CARING FOR PATIENTS THROUGHOUT THE CONTINUUM OF CARE: WHAT HAPPENS ONCE RESIDENTS DISCHARGE

BACK INTO THE COMMUNITY? Andria Eker, PharmD, BCACP, CDE

Healthcare reform is reaching the post-acute care (PAC) setting with CMS focusing on op-

portunities to standardize care and quality metrics to allow for reform of current payment models.

Recent reports have estimated that 35.2% of Medicare beneficiaries use PAC services at discharge

from acute care hospitals.1 With Medicare expenditure for PAC reaching $45 Billion in 2008, the

Senate Finance Committee invited PAC stakeholders to provide insight and comments related to the current standards and payment models.1 It became evident that there was a high degree of vari-

ation across PAC settings and that standardizing care and quality metrics would significantly reduce

cost. The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 is the foun-

dation to developing standards for post-acute care. The IMPACT Act requires PAC providers to

report standardized assessment data that will influence development of new payment models while

also protecting beneficiary choice and access to care.2 In response to this Legislation, The American

Healthcare Association (AHCA) has expanded their Quality Initiatives to target 8 goals that fall into

three main categories: Improving Organizational Success, Improving Short-Stay/Post-Acute Care,

and Improving Long-Term/Dementia Care.3 The AHCA goal for improving discharge back to the

community is to increase the rate by 10% or maintain a high rate of 70%. However; in recent years,

PAC providers have identified that newly admitted residents present at a higher acuity and shorter

lengths of stay are becoming more common due to inadequate insurance coverage. This presents a

challenge when paired with potential readmission penalties that could take effect in 2017.

Continued on Page 2

PILL-ANTHROPY POST W I N T E R 2 0 1 6

http://www.healthy.ohio.gov/hdsp/coverdell/Transitions%20of%20Care%20for%20Stroke%20Patients.aspx

P A G E 2

CARING FOR PATIENTS THROUGHOUT THE CONTINUUM OF CARE Continued from Page 1

So, what can skilled nursing facilities do to minimize risk at discharge? They can form part-

nerships with organizations that will coordinate care for patients when they discharge back into the

community. An emerging opportunity for PAC providers is to partner with Accountable Care Or-

ganizations (ACOs), which are providers working together across the continuum of care to meet

quality standards and reduce health care expenditure. ACOs are assessed by 30 quality measures in

four domains of patient experience, care coordination and patient safety, preventive health, and at

risk populations. Through this model of coordinated care, ACOs share in Medicare savings generat-

ed for their attributed patient panel; however, they also share the risk as well, and this is an incen-

tive to ensure optimal coordination of care. Another opportunity would be to partner with com-

munity pharmacies that offer innovative and collaborative programs within the community to im-

prove outcomes and reduce hospitalizations for residents transitioning back into the community.

Blue Ridge Pharmacy is a participating pharmacy within Community Care of North Carolina’s Com-

munity Pharmacy Enhanced Services Network (CPESN), which includes pharmacies throughout the

state of North Carolina offering enhanced services to Medicare and Medicaid beneficiaries. The ser-

vices provided include transitions of care support, medication therapy management (MTM), medica-

tion synchronization, and delivery service. (CPESN). Through this program, we are learning how to

improve outcomes for the highest utilizers within the Medicare and Medicaid system by offering

enhanced services and coordinating care. The health care system’s shift from a fee-for-service to a

pay-for-performance model is a challenge, and if we all collaborate we can be successful.

References:

1. U.S. Department of Health and Human Services. Assistant Secretary for Planning and Evaluation

(ASPE). Examining Post Acute Care Relationships in an Integrated Hospital System Final Report.

Available at: https://aspe.hhs.gov/pdf-report/examining-post-acute-care-relationships-integrated-

hospital-system.

2. House Ways and Means and Senate Finance Committee Staff. The Improving Medicare Post-

Acute Care Transformation Act of 2014. “IMPACT Act of 2014”. Available at: waysandme-ans.house.gov/UploadedFiles/PAC_Summary_FINAL.pdf.

3. The American Health Care Association. The AHCA Quality Initiative. Available at:

www.ahcancal.org/quality_improvement/qualityinitiative/Pages.

P I L L - A N T H R O P Y P O S T

P A G E 3 W I N T E R 2 0 1 6

Visit us at the North Carolina Health Care Facilities

Association Conference, Tuesday, February 23.

We will be rolling out the red, white, and blue carpet for this year's theme,

"The Art of Patriotism". You won't be able to miss us; booth 531 & 632.

MEDICATION SAFETY: TIPS TO AVOID ERRORS

In the January 2016 issue of ISMP’s “Long-Term Care Advise-ERR,” they

recount a story where an opened, used nasal decongestant was almost

administered to another resident. The error was discovered when blood

residue was found on the tip of the bottle.

The cause of the error was due to the safety seal not being removed in its

entirety when the product was initially opened. It appeared that when the

nasal spray was first used, the bottle had been opened by twisting off the

cap, but the tamper resistant seal was left on. It was then restocked in

the medication room by another staff member believing it had never been

used or opened.

Please remember to remove the entire safety seal when any

product is first opened to avoid potential med errors.

Reference:

1. ISMP. Could this happen at your facility? ISMP Long-Term Care Advise ERR 2016;1

(4):3-4. http://www.walmart.com/ip/EQ-Saline-Nasal-Spray-3-

oz/10316877

P A G E 4 W I N T E R 2 0 1 6

Vitamin D, a fat soluble vitamin, plays an im-

portant role in calcium and phosphorus regulation.

This helps ensure adequate levels of these nutrients

to allow proper bone development. Vitamin D is

mainly found in two forms which are relevant for hu-

man use, vitamin D3 (cholecalciferol) and vitamin D2

(ergocalciferol). Vitamin D3 is formed when skin is

exposed to sunlight or from animal sources while vita-

min D2 originates in plants. Both forms are metabo-

lized to 25(OH) vitamin D, thus they can be consid-

ered equivalent in terms of effect.

Populations most at risk of deficiency are breast

fed infants, dark skinned individuals, older adults, and

those with malabsorption diseases. Deficiency is most

often related to inadequate intake. The Recommend-

ed Dietary Allowance (RDA) for vitamin D is 600

units for ages 1-74 and 800 units for those >75 years

old. Vitamin D3 is the recommended form of intake

due to being readily available over the counter in

strengths of 400, 800, 1,000, 2,000, 5,000 and 10,000

units. Vitamin D3 has also been shown to be more

effective in raising 25(OH) vitamin D. Vitamin D2 is

available with prescription as 50,000 units. Due to

the higher dose of vitamin D contained in vitamin D2,

it is often used for those with severe deficiency, as it

allows the patient to take less pills in order to obtain

the needed amount. Vitamin D supplements are rela-

tively inexpensive with a wide safety margin.

Vitamin D has been used to treat rickets (bone

weakness in children), osteomalacia (bone softness

and muscle weakness in adults), and vitamin D defi-

ciency (as indicated by 25(OH) vitamin D levels below

20 ng/mL). Uses which have less robust supporting

data include anemia, cancer, fertility, and issues relat-

ed to aging. Functional decline often accompanies the

aging process. As lower extremity function declines,

individuals are at a greater risk for falls which can ulti-

mately lead to broken bones and loss of independ-

ence.

Due to the wide safety margin, many have recom-

mended higher daily doses of vitamin D. Ultra-high

doses (>50,000 units cholecalciferol daily) however

have been associated with toxic effects including ex-

cess calcium and phosphorus levels. The evidence for

higher doses is not without merit; however, robust

trials supporting this are lacking.

A recent Swiss study has shown that higher levels

of intake may actually lead to an increase in risk of

falls while having no effect on lower extremity func-

tion. Participants were randomized to receive one of

three treatments: (A) 24,000 units of vitamin D3 as a

single dose monthly (corresponds to daily intake of

800 units/day) (B) 60,000 units of vitamin D3 as a sin-

gle dose monthly (corresponds to daily intake of 2000

units/day) (C) 24,000 units vitamin D3 plus 300 mcg

calcifediol once per month. Calcifediol is a potent

metabolite of vitamin D3. When compared with

group A, participants in the two higher dose groups

did not show improvement in lower extremity func-

tion, had the highest percentage of fallers, and had the

most falls.

While the study supports the theory of high vita-

min D doses being potentially harmful, it is important

to note that the study used monthly dosing rather

than daily dosing. Further investigation is needed to

fully understand the optimal dosing strategy that will

reduce fall risk and improve muscle function.

References:

1. Bischoff-Ferrari HA. Monthly High-Dose Vitamin D Treat-

ment for the Prevention of Functional Decline. JAMA Intern

Med. 2016 Jan 4:1-10.

2. Mayo Clinic. http://www.mayoclinic.org/drugs-supplements/

vitamin-d/

3. National Institutes of Health. https://ods.od.nih.gov/ fact-

sheets/VitaminD-HealthProfessional/

Vitamin D and Fall Risk Are higher intakes necessarily better?

Teresa Bradford, PharmD candidate, UNC Eshelman School of Pharmacy

P A G E 5

P I L L - A N T H R O P Y P O S T

PHARMACY FACTS!

ELECTRONIC PRESCRIBING OF CONTROLLED SUBSTANCES

David Phillips, PharmD, BCPS

On June 1, 2010, the DEA began allowing the electronic prescribing of controlled substanc-

es (ECSRx). However, if state requirements were more stringent than the DEA's regulations, the

state requirements superseded any less stringent DEA provision, so many states did not allow

ECSRx initially. Only recently did electronic prescribing of controlled substances become legal in

all 50 states. Although state boards of pharmacy have made progress, there is still a concern that

electronic health record providers are not prepared. Per the DEA, any system for the transmis-

sion or receipt of electronic controlled substance prescriptions must be certified by the DEA or a

DEA-authorized entity as meeting the significant security requirements in the rule.

Blue Ridge Pharmacy utilizes a ECSRx certified system and is now able to accept electroni-

cally prescribed controlled substances (CII-V). Facilities and/or prescribers interested in this sys-

tem are encouraged to contact the pharmacy to learn more about this option. Also, prescribers

are urged to check with their software vendors to determine their systems’ certification status.

What if ECSRx is not an option?

For CII medications that are not electronically prescribed, the pharmacy will typically require a

hard copy prescription to dispense the medication. In order to expedite the delivery of the medi-

cation, the following steps should be followed:

1. Fax a copy of the prescription to the pharmacy at (828) 298-0155

2. Retain the original, hard copy prescription at the facility until the medication is delivered

3. Upon delivery of the medication, the driver will request the original prescription in exchange

for the medication

4. If any issues or questions arise during the above procedures, contact the pharmacy or on-call

pharmacist at (828) 298-7600

Contact Blue Ridge

Pharmacy at

(828) 298-7600 to discuss

e-prescribing and all of your

pharmacy needs!

To Search for Blue Ridge Pharmacy:

NPI: 1043386428

NABP/NCPDP: 3403552

P A G E 6

On September 15th, 2015, the US Food and Drug Administration (FDA) approved a new,

shared risk evaluation and mitigation strategy (REMS) for the atypical antipsychotic medication,

clozapine. This new, shared REMS program merged six previous registries into one. Here is what

you need to know:

What is clozapine? Clozapine is an antipsychotic drug used in the treatment of schizophrenia and recurrent suicidal behavior

in patients with schizophrenia or schizoaffective disorder.

Why does clozapine require a REMS program? REMS programs are required by the FDA for certain prescriptions drugs to ensure that the benefits of the

medication outweigh the risks. Clozapine is associated with severe neutropenia, which can lead to serious

and fatal infections.

What’s new with the “New” REMS? Substantial changes were made to the prescribing information with regard to how to monitor for neutro-

penia and manage clozapine treatment on the basis of the patient's absolute neutrophil count (ANC).

There are now two different monitoring algorithms and increased flexibility for prescribers to continue or

resume treatment in patients. The shared REMS was created to reduce the burden and possible confusion

related to having separate registries for individual clozapine medicines. With the unified or "shared" REMS,

prescribers, pharmacies, and patients are able to enroll in a single shared program that provides access to

all clozapine products regardless of the manufacturer.

Do patients who are currently receiving clozapine have to reregister? Data from the previous six registries were automatically transferred to the new clozapine REMS program;

however, it was been discovered that there were some challenges with migrating all previous patients. To

resolve the issues, it often requires contacting the call center to speak to a representative directly.

When do prescribers and pharmacies have to be registered in order to be compliant? The FDA extended the original November 23, 2015, prescriber certification deadline and the December

14, 2015, pharmacy certification deadline to help ensure that healthcare professionals have sufficient time

to complete the certification process and that patient access to clozapine is maintained. BRP has already

completed registration and is working with prescribers and patients to ensure compliance.

For more information, please visit www.clozapinerems.com

References:

1.https://www.clozapinerems.com/

2.Navigating the New Clozapine REMS. Medscape. Dec 04, 2015. Accessed Feb 02, 2016.

THE “NEW” CLOZAPINE REMS: WHAT YOU NEED TO KNOW

David Phillips, PharmD, BCPS

P I L L - A N T H R O P Y P O S T

P A G E 7 W I N T E R 2 0 1 6

SCOTT HENSON,

PHARMD

GET TO KNOW...

DANA LEAF,

CPHT

Dana joined Blue Ridge Pharmacy Access in

November. She moved here from an inde-

pendent pharmacy in Augusta, Ga. Dana has

been working in pharmacy on and off since

she was a senior in high school. She worked

in pharmacy while she was in college until

she received her BA in Business Administra-

tion in Management. After graduating, Dana

moved to Philadelphia and worked outside

pharmacy for 2 years before returning to the

profession. Dana has knowledge in medical

supplies sales/DME, compounding, long

term care, retail, compliance packaging, and

as a patient assistance advocate. She joined

Blue Ridge Pharmacy to expand her

knowledge as well as her business back-

ground. Dana enjoys exploring new areas

and trying new foods.

“I have no special talent. I am only

passionately curious.”

— Albert Einstein

Scott grew up in the small community of

Lake Toxaway, NC, and graduated from

Pharmacy School at the University of North

Carolina, Chapel Hill. He and his wife, Kris-

ty, have lived in Asheville for twenty years

where they both practice pharmacy. The

majority of Scott’s career-to-date has been

in the retail setting where he developed in-

terest and specialization in compounding.

He joined the Blue Ridge family in Novem-

ber, 2014, and serves as a staff pharmacist as

well as the compounding specialist. His fa-

vorite use of time outside of work is with

Kristy and their two kids, Ashley and Aaron.

Scott also enjoys fly-fishing, hiking, and being

outdoors in the mountains.

“Our greatest fear should not be of failure

but of succeeding at things in life that don't

really matter.”

― Francis Chan

Address: 1070 Tunnel Road | Asheville, NC 28805

175 Towerview Court | Cary, NC 27513

Phone: 828-298-7600 (Asheville)

919-377-0189 (Cary)

Fax: 828-298-0155

Hours: 9am- 6pm Mon-Fri, 9am-1pm Saturday, Closed Sunday

Online: www.blueridgerx.com

Address: 948 Tunnel Road | Asheville, NC 28805

Phone: 828-298-3636

Fax: 828-298-8190

Hours: 9am- 6pm Mon-Fri, 9am-1pm Saturday, Closed Sunday

Online: www.blueridgerx.com

LIKE US ON

Address: 948 Tunnel Road | Asheville, NC 28805

Phone: 828-348-3000

Fax: 828-298-8190

Hours: 9am- 6pm Mon-Fri, 9am-1pm Saturday, Closed Sunday

Online: www.blueridgerx.com

Contact Us!

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