Medication errors, infection mismanagement, mistakes in charting or documents, lack of proper documentation and the mishandling of patient falls compose the five major rationales for negligence or malpractice lawsuits against nurses, professional trade associations, government agencies and policymakers say.
Long-term care consulting by pharmacists and physicians for patients and their families about the most relevant categories of care needed, the variety of healthcare services open to them and the use of prescription drugs improves the results of such decisions and practices and reins in costs, medical experts say.
Pharmacists, primary care, family practice and internal medicine physicians and specialists such as geriatricians and gerontologists who serve as consultants in or for senior long-term care and short-term care facilities on behalf of patients achieve success in treating them and ensuring their recovery while hemming in medical expenses.
Federal research from the Census Bureau and the U.S. Commerce, Health and Human Services and Labor departments shows that senior long-term and short-term care makes up 20 percent of the entire healthcare industry, which, in turn, serves as the top employer in the nation because of the burgeoning need for such services.
Senior Patient Demographics, Care
The need is growing as seniors now comprise 14.5 percent of the nation’s population or one in seven Americans. The Census Bureau finds that the oldest Baby Boomers turn 70 this year and that, each year, 10,000 members of this generation (born between the years 1946 and 1964) have been turning age 65 starting in 2011 until 2030.
As they age, members of this group require a range of healthcare services, participation in the most relevant categories of care to their set of circumstances and greater use of prescription drugs.
The most relevant categories of senior long-term and short-term care include assisted living, congregate care, continuing care retirement communities (CCRCs), home health care, hospice, nursing homes, post-palliative/surgical care, senior independent living and skilled nursing facilities (SNFs).
At the same time, older seniors — namely members of the Silent Generation (birthyears 1927 to 1945) and the final tier of the Silent Majority Generation (birthyears 1908 to 1926) — too, will need more care.
The Centers for Disease Control finds that, by the year 2050, about 27 million patients will need such medical attention, an increase from 15 million in the year 2000.
Increasingly responding to these needs are patient-centered medical teams of short-term and long-term care pharmacists, primary care, family practice and internal medicine physicians and medical specialists such as cardiologists, endocrinologists, gastroenterologists, hematologists, hepatologists, nutritionists or dietitians, occupational, physical and speech therapists, oncologists, podiatrists, psychiatrists, psychologists, radiologists and renologists.
In carrying out their policies, these white-collar-level medical professionals are supported by an ancillary staff of physician assistants, nurse practitioners, registered nurses, licensed practical nurses, biomedical equipment technicians, certified medical assistants and nursing assistants.
Whether senior patients are electing to “age in place” or stay at home to recover or to move into assisted living facilities — a category of care growing faster than nursing homes, or other forms of long-term care than in decades past — pharmacists, physicians and specialists make key decisions and resolve issues for patients and their families about the type of care administered, the services offered and medications.
For example, long-term and short-term care pharmacists are offering home infusion services and specialty products such as those that treat cancers for seniors who choose to stay at home.
Some 1,200 independent long-term care pharmacies will serve patients in short-term and long-term care facilities in a manner comparable to the relations between independent community pharmacies and the chain drugstores.
In fact, as evidenced by the creation of such advocacy groups of wholesalers that cater to long-term care pharmacies as the Senior Care Pharmacy Coalition in Washington, D.C. in 2014, such pharmacies lobby for the same core issues as independent community pharmacies such as PBM (pharmacy benefit managers) do like reimbursements, federal regulations concerning compounding and overlapping U.S. Centers for Medicare and Medicaid Services (CMS) guidances.
According to the Centers for Medicare and Medicaid, more than 15,000 skilled nursing facilities, namely nursing homes certified to accept Medicare payments, operate nationally. About 70 percent are for-profit but the remainder are run by charities or community health services.
Meanwhile, the country claims at least 7,000 assisted-living, independent living and memory-care facilities while 45,000 such institutions fall into the remaining categories of senior short-term and long-term care around the nation.
As in previous decades, senior patients in independent living facilities are still likely to visit their local-area pharmacies or a doctor’s office. By contrast, however, long-term care pharmacies are the chief source of prescription drugs for patients in skilled nursing facilities, assisted-living facilities and similar categories of senior care.
Role of Long-Term Care Consultants
As most of the residents of nursing homes and other long-term care facilities suffer from cognitive impairment and multiple physical illnesses and, in some cases, co-occurring mental disorders, federal, state, county and city regulations and medical policies are in place to manage their care to ensure accountability and transparency.
The American Society of Consultant Pharmacists, a white-collar professional trade organization based in Alexandria, Va. of 8,000 pharmacists and some pharmacy students, says long-term care pharmacies recruit and retain the consultant pharmacists who are needed to review the prescription drug routines of a patient of a long-term care facility every month. As third-party pharmacists, they monitor whether the drugs are prescribed for good reasons.
Consultant pharmacists, primary care, family practice and internal medicine physicians, medical specialists and ancillary staff examine a patient’s drug regimen to evaluate factors such as the correct form and administration of medicines, drug interactions, lab checks and the use of medical cocktails.
They also act as educators and advisors to senior long-term and short-term care facilities, often serve on their boards or committees and carry out in-house services every three to four months on a particular category of chronic illness or regulatory subject.
Consultant pharmacists confirm, challenge and change the original drug choices made by primary care, family practice and internal medicine physicians, medical specialists and ancillary staff.
More specifically, the variety of physicians and medical paraprofessional staff who also make decisions beside the consultant pharmacists about patient medications and the drug formularies used by the long-term and short-term care facilities — as well as the categories of care and healthcare services needed — are the prescribing physicians, nurse practitioners, registered nurses and licensed practical nurses, the medical director and the pharmacy and therapeutic committee members.
The matrix of roles typically runs as follows: prescribing physicians or nurse practitioners identify the original prescriptions required for each patient; registered nurses and licensed practical nurses acknowledge symptoms calling for a particular therapeutic treatment choice, and; the medical director of the senior long-term care or short-term care facility and the pharmacy and therapeutic committee members create the drug formularies used.
With more of the healthcare industry heading for a pay-for-performance mode of operation, long-term care pharmacies are becoming more essential to greater patient outcomes.
Aside from reviewing, educating and advising on the drugs and therapies used for the facilities’ patients, designated long-term care pharmacies carry out the following tasks: managing formularies; drug utilization review and training for staff; medication packaging; drug-delivery formulations and compounding, and; managing reports, forms and ordering supplies.
In particular, industry leaders say unit-dose packaging helps patients access their medicines and stick with a drug regimen.
Additionally, long-term care pharmacies handle drug records, drug orders and emergency medicines, perform holistic medical reviews and they prepare drugs in unit doses or carry out compliance packaging.
Pharmacies and consultant pharmacists also conduct quality assurance with respect to the danger of drug overuse or the incompatibility of drugs, especially when senior patients are prescribed medical cocktails due to their various illnesses. Many of the drugs are narcotic pain drugs, antibiotics and psychotropic medications.
Industry research shows the increase of the use of the following classifications of medicines on the rise in use by senior long-term care and short-term care facilities: HIV medication, 13 percent increase; immune globulin therapy, 71 percent increase; hepatitis C treatments, 25 percent increase; multiple sclerosis medications, 13 percent increase, and; inflammatory conditions, 37 percent increase.
Indeed, as of 2015, researchers say the increase in the use of hepatitis C treatments in a greater market outside of senior long-term care and short-term care was 289 percent.
Generics share the same percentage of the drug market as long-term care facilities — 85 percent. Still, newer drugs are taking effect.
The array of drugs used in nursing homes and other long-term care facilities has stretched to include more treatments of chronic illnesses such as cancer, HIV infection, heart disease, multiple sclerosis, inflammatory conditions, diabetes and hepatitis C.
To pay for these medicines, about 57 percent of senior patients in long-term care and some short-term care settings have Medicare, Medicaid and dual-eligible status for those who have both. It is this same percentage that has no access to the nearly 800 Medicare Part D prescription drug benefit plans today.
Instead, they can only take advantage of the 231 Medicare Part D “benchmark plans,” a particular sector of Part D benefit plans that is meant to be affordable.
By comparison, 29 percent hold private insurance while the rest are private insurance patients. This cohort is privy to the 800 Medicare Part D plans available.
However, the benchmark plans require more rules with respect to the facilities’ formularies and authorizations. In intensive healthcare settings such as skilled nursing facilities, post-palliative or post-surgical care or hospices, physicians and medical specialists are required to only offer medicines under those benchmark plans to hem in costs.
The work of long-term care pharmacies and the facilities helps to lower health care costs among senior patients in part by cutting down on hospitalizations and emergency room visits.
The Henry J. Kaiser Family Foundation reports that scaling back on both among Medicare participants in long-term and short-term care would cut costs by $2.1 billion in 2011.
Savings stem from the high expenses of acute care, the danger of drug errors and hospital-induced infections that can take place at a hospital stay, especially among the sickest patients.
Research from sources other than the Kaiser Family Foundation found a 33 percent decrease in hospitalizations would save Medicare $1 billion a year. This finding leads to pressure on long-term and short-term care facilities from the Centers for Medicare and Medicaid Services to cut back on patient returns to skilled nursing facilities and nursing rehabilitation facilities.
The CMS averages the number of hospitalizations among Medicare and Medicaid participants receiving Medicare skilled nursing facility care or Medicaid nursing home care that could have been prevented to be 45 percent, judging that billions of dollars in care could have been saved and asking facilities to coordinate care earlier to avoid hospitalizations and high costs.
As a result, long-term care pharmacies and their consultant pharmacists are paying close attention to senior long-term care and short-term care facilities and their patients stricken with chronic illnesses such as heart disease, diabetes or chronic obstructive pulmonary disease (COPD) to provide reviews of their drug regimens and educate and advise the leadership and management staff of those centers.
Researchers say a short-term nursing home with 100 beds may average a stay of 20 days, translating into a turnover enabling 150 patients monthly to return home and receive home health care.
They say such patients benefit from the outcomes data, safety and clinical research that CMS and the long-term care pharmacies and their consultant pharmacists generate, making for an improved transfer of information for an enhanced patient care plan to mitigate the risk of adverse events.
Bell, Christina, MD; Blanchette, Lanoie, MD, MPH; Michiko Inaba, MD; Wendy Iwasaki, PharmD; Kojima, Gotaro, MD; Lubimir, Karen, MD; Masaki, Kamal, MD, and; Tamura, Bruce, MD. Reducing Cost by Reducing Polypharmacy: The Polypharmacy Outcomes Project. J American Medical Director Association. 13(9): 818.e11-818.e15. https://www.ncbi.nlm.nih.gov/pubmed/?term=Kojima%20G%5BAuthor%5D&cauthor=true&cauthor_uid=22959733. Published online Sept. 5, 2012.
Devinney, Jennifer, RPh, PharmD, Chief Clinical Officer for Grane Rx. An Interdisciplinary Approach to Long-Term Care Pharmacies. http://www.granerx.com/an-interdisciplinary-approach-to-long-term-care-pharmacies/ Accessed Nov. 29, 2016.
Shelley, Suzanne, Contributing Editor. Targeting the Gatekeepers in Long-Term Care: The ‘age in place’ trend creates challenges for market access to seniors. American Society of Consultant Pharmacists journal. Nov. 7, 2016.
As more members of the Baby Boomer generation start to age and will number 70 million nationally in the year 2030 when the last of them reach 65, a decades-old shortage of geriatric physicians still looms large, threatening their prospects for senior long-term and short-term care, university researchers and professional trade association leaders in the field say.
The American Geriatrics Society (AGS), a New York-based nonprofit focusing on the quality of life of seniors, reports that, with this evolving medical and sociological phenomenon, aging Boomers most in need of medical assistance and service are projected to have less access to the expertise of geriatricians than previous generations.
In fact, AGS’ leaders and other institutions such as the University of Maryland School of Nursing add that this trend may be taking place in the present as fewer medical school students have elected to enter this field over the years.