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LONG TERM HEALTH CARE OPERATION

Author: M.Thandava Lakshmi

Abstract

It is anticipated that as the older population in the US continues to increase alarmingly, so will the scope of their drug use. A usual senior patient frequently has several medical conditions which are treated with a variety of medications. This rate of adverse drug responses may rise exponentially in the elderly as the total number of medications taken rises. One medication may occasionally be prescribed to relieve the negative effects of another medicament. The extent of their drug usage is expected to increase as that the aging people in the US keeps growing at an alarming rate. A typical elderly patient has multiple medical issues that are typically treated with different drugs. With an increase in the overall number of prescriptions used, this risk of adverse reactions to drugs may exponentially increase in the elderly. On occasion, a prescription for one drug may be written to counteract the side effects of another. Studies show that the financial benefits of having consultant doctors evaluate individuals’ medication prescriptions in long-term care facilities resulted in a $220 million reduction. The influence of consultant pharmacists in lowering the number of prescriptions for drugs given to patients allowed for these cost savings.

Introduction

A recent commentary highlighted the importance of medication use in a population which uses more medicines compared with other groups, that is, older people. Avorn stated ‘The use of medications in older patients is arguably the single most important health care intervention in the industrialized world’ [Avorn, 2010]. However, this same commentary proceeds to highlight some of the deficits in prescribing in older people such as under-representation of older people in trials, poorly organized care and medical education lacking instruction on prescribing in this population [Avorn, 2010].

One group of older people, those who are residents in care homes (the collective term used to describe nursing and residential homes), require particular consideration. Care homes include nursing homes which provide 24-hour nursing care, residential homes which provide personal care only and mixed care homes, which offer both residential and nursing care [Barber et al. 2009]. These residents typically receive between 8 and 10 medications [Patterson et al. 2010; Barber et al. 2009] and may have at least four active medical diagnoses [Patterson et al. 2010], all of which require careful monitoring and optimization as and when required. However, the care home sector has also been the subject of intense scrutiny and criticism in relation to several aspects of the quality of care, and prescribing is no exception. There has been a legacy of overuse of inappropriate medication and underuse of medication required for the treatment and/or management of a range of medical conditions.

Long Term Care Pharmacy Operation

With the rising demand for higher levels of service and better care, establishments like such as those providing assisted living facilities or transitional nursing for the mentally disabled, have started to resemble conventional skilled nursing institutions more. These facilities now frequently offer services including special pharmaceutical packing and delivery. These Pharmacy services are required to help prevent the theft of illicit substances kept and dispensed in these facilities as well as to help assure correct and effective medication delivery to residents. Therefore, these facilities ought to be described in a way that takes into account the rising degree of pharmaceutical services. For instance, Alabama recently published a final rule that defines “institutional pharmacy” to include assisted living. There should be updates to other state pharmaceutical practice laws.

Nursing home prescribing: the impact of bad practice

In all of medicine, the conditions surrounding drug being used in nursing homes (NH) are some of the most complicated. Most of the people who live in New Hampshire are elderly and have a number of ailments, most commonly diabetes, arthritis, cardiovascular disease, and rheumatoid arthritis.  Roughly half are over 85 and suffer from debilitating dementia that makes it difficult for them to converse or carry out everyday tasks. Additionally, inhabitants of New Hampshire use seven to eight prescriptions on average each month, which puts them at a greater risk of medication-related issues such the usage of unsuitable therapies. Amidst clinical study data demonstrating little benefit for behavioral management11, 12 and mounting scientific proof of excessive incidence and death, antipsychotics are frequently utilized in the NH context and have grown to be the predominant therapeutic approach in NHs for treating cognitive symptoms of dementia. 8, 12, 13 In fact, despite global regulations10 and FDA15 alerts urging larger discipline in anti-psychotic use throughout older adults, the expansion of antipsychotic medication use between 1999 and 200614 recommends also that excessive consumption of antipsychotic drugs in NHs reflects one of the greatest failures of evidence-based medicine to date.

Methods for enhancing nursing home prescriptions

Prescription drug cost is on the rise, and it has become a major concern again for Medicare programs. The inclusion of such an offsite prescription medication beneficial to the Medicare event is the main topic of discussion about prescription pharmaceuticals at the federal level. Concern has been raised at the state level due to the double growth of Medicaid drug spending. The unique and significant subject of medications supplied to nursing home residents, however, has received very little attention up to this point despite the importance of a prescription drug expense issue. Prior to now, the majority of federal discussion of nursing facility pharmacy issues has been focused on quality and safety issues, notably the reduction of unwarranted sedation. The administration of prescription medicines in nursing homes, however, is about to become a crucial policy issue for a number of reasons. First, due to budgetary constraints that have pushed more vigorous medical care cost management, public knowledge of medication expenditure in care homes has increased. Second, new and pricey treatments are being created quickly for the aged population as pharmaceutical innovation continues. Third, physicians are worried about the increasing drug use among residents of nursing homes and the prevalence of hazardous drug reactions.

Major Trends in Drug Therapy in Nursing Homes

The number of old people in the US is rising, and those who reside in long-term care institutions are becoming more economical. The amount of people over 75 is expected to increase from 5.8% in 1997 to 9.4% in 2025 as a result of the ageing of the pediatric boom generation. 1 While this is happening, medical technology advancements will make it possible for ill people to live longer, occasionally with a lot of nursing care, poor housing, and/or a lack of social support. Although alternates to nursing homes (such community healthcare and assisted-living facilities) are expected to expand and become more significant, a need for nursing home care—even among the frailest—will likely increase at the same time that the older population is growing.

Evaluation of the effects of pharmacy intervention

The studies that have attempted to rigorously assess the effects of health professional services in nursing homes are those of high quality, as evidenced by the summary provided above. Some similarities exist between the research. Many of the studies focused just on process of medication review, pharmacist input on psychotropic drugs was frequently sought after (reflecting the history of consideration regarding these drugs), and a few studies made an effort to involve other important health professionals like the staff of nursing homes and GPs. The variety of outcome measures that have been utilized in all investigations is equally noteworthy, though. Some research chose more clinically applicable studies, while others used outcome measures depending on the amount of medications. evaluating the results of a pharmacist’s intervention

Clinical, economic, and humanistic outcomes have typically been the three categories used to classify results (health-related quality of life). On the basis of the aforementioned categorization, it is controversial as to if changes in prescribing, such as a decrease in the number of medications, translate into better outcomes. Studies that employed quality-of-life metrics as outcomes after implementing new care models or drug reviews discovered minimal difference [Pacini et al. 2007; Bernsten et al. 2001]. Any enhancement in well-being quality of life may not be realistically predicted when such measurements are applied to a nursing home population; the most that might be anticipated is a slowing of the deterioration in a quality-of-life measure. Studies that examined the health-related quality of life of senior citizens

Medicaid

The Medicare program funds for nursing home medications and care home facilities in one combined pack, in stark contrast to Medicaid. After a three-day hospital stay, Medicare pays certified nursing facilities (SNFs) a per diem prospective rate defined by CMS for the first 100 days of care all elderly and disabled beneficiaries23. The SNF progressive rate covers nearly all medically essential drug consumption that takes place throughout a resident’s stay, similar to what the Medicaid inpatient hospital payment does. 24 This implies that SNFs are responsible for the full cost among all patient medication use throughout a Medicare-covered stay and that Medicaid does not fund any expenses that are higher than the previously established rate.

Nursing homes and institutional pharmacies occasionally agree to a corrupted payment schedule for Medicare-covered medications, shifting the pharmacy’s risk of high drug consumption to the nursing home. For some of the more expensive medications, pharmacies frequently get fee-for-service exceptions to these corrupted arrangements. Institutional pharmacies benefit when prescribing physicians follow the formularies of the pharmacies as as closely as possible because they are able to provide competitor prices for drugs to nursing homes thanks to manufacturer special offers they start receiving when they include specific medications on their formulary.

Paying out of pocket

Prescription medications are often covered by insurance by the pharmacy to residents who pay outside for nursing home services or assisted living. Nursing homes and assisted living communities generally recommend or even demand that residents utilize the pharmacist with whom the facility has a contract in order to uphold quality and administration control.

Conclusion

The nursing facility setting brings this into stark contrast because prescribing predominates in the medical management of elderly patients. Surprisingly, there is a negative correlation between the amount of intervention studies conducted to figure out how to improve prescribing and the severity and scope of problematic prescribing in nursing homes. This may be partially attributable to a challenge involved in carrying out these studies, including accessing care facilities, obtaining written consent from vulnerable residents, and involving staff in the investigation. Such investigations are frequently prevented by a lack of funding, which makes it challenging to carry out lengthy trials or execute painstaking but detailed assessments of adverse medication occurrences. Accepting that the use of unsuitable substances will be reduced.

The nursing facility setting brings this into stark contrast because prescribing predominates in the medical management of elderly patients. Acceptance that a drop in the use of unnecessary pharmaceuticals is a clinically important outcome that would long-term serve residents should be taken into account in the lack of such resources. On the other hand, the underuse of potentially helpful medicine is a neglected issue. To achieve this, one must be able to distinguish between “many medicines” (which seem to be appropriate) and “too many drugs” (which are improper) [Aronson, 2004]. Despite having clinical relevance, such undertreatment is a significant result that is rarely examined [Aronson, 2004; Gurwitz, 2004], especially in the population of nursing homes.

Reference

1. Avorn J, Gurwitz JH. Drug use in the nursing home. Ann Intern Med. 1995;123:195–204. [PubMed] [Google Scholar]
2.  Magaziner J, German P, Zimmerman SI, et al. The prevalence of dementia in a statewide sample of new nursing home admissions aged 65 and older: diagnosis by expert panel. Epidemiology of Dementia in Nursing Homes Research Group.  2000;40:663–672. [PubMed] [Google Scholar]
3. Bernsten C., Bjorkman I., Caramona M., Crealey G., Frokjaer B., Grundberger E., et al. (2001) Improving the well-being of elderly patients via community pharmacy based provision of pharmaceutical care. Drugs Aging18: 63–77 [PubMed] [Google Scholar]
4. National Center for Health Statistics, “National Nursing Home Survey,” Centers for Disease Control and Prevention; accessed April 12, 2002, at http://www​.cdc.gov/nchs​/about/major/nnhsd/nnhsd.htm.
5. Jerry Avorn and Jerry H. Gurwitz, “Drug Use in the Nursing Home,” Annals of Internal Medicine, 123 (1995): 195–204 [PubMed].
6. Celia S. Gabrel, “An Overview of Nursing Home Facilities: Data from the 1997 National Nursing Home Survey,” National Center for Health Statistics, Centers for Disease Control and Prevention, Advance Data, 311 (March 1, 2000) [PubMed]; available November 6, 2002, at http://www​.cdc.gov/nchs/data/ad/ad311​.pdf.

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