My previous column featured the work of pharmacists in acute care (hospital) settings, emphasizing their work behind the scenes in hospitals compared to the visibility of pharmacists in the community pharmacy. In addition to being in community pharmacies and hospitals, one can also find a pharmacist in a long-term care facility (LTCF). Pharmacists that work in LTCF’s or skilled nursing facilities are called consultant pharmacists.
The history of consultant pharmacy can be traced to the enactment of Medicare and Medicaid Programs in 1965. The first regulations were known as Conditions of Participation (CoP), conditions LTCF’s must meet to receive reimbursement. It was not until 1974 that a monthly review of each resident’s medication regimen became a requirement of CoP. When this occurred, the result is what we know as a consultant pharmacist. In fact, the State of Florida has an additional licensure category called Consultant Pharmacist (CPh). A Florida CPh must pass a three-day initial certification class in consultant pharmacy and acquire an additional 12 hours of continuing education (CE) each year in addition to the required 15 hours of CE to maintain the traditional pharmacist license. A consultant pharmacist takes a minimum of 27 CE hours each year to maintain a license.
A consultant pharmacist is responsible for the entire medication system in an LTCF. They develop and maintain policies and procedures that address medication delivery, how to handle medication issues, storage, and the return of unused medications to the vending pharmacy, which is the pharmacy that dispenses the drugs for the residents.
One of the main functions of a consultant pharmacist is the medication regimen review (MRR). During this process, the CPh will make certain there are no unnecessary medications by confirming:
- Each drug has a corresponding diagnosis in the chart
- There are no duplicated medications
- Each drug used as p.r.n (Latin for pro re nata meaning “as the occasion arises”) has a specific indication for use
If duplications are found the CPh will contact the prescriber for clarification and request that unnecessary duplications are discontinued.
Many medications require routine laboratory testing, such as digoxin, furosemide, potassium chloride, blood thinners, and thyroid medications. These medications must have periodic laboratory testing for appropriate dosing. The CPh ensures there are orders for routine testing for these drugs and that the results are reported to the prescribers for their review. The CPh will make sure the prescriber acts on a result that is not in the therapeutic range.
During the medication review, the CPh checks the medication administration record (MAR). Certain drugs need parameters (blood pressure/pulse) recorded before the drug is given. Examples are drugs for hypertension that affect blood pressure and heart rate, which should not be given if the blood pressure or pulse are below certain values. These drugs affect the heart rate and require that the pulse is recorded on the MAR. If the pulse is below a certain level the medication is withheld. The recording of the information on the MAR helps to ensure the drugs are having their intended therapeutic effect, and if there are multiple times a drug must be withheld this would be an indication for a reduction in dose. If the parameters are consistently above normal this could indicate an increase in dose or a change of medications.
As in the hospital setting the CPh chairs the Antimicrobial Stewardship Committee to monitor the use of antibiotics in the facility to safeguard their appropriate use, to reduce the incidence of antimicrobial resistance, and to monitor any trends in usage.
The CPh observes medication administration passes each month to confirm that nurses are using the proper procedures and techniques required for specific medications, including making sure medications are administered in a timely manner. They are involved in other activities, such as serving as a medication educator for nursing by providing in-service training. The CPh prepares monthly and quarterly reports for the Director of Nursing and Administration. These reports include all the specific findings from each review, and in the case of the quarterly report, a summation of findings and any observation of trends to monitor. They are also expected to keep abreast of any regulatory changes that might affect the facility.
The consultant pharmacist is an integral member of the healthcare team in an LTCF. It was reported in 1997 that consultant pharmacists improved therapeutic outcomes by 43 percent and saved 3.6 billion dollars from avoided medication-related problems.
What do you think?