In 1969, a group of entrepreneurial pharmacists, who expanded their community pharmacy businesses to serve residents of nursing facilities, founded the American Society of Consultant Pharmacists (ASCP). They developed new medication distribution systems, computer software and equipment designed to distribute and dispense medications to long-term care (LTC) and post-acute care (PAC) populations. The federal government recognized the term consultant pharmacist, and it became part of federal regulation in 1974 when Medicare required every skilled nursing facility resident to receive a monthly drug-regimen review by a pharmacist. Today, ASCP has grown to represent more than 9,000 consultant pharmacists, pharmacy professionals and students serving the unique medication needs of the senior population.
In 1974, when new Medicare regulations were first published, most nursing facilities focused on providing end-of-life care. Today, that picture has dramatically changed. In fact, more than one million seniors are admitted to skilled nursing centers following an acute event and are discharged back to their homes following rehabilitation. It is expected that by 2018, seven out of ten patients admitted to nursing homes will return to their communities.1
As medication-related complications continue to be one of the leading causes of avoidable re-hospitalizations, provision of medication management by consultant pharmacists has expanded to include sub-acute care, in-home and community-based care and assisted living facilities, psychiatric hospitals, hospice programs and correctional facilities.
When discharged from hospitals to PAC, this growing sector of the population leaves the facility with, on average, 14 medication orders that are required to treat chronic diseases.2 The increasing number of patients being discharged back into the community increases the need for appropriate medication management. For example, beginning in 2018, in the nursing home population, avoidable re-hospitalizations will carry reimbursement penalizations. An increased focus on quality outcomes creates greater demand for collaboration among pharmacists and other clinicians to optimize medication therapy and patient safety. Reducing a resident’s length of stay while simultaneously reducing re-hospitalizations is a valuable measure of the pharmacist’s role in providing positive performance outcomes.
New reimbursement models based on performance, such as Value-Based Purchasing/Accountable Care Organizations and Bundled Payment for Care Improvement, provide opportunities for pharmacists to participate in moving the healthcare system from fee-for-service to payment based on quality. These are voluntary risk-sharing models where savings can be shared among the providers involved. Currently, pharmacists can participate in these models, and although they cannot be paid directly, they can be paid by the organization. However, in order for this to happen, they must convince providers in the organization to include them in the model by demonstrating the value their services contribute to the overall success of the organization, providing superior care at a lower overall cost.
Currently, Medicare does not cover pharmacist-provided clinical services, even if a pharmacist is permitted to provide such services under state scope of practice law. The pharmacy profession’s efforts to secure provider status for pharmacists under Medicare Part B is an important step in the evolution of our healthcare system. By including pharmacists on the list of providers in the Social Security Act, government programs will be able to directly recognize pharmacists in new payment models and will remove any perceived barriers for private insurance payment for services. Reform of pharmacy State Practice Acts also needs to take place to allow for pharmacists’ broader range of services. Many states have already enacted such legislation, and many others are following suit.
As patients move between settings, pharmacists play a critical role in managing medications during care transitions. State and federal policymakers recognized this in new regulations, such as the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, the Centers for Medicare & Medicaid Services (CMS) Mega Rule and the Centers for Disease Control (CDC) Antibiotic Stewardship Program.
The IMPACT Act
The IMPACT Act requires CMS to develop, implement and maintain standardized patient assessment data elements for PAC settings to facilitate care coordination and interoperability and improve Medicare beneficiary outcomes.The providers covered include home health agencies, inpatient rehabilitation facilities, LTC hospitals and skilled nursing facilities. An important piece of care coordination is medication reconciliation and management through these transitions. Pharmacists need to be a part of the discussion as these measures are implemented, because they provide another opportunity to show value for billable services.
The Mega Rule
The 2016 Requirements of Participation for Nursing Homes represent the greatest change in practice and care delivery since the revised rules of 1991. This final rule reflects advances in the theory and practice of service delivery and safety and implements sections of the Affordable Care Act. The final rule includes opportunities for greater collaboration between pharmacists and facilities especially upon admission, discharge and changes in condition. Specifically, CMS requires facilities to develop an Infection Prevention and Control Program (IPCP), which must include, at a minimum, a system for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals providing services under a contractual arrangement.
CDC Antibiotic Stewardship
Going hand-in-hand with the new requirements that CMS designated in their most recent rule for LTC facilities is the CDC’s Antibiotic Stewardship Program for LTC. ASCP has been working with the CDC for the past four years to define and clarify the concept of antimicrobial stewardship in LTC settings. As a result of this collaboration, the consultant pharmacist’s critically important role in the LTC sector is highlighted in the Core Elements for Antibiotic Stewardship in Nursing Homes, which adapts the CDC’s Core Elements of Hospital Antibiotic Stewardship into practical ways to initiate or expand antibiotic stewardship activities in nursing homes. This document lists the consultant pharmacist, medical director and director of nursing as the nursing home’s Antibiotic Stewardship Leaders. With the required implementation of an IPCP as of November 28, 2017, the consultant pharmacist plays a pivotal role in working with the rest of the clinical team in the PAC market to ensure antibiotic use is safe and appropriate. Again, this is another opportunity for pharmacists to take their rightful place as medication management experts on the healthcare team.
In the ever-changing PAC environment, including value-based metrics, quality measures across transitions of care and new CMS guidance on medication reconciliation and med management, the need for interoperability in health information technology (HIT) becomes mandatory.
ASCP is a member of the Pharmacy HIT Collaborative, which is a coalition of nine professional pharmacy associations and additional members representing the pharmacy profession in all matters related to HIT. The Pharmacy HIT Collaborative Value Set Committee published its initial version of Systemized Nomenclature of Medicine: Clinical Terms (SNOMED CT) value sets for pharmacy documentation. These pharmacy value sets are designed to support standardized documentation of pharmacy services across all practice settings, regardless of which electronic system is used to capture data. Any documentation derived from the value sets could be used to exchange clinical information between hospitals, clinics, pharmacies and other care settings or contribute to electronic clinical quality measurement calculations specified in public and private quality payment programs.
Over 25 stakeholders participated in the Pharmacy HIT Collaborative value set development process that generated a consensus on a standardized framework for documenting medication therapy management (MTM) services using SNOMED CT codes. This work was submitted to CMS for use in the Enhanced MTM Model, which lays a foundation for new models of MTM services.
A new, exciting pilot project is bringing to life all of the hard work that the pharmacy profession does to ensure interoperability between pharmacy systems and electronic health record systems. Community Care of North Carolina (CCNC) is facilitating a collaboration of HIT and pharmacy management vendors that aims to enhance the role community-based pharmacists play in providing integrated clinical services to patients. QS/1 is participating in this pilot project and will provide the portal within its pharmacy management systems to allow pharmacists to develop the care plan and then share it with healthcare providers. This additional documentation will allow all involved to see the progress, or any setbacks, in the patient’s health.
As the healthcare system continues to evolve from a fee-for-service to value-based care model, with an increasing focus on PAC, pharmacists will continue to have new opportunities to bring their education and skills to the table, showing their value as important members of the healthcare team.
1 “Nursing Homes Add Goals For Improving Care.” Inside Health Policy 2015 7 May.
2 Saraf AA, Petersen AW, Simmons SF, Schnelle JF, Bell SP, Kripalani S, Myers AP, Mixon AS, Long EA, Jacobsen JM, Vasilevskis EE, J Hosp Med. “Medications associated with geriatric syndromes and their prevalence in older hospitalized adults discharged to skilled nursing facilities.” 2016 Oct;11(10):694-700.