Catering to the golden oldies

The aging of the population has given rise to a new breed of pharmacists, the geriatric specialists. Although pharmacists have served geriatric patients in nursing homes for decades, today's geriatric specialists are pushing the boundaries, moving beyond nursing home practices to include patients residing in assisted living facilities as well as those living in their own homes. Bolstered by organizations such as the American Society of Consultant Pharmacists (ASCP), a small but increasing number of geriatric specialists are "hanging out their shingles" as independent practitioners.

Lori Daiello, Pharm.D., BCPP, president of Pharmacotherapy Solutions, Orlando, Fla., is one of the pioneers in the field. Long interested in psychiatry, Daiello concentrated her Pharm.D. electives in that area, emerging from the Ohio State University program with what she terms "a mini-residency" in geriatric psychiatry. After working for a long-term care provider for more than a decade, she started her own independent consulting business eight years ago. She noted that while there are only four million people in nursing homes, there are many more seniors in other types of settings. "There are not enough of us out there to provide what they need, she added.

Lisa Hettick, Pharm.D., CGP, emerged from a background in a skilled nursing home practice to start an independent community and assisted living practice in Cloverdale, Ind., just last year. Hettick chose her Growing Well practice setting because "I've seen a lot of [nursing home] admissions that could have been prevented or at least postponed had we managed the patient's medications at the home level-before they had their fall, before they had their myocardial infarction."

ASCP has been important in helping all three of these independent practitioners conceptualize and even market their practices. Daiello, Hettick, and Smith are all listed as senior care pharmacists on the Senior Care Pharmacists Web site, http://www.seniorcarepharmacist.com/. This Web site is sponsored by ASCP and its research and education foundation. However, the pharmacists' individual practices vary considerably, exemplifying the diversity of independent geriatric practitioners.

How they operate

In her practice, Daiello utilizes her background in psychiatry, focusing on seniors who are experiencing changes leading to behavioral and cognitive disturbances. Some of the changes have resulted from medication adverse effects, others from treatment-resistant psychiatric problems. Hettick deals with the gamut of geriatric problems, including medication management for chronic diseases such as diabetes and hypertension as well as risk assessment. Smith's practice includes not only geriatric patients but also consulting for an employer in her area. Smith does not find this incongruous. "When I am working with younger individuals, I'm also dealing with similar conditions that I deal with in the elderly, but they're at earlier stages."

Daiello's clients come to her by referral. "I am probably getting my referrals evenly split between physician direct referral, families who self-refer because they are concerned about a loved one, or social workers and nurses who are employed by nursing homes and assisted living facilities." Daiello sees her clients in all settings, sometimes heading off to a nursing home in the evening to check what is happening behind the scenes.

Hettick's clients come by referral, and sometimes as a move-in incentive from an assisted living facility. In working with assisted living clients, her services prove useful in helping patients become stabilized. "They've already had a decline and had to move into assisted living. We don't want them to have to take that next step [into a nursing home]. We want them to be able to age in place, so the assisted living facility brings me in as part of the group to help them stop their decline." Hettick often travels to clients' homes for an initial interview to better understand their medication problems.

Smith's clients come to her in a variety of ways. She commented, "In my community I do talks for federal retired employees and other groups along those lines. I do try to get information in the local paper about what I'm doing." Smith sees most of her clients in her office or consults by phone.

In general, Daiello, Hettick, and Smith have had a positive response to their services from the physicians in their communities. Daiello stated, "I have very little problem dealing with physicians. The way I set up my practice, I don't see patients without a physician referral. I started doing this early on because I wanted to be seen as a colleague of these physicians-not that they have to agree with me 100% of the time but that they feel they have a role in ordering the consult. By including them, I find they are much more likely to follow my suggestions."

Hettick approaches physicians as she did in nursing home practice. "In community practice, they probably never had a pharmacist write them a letter and say, 'I think this is the way you should be prescribing.' In the nursing homes we do that hundreds of times in each facility." In her community practice, she reminds physicians that she is not practicing medicine. She tells them, "I am practicing pharmacy, and as the drug expert and the geriatric expert in drugs, I have some information for you."

How they are paid

One thing Daiello, Hettick, and Smith have in common is that their services are all privately paid. At present, insurance coverage is simply not available for the types of services they provide. Although some pharmacists hold out hope for some cognitive service coverage under the new Medicare legislation, Smith is not optimistic. Daiello's fees are paid by her patients, the facilities, or individual families. She also does some indigent care via referrals from the Alzheimer's Association. Hettick markets her services as a yearly membership rather than a fee for service, so people won't be afraid to call her and keep ringing her when they need assistance. "I have an annual contract. Basically I am paid the annual membership at the front end. I do create a gift certificate or break it up into payments if people can't pay me at once. Usually it's not the seniors paying. Usually it's the sons and daughters who are trying to manage this on their own." Smith charges an hourly fee for her services. Services such as Smith's usually command $60 to $110 per hour.

Although Daiello, Hettick, and Smith entered independent consulting after years of experience as long-term care consultants, geriatric expertise can also be gained through geriatric electives or residencies, and some practitioners have chosen that route as a starting point.

Among her responsibilities, Myra Belgeri, Pharm.D., CGP, BCPS, FASCP, assistant professor of pharmacy practice, St. Louis College of Pharmacy, GRECC, Jefferson Barracks VA, St. Louis, covers geriatric issues in her courses and is also the program director for a geriatric residency. Belgeri considers the biggest problem in geriatrics-aside from the altered pharmacodynamics and pharmacokinetics-to be polypharmacy. "I like to call it polyprescribing, though," she stated. To Belgeri it is not the number of medications a patient is taking, but rather "using drugs inappropriately either for something the patient doesn't have and for which there is no indication, or using totally inappropriate drugs in elderly patients." Belgeri teaches pharmacists to assess geriatric therapy according to function and quality of life and select medications accordingly, rather than treating patients based on standardized guidelines. She noted that one of the challenges of using drugs in the geriatric population is the paucity of studies in the older populations.

In addition to geriatric residencies, there is also certification. ASCP efforts to substantiate competency have led to the establishment of an independent credentialing organization, the Commission for Certification in Geriatric Pharmacy, which offers the Certified Geriatric Pharmacist (CGP) designation. A commission spokesman said that over a thousand pharmacists have obtained this title since the certification began in 1997, adding that many are preparing for the exam, given the changes in the Medicare legislation.

The changing demographics of the American population suggest an increasing need for geriatric specialists. The pharmacists interviewed have found geriatric practice very rewarding and are optimistic about the future. Hettick noted, "There are plenty of seniors out there for all of us. It's not a competitive market."