by Will Lockwood

The long-term care market has a lot to offer pharmacies willing to invest in the tools and processes needed to compete. If you are looking to serve LTC facilities as an addition to your retail business, then some of these tools may already be in place in the form of an LTC module in the pharmacy management system or automated and robotic dispensing in use for retail operations. And if you decide to ramp up an existing LTC business, then you may want to look to systems designed specifically for the demands you’ll face. The good news is that, whether you are just getting in or you are looking to get better, there are plenty of solutions available to help you.

The Right Mix

Pharmacist Brian Beach is VP and co-owner of Kelley-Ross and Associates in Seattle, Wash., and has primary responsibility for running the LTC operations. Kelley-Ross, a long-time presence in Seattle pharmacy, currently operates five stores, including three small apothecary-style stores, one contract-only mail-service pharmacy, and a closed-door LTC pharmacy that has been open for just over a year. “We had been doing LTC in smaller portions for about 35 years,” Beach explains, “but we’ve been growing steadily, and felt that opening a dedicated store would increase our service levels.” At this point, Kelley-Ross is serving more than 40 facilities, as well as a group of independent residents that have homecare nurses but require medication compliance administration help, for about 1,800 patients total. “This has grown from under 500 before we decided to really focus on the segment,” says Beach.

This brings up the first major decision you may face: Do you go for a mix of retail and LTC, or go with LTC only? Beach points out that there are advantages to the mix if you are starting out. But there are also good reasons to open a separate operation. “You can really focus employees on serving LTC and really streamline your process,” says Beach.

The Right Tools

One way to get the right process is to make sure you are using the right tools. Phillips Healthmart Pharmacies in Mauston, Wisc., is a pharmacy growing through LTC while continuing to offer a full array of other services, including HME, mastectomy fittings, IV services with two registered nurses on staff, compounding, chemotherapy, and even gifts. At a certain point, Phillips Pharmacies moved to a specialized LTC system to help handle this growth. According to Craig Arisman, IT administrator and billing manager, Phillips Pharmacies began using the RNA Helix pharmacy system to manage LTC, IV, and compounding about 16 months ago. “Before that we’d been using a system geared more toward retail,” explains Arisman. This change has brought a number of positive results. One that Arisman cites is billing capabilities better suited to LTC demands, including keeping track of admits and discharges and different sorts of stays, such as when a resident splits a stay between Medicare and private pay. “We need the right billing tools in order to know that we are going to get paid,” says Arisman. “Billing is getting to be a bigger part of things. We’re also seeing more and more drugs that require prior authorization.”

Billing requirements were on pharmacist Patrick O’Donnell’s mind when he went shopping for a system to handle the booming LTC component of his business at Lincoln Pharmacy in Tacoma, Wash., which grew from 400 to 1,800 beds in three years. In this case the system had to be nimble enough to handle the split billing for Washington State. “I was also looking at workflow features and signature capture. I wanted to be able to find a script right away,” O’Donnell says. “Long-term care was growing so fast.” On top of all this, after a few audits that cost more time than money, he didn’t want to get bogged down in manually searching signature logs. He wanted to go paperless. O’Donnell eventually chose SuiteRx, which offers a built-in fax server. With better billing, workflow, and document management, O’Donnell now has time to visit homes and talk about the services he offers.

Pharmacist Eric Donley offers these thoughts on a few of the features that he considers highlights in the QS/1 Primecare LTC system he uses at Alert Pharmacy in Mount Holly Springs, Pa. Alert is a closed-door pharmacy 30 miles north of the rolling battlefields of Gettysburg and serves about 3,000 patients. “Each technology plays a specific part in the filling of each script and creating a smooth workflow,” says Donley. One important feature, according to him, is the fill list, which adds another level of control in the workflow by eliminating the need for facilities to fax a sheet of pull stickers to the pharmacy to order refills. “With the fill list our system tracks when a refill is needed automatically, whether it’s a two-week or a four-week cycle,” explains Donley. “Once the facility is on the fill list, this helps us manage our workflow by setting up the fill for a specific day.” There’s also an important feature for helping schedule the weekly activities required for smooth LTC operations. Here, QS/1 lets Donley manage customized reports and forms that run on specific days of the week. “I have set up and saved the details for each day’s Mediset cards,” Donley explains. That means that instead of having to set the options manually every time for each day’s cards, all Donley has to do is choose the day’s customized report. “You have to ask yourself what technology is available to make day-to-day operations organized and streamlined,” Donley explains. “The accountability starts at the pharmacy. That’s our goal.”

Flexible and Responsive

A good LTC pharmacy is not only organized and streamlined, it is also flexible and customer focused, according to Patrick O’Donnell. “If the home says they need something, you want to say yes,” he says. “If they want a special MAR or want a different label, I can give it to them.”

Craig Arisman offers an excellent example of how this flexibility comes into play with medical records. “We print most of the medical records and physician orders for facilities, and we have to be able to generate these in a facility-specific format,” says Arisman. “For instance, we have a new facility we’re serving that wants the physician’s order to look more like a medical record chart.” Arisman also notes that many facilities ask for color-coded MARs, such as blue for routine, red for diabetic, purple for behavioral, and green for treatments. “Some facilities like this and want certain meds on separate medical records charts,” he says. “Others want everything together. We want to give each facility what it needs.”

This flexibility comes into play in other ways. Consider Advanced Pharmacy, for instance. Since opening in 2002, this pharmacy has grown to three locations — one each in Houston, Texas; Columbia, Md.; and Lake Mary, Fla. — offering LTC service to over 36 facilities. “For the most part, facilities are really just beginning to create an electronic medical records atmosphere,” says Mary Ann Miller, senior VP of sales and marketing. “We need a very open platform that accepts orders from just about any facility’s medical records system.” For example, all the facilities that Advanced Pharmacy works with in Texas have different medical records systems. Yet according to Miller, there is still great two-way communication between these systems and Advanced Pharmacy’s FrameworkLTC pharmacy software from SoftWriters. “We can also handle facilities still on paper med records,” she adds.

Communication

Connecting with the facilities you serve is clearly a top priority in long-term care pharmacy, and there’s a specific set of players that need to be in the loop. Brian Beach calls this “the triad of care”: patient/caregiver, pharmacy, and doctor. “A lot of times, an order comes from the doctor and has to go to both the facility and the pharmacy,” he says. “Occasionally, it will go one way or the other and not to both. You can end up out of the loop.” This means there’s a need to be able to search for and verify orders quickly  — something that’s hard to do when you are sorting through paper. SuiteRx is the pharmacy system at Kelley-Ross as well, and the staff there takes full advantage of the built-in fax server’s ability to support this communications triangle by automatically digitizing and storing documents. “When we need to verify orders, this can be one huge timesaver,” says Beach. “We’ve also created a preformatted prior-authorization form that links to fields in the pharmacy database, which is a really clean method for getting these critical requests out both quickly and accurately.”

It’s worthwhile to put into context just how important the fax has traditionally been in LTC pharmacy. Mike Welsch, who owns Millers Pharmacy in West Henrietta, N.Y., says he receives about 10,000 faxes a month. This is at a pharmacy that serves seven clients right now, representing about 1,200 residents. Craig Arisman corroborates this volume, noting that Phillips Pharmacies receives hundreds and sometimes thousands of faxes in a day. Both pharmacies have taken steps to manage these loads, with Millers Pharmacy making heavy use of a fax server and Phillips Pharmacies employing an Internet fax service that means there’s never a busy signal — essentially an outsourced fax server.

Considering the sheer volume of paper that can come the way of a pharmacy serving LTC, it is no wonder that pharmacies are working hard to install systems to handle the issue. Wilson Pharmacy, located in Johnson City, Tenn., has done just this for its LTC operation that serves about 3,000 beds. This is in addition to operating three retail locations, as well as home infusion, compounding, and PBM businesses. According to Wilson Pharmacy IT project manager Jason Guinn, the Integra DocuTrack system in use allows the staff to archive every single inbound and outbound communication and associate them with the electronic prescription record in the pharmacy system. “This means that orders, clarifications, insurance information, census data, and delivery manifests can be retrieved in literally seconds — even if the document was received years ago,” says Guinn. He points to two other important features of this system. The first is an automatic fax-back feature that returns a fax containing thumbnail images of received documents to the original sender as confirmation of receipt. The second is dynamic barcode routing technology that allows documents to be automatically associated with the original document and routed appropriately, even to multiple departments.

Yet another important communications tool available to LTC pharmacy is the secured Web interface. For example, SoftWriters’ FacilityLink, the version of this tool that Wilson Pharmacy is running, provides on-demand printing of medical records, allows facility staff to update orders on the fly and immediately generate an up-to-date medical record, and reduces transcribing errors by allowing authorized users at the facility to communicate drug orders using electronic messaging. “One of the best features is the instant and immediate access to an up-to-date medical record,” says Guinn. Some physicians and facilities even prefer to use the portal to send new orders and new admissions rather than faxing all the paperwork, notes Guinn. Of course, facilities still use fax machines, and this is where the document management system and the Web portal work in concert. “Floor nurses and off-site physicians, such as emergency room doctors, tend to use the fax because it is quick and convenient from their perspective,” says Guinn. “Higher levels of facility administration are more likely to use the Web. We’re going to need this combination for the foreseeable future.” Whether using the Web portal or sending a fax that enters the document management system, doctors, facilities, and the pharmacy are all sure to be in the loop. And all the communication is electronically connected to patient records, as well. The barcode-authenticated steps in the workflow process are also available to the facility staff through the Web interface. “Facilities no longer have to call the pharmacy to determine the status of an order,” Guinn explains. “They can simply log into their Web portal and see the status at any point in time.” While Wilson Pharmacy is still in the process of migrating customers to the new software, Guinn says that there’s been a tremendously positive response.

Communication tools are also paramount at Advanced Pharmacy. Here they have deployed what Mary Ann Miller calls a fully integrated system for medication packaging, reporting, inventory and delivery control, and facility support. The key nodes in this system are its proprietary automated remote dispensing system, PassPort; its reporting system, MedManager; and its 24-hour support center, OnCall. “With our technology we can track and predict, among other things, medication use trends, physician prescribing patterns, and formulary compliance,” says Miller. “There are many reports that the nursing facility can print off live from MedManager, which gives them valuable data on the prescribing habits of doctors, the medications used by patients, and reports by drug class, such as for pain meds.” And the pharmacy’s FrameworkLTC system integrates with OnCall to allow monitoring and data management for immediate response to nurse’s questions.

Increasing Efficiency

Once the orders and other communications have been taken care of, it frequently becomes the job of automated dispensing and robotics to streamline the labor-intensive tasks of dispensing and packaging prescriptions. For example, pharmacist Larry Cowan’s Glenview Professional Pharmacy in Fort Worth, Texas, has seen major gains in efficiency at his closed-door LTC pharmacy while processing 1,000 prescriptions for more then 40 facilities across the Dallas/Fort Worth metropolitan area. These gains have come from installing three SmartCabinets from Innovation early in 2008. “The majority of prescriptions must be unit dose in blister or bubble packs,” Cowan explains. Before automation, he depended on technicians to work from the stock bottles to fill these bubble packs. Now, as Cowan describes it, he can load up 150 drugs into the cabinets, drive the counting from the prescriptions entered into his Rx30 pharmacy management system, use the bar codes on the labels generated to release the counted prescriptions into vials, and then fill the bubble pack from these. “One of my major costs is the technician labor for packaging medications,” he says. “Anything to make this process more efficient is good.” In addition to increased labor efficiency, Cowan has also gained better control over his inventory. “Before, I might have had two dozen open bottles of a drug floating around the pharmacy,” he explains. Centralizing the majority of LTC inventory in the SmartCabinets saves technicians footsteps, since they no longer have to locate a stock bottle and then return it to the shelf after counting. The barcode-driven replenishing and accuracy of counting also help Cowan reduce the risk of controlled-substance diversion by providing a detailed and reliable record of events.

Eric Donley has seen significant improvements from a recent counting technology upgrade at Alert Pharmacy as well, in this case to Parata Mini. “For all the people who aren’t on bubble cards, we fill a weekly Mediset planner,” says Donley. “We scan the prescription label and Mini counts out a 30-day supply into a vial that we then use to fill the Mediset.” Much like at Glenview Professional Pharmacy, Donley’s staff used to do all this work by hand. “This is a pretty efficient way to do these fills,” he says.

Millers Pharmacy’s Mike Welsch is having a great deal of success with SP 200 robotics from ScriptPro. “We are told that we have the most customized SP robot out there,” he says. For example, Welsch’s robot had to be able to run peel-tab labels, which he provides so that facilities can quickly and easily apply them to refill order sheets. “We were using these labels before we got our robot,” says Welsch. “So this had to continue to work.” For another example, Welsch has tailored the slots in the robot’s collating control center so that there are two for retail prescriptions, two for LTC, and two dedicated to a particular high-volume LTC account. But he hasn’t stopped here. Welsch is getting even more functionality from the robot by having it programmed with logic to handle prepacks, which are pre-made, standard, high-volume punch cards that Welsch keeps in inventory. “We do this for about 75 drugs,” he says. “Not all facilities can use these. A few use retail bottles. Another uses a unit-dose system. One facility will only take a 30-count card, as opposed to the 60/90 that’s standard.” So the robot has to be able to understand if a prescription is retail or LTC and, if it is LTC, whether it is a prepack, punch card, or vial. “We’ve worked with ScriptPro to program in a variety of indicators that let the SP 200 analyze each prescription and figure these things out,” says Welsch. There’s more. According to Welsch, New York State has certain rules specific to punch cards — for example, requiring a lot number and an expiration date that fits certain parameters. The SP 200 has to know to put the appropriate information on LTC labels, but not on retail labels. “We have three different label templates built in,” says Welsch.

Advanced Pharmacy’s Mary Ann Miller is a firm believer in dispensing technology’s ability to improve operations. Even more than this, though, she holds firmly the view that automation is ultimately one key component in a process that enhances patient care, improves financial performance, and supports regulatory compliance.

Looked at from the facility’s standpoint, Miller notes that Advanced Pharmacy’s PassPort automation ensures immediate medication availability. “Nursing homes have changed dramatically over the years,” she explains. “Residents are more frail and have more immediate needs than in the past. It is our goal to make sure that facilities have the drugs on hand when the resident needs them.” The technology automatically packages each patient’s medications in an individual envelope, properly labeled, for a specific med pass for ease of administration by the nurse. There is also a medication report provided that matches what’s in the med pass tote exactly, including a color image of each drug. All this is organized in room number order.

This dispensing process, when combined with the integrated communications that Advanced Pharmacy provides facilities, also has an impact on financial performance, according to Miller. “Because it is real-time and because it is only packaging one med pass ahead, the payer is only paying for doses used,” she says. This helps facilities avoid the process of documenting, returning, and reconciling medications that aren’t administered for one reason or another, such as discharges, deaths, or discontinued drug orders. A nurse simply pulls up a patient’s record in PassPort, cancels the order, documents the reason for the return, and places the envelope in the return bin that is part of the machine. “That’s huge savings for facilities,” explains Miller, “since we still get our dispensing fee on returns. There are even some states where you can’t return.” There’s also a tight formulary control process with each facility to make sure PassPort is stocked with clinically and price-appropriate medications.

Delivery

Of course, even the most highly organized pharmacies with efficient processes and tight communication links need to pay attention to that physical link to the facilities: delivery. Mike Welsch, in his quest for the best controls over process and procedure at Millers Pharmacy, has brought what he calls a fair amount of in-house proprietary programming to bear on this task. “To give you an idea of how complex delivery can be,” says Welsch, “we have one group home contract that requires delivery to 32 different locations.” Welsch’s answer has been to create a customized delivery program that is barcode driven. This allows his staff to identify every item set for delivery by patient name and location.

The delivery program also takes advantage of Microsoft’s Access database, to which the pharmacy management system exports be- tween 60 and 75 pieces of information about each prescription. “We used to get killed with people

saying we didn’t get this,” explains Welsch. “Our system allows us to quickly look up the delivery information by querying the Access database rather than looking at paper delivery logs.” Millers Pharmacy’s staff has access to filled date, out-for-delivery date, and which delivery run during the day a medication went out on. “We’re working on integrating e-signature into this,” adds Welsch. “But we can still pinpoint the paper delivery manifest we need much faster now.”

What’s Next?

With all this technology already in play in LTC pharmacy, is there anything on the radar? In fact, there are at least a few things. Electronic medication administration records (eMARs) are one hot topic. Craig Arisman says that Phillips Pharmacies is looking to expand on the service level offered by its facility-tailored MARs by going with AccuFlow’s eMAR. “We would get better communication with the facilities,” says Arisman. “An eMAR lets facilities enter their own orders, the medical record reads exactly how they want, and they’ll be able to reproduce these at any time without having to call or contact us.”

Brian Beach at Kelley-Ross also wants facilities to have real-time access to information in the pharmacy system. “We’re looking at a tool that will give facilities the ability to document doses administered in real time, generate minimum data sets, and print MARs on demand,” he says. Beach also sees this tool streamlining the refill process to prevent faxing and phone calls. “It is much better to use a quick electronic communication that’s routed automatically in the system, instead of getting on the phone,” he says.

Eric Donley knows a little bit about what eMARs can do, since he has actually implemented them at eight of the facilities that Alert Pharmacy serves. “They give us the ability to provide a product to nursing homes that improves patient safety,” explains Donley. This is how it works. The nurse making the med pass scans the barcode label on the packaging provided by Alert Pharmacy. This verifies that the medication is the correct one for that patient at that time. “The eMAR application travels with the nurse on the med cart and stays connected with a wireless router. Facilities are really enjoying the access to up-to-date information.”

Returning to the topic of delivery, Jason Guinn says that Wilson Pharmacy is looking into a commercially available solution, Integra’s DeliveryTrack. “Our delivery agents serve retail and home infusion customers on the same routes as our LTC customers,” says Guinn. “So we need a solution that interfaces with all of our information system packages and provides a consolidated route management and tracking system for all of our lines of business.” Guinn anticipates that delivery technology will make information available in the pharmacy management systems much faster — within minutes rather than overnight. “Improving delivery is an ideal application for technology,” he says. “We’re looking for the right tool to manage what is a very complex part of our business.”

A Dynamic Opportunity

What’s clear is that long-term care offers a lot of opportunity for pharmacists motivated to invest in the high levels of service that win facilities over. “In long-term care, you are competing on service, even more so than in retail,” says Larry Cowan from Glenview Professional Pharmacy. “The number-one concern for facilities is getting meds to patients in a timely and dependable manner. Get in, do a good job at a small scale, and then grow. That’s what we’ve done.” Of course, technology is going to play a big role in helping pharmacies meet service goals. Eric Donley from Alert Pharmacy has this advice to offer: “Make sure you’re keeping up with technology. If there are pharmacies that aren’t going to adopt the technology, they are going to have a hard time keeping up. You have to cost-justify what you purchase, but so far, we’ve been able to do that.” This is something that Jason Guinn at Wilson Pharmacy can agree with. “Invest early in technology that has good support and is proven to interoperate with ease and reliability,” Guinn advises. “Be prepared to use the technology to accommodate various customer customization requests and be prepared to approach your technology vendors with change requests so you can accommodate future demands from your LTC customers.” It is also extremely important to make sure the facilities you serve understand just what your investments in technology mean to them, according to Brian Beach from Kelley-Ross “There’s an element of marketing to LTC that doesn’t really exist in retail. I’m not really a salesman at heart, but you have to stay in constant contact and constantly remind them of what you do that they aren’t using. You don’t want to be overbearing, but you have to make sure that you know the area you are serving, stay in touch with the right people at facilities, and are educating people about everything you offer.” CT

Will Lockwood is a senior editor at ComputerTalk. He can be reached at will@computertalk.com.