Coming regs expand pharmacist role in LTC


“Basically, everything we know will be gutted over the next three years.”

Payment rules and regulations taking effect over the next three years will significantly change how long-term-care (LTC) facilities operate, Keri Hart, MS, CCC-SLP, CHHRP-QT, RAC-CT, told McKesson’s ideaShare 2016 in Chicago.

Largely aimed at improving quality of life for residents and reducing avoidable complications and hospital readmissions, the rules expand pharmacist responsibilities and create new opportunities for partnering with LTC facilities.

The rules address patient needs in a system treating sicker patients who transition often among hospitals, LTC, and home, and are typically prescribed several medications by several doctors.

“In this complex environment, the role of the pharmacist has evolved beyond merely dispensing prescribed medications to playing a key role within the multidisciplinary team managing patients’ care across the continuum,” said Hart, who is vice president of clinical operations/education and training at Harmony Healthcare International, Topsfield, Mass.

The changes range from integrating quality improvement into LTC operations to specific requirements for medication prescribing, reconciliation and discharge planning. “Basically, everything we know will be gutted over the next three years,” said Hart.

Quality focus

Many of the changes are in proposed LTC conditions of participation in Medicare and Medicaid published last year. The first overhaul since 1991, the proposal drew a record number of comments, so the final probably won’t appear before September. But the major themes are clear, Hart said.


Passive Quality Assurance (PQA) will transform into active Quality Assurance Performance Improvement (QAPI). “Instead of reporting data each quarter you will analyze that data, develop a plan, and a form a team to fix the problem,” Hart said.

For pharmacists, this means identifying root causes of issues like overuse of antibiotics, or drug involvement in patient falls and hospital readmissions, and developing specific performance improvement plans that address them. In addition to staff, residents and family members will help set goals and evaluate progress.

Pharmacy service changes

Responsibility for unnecessary drugs, antipsychotics, medication errors and immunizations now scattered among departments will be consolidated in pharmacy, Hart said. “It’s a lot more pressure on pharmacy services.

For antibiotics, dose, duration, and indication, and use of microbiology testing must be documented. Facility-specific treatment recommendations also must be developed.

Psychotropic drugs are redefined as any drug that affects mental processes and behavior. Dose reduction and behavioral interventions must be tried unless clinically contraindicated, and new psychotropic agents may be prescribed only if medically necessary. PRN orders must be reviewed and rationale documented by a physician within 48 hours, though this might stretch to 72 hours in the final rule, Hart said.

Monitoring for unnecessary drugs will expand beyond antibiotic and psychotropic drugs to include any drug designated by the facility. The goal is reducing drug use of all types, Hart said.


Pharmacists must review resident charts at least every six months, and any time a resident is admitted, re-admitted, or returns after a hospital stay. Monthly reviews of antipsychotic, antibiotic, and any drug designated by the facility are also required. Irregularities must be reported to attending physicians, and facility medical and nursing directors. Drug reviews and reconciliation also are required for discharge plans.

Attending physicians must document any refusal to implement pharmacist recommendations. “If you don’t want to change the meds, you have to take ownership in writing,” Hart said.

Collaboration incentive

Because these rules will be part of Medicare and Medicaid conditions of participation, LTC facilities could lose eligibility if they don’t comply, Hart said. This is a powerful incentive to collaborate with consultant pharmacists.

Pharmacists who are transparent about quality and outcomes, benchmark performance, and can show progress on key measures such as hospital readmission rates will be in demand, Hart said. “Successful QAPI will not be a department, but a way of life in the organization.”

Howard Larkinis a freelance writer based in Oak Park, IL.


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