Cover Story | Driving LTC Evolution

There’s a great deal that’s changed in the longterm care (LTC) market in the past few years, and there’s more change happening now. These forces are driving a transition away from manual processes, which is visible both in the automation applied to filling prescriptions and in the critical communications links between pharmacy and facility.

A Changing Market

Sidebars: Find out about barriers to implementation and costs and ROI…

There have been significant changes brought on as waves of economic challenges hit LTC facilities. Kevin Fearon points out that the states and Medicare are looking at ways to control costs, particularly in the skilled-nursing market. The end result of this has been a much more transient patient base, Fearon explains. “We aren’t seeing placement homes any more,” he says, meaning an older model of care where residents entered to age in place. “Instead, we’re seeing patients come in who are recovering from a stroke, a surgery, or some other significant health event, and they are there for a short stay to transition back home or to an alternative setting. The amount of drug supply, how quickly they need the drugs, the level of acuity of the patient, it’s all much more demanding and much more centered on how you can do this efficiently and at the lowest cost possible.” 

Kevin Fearon, R.Ph.
Absolute Pharmacy
North Canton, Ohio

Family-owned pharmacy serving skilled-nursing and assisted-living facilities. 

Add to this the rise of accountable care organizations (ACOs) and bundled payments, and Fearon points to a real need for pharmacies to develop processes and tools that support continuity of care across a range of settings. “Typically in today’s market,” explains Fearon, “when a patient leaves the skilled setting, there’s a handoff to another pharmacy, to a home care agency, or some other entity for care. There is an opportunity, though, for us to adapt and extend our resources and reshape our business models so that we can offer more continuity of care and follow the patient as he moves to a different care setting.”

This is easier said than done. Fearon points to the need for pharmacy technology to evolve to handle these transitions seamlessly. The old way of depending on paper and fax machines needs to transition into electronic channels so that information is not just moving point to point among the different providers of care, but is instead seamlessly available to pharmacies, nursing homes, doctors, and insurance companies as needed. “How do you get this information moving and in a way that all the different systems within the longterm care environment can make use of it?” says Fearon. “Everybody is attempting to digest that.”

This is something that Jason Jung is seeing, too. “We’ve been moving toward cognitive services and areas where the pharmacist’s knowledge can add value to care,” he says. “I really see a lot of opportunities for pharmacies that are fast and nimble in responding to these market trends.”

Automation Continues to Drive Change

LTC pharmacy, of course, remains a production environment, where dispensing and delivering medication doses is as critical as it has ever been. Fortunately, dispensing automation — and packaging functionality in particular — has been evolving rapidly to meet these challenges.

Kevin Fearon, whose Absolute Pharmacy uses MTS’s On Demand Accuflex automation for single-dose blister packaging, has seen the software powering automation become more flexible and the automation evolve to have greater capabilities for packaging in different formats. “As barcoding became more accurate,” Fearon says, “you could be certain that the automation was putting the right drug into the right package. That has evolved to where we now have the ability to label the packages by day or by hour of day to whatever level of detail you desire.” Fearon’s automation also allows him to sort packages by batch, time, facility, or patient.

Jason Jung
Fox Drug Store
Selma, Calif.

Family-owned independent pharmacy with three retail locations and a closed-door LTC pharmacy.
Jung, center, is seen here with two of Fox Drug Store’s technicians, Jason Salvatierra, left, and Dustin Rocha, right.

The range of choice in packaging automation has also expanded, with a number of options in the market now that allow pharmacies to pick the technology best suited to the types of LTC facilities they are serving, their throughput needs, their specific regulatory environment, and their budget. And automation has an impact from end to end, from within the pharmacy, out to the facility, and finally to the patient.

Barry Leskowitz, who is using DOSIS automation from Manchac at PharmcareUSA to fill unit-dose blister cards, offers a view on automation’s impact in the pharmacy. “I look at it in two ways,” he says. “One is with respect to inventory, and the other is with respect to labor.” The throughput of the DOSIS automation matches up well with the pharmacy’s volume so that Leskowitz can operate on a just-in-time model, both for inventory deliveries and dispensing. This, as he notes, is opposed to prepacking fast-moving medications, which is a common dispensing model in LTC pharmacy and one that automation can support as well.

However, Leskowitz took a close look at the impact of automating his packaging process and decided that there was no reason to prepack and carry the extra inventory that results. Instead, he is relying on the automation to dispense and package medications on demand whenever the pharmacy system calls for them. Leskowitz focuses on tracking his dispensing needs for the next few days, with the knowledge that keeping the canisters in the DOSIS machine filled has a minimal impact on workflow and that the automation has the capacity to meet the pharmacy’s dispensing demand in real time. “This was something we knew about going into this,” he says, “but we’ve seen an even greater impact than we were expecting.”

Don Brindisi can also speak to the big impact dispensing automation has on pharmacy efficiency. Masonic Villages at Elizabethtown relies on the TCGRx ATP for multidose pouch packaging of around 260,000 medications a month into about 50,000 pouches. This is impressive, but Brindisi notes that solving one problem can often highlight another. “We were about a year in with the multidose packaging machine,” he says, “and we realized that the bottleneck had shifted to the pharmacist verification step, which with a weekly cycle fill was happening four times as often as before.” By Brindisi’s calculation, manual inspection of the pouch packaging required between 24 and 26 pharmacist hours each week. This led to the next piece of automation from TCGRx, InspectRx. This creates an exception-based verification process that has brought the pharmacists’ hours applied to this task under control.

  Barry Leskowitz, R.Ph.
VP, Eastern Region
Edison, N.J.

Eleven pharmacies nationwide. Leskowitz serves both subacute units and the longer-term units within facilities. 

Building Out Around Automation Jason Jung had the advantage of bringing packaging automation in with a clean slate when Fox Drug Store decided to break its LTC operations out into a closed-door business over three years ago and bring in Synergy Medical’s SynMed blister card packaging automation. “We looked at the numbers and saw that it made sense for us to consolidate our long-term care operations into a closed-door pharmacy,” he explains. “We also realized that this would mean that we would have a nice opportunity to plan the workflow around the automation.” For example, Jung points to something as simple and logical as placing oral solid inventory for replenishing SynMed next to it, while liquids and inhalers are in a separate area — something that might not have been possible if Fox Drug Store had simply installed the machine in existing available space. “We didn’t want the technician running the machine to go crisscrossing the pharmacy to get stuff,” says Jung. “Most pharmacies weren’t originally built or designed for automation, and the approach is often that they just try to fit it into a corner. But you lose a lot of the efficiency if it’s not in the right spot.” This forethought has been helpful, notes Jung, for ensuring that Fox Drug Store is getting the full benefit of SynMed’s capabilities.

Flexibility in Packaging and Labeling

There’s increasingly a great deal of flexibility built into packaging automation as well. And, as Kevin Fearon noted earlier, this is important in the face of the challenge presented by the increasingly transient patient populations LTC pharmacies are serving. Fearon notes that when an individual is in skilled nursing with a registered nurse or licensed practical nurse assisting with care, the pharmacy can label using medical terminology and relatively simplistic labeling. But if that individual transitions into an alternative, lower-acuity setting, the labeling needs are quite different. So while precision in packaging is a fundamental need, software systems that are intelligent and flexible enough to print the information appropriate for the care setting are also critical, according to Fearon.

This is driven in part by how well the pharmacy management system and packaging automation work together. “We wouldn’t be able to be as clear and concise as we are in our labeling without the very good interface QS/1 and TCGRx have built,” says Charlie Fanaras of The Prescription Center and Northeast Pharmacy Services.


Don Brindisi, R.Ph.
Pharmacy Manager
Masonic Villages

Elizabethtown, Pa.

Continuing care retirement community on 1,400 acres, with 1,600 retirement-living residents, 127 personal-care suites, and 450 skilled beds. 

This need to meet the demands of a variety of care settings can also call for flexibility in the packaging format itself, notes Jason Jung. This is why he was pleased to find that SynMed is able to accommodate a wide range of blister cards, including the DISPILL multidose card Fox Drug Store was already using. “We were happy about this because we were using a multidose card that we felt was a step up from the traditional kind,” says Jung, “and SynMed was able to work with that. At the same time, if we had a facility that prefers unit dose, we can also do that. We value having multiple options without actually having to buy different machines.”

And while more options are proverbially better, it’s not always so cut and dried in the complex world of LTC pharmacy. You may also need to consider operating parameters set by state regulations and take a look at the balance of cost and functionality. Barry Leskowitz, for example, reports selecting Manchac’s DOSIS as a packaging solution for his skilled-nursing patients, even though he did not anticipate it being a solution for his assisted-living customers. Leskowitz could have made a bigger investment in automation with the idea of eventually using it to package for both sets of patients, but instead he found that Manchac’s DOSIS did the best job of meeting PharmcareUSA’s volume, packaging, and labeling requirements for serving skilled facilities, where the need was most evident, and at an investment level that made sense.

And even if you do want to focus just on one type of packaging and labeling, as in Leskowitz’s case, there’s still value in being able to match output to a specific pharmacy’s needs. “Since we have multiple pharmacies located in different states, we needed automation that could adapt to each location’s specific requirements,” says Leskowitz. For example, one pharmacy may have three delivery times, while another has five. The software powering the Manchac automation PharmcareUSA selected had to have the ability to make sure that the cards dispense in conjunction with those delivery times. “And then we needed to be able to have different labeling rules to meet the requirements of the different states we work in,” says Leskowitz.

Getting That First Dose Out

  Mary Glavan, R.Ph.
Chief Compliance Officer/Pharmacist in Charge
Des Plaines, Ill.

Independently owned LTC pharmacy opened in 2014. 

Long-term care pharmacies also have the unique task of making sure patients receive the first doses and PRN medications they need when they are admitted to a facility. This is a challenge, and an important one, since the pharmacy does not control the timing of admissions, and the prompt delivery of medications is both a clinical and a regulatory necessity. All of the dispensing activity has to be tracked and the medications replenished. Traditionally, it has been a manual process, with large tackle boxes holding the medications and paper records of what’s been administered.

The various issues associated with the old way of handling first doses and PRNs were obvious to Mary Glavan and her partner when they opened MAC Rx Pharmacy. As a result, they decided from the beginning to make Capsa’s FirstDose medication storage cabinets a standard part of their offering. They now have 25 in the field. The package includes a secured med cart as well as secure Web-based software that gathers all utilization data. “Nurses log in and tell us who the doctor is, who the patient is, what the medication is,” explains Glavan. The cart shows nurses where to locate the medication they are looking for by drawer and slot so that they don’t have to open up a number of drawers and go hunting. This data is all recorded and available for reporting to the pharmacy and the facility’s director of nursing, which allows daily visibility into utilization.

Glavan also notes that the carts and Web interface are both flexible enough to allow MAC Rx to meet the needs of a variety of acuity-of-care levels at facilities. “There are multiple doses of 250 different drugs, including controlled substances,” she says. Controlled substances are kept in a secured drawer that can be set to require two nurses’ log-ins to open, and then has the individual medication containers secured by color-coded and sequentially numbered plastic locks — one color when the container is locked after being filled by the pharmacy and one for the nurses to use when they relock it. Again, all these details are logged by the nurse in the software and are available to the pharmacy and facility administration.

Service as Part of the Package

Charlie Fanaras, R.Ph.
The Prescription Center and Northeast Pharmacy Services
Concord, N.H.

Family-owned independent pharmacy with three locations. LTC pharmacy serves nursing homes, assisted-living, residential care, behavioral health, and group homes.

And while automated packaging, with all its attendant benefits, can be made the default offering for skilled settings, there’s a little more work to be done for pharmacies that want to offer it to a broader group of patients in order to control costs and to keep them out of skilled-nursing settings as long as possible. This is where Charlie Fanaras has built a service offering around The Prescription Center and Northeast Pharmacy Services’ adherence packaging. “We’ve embedded a pharmacist into our local visiting nurse association,” he says, “and she identifies those patients who would most benefit from med management packaging.” The goal here is to make sure that, whether patients are in an assisted-living facility, in a retirement community, or living at home, The Prescription Center and Northeast Pharmacy Services are supporting them with packaging that helps them take the right meds at the right time.

“We’ve talked for a long time about the importance of helping patients stay in the community,” says Fanaras, “but by working at identifying candidates for packaging we can take it to the next level and really provide both the resident and the caregiver with the peace of mind that comes from being able to monitor and manage medications easily.”

Communications: Evolving and Dynamic

Communication is another critical aspect of LTC pharmacy, and one that’s been evolving rapidly. First, as we’ve seen, increasingly sophisticated dispensing automation options need pharmacy systems that can pass the right information at the right time to keep the process moving and the output labeled correctly. The demands on a LTC pharmacy management system reflect the complexity of these systems, explains Charlie Fanaras. “There are a lot more data fields required in a long-term care setting,” he says, “especially if you’re going to get into any level of sophistication with med management. For example, you’re going to want to be able to get down to the times that you want to start and end certain medications, as well as details on the patient, the medications, and the time of administration.” Kevin Fearon notes that you may also need to communicate to the automation whether a medication is destined for multidose or single unit-dose packaging.

This is complex enough, but then there’s the fact, notes Fanaras, that medications change. “They change more than they used to,” he says. “And changing meds is where confusion can set in for patients who aren’t in a skilled-care setting.” The result is a real risk that patients will continue to take discontinued medications, because they are still in possession of them.

But there’s not just a need for systems to talk to each other effectively. There are a lot of people in the LTC process as well, and technology needs to support great communication among them. “The process is only easy when everybody is on the same page and everybody is communicating,” says Fanaras. 

    Neil Marshall
VP, Pharmacy Services
Consonus Pharmacy
Milwaukie, Ore.

Serves both skilled-nursing and assisted-living facilities from locations in Portland, Seattle, and Sacramento.

Consonus Pharmacy’s Neil Marshall has a lot of experience with the different communications channels out there, whether we’re talking about electronic health record (EHR) systems or electronic medication administration record (eMAR) systems and one-way or bidirectional connectivity. In fact, Consonus Pharmacy is on a multiyear arc of getting more connected with facilities. “We’re now connected with about two-thirds of our customer base and growing,” says Marshall. “Along the way we’ve done studies to make sure that each time we decide to step on the accelerator further and add another system, we study the safety and effectiveness of the connections that we have in place now.” What Marshall and Consonus Pharmacy have learned is that digital communications are absolutely a safer and more reliable way to operate, if you do all the right training and you make sure that the users on both sides of the system understand the process. “We’ve had to work with our staff to help them understand things like the immediacy of the communication,” he offers by way of example. “When you take an action inside the pharmacy now, it’s immediately visible to the caregiver on the other side, and you need to be cognizant of that.”

There’s also some real strategy involved in opening up these digital communications channels, since different areas of the LTC facility market are at different levels of technology deployment. “Our experience has been that the skilled facilities were out ahead of the curve a little bit and had largely made their own selections of EHRs,” says Marshall. As a result, Consonus Pharmacy needed the flexibility to be able to connect its FrameworkLTC pharmacy software from SoftWriters with the technology these facilities had already chosen. “In the ALF [assisted-living facility] market, it’s more common for them to be in a position where they are ready for us to help them make a choice,” Marshall says.

No matter what the situation, there are nuanced differences in each case that Consonus Pharmacy has to take into consideration when it connects with a facility. And there’s also room to take the benefits of a digital channel and run with them. For example, Consonus Pharmacy is using the SoftWriters Facility- Link product to give facility staff real-time visibility into the status of orders as they flow through the pharmacy. Marshall reports that they have taken this one step further by converting the spreadsheet-style presentation into a visual dashboard. “We use consumer applications as design inspiration, so that our solutions are easy to use. I don’t know if you’ve ever seen the Domino’s [Pizza] Tracker,” says Marshall, “but it’s like that in that we are providing a really easy visual experience using icons and color so that facility staff can see the status of orders at a glance.”

What’s on the Agenda

While it’s good to know what’s working now, it is also useful to find out what a group of dynamic long-term care pharmacies have on their to-do lists and wish lists.

Don Brindisi, for one, is working on rolling out the TCGRx pouch packaging to Masonic Villages at Elizabethtown’s personal-care residents. “If you look at personal-care, the average resident is on 14 medications,” he says. “And so I think the overall impact of the adherence packaging out in the community would be fantastic. That’s why this is probably my most immediate goal.”

Neil Marshall reports that Consonus Pharmacy will continue to push on the connectivity front with the goal of ultimately getting 100% of facilities on board. “We don’t want to lose sight of that, because we’ve learned that when done properly, it is a safer, more efficient way to operate,” he says.

But perhaps even bigger is a move toward making sense of all the data Consonus Pharmacy is handling. “We’re so transaction intensive, with thousands of data points every day,” says Marshall. “Now we’re stepping back and asking ourselves what we can learn from all of this information. How do we pair it up with what we’re learning in the EHR system so that we can help our clinical decision-makers use that data to improve the effectiveness of their work?” To this end, Consonus Pharmacy has established a data warehouse to pull together data from the FrameworkLTC pharmacy operating system, as well as the software its consulting pharmacists use out in the field. “We can look at things such as all the clinical interventions made by pharmacists,” he says, “whether it happened inside our building or out in the field. Then, ultimately, we will work toward the ability to map that to clinical outcomes, so we can say, based on the timing and/or nature of those interventions, what the effect was on the outcome for the resident or patient.”

And when it comes to wish lists, Mary Glavan’s has an integration of systems near the top of hers. In this case, her goal would be to pull FirstDose utilization data automatically into MAC Rx’s FrameworkLTC system. “Then we could automatically manage the billing and replenishment,” she says. “That would eliminate the main daily administrative task we have with FirstDose and make the process even more efficient.”

Then Kevin Fearon sees the day coming when he’ll be able to easily track patients across care settings and have intelligent automated packaging that recognizes whether that patient needs a unit-dose card or a multidrug packaging style. “This would be the perfect storm of both the automation and the software coming together,” says Fearon.

Considering the pace of change and the waves of change that seem to constantly break over the LTC market, it won’t be surprising at all to see these needs met the next time we check in. CT

Will Lockwood is VP and a senior editor at ComputerTalk. He can be reached at


Barriers to Change

Don Brindisi, R.Ph.: “Nursing facilities can be scared of multidose packaging. You’re going to have about 30% to 40% of people who are on board, and the rest are going to sit there and say, ‘Well, I don’t know.’ Many of our nurses have been here for many years, and it can be difficult to make changes to their routines. I can reassure them by showing them how the packaging improves their work. I show them that if they look at our packages it tells them the atorvastatin is white and oblong, with #10 written on it so they can verify it. And now, instead of looking for six cards, they’ve got one pouch for that patient and that med pass time. Once they get a good look at it, the trust issues go away.”

Kevin Fearon, R.Ph.: “The challenge with the eMAR market from the pharmacy perspective is that it’s very fragmented. There’s a lot of providers out there, so you literally have to make arrangements for interfacing with all of them, potentially. There is a standard out there, but everybody has their nuances for how you get information back and forth to each other, and when you’re dealing with drugs and medical information, it needs to be 100% accurate. It can’t get truncated or populated into the wrong field.”

Mary Glavan, R.Ph.: “When an existing pharmacy has made a commitment to the system, even if it’s just a tackle box, it takes time to switch over. There may be the barrier of going to the board of pharmacy for approval. The cost may look prohibitive. And it can be difficult to run two systems in tandem while you’re converting from one to another.” CT


Considering Cost and ROI

Don Brindisi, R.Ph.: “When we made the capital spending request for the TCGRx ATP, we calculated that short-cycle fill requirements would increase the pharmacy workload by two to four technician FTEs, while bringing in the automation would require no additional FTEs. But in our case, pharmacy payroll costs weren’t the only component. We also took into account the nursing time saved from reduced med pass times, savings of about 40% on pharmacy production costs per patient per month, and a reduction of almost 80% in pharmacy waste costs. Overall, we expected to see an ROI in just under two years. For InspectRx, the calculation for an ROI is about three years, based on an 85% reduction in pharmacist time spent on verification.”

Mary Glavan, R.Ph.: “We’ve made a commitment to offering facilities a better solution for first doses and PRNs, and we have found that Capsa’s offering had the right combination of features at the right cost. We realized that we couldn’t afford to have 25 higher-cost machines out there. What FirstDose provides is an electronic accountable system that’s actually affordable for the long-term care pharmacy and the facility to have available.”

Barry Leskowitz, R.Ph.: “None of our pharmacies currently use multidose, so the main considerations were the upfront costs, which we found to be modest, and the flexibility within the organization. Manchac assured us that they would be very flexible and be able to meet whatever needs we had, as far as the interface requirements and the workflow requirements. We were also satisfied that the volume would be sufficient for our environment, especially with the ability to be able to run the machine overnight.” CT