No turning back

DATE: April 3, 2018

Published by McKnight’s Senior Living

Few industries are more a reflection of the constituents it serves than senior living. And keeping pace with its evolution is a head-spinning exercise.

When industry veterans look back at the issues that occupied assisted living owner-operators not long ago, that segment bore very little resemblance to today’s senior living world.

“When I started in senior care in 1998, we still had nursing centers called ‘rest homes,’ ” says Chad Worz, Pharm.D., BCGP, executive director and CEO of the American Society of Consultant Pharmacists. “Those are a thing of the past. We now have ‘post-acute rehabilitation centers.’ Not only does that define the changing patient, but it requires a change in clinical acumen for practitioners.”

Residents in these settings today are typically sicker and more medically complex. As a result, medication services and delivery methods have changed exponentially. Pharmacy services for senior living are undergoing dramatic change. Consultation, compliance management, risk reduction, medication reviews and more are increasingly commonplace. And with assisted living settings taking on higher acuity residents, the stakes are higher than ever before.

RAPID PACE OF EVOLUTION

Alan Rosenbloom, president and CEO of the Senior Care Pharmacy Coalition, believes the “increasingly central role of medication therapy to healthcare and quality of life” is one of the four biggest drivers of this “very complex, multi-variate environment,” along with an aging population, consumer choice and resource allocation.

“Control” is the one word the defines how medications were managed in assisted living’s nascent years versus today.

“Residents and their families used to manage their own medications and looked to local pharmacies when it came to medication distribution,” observes Travis Palmquist, vice president and general manager of senior living at PointClickCare. “In fact, medications themselves were often kept at a resident’s bedside for self-administration. Today, we’re seeing residents with more chronic conditions and more complex medication regimes, or who may be cognitively impaired.”

Today, assisted living providers rely on pharmacy service companies and as much for adherence as they do on drug dispensing and distribution.

Khristy McClelland, president of Guardian Pharmacy of Jacksonville, FL, points to facilities’ need for long-term care pharmacies that work on each resident’s behalf to resolve insurance issues and reduce costs. “Payment models have also become more complex, with an increasing amount of medications that are non-formulary or require prior authorizations,” she adds.

In so many ways, medication management in assisted living is not unlike the skilled nursing side.

“There’s increased demand for consulting services and cart auditing to keep up with ever-changing regulations,” says John Dombach, Pharm.D, general manager of Turenne PharMedCo’s Tennessee, Kentucky and Florida client operations. “Depending on the state regulations, many non-skilled senior living settings have unlicensed personnel helping assist residents. As a result, non-skilled facilities often depend heavily on the pharmacy for clinical support and assistance to ensure regulatory compliance through on-site consulting services and training on medication pass technique, pharmacy regulations and infection control.”

Along the way, many owner-operators wrestling with polypharmacy issues are seeking to simplify arrangements with pharmacy companies to reign in the almost mind-boggling numbers of medications – an average of 12 to 14 per day for the typical assisted living resident.

“Many are moving to single-source ‘contracted’ or primary pharmacy providers,’” observes Tim Quarberg, vice president, medication management, of MatrixCare. “They want consistency and quality of medication packaging and consulting services. They also want reliability of delivery service and other advancements such as electronic prescribing and pharmacy integration.”

GROWING PAINS

Consumer choices that Rosenbloom alluded to could explain one reason for the rising acuity levels in assisted living. Seniors aren’t necessarily sicker; there are simply more of them choosing assisted living over nursing homes. In some respects, the industry wasn’t prepared for it, and it’s playing catch up, observers say.

Seniors today also are taking more and different medications than ever before. McClelland blames some of it on marketing, or “direct consumer advertising for pharmaceuticals and a substantial rise in OTC dietary supplement usage.”

Finally, resident acuity in general actually is rising, which leads to more complex medication regimens. It’s hard sometimes to decide which of all this leads to the other. For the typical assisted living owner-operator, the risks are higher than ever before.

Another vexing issue is coordinating each resident’s care as they move from one setting to another — from home to hospital to home to assisted living and so on. Vital information can fall through proverbial cracks during each transition. “From an operations standpoint, navigating all the communication methods to the pharmacy is complex and, at times, more information, more data equate to more room for error,” explains Sarah Barker, Pharm.D., general manager of Montgomery Pharmacy, Turenne PharMedCo.

Rosenbloom calls poor care coordination a “principal impediment” to effective medication management, adding “business models and regulatory approaches that bifurcate care settings from healthcare services make decreasing sense.”

There’s also a people problem affecting medication services outside of skilled nursing facilities. McClelland asserts assisted living is based on a “social rather than medical model,” which leaves a kind of clinical vacuum. “Because of this, these settings may or may not be staffed with nurses, and prescribers and pharmacists located off-site,” she adds.

TECH TO THE RESCUE

So, as assisted living plays catch-up to its elder sister, technological innovations have vastly improved dispensing, distribution and security.

Many cite specialized and multi-dose packaging as critical improvements. Worz, for example, says multi-dose packaging systems promote easier nurse administration or easier patient administration at home.

Joe Kramer, vice president of sales and marketing for Geri-Care Pharmaceuticals Corp., credits geriatric-trained nurses for playing an innovative role in medication service and delivery in the past few years. “The Program for All-Inclusive Care for the Elderly, or PACE, is an example of a nurse-driven innovation in geriatric care,” he says. “By using coordinated medical, health and social support, the program, as a result, has allowed seniors to remain living in their respective homes for longer periods of time. Geriatric consultation expansion has also played advances in medication services and delivery, and computer-based consultation services are allowing primary care physicians to receive guidance from geriatricians.”

In the end, seniors themselves are the biggest incubators of all.

Says Kramer: “One of the biggest advances in senior care isn’t necessarily the care itself but the seniors who need it. As we begin to get more technologically savvy, so do the seniors who need to be cared for, and many seniors are actively seeking tech to make their living experiences much easier.”