Author: Jyoti Suthar

Abstract

LTC (Long Term Care) pharmacies provide smashing services to patients suffering from chronic ailments and those who continuously rely on medication for health care. They have an essential role in health care and communities such as individualized and care-centered services. Ensures patients receive the right medications in the right doses at the right time. They have more focus on improving clinical outcomes, reducing costs, and providing good quality care to the residents.

Figure 1: Long-Term Care Pharmacy

Introduction:

Long-Term Care (LTC) Pharmacy

“The service you expect from the partner you trust”

The specialists in geriatric pharmacy have a better understanding of the unique needs of the senior population. The community pharmacy’s specialty department provides a variety of services and products to long-term care facilities, residents, and senior populations living independently.

Older and frailer individuals are generally admitted to the nursing facility for the management of multiple chronic diseases which required 24 hours in 365 days of nursing care. Clinicians and pharmacists have the specialized knowledge to regularly monitor these beneficiaries for drug interactions and other adverse reactions to medications.^1,2

Major tasks that LTC pharmacies will accept include:

• Actual dispensing of materials for an extended care
• As a resource for information and education as a consulting service.

Helping hands provided are generally beyond the scope of allocates of retail pharmacies to the beneficiaries. For special needs required for patients, nursing facilities contract with LTC pharmacies and provide the best prescription drugs and best consultant pharmacist services.^1,2

Chronic Diseases such as diabetes, arthritis, hypertension, and lung diseases make the life of senior citizens difficult to manage. Now, these are embedded so deeply in society and face multiple challenges such as a person’s ability to perform important activities and their enjoyment with family and friends. LTC pharmacies give such caregiving and social support to seniors.³

Figure 2: Medical Services

Table 1: Services provided by LTC pharmacy                                                                  

For senior living communities long-term care would be a better pharmacy option, as the advancing medical science we must be more responsive to those who have the most significant medical needs. Caregivers must endure helping with proper treatment.

During this the complexities that we need to ease such as medication organization, dosage confirmation, proper scheduling, and prescription drug acquisition.⁴

Retail community pharmacy dispenses medications to the general public at retail prices but the LTC pharmacies are not open to the public they do not sell convenience items. Majorly rely upon revenue from dispensing prescriptions and providing consultative services.

The operating costs of LTC pharmacies are soaring due to myriad legal and regulatory mandates. The National Community Pharmacists Association (NCPA) estimates that the cost to dispense for LTC pharmacists is 25% more than the retail pharmacist.^4,5,11

Retail pharmacies provide medication directly to consumers after confirming payer coverage. While LTC pharmacists coordinate with the facility, provider, and payer and have a glance at prescriptions to compare against known medication, verify coverage, meet the packaging and delivery requirements, and stand ready to deliver medication at all times.^4,5

Challenges faced by Long-term Care (LTC) Pharmacy during COVID 19

During the Covid 19 pandemic, LTC pharmacies caring for this population face a myriad of unique obstacles. During that time, it has been a great concern for senior citizens and people living in long-term care facilities.

It is essential to address the physical and mental impact of the pandemic on seniors, particularly loneliness and isolation. Older adults are at greater risk from COVID-19 and approximately 8 out of 10 covid 19 deaths reported in the U.S. have been adults 65 and above.⁶ In the COVID-19 crisis, the US population living in long-term care facilities was less than 1%, yet the LTC residents and staff account for 37% of reported COVID-19 deaths. As the cases were rising rapidly and once again they had entered the doors of nursing homes and assisted living facilities.⁶

Recognizing the risk of vaccine distribution guidelines has prioritized long-term care facilities in older adults yet the rollout has been met with challenges including staffing shortages scheduling issues and vaccine hesitancy among older adults but also among facility staff.⁶

Infection Control: Nursing homes should coordinate with Medical Director, Infection Preventionist, and consultant pharmacist to avoid any kind of Unintended consequences.¹⁰

Long-Term Care (LTC) Guidance⁷

This guidance has been organized to address pharmacy performance and services criteria, convenient access standards formulary considerations, and other beneficiary protections.^7,8

• Guidance to assist Medicare:

1)  LTC Pharmacy Performance and Service Criteria

• CMS has developed the following minimum performance and service criteria for pharmacies providing LTC service
• Comprehensive Inventory and Inventory Capacity — provide a secured area for the physical storage of drugs, with necessary added security as required by federal and state law for controlled
• Pharmacy Operation and Prescription Orders – provide services of dispensing pharmacists to meet the requirement of dispensing prescription drugs to LTC They must conduct Drug Utilization Review (DUR) to identify adverse drug reactions and inappropriate drug usage etc.
• Special Packaging – Network LTC pharmacies provide specific drugs in special packaging such as unit doses and

2) Convenient access

CMS (Centers for Medicare and Medicaid Services) assists LTC facilities in finding the best fit for operational needs. As it expects to provide pricing and access information to beneficiaries and their representatives.

3) Formulary

Access to necessary medication for LTC residents may be provided through formulary inclusion and utilization management tools. Appropriate access should be provided to LTC medications.

4) Exceptions and Appeals

Grievance, coverage determination, and appeals processes will ensure that long- term care residents receive quick determinations regarding the medications they need.

Newly arrived perspectives of Long-Term Care (LTC) Pharmacies                          

Nowadays the quantum jump is abruptly modifying prescription drug practices in the long- term care (LTC) market.

Pharmacies are focusing more on re-evaluation in such a way as to serve the industry to meet patient safety and quality of care standards – particularly considering health legislation passed this year. This amelioration has a direct impact on the LTC industry.

And it has mandate for LTC pharmacies to adopt dispensing techniques such as weekly, daily, or automated dosing. Because of that many pharmacies and recast their prescription delivery models as a result they have reduced or eliminated medication waste in LTC facilities.⁹

• Two main categories of LTC medication distribution systems:⁷
• Centralized dispensing
• Facility-based dispensing

This category is analyze based on operational efficiency, capital requirement, and timeliness and accuracy of medication.

• Centralized dispensing — Involves local pharmacy. These pharmacies package and label medications at their pharmacy.
• Facility-based dispensing — Medication dispensing at the nursing facility is accomplished through the use of automated dispensing systems located at the Here the waste is virtually eliminated and provide medication promptly.

Healthcare Payment Structure

Figure 3 shows Reimbursement Model with PBMs (Pharmacy Benefit Managers).

Prior to the rise of PBMs cash flow has started with CMS who provide health benefits for employees through contract with health planes. Due to augmentation of prescription, health plans found processing the ample of claims to be unmanageable their own. Thus chose to delegate this task to PBMs, thus introducing PBMs as major player. PBMs began managing medication formulary, choosing default medication in pharmacy inventories and influencing which medications became the preferred choices by insurance plans.¹²

Figure 3: Reimbursement Model

CMS- Centers of Medicare and Medicaid Services

PBM- Pharmacy Benefit Manager

DIR- Direct and Indirect Remuneration

Conclusion:                                                                                                                                The benefits to the organization and the residents include additional oversight to ensure safe and timely prescription ordering and delivery, medication cost saving, and a streamlined medication pass process, which gives staff more time to focus on residents. It is important to consider that a integrated, collaborative relationship with an LTC pharmacy promotes best clinical practice in assisted living and reduces the likelihood of hospitalization or decline due to medication-related issues.

It is challenging to balance the rights of the individual resident and the benefits to the community for use of the LTC pharmacy partner. We can make this less difficult by changing the narrative, explaining needs from resident’s perspective and by emphasizing more on safety and quality of care.

References:

• Review of Current Standards of Practice for Long-Term Care Pharmacy Services: Long-Term Care Pharmacy Primer. (The Lewin Group, 2004).
• Latest health news https://medicorx.com/what-is-a-long-term-care-pharmacy/
• Chronic Disease Self-Management Fact Sheet. (National Council on Aging, 2014).
• https://macspharmacy.com/blog/differences-between-an-ltc-pharmacy-and-a- retail-pharmacy/
• New Avalere Health Study Details Stark Difference Between LTC and Retail
• The Challenges of Aging During COVID-19: Long-Term Care, Vaccination, and Isolation https://nihcm.org/publications/the-challenges-of-aging-during-covid-19- long-term-care-vaccination-and-isolation
• Long-Term Care Guidance https://cms.gov/medicare/prescription-drug- coverage/prescriptiondrugcovcontra/downloads/ltcguidance.pdf
• Long-Term Care Facilities Guidance https://dph.illinois.gov/covid19/community- guidance/long-term-care.html
• A new age for long-term care pharmacies. (JASON SPEARS, October 4, 2010) https://mcknights.com/blogs/guest-columns/a-new-age-for-long-term-care- pharmacies/
• Lon-Term Care Pharmacy Best Practices During a Pandemic https://remedirx.com/blog/2020/05/06/long-term-care-pharmacy-best- practices-during-a-pandemic/
• Study Finds Long-Term Care Pharmacies Face Higher Dispensing Costs; Must Meet Specialized Patient Needs (February 22, 2013)
• Choosing Evolution over Extinction: Integrating Direct Patient Care Services and Value-Based Payment Models into the community-Based Pharmacy Setting https://pubmed.ncbi.nlm.nih.gov/32722217/