them. The utilization of pharmacists and LTC pharmacy services can have a profound outcome on a resident’s health and help to reduce resident falls.

Medication Management Keeps an Eye on Polypharmacy

A major issue, especially in regards to medication-related falls, is polypharmacy, or the use of multiple medications. Polypharmacy is prevalent in the long-term care setting. The Centers for Medicare & Medicaid Services implemented a quality indicator measure that targets residents on nine or more medications. A study that utilized this information found that 39.7 percent of nursing home residents had polypharmacy as defined by the quality indicator measure. Residents age 85 and older represented the group with the lowest rate of polypharmacy, with 34.8 percent of this group taking nine or more medications. Polypharmacy has many far reaching negative consequences associated with it, contributing to healthcare costs for both the resident and the healthcare system. There is an associated increased risk of taking a potentially inappropriate medication, an increased risk of outpatient visits, and an increased rate of hospitalization. Polypharmacy also contributes to an increased rate of adverse drug events. In Skilled Nursing Facility residents, the rate of adverse drug events is twice as high in residents taking nine or more medications compared with those taking less. Medication non-adherence has been associated with complicated medication regimens and polypharmacy, and can lead to potential disease progression, treatment failure, hospitalization, and adverse drug events. Polypharmacy has also been found to contribute to falls. A study found that the risk of older adults experiencing a fall rose 7 percent for each additional medication they are prescribed. [Tweet “2 ways that #medicationmanagement plays a role in a #fallprevention plan. #LTCpharmacyservices”]

Medication Management Seeks to Help Educate Residents About Medications

Another issue is that healthcare professionals often assume that residents have been educated on and understands their medications. Many healthcare providers lack the time to adequately educate residents on their medications and disease states. Additionally, many clinical trials do not include the elderly population, and so the effects of certain medications on older adults are not entirely known. Pharmacists can help solve these medication-related issues—they’re considered the most accessible healthcare professionals and have an intimate knowledge of medications and the potential issues they pose to residents. Through medication reviews and therapy management, pharmacists are able to reduce the chances of an older adult falling due to medication. As the pharmaceutical industry innovates, both the medications and the standard of care for disease states have become more complicated. Resident education about both disease state and medications has taken on an increasing role of importance. Residents need to understand what each medication is for, potential adverse reactions, and which medications can increase the risk of falling. An issue that is especially felt in the long-term care setting is the transition of care. Poorly executed transfers of older residents from hospitals to the long-term care setting, from long-term care setting to long-term care setting, or from long-term care setting to home carry the risk of fragmentation of care, poor clinical outcomes, inappropriate use of emergency department services, and hospital readmission. Utilization of a pharmacist or long-term care pharmacy services and medication management can help provide residents with a more complete transition and help to reduce some of the errors seen in resident transition, specifically in regards to medication.

How Grane Rx Can Help

Grane Rx is available to help with all of your medication-related questions or issues. A thorough medication review can be requested at any time for any residents experiencing a fall or other acute status change by utilizing the Medical Regimen Review Request Form located in your Grane Rx Policy and Procedure Manual. We’re committed to providing residents with the utmost care—and that includes using effective medication management to minimize fall risk. Get started working with our team today by calling (866) 824-MEDS (6337) or filling out this quick form.]]>

Medications and their side effects are a leading cause of falls in older Americans, and one that long-term care pharmacy providers needs to remain vigilant about. Falls in older adults can be debilitating, so it is important that all providers look out for medications that are known to have exaggerated side effects in older adults. Whenever possible, providers should stop medications, switch to safer alternatives, and reduce medications to the lowest effective dose. There are certain medications that should be monitored closely and are included in the BEERS Criteria, which are guidelines for providers to help improve the safety of medications in older adults.

What Is the BEERS Criteria?

For more than 20 years, the BEERS Criteria for Potentially Inappropriate Medication Use in Older Adults has been the gold standard for information on safe medication prescribing for seniors. The criteria are referenced in post-acute care pharmacy as part of regular medication reviews. The American Geriatrics Society has continued to regularly update and expand this resource to continue to help prevent adverse drug effects and other medication-related problems in older adults.

Why Do We Need the BEERS Criteria to Mitigate Fall Risk?

As residents age, their bodies change. These changes include things such as decreased renal clearance and increased body fat percentage. Due to the way the body changes as we age, older adults are at an increased risk of having unintended side effects from medications they are taking. [Tweet “Every year one in three adults 65 and older has one or more adverse reactions to a medication http://bit.ly/2ld6EFN”] Every year one in three adults 65 and older has one or more adverse reactions to a medication. It’s important to remember that healthcare providers should not make prescribing decisions based only on the BEERS Criteria. The criteria does not apply to all residents in all situations. Furthermore, different residents respond differently to the same medication, and so it is possible that a medication on the list may be the best choice for some residents. As always use the best clinical judgment when making prescribing choices.

Anticholinergic Burden and Fall Risk

Anticholinergic burden refers to the cumulative effect of using multiple medications with anticholinergic properties concomitantly. Medications with anticholinergic properties are commonly used in the elderly population. Some medications, such as atropine, benztropine, and oxybutynin are used specifically for their anticholinergic properties, and others such as diphenhydramine, cyclobenzaprine, and olanzapine have anticholinergic properties unrelated to their primary use. Studies have shown that medications with anticholinergic properties are associated with clinically significant adverse events such as blurred vision, dry mouth, urinary retention, constipation, cognitive impairment, confusion, delirium, increased heart rate, and drowsiness. While this list is in no way exhaustive of all of the potential adverse events associated with anticholinergic medications, it does highlight many of the adverse events that should be of concern to long-term care facilities and their residents, especially because of the ability of many of these adverse effects to increase fall risk. The risk of these adverse events increases with medications that have strong anticholinergic properties, higher doses of medications with anticholinergic properties, or a greater total number of medications with anticholinergic properties. Older adults are also more susceptible to the adverse events of anticholinergic medications due to physiological changes and preexisting clinical conditions. Older adults are both more likely to use medications with anticholinergic properties and are more sensitive to their adverse effects. It is important to assess anticholinergic burden in this population and take steps to reduce the burden. Medications with anticholinergic properties should be avoided in older adults whenever possible, unless deemed clinically necessary. If the medication is deemed a clinical necessity, it should be used at the lowest dose and for the shortest duration possible. The anticholinergic burden can be further reduced by replacing medications that have strong anticholinergic properties with alternatives or non-pharmacologic interventions.

When a Fall Occurs

While it’s important to reduce fall risk through effective medication management, it’s impossible to eliminate falls in a long-term care setting. When a fall occurs, it is vital to assess the resident’s medications and determine what may have contributed to the fall. For instance, if a resident has recently fallen, take the time to look back and see if a medication dose has been increased, a new medication has been added, or if the resident has been requesting more of an as-needed medication that could contribute to a fall. By constantly reviewing resident’s therapies and creating an action plans when a fall occurs, a long-term care facility can provide residents with the best possible care. The chart below includes a sample of commonly prescribed medications which may contribute to falls: Medications that increase fall risk. Our Grane Rx LTC pharmacy services providers use a multifaceted approach to medication management, including regular medication regimen reviews. Discover the Grane Rx difference today by calling (866) 824-MEDS (6337).]]>

Although most of our residents are protected from exposure to the outdoor winter elements the majority of the time, the winter weather can still have harsh effects on those indoors. It’s important for post-acute care pharmacy providers to remind other care providers that proper skin care is even more prudent for those residents with diabetes. Up to one-third of diabetic patients will experience skin complications related to their condition at some point in their lives. The most common types of complications are bacterial infections, fungal infections, and itching.   Commonly seen bacterial infections are eye styes, boils, folliculitis, carbuncles, and infections around the nails. Commonly seen fungal infections are Candida albicans (moist red, itchy areas surrounded by tiny blisters and scales that typically occur in skin folds), athlete’s foot, ringworm, and yeast infections. Itching that is seen in diabetic residents can be the result of either bacterial or fungal infections, but may also be the result of dry skin or poor circulation. When itching is caused by poor circulation, the lower legs are normally the most affected area.   

Skin Care and Diabetes: Why It’s Different in the Winter

Chronic high blood glucose levels can impair the ability to fight infection and can increase the overall risk for infections; however, this risk can be further enhanced when the skin is dry. When dry skin occurs, small cracks or breaks in the skin can be an entry point for bacteria or fungus into the body. During the winter, skin dries out for a number of reasons. Drier air, heating systems, hotter water temperatures, more clothing, and more irritating fabrics such as wool can all be contributing factors. [Tweet “A winter guide for skin care and diabetes. #longtermcarepharmacy #skillednursing”]

Skin Care and Diabetes: Steps for Good Health

Most of the skin conditions listed above can be treated easily when identified early; however, good skin care is important to help prevent the skin problems from developing at all. The following tips can assist  you with providing good skin care for your residents. While we may not be able to prevent all skin complications from occurring, proper skin care, especially during the colder, drier winter months, may help reduce the occurrence of these bothersome issues.   Want a long-term care pharmacy provider that works as an extension of your team to promote positive outcomes for your residents? Get started working with our team today by calling (866) 824-MEDS (6337) or filling out this quick form.]]>

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