influenza (flu) virus is a relatively common but potentially life-threatening respiratory illness that affects millions of people every year in the United States and around the world. The effects of the flu are particularly profound among the senior population, making it important for long-term care providers, including LTC pharmacy services, to stay up to date on the condition. It is often characterized by symptoms including fever, cough, sore throat, muscle aches, vomiting, diarrhea, and chills. The flu is highly contagious and can be spread by water droplets and fluids that are released when infected individuals sneeze, cough, or talk. Furthermore, touching contaminated surfaces, followed by touching one’s own mouth, eyes, or nose, can also lead to transmission of the flu. It is important to note that the flu is not the same as the cold. While they may share some similar symptoms, colds usually go away after several days while the flu may persist for weeks and can lead to more serious complications such as pneumonia. Also, the flu can present with symptoms such as vomiting, diarrhea, and muscle aches that are not typically seen with the cold. [Tweet “While they may share some similar symptoms, colds usually go away after several days while the flu may persist for weeks.”]
While the flu affects all ages and populations, it can cause serious problems in high-risk population groups, including the elderly and those with chronic medical conditions such as asthma, diabetes, or heart disease.
This is particularly important, especially in Skilled Nursing Facilities, where residents tend to be elderly and have comorbid chronic diseases. To combat the flu, there are several recommended steps that both employees and residents should take.
The best way of treating the flu is to prevent it in the first place. Indicated residents and employees, including post-acute care pharmacy providers, should receive the annual flu vaccination when available.
Furthermore, sanitary practices should be employed, including properly washing hands with soap after contact with residents, covering one’s mouth when coughing/sneezing, and providing adequate access to hand sanitizers. Also, quarantining infected residents can reduce the risk of flu transmission to others within the SNF.
In the event of an outbreak (>2 infected residents), active surveillance must be conducted for at least one week from the last influenza case. All potentially ill residents should be tested via throat swab or other methods for confirmation of influenza.
Also, it is important to note that some immunocompromised or post-surgery residents may not show typical signs of flu such as fever—and it is important to monitor for other signs such as changes to cognitive function.
Furthermore, Standard and Droplet precautions must be implemented, including quarantining the sick resident and requiring all employees to wear a facemask prior to entering the resident’s room, in order to reduce the risk of flu transmission.
Immediate antiviral therapy should be initiated within 24 hours of detecting flu symptoms, especially if the resident has a fever. It is important to keep in mind that although these medications will not cure the flu, they will reduce the duration and severity of the resident’s flu symptoms, resolving symptoms in as short as three days.
Options include oral oseltamivir (Tamiflu®) or zamamivir (Relenza®) inhalation, which both are usually given twice daily for five to 10 days. Although commonly prescribed, oseltamivir dosing must be adjusted for residents with renal insufficiency.
For residents who cannot tolerate oral therapy or have renal failure, IV options include peramivir (Rapivab®), which is given as a single dose.
In addition to the resident receiving the medications, all residents within the same wing/hall of the infected resident should also receive antiviral prophylactic therapy, regardless of whether they are showing flu-like symptoms or not. This prophylactic therapy should continue for seven days following the last positive flu diagnosis in that wing/hall.
These medications tend to have minor side effects, which may include headache or nausea. However, for residents with asthma, COPD, or other respiratory disorders, zamamivir may exacerbate these conditions and should be used with caution.
Through both preventive and reactive measures, we can work together to reduce the risk of flu outbreaks and reduce severity of these outbreaks if they occur.
Long-term care pharmacy encompasses more than just oral medications—immunizations are also important. Our Grane Rx team stays informed about the latest related to health conditions and passes that knowledge to your team. Call (866) 824-MEDS (6337) to find out how your SNF could benefit.
PACE population, are susceptible to serious complications from the influenza, or flu, virus. In the United States, flu complications among seniors cost a staggering $56 billion annually, mainly driven by costs related to hospital admissions and death. This large clinical and economic burden has long motivated influenza vaccine manufacturers to pursue the development of an improved annual influenza vaccine for older adults. [Tweet “In the United States, flu complications among seniors cost a staggering $56 billion annually.”]
One such vaccine, the trivalent inactivated influenza vaccine Fluzone High-Dose was licensed in the United States in 2009, and was subsequently shown to offer improvements in efficacy and effectiveness compared with standard-dose influenza vaccine in adults age 65 and older.
The efficacy of the high-dose vaccine was shown in the randomized controlled FIM12 study, in which a total of 31,989 participants were enrolled from 126 research centers in the United States and Canada.
The results of this study demonstrated that among those age 65 years or older, Fluzone High-Dose induced significantly higher antibody responses and provided better protection against laboratory-confirmed influenza illness than Fluzone Standard-Dose.
Comparative effectiveness was shown by investigators from the US Food and Drug Administration, the Centers for Disease Control and Prevention, and the Centers for Medicare & Medicaid Services, who reported that the high-dose vaccine was 22 percent more effective than the standard-dose vaccine for the prevention of probable influenza disease. It was also 22 percent more effective for prevention of influenza-related emergency department visits and hospital admissions, both important factors to consider among PACE participants.
The next key public health question for the high-dose vaccine concerns its cost-effectiveness: What role could the vaccine have in reducing the substantial economic burden of influenza in adults age 65 and older?
In one cost-analysis study, the findings show that the high-dose trivalent inactivated influenza vaccine is a cost-saving alternative to the standard-dose vaccine. More specifically, the additional cost of administering high-dose instead of standard-dose vaccine yielded a 587 percent financial return to the healthcare system alone.
Most of the savings were driven by reductions in cardiorespiratory hospital admissions plausibly related to influenza. As such, the results of the study suggest that the high-dose vaccine was cost saving over the analyzed 2-year period, and therefore had a better cost-effectiveness proposition than most other strategies used in the prevention of infectious disease.
Only one other study has performed this type of analysis, also demonstrating the cost-effectiveness of the high-dose vaccine when compared to the standard-dose vaccine.
Though upfront costs for the high-dose trivalent inactivated influenza vaccine are higher than the standard-dose vaccine, results of cost analysis have been majorly in favor of the high-dose vaccine, mainly driven by a reduction in the number of hospital admissions.
With patient-centered care in mind, PACE providers must consider the well-being of the participant as well as cost savings when recommending immunizations during the coming flu season.
Seniors, including PACE participants, have unique and specialized needs. Our Grane Rx team of geriatric-specialized pharmacists understands those challenges and works with PACE centers to overcome them. Partner with us today by calling (412) 449-0504.]]>
long-term care pharmacy. The Final Rule for long-term care facilities participating in Medicare and Medicaid programs was published by CMS on Oct. 4, 2016. The three phases of these regulations have implementation dates of Nov. 28 in 2016, 2017, and 2019. Because these are the most significant and comprehensive regulation changes in recent history, there are multiple sections that have implications for medication use. One of the most important medication-related changes concerns psychotropic medications. These changes affect both how psychotropic medications are defined and how they are prescribed, both of which impact post-acute care pharmacy.
According to the final rule, a psychotropic medication will be defined as any medication that affects brain activities associated with mental processes and behavior. This includes—but is not limited to—medications in the following categories: antianxiety, antidepressant, antipsychotic, and sedative-hypnotic. Previously, the focus was primarily centered around antipsychotic medications, so added attention will need to be provided to these additional classes of medications. Several of the required provisions are intended to reduce or eliminate the need for psychotropic medications, if not clinically contraindicated, to safeguard residents’ health.
As part of phase 2, there are several changes related to the prescribing of psychotropic medications. According to the final rule, when prescribing psychotropic medications based on a comprehensive assessment of a resident, the facility must ensure that:
Resident-centered care with the goal of maintaining the highest mental, physical, and psychosocial well-being is a focus of these requirements.
One provision that will be implemented in phase 2 is that the resident’s medical chart must be reviewed every month as part of the monthly medication regimen review.
The facility must develop and maintain policies and procedures for the monthly medication regimen review that include timeframes for the different steps in the process as well as steps that the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
These changes have already been previously implemented by your Grane Rx LTC pharmacy services team.
The final rule implements regulatory changes that may lead to a reduction in the unnecessary use of psychotropic medications (such as antipsychotic medications) and improvements in the quality of behavioral health care. Medications are often an integral part of interventions and plans of care, which require ongoing interdisciplinary collaboration. Medication stewardship needs to be a multidisciplinary effort that includes the ongoing participation of the post-acute care pharmacy team.
Access to information is critical for all team members. Overcoming obstacles to accessing and documenting medication care plans within electronic medical records across the continuum of care needs to be part of this ongoing work. Continuing advocacy and interprofessional engagement are needed to improve the delivery of care for the post-acute care setting and the residents who are served.
The Grane Rx team works diligently to analyze and review regulatory and guideline changes, then put that information into action. Could your SNF benefit from our services? Call (866) 824-MEDS (6337) to find out more.
post-acute care pharmacy providers. In fact, the American Diabetes Association reports that 11.2 million Americans age 65 and older—or approximately 26 percent of that population—have been diagnosed with diabetes. Many more have prediabetes, meaning they’re at risk of developing Type 2 diabetes. These numbers are important because those with diabetes are at an increased risk of developing cardiovascular disease, which is the leading cause of death among seniors. The most common type of heart disease is coronary heart disease, in which there is a buildup of plaque in the heart’s arteries that can lead to angina, heart attack, and stroke. Those with diabetes are also more likely to have other risk factors for heart disease, including high blood pressure, abnormal cholesterol, obesity, and lack of physical activity. Luckily, these risk factors for heart disease are modifiable, meaning that they can be controlled in order to decrease the risk of complications from heart disease, including heart attack and stroke. Medications and medication management are one facet of care for diabetes, but there are other ways to help residents decrease their risk of heart disease and stroke. Your Skilled Nursing Facility’s multidisciplinary team should work with residents to manage their “ABCs”—A1C, Blood pressure, Cholesterol, and Smoking.
PACE participants, to treat chronic obstructive pulmonary disease or asthma. Each inhaler works a little differently, and proper administration technique is important to ensure participants receive the appropriate amount of medication to make a difference in their disease state and improve lung function. With any type of inhaler, it’s important for PACE pharmacy providers and other members of the PACE center’s multidisciplinary to provide careful, clear instructions to participants and their caregivers.
These devices come in the form of a pressurized canister containing the medication mixed with propellants and other agents to assist the medication in properly reaching the lungs. Hydrofluoroalkane (HFA) is the propellant used in these inhalers. They work well in participants who have lesser inspiratory flow because they do not rely only on the participant’s own breath for actuation to the lungs. However, timing is important for these devices to allow for the release of the medication at the same time as the participant inhales. Spacers and holding chambers are devices that may be used with an MDI to give the medication time to slow before reaching the mouth. These devices decrease the amount of medication lost to the mouth and pharynx and also allow for stepwise administration, rather than simultaneous medication release and inhalation. Spacers and holding chambers may be helpful for participants who have trouble coordinating inhalation with activation. Priming must be performed prior to each initial use and if the inhaler has not been used for two weeks or longer. This is done by shaking the inhaler for five seconds and then pressing down on the canister to release a puff of air four times. Cleaning of the inhaler should be done by rinsing the mouthpiece with warm water weekly after removing the canister. It should be left to dry overnight before the next use.
Diskus® devices, Twisthalers®, and Handihalers® are all DPIs, designed to administer medication in a solid form via the PACE participant’s breath. They contain a capsule, blister, or reservoir containing medication mixed with lactose or glucose that is inhaled. Because the medication is actuated by breath alone, a deep and steady rapid inhale is required to properly aerosolize the medication. This means participants who cannot breathe deeply, such as those suffering from COPD, may not be good candidates for these inhalers. HandiHaler and other single-use inhalers must be loaded with a capsule prior to each use. The capsules should be removed one at a time from their packaging only when a participant is ready to administer the medication. Each inhaler can be opened to reveal a hole where the capsule should be placed. The inhaler should be closed until a click sounds, which indicates the puncture of the capsule to release the medication. Once the capsule has been punctured, the device should not be tilted, since doing so can result in a loss of medication. The punctured capsule should be disposed of after each use. Diskus and other multi-use inhalers already contain all doses of the medication. These medications are loaded in different ways, depending on the medication. With Diskus, Breo®, Twisthaler, and Respiclick®, each dose is loaded prior to use by opening the inhaler fully until a click is heard. With Pressair®, you press a button, while with Flexhaler®, you twist the inhaler in one direction and then the other. It should then be inhaled immediately without tilting the device, since doing so may cause loss of medication. Cleaning should be done on the outside of the mouthpiece with a damp cloth, only if necessary. No water should be used inside the inhaler. [Tweet “A look at #inhaler best practices for PACE participants. #postacutecarepharmacy”]
The Respimat® is a common SMI, which releases medication without propellant but in a form that remains aerosolized for six times longer than an MDI. Because the particles of medication are released at a lower velocity, less medication is lost to the mouth and pharynx. In addition, because the medication remains in the air longer, the need to carefully time inhalation and medication release is lessened.
The first use requires loading of the canister by removing the clear base and inserting the narrow end of the cartridge into the inhaler firmly by pressing it down on a hard surface until it clicks. The base can then be replaced and turned for half a turn until it clicks and is ready to be primed by opening the cap fully and pressing the button. Turning, opening, and pressing the button should be repeated until a mist is released.
Participants should be instructed to exhale normally prior to the use of any inhaler. Then, after the inhaled medication is used, participants should hold their breath for at least five to 10 seconds to ensure the medication properly deposits in the lungs.
After use of any medication containing a corticosteroid (such as fluticasone, budesonide, betamethasone, and mometasone), the mouth should be thoroughly rinsed with water to prevent oral thrush.
Between puffs of the same medication, wait at least 15 to 30 seconds. When using multiple inhaled medications, the fastest-acting bronchodilator should be used first, followed by other bronchodilators.
Corticosteroids should be administered last, once the airways have been dilated by the fast-acting inhaler. Each administration of a different medication should be spaced by at
least 60 seconds.
Your goal is to provide comprehensive care for your PACE participants, and our goal is to provide you the PACE pharmacy services to do just that. To learn more or get started, call (412) 449-0504 or email paceteam@granerx.com.
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.
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.
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”]
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.
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.
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”]
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.
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.
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.
Copyright © 2023 Grane Rx. All rights reserved. / Privacy / Health Information Practices
