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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.]]>

When working with residents who have chronic diseases, such as diabetes, it’s important for long-term care pharmacy providers to consider all facets of care, including vaccinations. So what’s the connection between vaccines and diabetes? There are two very important reasons why vaccines have a high level of importance for residents with diabetes—both Type 1 and Type 2. First, even if tightly controlled, diabetes has an effect on the immune system where it is harder for the body to fight infections. This increases the potential likelihood for infections including those that may be preventable with a vaccination. Secondly, residents with diabetes are at risk for more severe complications compared to residents who do not have diabetes. For example, some infections such as influenza can increase blood glucose levels to dangerously high levels. People with diabetes also have an increased risk of death from pneumonia and bacteremia.   The CDC has identified five vaccinations that should be carefully considered for administration in residents with diabetes. They include the influenza, pneumococcal, hepatitis B, zoster, and Tdap vaccines. Let’s review some of the key reasons why these vaccines should receive special consideration from your post-acute care pharmacy team and the team at large for residents with diabetes.

Vaccines and Diabetes: Influenza (Flu)

The flu virus can complicate diabetes control by altering the body’s metabolism and by affecting the desire to eat, thus resulting in the potential for significant increases or decreases in blood sugar levels. In addition, the flu is the hardest on individuals age 65 and older, those who have underlying conditions, and those with weakened immune systems. Individuals who reside in Skilled Nursing Facilities and those with diabetes are two groups of people who are at high risk for developing flu-related complications such as pneumonia, bronchitis, and sinus or ear infections.   While receiving the flu vaccine may not provide absolute protection against the flu, those who receive the vaccine and then get the flu are generally less sick and sick for a shorter duration of time.   Annual flu vaccines are already recommended for all people over age 6 months, but should be considered even more so by residents with diabetes.

Vaccines and Diabetes: Pneumococcal (Pneumonia)

Individuals with diabetes have been shown to have a three times higher risk for contracting pneumonia compared to healthy adults the same age. This is coupled with the fact that a diabetic resident is also predisposed to severe complications from pneumonia.   The guidelines for pneumococcal vaccination have recently changed with individuals over age 65 now being recommended to receive both the pneumococcal conjugate vaccine (Prevnar 13) and pneumococcal polysaccharide vaccine (Pneumovax).   Due to the recent guideline changes coupled with the potential risks for diabetic residents, you may wish to review and update your current pneumonia vaccination protocol.

Vaccines and Diabetes: Zoster (Shingles)

Type 2 diabetes has been associated with an increased risk of developing herpes zoster (shingles), especially in those individuals over age 65. The CDC currently recommends the shingles vaccine for anyone age 60 and older. The vaccine is also recommended for those who have already had shingles in an effort to prevent recurrences. The shingles vaccine has been shown to successfully reduce the risk of developing shingles by 51 percent and postherpetic neuralgia by 67 percent. [Tweet “What’s the connection between vaccines and diabetes? We’ll tell you. #longtermcarepharmacy”]

Vaccines and Diabetes: Hepatitis B

The CDC reports that people with diabetes have been shown to have higher rates of hepatitis B than the rest of the population. Additionally, outbreaks of hepatitis B have been associated with improper blood glucose monitoring and insulin pen utilization and have occurred among residents with diabetes in long-term care settings. While some individuals may have already received the hepatitis B vaccination series, it is advisable to determine a resident’s vaccination history when assessing vaccination needs while in the facility.

Vaccines and Diabetes: Tdap

Vaccination has been identified as the best way to protect against pertussis (whooping cough); however, over time, our level of protection from this vaccine begins to fade. Consequently, over the past several years, the number of pertussis cases has been on the rise.   At this time, the Tdap vaccination, which protects against tetanus, pertussis, and diphtheria, is recommended for adults every 10 years. Due to the recent changes in pertussis exposure and cases, it is a good time to review your current guidelines and processes for this vaccine. Grane Rx LTC pharmacy services encompass all aspects of a resident’s medication-related health, including vaccinations. Discover the Grane Rx difference today by calling (866) 824-MEDS (6337).]]>

Long-term care pharmacy services aren’t limited to the dispensing of oral medications—vaccines and insulin injectables are also among the items dispensed. Staying up-to-date on the latest findings related to injections is key for LTC pharmacy services providers. Blood glucose control can be a challenge in our geriatric resident population for a variety of reasons. As we age, a number of factors can affect blood glucose management, ranging from physiological changes and erratic nutritional intake to impaired renal or hepatic function to variable physical activity and even polypharmacy. Trying to pinpoint the culprit of blood glucose swings can be a daunting task. In addition to these common potential sources of blood glucose variability, there are several often-overlooked factors—a person’s skin, insulin injection technique, and injection site rotation practices. Let’s take a look at some important considerations and best practices associated with insulin injection technique and injection site rotation recommend by post-acute care pharmacy providers.

LTC Pharmacy Services Best Practice: Why Injection Site Rotation Is important

Repeated injection into the same site can cause lipohypertrophy and lipodystrophy.   Lipohypertrophy is the buildup of fat under the skin. Subsequent injection into areas of lipohypertrophy can lead to lipodystrophy, which is scarring of the fat. Subsequent injection into areas with lipohypertrophy or lipodystrophy can significantly slow the absorption of insulin.  The altered insulin absorption may lead to elevated glucose levels, which may be attributed to insufficient disease management instead of poor insulin administration technique.   [Tweet “DOs and DONT’s related to insulin injection in the #longtermcare setting”]

LTC Pharmacy Services Best Practice: Insulin Injection and Injection Site Rotation

Insulin is best absorbed from the abdomen, hips, upper buttocks, outer thighs, and the backs of the upper arms. Insulin is absorbed at different speeds depending on the injection site location. The abdomen is generally the fastest, followed by the upper arms, upper thighs, and buttocks. Because of the variability in absorption, it is suggested to use the same area of the body for different administration times to maintain as much consistency as possible. For example, if a resident has an order for insulin injections three times daily with meals and at bedtime, you may want to consider the following insulin administration plan: For someone that is just getting meal doses, it is generally not recommended to give in the abdomen one day and the buttocks the following day due to the absorption variability and the need for these therapies to be faster-acting. To avoid lipohypertrophy and lipodystrophy, injections should be rotated within the general area of the body by switching sides, spacing injections by at least 2 inches from the previous injections, or by using the face-of-the-clock technique to keep track of injection location. Clear and consistent documentation on the medical administration record is important in the long-term care setting due to the variability in nurses who are providing the injections based on shifts or days of the week. The table below highlights some additional important considerations to administering insulin injections. Best practices related to insulin injection in LTC pharmacy services. While good insulin injection practices and injection site rotation are not the magic bullet for optimal blood glucose control in our resident population, it is a solid practice standard that should be utilized on a daily basis. If you have a resident that has poorly controlled blood sugars that cannot be attributed to other common areas of concern, injection techniques and site rotations may be areas of special consideration to try to find the root cause of the issue. Our Grane Rx team works with your team to help ensure optimal care for residents. Learn more about our long-term care pharmacy services and how we can partner by calling (866) 824-MEDS (6337).]]>

At the end of September, CMS finally approved and released the roll-out schedule for the long- awaited Final Rule, which includes some regulations related to LTC pharmacy services. Phase 1 was effective on Nov. 28, 2016, and Phase 2 will be effective on Nov. 28, 2017. The Final Rule encompasses the first major revisions to the Nursing Home Requirements for Participation since 1987, and it touches on essentially every aspect of our scope of practice, including long term care pharmacy. Grane Rx has been reviewing the new regulation changes and is prepared to accommodate all of the required changes and to support Skilled Nursing Facilities during this transition. Read on for a look at the upcoming changes as they relate to post acute care pharmacy.

Long term Care Pharmacy & Monthly Medication Regimen Reviews

With the new regulations, monthly medication regimen reviews must include a review of the resident’s medical chart. Grane Rx consultant pharmacists are already reviewing the resident’s medical chart and documenting the review accordingly in the chart on a monthly basis. There will not be changes to this practice. Any irregularities identified during the pharmacist’s monthly medication regimen review are to be reported in a separate report to the resident’s attending physician and the facility’s Medical Director and Director of Nursing. A new process and report was implemented by Grane Rx consultant pharmacists on Nov. 28, 2016, which will provide the aforementioned report to the identified parties. This change was in addition to our previous processes and methods of communication for recommendations and reports.   As a reminder, all residents’ medication regimens must be free from unnecessary medications.  An unnecessary medication is any medication that is being utilized in excessive dose (including duplicate therapies), for excessive duration, without adequate monitoring, without an adequate indication for use, or in the presence of adverse consequences—or any combination of these reasons.   Additionally, when an irregularity has been identified by the consultant pharmacist, it is the responsibility of the resident’s attending physician to document that the irregularity has been reviewed and what action has been taken. Even if the attending physician disagrees with the recommendation and no action is taken, documentation must be provided for the rationale. This documentation should be part of the resident’s medical record. While changes to the Monthly Medication Regimen Review are not effective until Phase 2, Grane Rx is prepared to be in compliance at this time.

Long term Care Pharmacy & Psychotropic Medications

The definition of psychotropic medication has been changed and expanded to include any medication that affects brain activities associated with mental processes and behavior. This includes the following medication classes—antipsychotics, antidepressants, anxiolytics, and hypnotics. During medication regimen reviews and data reporting, Grane Rx consultant pharmacists are presently including and considering all of the above identified medication classes. Additionally, as regulated, consultant pharmacists monitor that psychotropic medications are being used to treat a specific condition that is diagnosed and documented in the resident’s clinical record. We also monitor and intervene to ensure residents who are receiving psychotropic medications receive gradual dose reductions and behavioral interventions, if appropriate, in an effort to discontinue these medications when possible. For Phase 2, specific focus and processes will be developed for PRN psychotropic medications.   Beginning in Phase 2, the following conditions must be met for PRN psychotropic medications: More information will be coming in the future on the PRN psychotropic regulation change. [Tweet “Making sense of the CMS Final Rule: 4 things to know. #longtermcarepharmacy”]

Long term Care Pharmacy & Medication Errors/Influenza and Pneumococcal Immunization  

The requirements of the medication error and influenza and pneumococcal immunization tags are moving to the Pharmacy Services area. Skilled Nursing Facilities are still required to maintain a medication error rate below 5 percent and to ensure that residents are free from significant medication errors. The influenza and pneumococcal immunization tags also remain unchanged and continue to include proper education, vaccination, and documentation of immunizations of eligible residents.

Long term Care Pharmacy & Antibiotic Stewardship  

As we progress into planning and implementation of Phase 2, attention will be given to the Antibiotic Stewardship Program. Your consultant pharmacist is already a required part of your facility’s Infection Control Committee but will also be an integral part of an Antibiotic Stewardship Program. Grane Rx consultant pharmacists are presently undergoing education and training to support you in this area. As we embark on this journey together, we look forward to continued partnership and collaboration to ensure on-going success. Grane Rx pharmacy providers partner with Skilled Nursing Facilities to understand and implement regulatory changes like the Final Rule. Get started working with our team today by calling (866) 824-MEDS (6337).]]>

At Grane Rx, we’re committed to providing the highest-quality LTC pharmacy services. As part of that commitment, we share an ongoing series of pharmacy updates from our Chief Clinical Officer, designed to keep you in the know on clinical topics related to longterm care pharmacy and PACE pharmacy. At times, residents are ordered the combination of vitamin C and zinc for wound prevention and healing. The idea of using vitamin C as a supplement in wound healing has been discussed since 1937 when two Harvard medical school surgeons published an article concerning its use for this purpose. Since then, there have been some additional studies and opinion articles written on the topic, but there have been no well-powered, randomized, controlled trials (RCTs) evaluating whether the use of vitamin C (and also zinc) is efficient in helping wounds heal. This bears the question: is using this vitamin and mineral supplement combination for wound healing potentially beneficial?

Considerations for the Use of Vitamin C in LTC Pharmacy Services

When residents are experiencing vitamin C deficiency, they have impaired collagen cross-linking, reduced wound tensile strength and increased wound dehiscence (rupture along a surgical incision). The elderly are at the highest risk due to poor dietary intake and malnutrition. According to the Hospital of the University of Pennsylvania, a resident is indicated for vitamin C supplementation when there is a deficiency. However, the level of deficiency is difficult to determine—and thus, the appropriate dosing is also difficult to determine. Supplement dosing needs to also take into consideration whether a resident is taking a multivitamin, as this may already provide some vitamin C supplementation. While vitamin C is essential in wound healing, vitamin C supplements may interact with other medications, such as chemotherapy drugs and warfarin, which are both common among residents needing LTC pharmacy services. Vitamin C total intake should not exceed 2 grams per day, as there is no added benefit from higher doses. In fact, high doses of vitamin C have been associated with many serious adverse effects, such as blood clotting, kidney stones, digestive system problems and red blood cell destruction.

Considerations for the Use of Zinc in LTC Pharmacy Services

When residents are experiencing a zinc deficiency, they have reduced wound strength, decreased collagen synthesis and decreased immunity. Some risk factors for deficiency are wound vac drainage, diarrhea and malabsorption. According to the Hospital of the University of Pennsylvania, zinc supplementation is indicated when zinc is deficient; but, as with vitamin C, this is difficult to determine. In comparison to vitamin C, zinc is not essential to wound healing, it simply stimulates it. If zinc supplementation is used long term, it is possible that a copper supplement may also be needed. It has also been found that high doses of zinc can suppress the immune system and have even been linked to an increased risk of some cancers. [Tweet “In this #LTCpharmacyservices update, learn about how supplements affect wound healing”]

The Bottom Line: Vitamin C and Zinc in LTC Pharmacy Services

Taking into consideration all of the information available, the routine use of vitamin C and zinc supplementation for wound healing is not recommended. Vitamin C and zinc supplementation may be considered on a case-by-case basis, but it’s important to look at the whole picture of the resident to determine if supplementation is actually appropriate. When well-powered RCTs and more information on the topic become available, a re-evaluation of this recommendation will need to occur.       Our post acute care pharmacy team stays up to date with the latest clinical information—and utilizes that information to the benefit of SNF residents. Get started today by calling (866) 824-MEDS (6337).]]>

At Grane Rx, we’re committed to providing the highest-quality long term care pharmacy services. As part of that commitment, we share an ongoing series of pharmacy updates from our Chief Clinical Officer, designed to keep you in the know on clinical topics related to LTC pharmacy services and PACE pharmacy. Antibiotics are some of the most commonly prescribed medications in Skilled Nursing Facilities. It has been shown that up to 70 percent of SNF residents will receive at least one antibiotic over the course of a year; however, approximately 25 to 75 percent of these antibiotics are prescribed incorrectly or are unnecessary. Overuse of antibiotics contributes to increased antibiotic-resistant bacteria, adverse drug events, drug interactions, colonization (where a resident has bacteria present in his or her system, but it is not causing an illness), secondary infection from resistant organisms and complications such as Clostridium difficile. Despite all of the risks associated with their use, antibiotics are still a necessary piece in the care of our elderly residents, especially those who reside in a long term care setting. These residents have a higher incidence of infections due to increased risk factors such as underlying disease states, age-related physiological changes, increased exposure to bacteria secondary to the environment of an SNF, and the use of invasive devices such as catheters or feeding tubes. A common ground needs to be achieved where a long term care facility is able to stop the misuse of antibiotics while still treating their residents appropriately—this is referred to as antibiotic stewardship.

The Role of Long term Care Pharmacy in Antibiotic Stewardship

The Centers for Disease Control and Prevention has stated that antibiotic stewardship is “a set of commitments and activities designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.” Following President Obama’s executive order for a national action plan to combat antibiotic resistance, the Centers for Medicare and Medicaid Services proposed expanded requirements in the conditions of participation beyond the ones already in place to review and monitor the use of antibiotic drugs. On Sept. 29, 2016, CMS released these new regulations—the requirements revolve around facilities having an infection prevention and control program (IPCP). This IPCP must include protocols for controlling infections and communicable diseases as well as using antibiotics and monitoring their use, incorporate education and training sessions for facility staff, and be reviewed and updated annually. The IPCP must have been created by Nov. 28, 2016, with the antibiotic stewardship program being implemented by November 28, 2017. The IPCP must also have a designated infection prevention/control officer who is a clinician with specialized training in infection prevention and control in place by Nov. 28, 2019. The consultant pharmacist is one of the people who are qualified to fill the role of an infection prevention/control officer. The American Society of Health-System Pharmacists (ASHP) believes that pharmacists have a responsibility to take prominent roles in antibiotic stewardship by 1.) promoting the optimal use of antibiotics, 2.) reducing the transmission of infections and 3.) providing education to health professionals, patients and the public. These roles are all needed in an infection prevention/control officer. [Tweet “Learn about the role of consultant pharmacists in this #longtermcarepharmacy update”]

How Can Your Long term Care Pharmacy Consultant Help You Beyond the Monthly Medication Regimen Review?

  1. Promoting the Optimal Use of Antibiotics. Consultant pharmacists (as infection prevention/control officers and in general) have the responsibility to ensure the optimal use of antibiotics throughout the facility. One way this can be done is by encouraging interprofessional collaboration within the facility to ensure the best team is put together to maximize resident outcomes. This team would focus on optimizing resident antibiotic care by establishing restricted antibiotic-use procedures, therapeutic interchanges and treatment guidelines to aide in the appropriate selection, dosing, monitoring and de-escalation of antibiotic therapy. Additionally, consultant pharmacists can generate and analyze quantitative data on antibiotic use through working with the lab to ensure appropriate microbial susceptibility tests are reported on residents in a timely manner. Finally, long term care pharmacy consultant pharmacists can also use information technology to enhance stewardship through surveillance, utilization and outcome reporting, and use efficient and effective systems to reduce potential errors and adverse drug events.
  2. Reducing the Transmission of Infections. Reducing the transmission of infections is just one of the many roles a consultant pharmacist would have as a part of antibiotic stewardship. Different ways this could be accomplished would be by encouraging routine immunization of facility staff and promoting screening for transmissible diseases, promoting adherence to standard precautions, striving for zero tolerance of health care-associated infections, and collaborating as a member of the interprofessional team in the development of guidelines for risk assessment, treatment and monitoring of patients and healthcare workers, who have been in contact with a person with a transmissible disease.
  3. Providing Education. A consultant pharmacist has the ability to educate all stakeholders in the antibiotic stewardship process including fellow health professionals, residents, family members and the public about antibiotic stewardship and infection prevention and control. This can be completed many different ways, but some examples of this are as follows:
Consultant pharmacists for long term care pharmacies have the potential to be the leader of the IPCP—their extensive knowledge of antibiotics and how to reduce the transmission of infections allows them to educate the interprofessional team to have the best antibiotic stewardship possible. Antibiotic stewardship is a huge undertaking and is best tackled in a stepwise approach. Consultant pharmacist are able to guide what activities the facility is ready to undertake and work toward the end goal of an IPCP and antibiotic stewardship, focusing on one or two key topics to start and then expanding outwards. Pharmacists are an essential resource to ensuring appropriate antibiotic stewardship with the end goal of optimal resident care always in sight. When you partner with Grane Rx, our consultant pharmacists serve as true partners with your team, passing their knowledge on to you. Learn how your center can benefit by filling out this quick form or calling (866) 824-MEDS (6337).]]>

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