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Care Points
1 S T Q U A R T E R 2 0 1 6
Welcome to Care PointsWelcome to the 1st Quarter 2016 edition of the Care Points Newsletter. This quarter’s newsletter will focus on the following items:
Industry Hot Points:
•Medicare-MedicaidPlans
•PayrollBasedJournal
•FocusonSignificantChanges in the 2015 AGSBeersCriteria
What’s new at Omnicare:
•CVSHealthUpdate:FocusonBack-upPharmacyProcess
•WelcomePackets
Customer Focus Point:
•ePrescribing
•EnhancedAssisted Living Program
Infusion Focus Point:
•SIGMASpectrumSmartPumpUpdates
©2016Omnicare CarePoints|FirstQuarter2016
IndustryHotPoints
> Medicare-Medicaid Plans
TheMedicare-MedicaidPlandemonstrationseekstoimprovethebeneficiaryexperienceof“dualeligibles”(personsthatqualifyforbothMedicareandMedicaid)withanintegratedapproachdesignedtoimprovequalityandcoordinationofcare.OutlinedbelowisanupdateregardingtheRhodeIslandDualDemo:IntegrityProgram.
Opt-In Enrollment
March31,2016(tentative) Firstopt-innoticestoeligible RhodeIslandersmailed
May1andJune1,2016 Effectivedatesoftwowavesof opt-inenrollment
Passive Enrollment
April15,2016(tentative) Firstpassiveenrollmentnoticesmailed
July1–December1,2016 Effectivedatesofpassive enrollment waves
January1,2017 Steadystateenrollment
> Payroll Based Journal
TheAffordableCareActrequiresallnursingfacilitiestoelectronicallysubmitdirectcarestaffinginformation(includingagencyandcontractstaff)toCMSbasedonpayrollandotherdata.Whencombinedwithfacilitycensusinformation,thedatacanthenbeusedtoreportonthelevelofstaffineachnursingfacility,andalsoprovideinformationonemployeeturnoverandtenure,whichcanimpactthequalityofcaredelivered.ThesedatacollectingandreportingrequirementsbecomeeffectiveonJuly1,2016.
Tofulfillthisrequirement,CMShasdevelopedasystemforfacilitiestosubmitstaffingandcensusinformationknownasa“Payroll-BasedJournal”(“PBJ”).ThisreportingmustalsoincludedirectcareprovidedbyConsultantPharmacists.
Omnicarewillbeprovidingcustomerswithoptionsforreceivingthisdata.ItisourgoaltohavetheseoptionsavailablebyJuly1,2016,andmoreinformationwillbeprovidedasthisdateapproaches.PleasecontactyourConsultantPharmacistwithanyquestions.
> Focus on Significant Changes in the 2015 AGS Beers Criteria
Since1991theBeersCriteriahaveprovidedhealthcareprofessionalsingeriatricslistsofpotentiallyinappropriatemedications(PIMs).InOctober2015theAmericanGeriatricsSociety(AGS)publishedthefifthversionoftheCriteria(hereafterreferredtoas“the2015Criteria”),whichupdatestheinformationAGSfirstbegantoprovidein2012.The2015AGSupdateincludesfiveliststhatcomprisethe2015Criteriaaswellasthreeothersupportingdocuments.Theseincludemorethan40potentiallyproblematicmedicationsorclassesof medications.
Lists Comprising 2015 Data
• PotentiallyInappropriateMedication(PIM)Use
• PIMUseDuetoDrug-DiseaseorDrug-SyndromeInteractions
• PIMstoBeUsedWithCaution
• ClinicallyImportantNon-Anti-InfectiveDrug-DrugInteractionsThatShouldBeAvoidedNEW!
• Non-Anti-InfectiveMedicationsThatShouldBeAvoidedorHaveTheirDosageReducedBasedonKidneyFunctionNEW!
Supporting Documents
• How-to-UseGuide
• EvidenceTables(625pages)
• SuggestedAlternativesNEW!
Inadditiontostatingthatthe2015CriteriaareNOTintendedforuseinolderadultsinpalliativeorhospicecare,AGS’underlyingprinciplesforuseofthe2015Criteriaincludethefollowing:
• Medicationsincludedarepotentiallyinappropriate,notdefinitelyinappropriate. (TheyareNOTuniversallyinappropriate)
• Readtherationaleandrecommendationsforeachcriterion —thecaveatsandguidanceareimportant• Understandwhymedicationsareincludedandadjustyourapproachtothesemedicationsaccordingly.• OptimalapplicationinvolvesidentifyingPIMsand,whereappropriate,offersafernonpharmacologicaland
pharamcologicalalternatives• TheCriteriashouldbeastartingpointforacomprehensiveprocessofidentifyingandimprovingmedication
appropriatenessandsafety• AccesstoincludedmedicationsshouldNOTbeexcessivelyrestrictedbypriorauthorizationand/orhealthplan
coveragepolicies
Theremainderofthisarticlewillfocusonthesignificantadditionsand changes within the 2015 Criteria.
©2016Omnicare CarePoints|FirstQuarter2016
IndustryHot Points
AccordingtoAGS,the2015
Criteria “serve as a ‘warning
light’toidentifymedications
thathaveanunfavorable
balanceofbenefitsand
harmsinmanyolderadults,
particularlywhencompared
withpharmacologicaland
nonpharmacologicalalternatives.”
Changes in the 2015 AGS Beers Criteriacontinuedonnextpage.
The 2015 AGS Beers Criteria and other resources are available for FREE at: http://geriatricscareonline.org
IndustryHot Points
©2016Omnicare CarePoints|FirstQuarter2016
Significant Updates
Althoughnotasextensiveasthe2012revisions,the2015Criteriaincludeseveralupdates.Whilesomemaybedeemedminor(e.g.,nolongersayingtoavoidtrimethobenzamide),importantchangesinthePIMlistaresummarizedbelow.
Drug or Category New Update Guidance Why Included?
Nitrofurantoin
•
ChangedguidancetoavoidinCrCl<30mL/mininsteadofavoid<60mL/min;Long-termuseshouldbeavoidedduetopulmonary,liver,andnervetoxicity
Morerecentclinicaltrialsdemonstraterelativesafetyandefficacywithshort-termuseinthosewithurinarytractinfectionsandCrCl≥30mL/min
ClassIa,Ic,IIIAntiarrhythmicsinAFib •
Removed“entireClass”;amiodaroneand dronedarone are now listed individually
Newevidencesuggestsrhythmcontrol can have equal or even favorableoutcomescomparedtorate control
Digoxin
•AvoidasfirstlinetherapyforAFiborHF;Avoiddoses>0.125mg/day(anyindication)
Possibleincreaseinmortality;questionableeffectsonhospitalizations
Non-benzodiazepineHypnotics(e.g.,zolpidem)
•Changed“Avoidchronicuse(>90days)”to“Avoid”regardlessofduration
Evidenceshowsanincreaseinharmwithminimalimprovementinsleeplatencyandduration
Desmopressin • Avoid for treatment of nocturia or nocturnalpolyuria
Highriskofhyponatremia;saferalternativesavailable
ProtonPumpInhibitors(e.g.,omeprazole) •
Avoidroutineusefor>8weeksexceptinhigh-riskpatients(e.g.,NSAIDuse,Barrett’sesophagitis)
RiskofClostridium difficileinfection,boneloss,andfractures
SlidingScaleInsulin
•Clarifieddefinition=“referstosoleuseofshort-orrapid-actinginsulinstomanageoravoidhyperglycemiainabsenceofbasalorlong-actinginsulin”
**Guidance to Avoid use of sliding scale insulin remains**
CrCl=creatinineclearance;AFib=AtrialFibrillation;HF=HeartFailure;NSAID=NonsteroidalAnti-inflammatoryDrug
AfewchangeswerealsomadeinthePIMlistinvolvingspecificdiagnoses.
Disease or Syndrome Drug/Drug Class New Update Description of Change
Delirium Antipsychotics(e.g.,quetiapine) • Avoidunlessnonpharmacologicaloptions(e.g.,behavioralinterventions)havefailedorarenotpossibleANDtheolderadultisthreateningsubstantialharmtoselforothers
Dementiaorcognitiveimpairment
Antipsychotics(e.g.,quetiapine)
•
Dementiaorcognitiveimpairment
Eszopicloneandzaleplon • AvoidduetoriskofadverseCNSeffects
Changes in the 2015 AGS Beers Criteriacontinuedonnextpage.
IndustryHot Points
©2016Omnicare CarePoints|FirstQuarter2016
Disease or Syndrome Drug/Drug Class New Update Description of Change
Constipation Drugsassociatedwithconstipation(e.g.,anticholinergics)
DELETEDConsidered“commonknowledge”andnotspecifictotheelderly
Historyoffallsorfractures
Opioids
•
Maycauseadditionalfallsorimpairpsychomotorfunction.Mayuseforpainmanagementduetorecentfractureorjointreplacement.Ifmustbeused,considerreducinguseofotherCNS-activemedications(e.g.,sedatives,anticonvulsants,antipsychotics,antidepressants)andimplementfallriskreductionstrategies.
UrinaryIncontinence(alltypes)inwomen
Peripheralalpha-1blockers (e.g.,doxazosin) • Combinedfromthe2012categoryfor
“Stressormixedurinaryincontinence”
Clinically Important Drug-Drug Interactions **New**
Oneofthenewadditionsinthe2015Criteriaisalistof13selectdrug-druginteractions(excludinganti-infectivemedication-relatedinteractions).Althoughthislistisnotmeantto“diminishtheclinicalimportanceof[other]known-knowninteractions”,theseinteractionshave“evidenceinolderadults…ofseriousharmif…thedruginteractionisoverlooked”.
Drug A Drug B Interaction Risk Recommendation
ACEInhibitors Amiloride or Triameterne
⬆ riskofhyperkalemia Avoid routine use (unlesstheyhavehypokalemia)
Anticholinergics Anticholinergics ⬆ riskofcognitivedecline Avoidorminimizenumberofagents
Antidepressants
TwoormoreCNS-active drugs
⬆ riskoffalls
AvoidthreeormoreCNS-activedrugs;minimizeuse
Antipsychotics ⬆ riskoffalls
Hypnotics ⬆ riskoffalls
OpioidAnalgesics ⬆ riskoffallsandfractures
Corticosteroids (oralorparenteral)
NSAIDs ⬆ riskofGIbleeding/pepticulcerdisease
Avoid.Ifmustuse,alsouseGIprotection
Lithium ACEInhibitors ⬆ riskoflithiumtoxicity Avoid.Ifuse,monitorlithiumconcentrationLithium LoopDiuretics
PeripheralAlpha-1Blockers
LoopDiuretics ⬆ riskofurinaryincontinenceinolder women
Avoid in older women
Theophylline Cimetidine ⬆ riskoftheophyllinetoxicity Avoid
Warfarin Amiodarone ⬆ riskofbleeding Avoidwhenpossible.Monitorcloselyforbleeding(e.g.,INR)Warfarin NSAIDs ⬆ riskofbleeding
Changes in the 2015 AGS Beers Criteriacontinuedonnextpage.
IndustryHot Points
©2016Omnicare CarePoints|FirstQuarter2016
PIMs Based on Kidney Function **New**
Beyonddruginteractions,the2015Criteriaalsoidentifyaselectgroupofchronicmedicationsthatshouldbeavoidedorhavetheirdosereducedbasedontheindividual’skidneyfunction.SomerecommendationsmaydifferfromtheFDAlabeling.
Drug Category MedicationCrCl
(mL/min)Rationale
Action
Avoid Reduce
Potassium Sparing Diuretics(Amiloride,Spironolactone,Triamterene)
<30 ⬆ potassium±⬇︎ sodium X
Ant
ico
agu
lant
s
Apixaban < 25 ⬆ riskofbleeding X
Dabigatran <30 ⬆ riskofbleeding X
Edoxaban
30-50 ⬆ riskofbleeding X
<30or>95 ⬆ riskofbleeding(<30);⬆ riskofstroke(>95)
X
Enoxaparin <30 ⬆ riskofbleeding X
Fondaparinux <30 ⬆ riskofbleeding X
Rivaroxaban30-50 ⬆ riskofbleeding X
<30 X
CNS Analgesics
Duloxetine <30 ⬆ riskofGIsideeffects X
Gabapentin < 60 CNSadverseeffects X
Levetiracetam ≤80 CNSadverseeffects X
Pregabalin < 60 CNSadverseeffects X
Tramadol <30 CNSadverseeffects X(ER) X(IR)
H2 Antagonists(Cimetidine,Famotidine,Nizatidine,Ranitidine)
< 50 Mentalstatuschanges X
GoutMeds
Colchicine<30 GI,neuromuscular,and
bonemarrowtoxicitiesX
Probenecid <30 Loss of effectiveness X
Applying the 2015 AGS Beers Criteria Update
AGSprovidesvarioussuggestionsforapplyingthe2015Criteria:
• Avoidabruptstoppingofmedications.UsetheCriteriaasa“warninglight”forclosereviewandmonitoring.• Closelyassessforpotentialadverseeffects(manymaybesubtleyetimportant).• UsetheCriteriaasastartingpoint“intoalargerreviewanddiscussionofmedicationprescribingquality.”• Addressingthemanagementofthesemedicationsshouldbeinterdisciplinary(e.g.,prescribers,nurses,pharmacists).• TheCriteria“arereasonabletouseforperformancemeasurementacrosslargegroupsofpatientsandprovidersbutshould
notbeusedtojudgecareforanyindividual.”• TheCriteriashouldnotdistractcliniciansfromattendingtootherimportantaspectsofpharmaceuticalcareinolderadults.• Throughoutthecareprocess,alwaysdeterminewhythepatientistakingthedrug,ifitistrulyneeded,andwhethersaferor
more-effectivealternativesareavailable.
Ashealthcareprovidersbecomeincreasinglyfamiliarwiththe2015Criteria,theAGS’goal“tosupport,ratherthansupplant,goodclinicaljudgment”canbeaccomplished.
©2016Omnicare CarePoints|FirstQuarter2016
What’s New at Omnicare
> CVS Update: Focus on Back-up Pharmacy Process
NowaspartofCVSHealth,wehaverapidlyembracedourroleasapharmacyinnovationcompanyandremaincommittedtoreinventingpharmacyforthebenefitofourcustomers.AswebecomemoreintegratedwithinCVSHealth,youwillseemanyexcitingnewaswellasenhancedservicesandsolutions.
ThefirstnewdevelopmentwewouldliketosharewithyouisourbackuppharmacyprograminwhichweutilizetheCVS/pharmacyretailfootprinttoextendournetwork.
WebegantestinganewprocessinDecemberinwhichCVS/pharmacieswereusedasourbackuppharmacyinColumbus,Ohio,andtheresultshavebeenfantastic.
WeweresuccessfulduringthetestbecausewewereabletoinstillaseamlessprocessatOmnicareandCVS/pharmacy,somethingwecouldnotdobeforebecomingpartofthelargerenterpriseofCVSHealth.Wehavebeguntolaunchthisinitiativeinselectmarkets,andweexpecttohaveitimplementedacrossthemajorityofournetworkinlessthantwomonths.Andwiththe10,000CVS/pharmacylocations,weexpecttodeploythisprocessforthemajorityofourbackuppharmacyneeds.Weareintheprocessofdevelopinganameforthisgreatnewprogram.Staytuned!
WehaveanumberofnewinitiativesindevelopmentthatutilizethemanycapabilitiesofCVSHealthtobringnewpatientcaresolutionstoourcustomers.WelookforwardtosharingmoreoftheseserviceswithyouinfutureeditionsofCarePoints!
> Welcome Packets
AnelectronicversionoftheupdatedResident Admission Welcome PacketthatisavailableonOmniviewaswellasMyOmniview.
Theupdatedversioncontainstimelyresidenttopicsincludingbutnotlimitedto:
• OmniPlanFinder• MedicarePartD• PharmacyStatementInformation• Online and Over the Phone
PaymentOptions
Path for Omniview Access:ReferenceLibrary>PharmacyBillingGuidelines>OmnicareToolsforFacilities>WelcomePacketforNewResident
Ofnote,whenresidentsregisterforMyOmniview,theyreceiveanelectronicversionofthewelcomepacketintheirinbox.
©2016Omnicare CarePoints|FirstQuarter2016
> ePrescribing
Committedtechnologyofferingsresultingreateraccuracy,speedandconsistencyofservice.Thisleadstoimprovedpatientcare,increasedefficienciesandreducedcost.
Earlylastyear,OmnicarebeganreceivingElectronicPrescribingofControlledSubstances(EPCS)viaSurescripts.Surescriptsisthenation’slargestePrescriptionnetwork.ThisallowsanyprescribertoaccessanypharmacyconnectedwithinthisnetworkusingtheirofficesoftwarepackagesviatheSurescriptstransmissiongateway.Prescribersusingthisoptionincludephysicians,specialists,nursepractitionersandphysicianassistantswhohavecommunityofficepracticesandcontinuetocarefornursinghomeandassistedlivingpatients.
Omnicareiscommittedtosupportingtechnologyastheindustryadvancestoamoreelectronicprocess.
> Enhanced Assisted Living Offering
CustomerFocusPoint
> SIGMA Spectrum Smart Pump Updates
©2016Omnicare CarePoints|FirstQuarter2016
InfusionFocusPoint
Omnicare’scommitmenttobringinnovativeandbestinclasstechnologytoourcustomers,directedourdecisiontobeginthenationwideconversionofourfleetofBaxter6201Flo-GardinfusionpumpstoSIGMASpectrumSmartPumpTechnologyin2012.DuringthepastthreeyearswehaveexperiencedunforeseendelayscausedbypumpavailabilityfromthemanufacturerandstringentFDArequirementsformedicalequipment.
WebelievetheSigmaSpectrumisthebesttechnologyavailabletomeettheneedsofourcustomerswhoareadmittinghigheracuitypatentsasaresultoftheeverchanginghealthcareenvironment.TheSIGMASpectrumInfusionSystemDoseErrorReductionSoftware(DERS)canhelpreducepumpprogrammingerrorsandadversedrugeventsby:
• StartingdoseratesandconcentrationscustomizedspecificallyforOmnicarecustomerswiththeOmnicareMasterDrugLibrary(MDL)
• HardandsoftdrugdosinglimitsestablishedbyOmnicarePharmacists and Clinicians
• CheckFlowatStartoftheinfusionhelpsensuretherearenoclosedclampsorkinksintubingthatmaypreventtheflowofcriticalmedications
• SecondaryInfusionContainerCheckpromptsthecliniciantoverifymedicationflowfromthesecondarycontainerandnottheprimarycontainer
OurgoalistocontinuemovingforwardwiththeSigmaSpectrumconversioninawell-plannedprocessoverthenext24months,withatargetcompletiondateofDecember,2017.Belowisamaprepresentingthecurrentconversionplan.
Current Conversion Plan
SIGMA SpectrumInfusion System
Pink:Conversioncompleted
Purple: Planned for 2016
Blue:Plannedfor2017
Managing Pump Returns to Omnicare
Omnicaremanagesafleetofover15,000infusionpumpsnationwide.OurpumpfleetrepresentsanextremelyvaluableassettoOmnicareandanimportantresourceforourcustomers.Weemploytheuseofanelectronicassettrackingandpumpmanagementsystemthatallowsustotrack:usage,location,maintenance,identification,andqualitychecksbetweeneachpatientuse.TheinfusionpumpisthepropertyofyourOmnicarePharmacy.Pleasereturnthepumptothepharmacywhenthetherapyisdiscontinuedorwhenthepatientistransferred/discharged.
Pumps must be returned to the pharmacy between each patient for terminal cleaning, disinfection and testing per manufacturer’s recommendations and FDA regulation.
Omnicarecourierservicedriversareroutinelyatyourfacilityandwillpickuppumpswhenpickingupmedicationsforreturn.Intheeventofloss,assesseddamageordestructionoftheequipment;thelongtermcarefacilitymaybechargedthereplacementcostoftheinfusionpump.
OmnicareInfusionServicesstrivetoprovideyouwiththebestserviceandstateoftheartequipmenttosafelymanageyourpatient’sinfusionneeds.
EditorialBoard
BethCoryea,PharmD-SeniorEditorSeniorDirector,AccountManagement
BarbaraConnolly,MS,RPhSeniorDirector,ClinicalServices
KathleenEarly,RPhSeniorDirector,Operations
JeffWoodside,RPhSeniorDirector,AccountManagement
Contributing Authors for this Issue:
CoreyBishop,RN,CRRN,CRNINationalDirectorofInfusionNursing
MelanieKincerProductManager,OmnicareDigital
PatrickLeeVicePresident,LTCProduct&BusinessDevelopment
AllenL.Lefkovitz,PharmD,CGP,FASCPDirector-ClinicalPharmacyEducationandDrugData,Omnicare,Inc.
TerryO’Shea,BSPharm,PharmD,CGPSeniorDirector,ConsultantPerformance
ColinUphamSeniorDirector,PayerRelations
HollyVenezianoSeniorManager,BillingDepartment
JimVett,SeniorDirectorALMarketingandCommunication
InfusionFocusPoint
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