Technology Strategies that Work in LTC Pharmacy

Publication: ComputerTalk for the Pharmacist

Author: Will Lockwood

Date Published: November 8, 2011

There are a handful of significant realities long term care (LTC) pharmacies are confronting as 2011 winds down. There’s the continuation of the recent trend toward higher-acuity residents at any given level of care; the substantial reduction in Medicare reimbursements; the pending implementation of the federal requirements for short-cycle filling; and a general concern over stemming the costs of medication waste. And then there’s the need to work toward ever more tightly integrated systems as technology moves further from centering mainly on the pharmacy system to encompassing dispensing automation both in the pharmacy and in the facility, workflow, document and delivery management, facility communications, and digitization of medication administration records. We find a range of different strategies in play now by LTC pharmacies to meet these challenges, position for the future, and continue to provide the highest level of service in a very competitive environment.

Meeting Residents’ Needs
Keith Taylor, an owner of Pharmacy Concepts, has been in healthcare and pharmacy for 25 years. He’s got his eye on two of the realities we’ll review. Over the longer term, he’s seen firsthand how the level of care provided in different facilities has changed. “What’s happened is that a lot the patients who used to be in hospitals are being placed into high-acuity LTC facilities,” says Taylor. “And the patients who were in these are being placed in nursing homes, those patients have moved to assisted living, and those formerly in assisted living have moved to independent living.” As an example, Taylor offers hip replacement patients, who now typically recover in a skilled-nursing facility (SNF) instead of the hospital. These patients have a level of pain that needs to be managed and antibiotic therapy that needs to be started immediately, and so require service from a pharmacy that meets the need for rapid processing and delivery. Taylor also points to the 11% cut in Medicare reimbursements to LTC facilities that began on Oct. 1. In his mind this is the biggest thing going on at the nursing home level right now. “Facilities are looking to us for anything we can do automation-wise to lower the medication cost, reduce their inventory, cut out waste, and provide time-savings,” says Taylor.

Automation and Packaging
Taylor has a lot of experience with dispensing automation, one technology that he sees helping to meet these challenges and also helping reduce expenses for the nursing home. Pharmacy Concepts has two Parata PACMED units, which have been in use for over two years and provide 95% of the residents the pharmacy serves with their medications in multidose strip packaging. “We have two, not just for scale,” says Taylor, “but also for redundancy.” Taylor notes that some facilities have documented savings of 50% in time spent on med passes because of the packaging. “CNAs and nursing staff are able to spend that time working with the residents to provide more care,” Taylor points out.

While Pharmacy Concepts has been working with automation and packaging for some time, there are other pharmacies that are just getting started. Preston Pharmacy, for example, is around eight months into a deployment of Manchac’s DOSIS automation for packing blister cards — the pharmacy’s first foray into dispensing automation of any sort.

The need to drive efficiency played a key role in the decision at Preston Pharmacy. “We decided that we needed a technology that would allow us to produce at a lower cost,” says Mike McNaught, pharmacy manager. But it was also important for Preston Pharmacy to be able to bring technology to its facilities’ existing packaging preferences. The pharmacy packed 99% of its orders in blister cards before automation, and didn’t want to change that. Now McNaught reports packaging 35% of the monthly fill and 5% of prepacks using one DOSIS machine that works at a rate of 40 cards an hour, or 600 cards a day. Delivery of a second DOSIS is pending by years’ end. McNaught estimates that this should take the percentage of orders automated up to around 70%.

For proof of efficiency, McNaught points to the fact that Preston Pharmacy has already been able to reassign one FTE away from packaging to another department. “We are in a better position to seize opportunities for growth now,” he says. “And we feel like we could also shift another half an FTE away from filling soon.” Extrapolating on these early results, McNaught anticipates gaining a total of three reassignable FTEs once two DOSIS machines are running.

Reducing Waste, Increasing Access
Returning to Keith Taylor, another major demand he’s seeing among facilities is for help eliminating medication waste. Here, shorter dispensing cycles supported by automation have a big impact. “We have several facilities that have documented for us that using the automated system the way that we do, we’re able to eliminate 70% of their waste,” says Taylor.

In-facility automation can enter into the mix as a way to reduce medication waste, too. At the same time, it helps solve the problem of providing prompt first doses along with easy access to stat and PRN orders.

Scott Peterson, assistant director of pharmacy for Rapid City Regional Hospital, works with Talyst InSite remote dispensing systems to provide medications on a daily cycle for patients in two of the hospital’s larger LTC facilities: Custer Regional Senior Care in Custer, about 40 miles away from Rapid City; and Sturgis Regional Senior Care in Sturgis, about 30 miles away. Both have approximately 80 beds, the scale that Peterson has judged to make in-facility automation financially feasible for Regional Health.

According to Peterson, the InSite technology is also a solution for those orders that need to be filled right away but don’t mesh with the pharmacy’s delivery schedule. Common pain meds and antibiotics, as well as first doses, can be stocked, eliminating delays in administration in most cases. “We can enter an order at our pharmacy and have it available for the nurse from the automation in just a matter of minutes,” explains Peterson. “It really prevents delays in therapy.” In-facility automation brings with it some important changes for the facility staff and the pharmacy, notes Peterson. “The nursing staff needs to get used to being responsible for dispensing a day’s worth of medication from the automation on their own,” he says. “We have to help them be comfortable through training and by showing them that this will help them take better care of their residents.”

At the pharmacy, Peterson has had to work through a set of decisions as well. For example, he’s had to decide who at the facilities has permission to take various actions, such as restocking the machines. He also decides which nurses and med techs have access to certain medications — controlled substances, for instance — which reduces the potential for diversion. “You have to work through the details here,” he says. “And these will be unique to the pharmacy and to the facility.”

A Hybrid Approach Rick Rondinelli, president and CEO of In Touch Pharmaceuticals, weighed in on short-cycle dispensing in last year’s coverage of LTC pharmacy. This year he offers some thoughts on a new strategy deployed over the last year that combines short-cycle dispensing with in-facility automation. “We see residents now coming into skilled-nursing facilities for relatively short-term rehab or physical therapy, and this can lead to 20 or 30 new admissions a week,” Rondinelli says. These dynamics led In Touch to look for a better and faster way than emergency medication kits or backup pharmacies to get the first dose dispensed. Since October 2010, In Touch has installed 40 Pyxis machines at the facilities it serves. The results, according to Rondinelli, are decreased use of backup pharmacies, decreased medication inventory at facilities, reduced errors, and reduced misuse and diversion. There’s also an emergency preparedness angle, notes Rondinelli, since short-cycle dispensing means that there’s less medication on-site for a resident at any given time. The process, as described by Rondinelli, is a closed loop that builds on In Touch’s existing automation technology. A combination of TCGRx ATPs, both the larger 384s and the smaller 71s, not only produces orders on 7-day and 4-3 cycles, but is also used to stock Pyxis Cubies — microchipcontrolled, sealed containers that can only be opened by the automation. These are then delivered to the pharmacy filled with the same unitdose medication packaging as the regular orders. The secure nature of the Cubies allows Rondinelli to task delivery personnel with restocking the Pyxis machines without risk of diversion or error. In Touch tracks minimum product levels in the Cubies and replaces those that fall below the thresholds. Since the medications in Pyxis haven’t been dispensed or billed yet, notes Rondinelli, they can be brought back to the pharmacy for restocking without being deemed returned medications.

Maximizing Efficiency
Considering the investment that’s required to place automation in the facility, both Peterson and Rondinelli have found it critical to make formularies as efficient as possible. This means working with physicians to arrive at the right set of medications to stock. “What you want to do is take care of as many patients as you can with a particular drug or class,” says Peterson. For example, he says, there are seven or eight commonly prescribed ACE inhibitors, and then four or five different strengths for each. “If I allow all of these in my machine, I’m not going to have any room left,” he says. In this case, Peterson has worked with area physicians to pick one ACE inhibitor and identify the key strengths.

“Our formulary is about 170 meds for the 240 slots in the Talyst automation,” he says. The result is that between 90% and 95% of oral solids are dispensed by the in-facility automation at the Custer site. In Sturgis, the rate’s only running around 80%, because Peterson has yet to get the formulary fine-tuned.

Supporting Facilities: eMARs
As critical as dispensing automation clearly is in LTC pharmacy, there are certainly other technologies that are at the forefront. Northwest Health System Pharmacies’ president Kevin King points to electronic MARs (eMARS) as one good example. “What the pharmacy has done traditionally is provide the meds,” he says, “but you aren’t winning accounts doing just that anymore. eMARs really stretch pharmacy by making you an active part of the medication management program.” King has found that an eMAR can save up to 35% of labor hours by, for example, increasing the efficiency of med passes and eliminating the end-ofmonth comparison between the old and new MARs.

PDC Pharmacy has been using the Web-based MedSupport eMAR from CaraSolva for about five years, according to executive vice president Eric Folino. This is a tool that Folino reports facilities are asking for, and one that is particularly important in the niche PDC Pharmacy serves. The facilities PDC Pharmacy serves are small and spread over a wide area, and medications are passed primarily by personnel who aren’t licensed healthcare professionals. All this makes direct supervision by professional staff impractical.

In Folino’s opinion, the critical eMAR feature for these circumstances is an alert function that helps eliminate what he cites as the number-one error a facility can make: forgetting to give the medication. This alert can be configured to deliver a notice by a variety of channels, such as text message or pager; this notice informs the caregiver that a medication has not been passed at the specified time. It’s important to receive timely notice and take corrective action, since a medication passed within an hour of the scheduled time is considered to be on time, according to Folino. “This alert can go to as many people as you want,” he says. “It can go to the caregiver, to a nurse, and to a supervisor. This allows for direct oversight, and lets the administrative staff know when a med is missed.”

The impact for the facility operator is significant, according to Imagine! business development director Greg Wellems. Imagine! is also using CaraSolva’s MedSupport. “Using an eMAR has been an incredible cost savings for us,” he says. “It’s been the most effective software program that we’ve used. The most expensive staff members we employ are our RNs, and their time is better spent on client relations and management, rather than tracing down errors and managing med sheets. For us it saves two nursing FTEs, which more than pays for the application costs.”

Wellems says that before going electronic, each resident had up to 10 pages of MARs per 24-hour period, which translated into facility staff carrying around hefty binders filled with paperwork. With the eMAR, staff simply log on to see what meds are due at what time. Imagine! Also has gained the ability to control staff access to just the records pertinent to a given resident, and has the ability to record vitals monitoring as well.

Efficient and error-free communication between the pharmacy and facility is another major need that eMARs can support. Folino notes that PDC Pharmacy has recently acquired an HL7 interface between its FrameWorkLTC pharmacy software from SoftWriters and MedSupport. This gives the ability to pass information quickly from the doctor to facilities in a way that eliminates any errors that might result from reentering information into the eMAR. “We know, and the facility knows, that the information in the eMAR is exactly what we entered in our pharmacy software,” says Folino.

Closing a Loop
Mark Adler, who has been using a Web-based eMAR from Catalyst for about three years at Adler’s Pharmacy, is a big believer in getting the eMAR tied into his other systems. “What’s key is to make sure all your software talks to each other,” says Adler. “You need your pharmacy system, your packaging system, and your eMAR to interface. This is what creates a closed loop.” In his case, this means that the eMAR connects directly with his QS/1 PrimeCare LTC software to pass medication details to the facility and receive orders back. Next, it uses the barcode applied to the strip packaging produced by his Parata PACMED during the med pass to double-check and record that the right drug was passed at the right time to the right resident. All of this is immediately visible in the pharmacy system. “This is a real differentiating service right now,” says Adler.

Getting Systems Working Together
There are a few other ways that strong interfaces can be part of LTC operations. For example, Mike McNaught reports that Preston Pharmacy is working to create an order flow that integrates the ability of its DocuTrack document management system to read barcodes on faxed refills with the auto-fill feature in QS/1’s PrimeCare. This will allow clean refills to pass directly to DOSIS for filling. “Our goal is to get this happening in the next 60 days,” he says. “We’ll run this process at night, instead of using the machine to do prepacks. So the next morning when we walk in, there will be 300 cards of refills labeled and ready for delivery.”

John Sherwood, co-owner of Integrity Pharmacy’s LTC division, says the key to his pharmacy’s business is the seamless integration offered through Speed Script’s LTC software, which he’s recently deployed.
“Information flows from the facility via the cloud to the dispensing software for review, and then to our PACMED automation,” says Sherwood. “This integration means that there are fewer keystrokes on the dispensing software — a lot fewer keystrokes — and so less potential for error.”

The best aspect of the Speed Script LTC system, in Sherwood’s view, is the flexibility on the facility side. The facility staff may use the cloud-based application to reduce the amount of writing they do for treatments and drug orders, according to Sherwood, because the orders come in and then become
electronically linked with physician orders and eMars. The information is also pushed into the pharmacy for the pharmacists to review against the communication with the doctor’s office. “We have the opportunity to review the order before it becomes active,” he says. “Any subsequent corrections are then pushed back to the facility eMAR and POS. This action reduces labor that would be used to write and rewrite orders.” The homecare model uses the same principles as in LTC, only rather than networking with a facility it networks with a home health company. This is important because homecare patients, notes Sherwood, are generally the ones who struggle with compliance, or who have caregivers that can struggle with coordinating the medications and care required to administer the medications. With communications coordinated between the pharmacy and the homecare company, and the medications packaged by time of administration by PACMED, Sherwood’s staff has put the patient on the right path to compliance, and also provides oversight that the patients are following their prescription regimen. “Our technology takes away a lot of the extra effort from the caregiver,” says Sherwood. “It keeps the patients healthy longer and reduces hospitalization and adverse events.”

Communication Is Key
The premium John Sherwood places on effective, integrated communications with facilities is echoed by Kevin King, who reports that Northwest Health System is using no fewer than four different technologies to achieve a similar goal. First the pharmacy works to interface its SoftWriters FrameWorkLTC pharmacy management system with the software that runs its clients’ facilities. “These facility systems record assessments, care plans, labor hours, diets, all of that,” says King. “When we interface to these programs, it’s easier for us to access raw data when a new patient arrives.” This is particularly important when it comes to collecting accurate billing information in a timely manner, he notes.

Next, there’s FacilityLink, also from SoftWriters. According to King this allows facilities to order refills, log in to check billing information, review a price quote, or print a paper MAR if necessary at the facility. King calls Facility Link the primary communications channel for facilities not using an eMAR, which is the third communications channel offered. Finally, there’s inbound and outbound document management with Integra’s DocuTrack. “With these tools, we keep very few hard copies now,” says King.

And once systems are efficiently integrated, the right communications channels are open, and the tide of paper is being held back, there’s time to worry about other things — the complexities of billing, for example.

Managing Billing
The task of learning to manage billing in the LTC environment is something with which Teresa Coleman, controller at Propac Pharmacy, has extensive experience. Coleman was originally brought in to Propac for this task, along with her financial and accounting expertise, and has since deployed two services from Net-Rx to augment her efforts.

When Coleman started, the pharmacy had no reconciliation processes in place. There wasn’t a lot of attention being paid to claims before they were submitted, either. “When you’re working day-to-day just to get prescriptions out the door, reimbursements and reconciliation tend to move to the background,” says Coleman. “You have to figure out how to get these processes into the workflow and not slow down.”

These circumstances led Coleman to Net-Rx’s RecRx — which she reports has really helped with managing remittance advices and pursuing payment issues with third-party payers — and EditRx, which helps to keep an eye on third-party reimbursement and procedures that affect proper reimbursement during the data entry process. With these two tools in place and the support of an analyst at Net-Rx, Propac now has a staff member who devotes three-quarters of her time to working on managing claims and reimbursements. Coleman has also been able to bring RecRx to bear on one of Propac’s latest challenges: Medicare co-pay audits. “Plans have started to go back and look at how they’ve been charging co-pays out,” she explains. “They are going back a year, a year and half, or more, and fixing what they did wrong by requiring co-pays for low income, dualeligible patients.” Sometimes these changes come through buried in fees listed at the end of a remittance advice without explanation, and Propac has been left trying to figure out what was going on. Net-Rx responded, Coleman reports, by creating coding so that now a report can be generated and used as the basis for pursuing the co-pay changes, as well as other adjustments. “We still end up calling the plan,” says Coleman. “But we have a place to start, when we didn’t before. We can come to these conversations knowing exactly which claim we want to discuss and exactly what dollar amount. Then we can say to the plan ‘Why did you adjust what you did?’ The more information we have on these calls, the better.”

Creating New Workflow Points
Bob King is director of IT for Alternative Care Pharmacy, which is a start-up backed by USA Drug. This financial backing brings resources that have allowed King to jump immediately into document and delivery management with Integra’s DocuTrack and DeliveryTrack. And while both these technologies fundamentally reduce the amount of paper associated with pharmacy operations, they are also bringing technology-driven workflow to new points in the pharmacy process, according to King. “These systems, combined with the workflow steps in our SoftWriters pharmacy system, mean that every step taken is recorded — from the time the order comes into the pharmacy until it is signed for at delivery,” says King.

DocuTrack is receiving and storing all incoming documents in a secured digital environment, allowing for immediate retrieval and for multiple people to use the same document at once, among other features, according to King. It is also managing and storing many outbound communications through easily prepopulated forms.

DeliveryTrack puts portable devices in the hands of delivery drivers. These devices collect information, such as signatures and GPS details, and transmit it back to the pharmacy in real time through a cellular connection. “We can check the driver’s location and generate an estimated time of arrival out of Delivery- Track,” says King. “And since it’s real time, we know just minutes after someone has signed for a delivery.” Strong interfaces come into play here again, as all the information flows from DeliveryTrack through to the DocuTrack server and then on into the pharmacy system server, creating what King calls real synergy from the systems.

This synergy, and the expanded scope of workflow tracking that it allows, can be particularly useful when responding to requests for information from facilities or state and federal regulators. Alternative Care staff has the ability to search for a record and filter information in DocuTrack using various criteria and then quickly pull up all the documents that are associated with it, as well as any notes added later. Ultimately, there’s a complete time-stamped timeline from receipt of the order from the facility or physician all the way to a delivery signature. “It saves so much time in the pharmacy to have all this information at our command right at our workstations,” says King.

Building Partnerships
It’s not hard to cover a lot of ground talking about LTC pharmacy. There are so many nuances, and most often a technology solution to address each. Perhaps the importance of doing more than simply dispensing medications is one overarching need that can be distilled from the many technology-based strategies out there. This is what Northwest Health Systems’ Kevin King thinks. “Partnering with the facilities by using technology creates stickiness,” says King. Facilities can come and go as they please, he points out — particularly in assisted living, which is where he sees the growth. “We are always looking to get our technology imbedded in the facilities,” says King. “And we invest heavily in training.” The intended result is that it’s not an easy endeavor for another pharmacy to jump in and offer the same level of service. “When you make a real commitment to technology and make a real investment to do it right, it’s a game changer,” he says.

And it’s best to get started now with planning your next strategic technology investments, according to Pharmacy Concepts’ Keith Taylor. “Parata just got some LTC pharmacy owners together for a few days,” he says, “and one of the things we discussed was how, if facilities think they will want something new in two years, you better have it in a year — you better have it in six months.” Taylor reports that he and his colleagues all agreed that, if you are going to get into automation and technology, then you have to be proactive and move forward fast. “The market is going to demand that we make changes,” he says. “We have to be ready to make the right investments to meet these new needs.”

Source: ComputerTalk for the Pharmacist