Long-term care (LTC) pharmacy has an increasingly important role in patient care, as the population in the United States continues to age.
Here we’ll take a look at the current trends in the sector as the COVID-19 pandemic wears on, which may bring with them significant changes to pharmacy workflows, a need to emphasize and document LTC pharmacy services, and a movement to base LTC billing on the level of care rather than the patient’s status as a resident of an LTC facility. We reached out to three experts in the area: The Senior Director of Program Development and lead for the National Community Pharmacists Association (NCPA) Long-Term Care Division Bri Morris, Pharm.D.; Paul Shelton, president of PharmaComplete Consulting Services; and the American Society of Consultant Pharmacists (ASCP) Vice President of Pharmacy Practice and Government Affairs Arnie Clayman.
CARE SETTINGS ARE CHANGING
The LTC facility census has traditionally been a major driver of a variety of pharmacy metrics, starting with overall prescription volume and carrying through to staffing, technology needs, and financial performance.
Those census numbers saw steep declines in 2020 and early 2021 as a result of the COVID-19 pandemic. According to Paul Shelton, at the lowest census levels skilled nursing facilities saw a 13% decline. “It went from 80% pre-pandemic, which has historically been a rate that’s marginally profitable for a skilled nursing facility,” says Shelton, “down to 67% in January 2021. Census numbers have crept back up to a little over 70% as of June 2021.” And while Shelton judges that we’ve seen the bottom, and the trend is to higher occupancy rates, what’s interesting in his view is that the overall population of Americans who need LTC services is never going to be completely addressed by facility-based care, even at 100% occupancy.
“As of 2020, about 14 million Americans need some sort of longterm care,” Shelton notes. “There are only about 3 million beds in facilities. Where do the other 11 million people receive care?” The most likely answer is at home, although there are some real problems to solve here, not least of which are a fragmented and understaffed market for providing home health nursing and the fact that payment models are based on patient location and not service level.
Shelton’s take is backed up by an analysis of Medicare data performed by the Senior Care Pharmacy Coalition (SCPC) and ATI Advisory, which shows that a need for LTC services exists independent of a patient’s location. In fact, SCPC’s summary of the study states that medical and pharmacy expenses and complexity are similar whether people are aging at home or are resident in LTC facilities. SCPC goes on to state that:
“Despite this close resemblance, current policy limits LTC pharmacy services to individuals living in facility settings (e.g., skilled nursing facilities and assisted living communities), leaving older people who choose to live at home with potentially unmet needs. SCPC/ATI research shows that nearly 75 percent of today’s Medicare beneficiaries with LTC needs live at home or in other community settings (e.g., independent living and retirement community), suggesting a gap in access to important services for these individuals and pointing to the need to clarify and expand current policy.”
SUPPORT FOR AGING IN PLACE
“There’s been quite a bit of industry effort around the movement for the medical home,” says NCPA’s Bri Morris. “We’ve seen aging in place really accelerate during this pandemic. And so this shift has been something that’s top of mind. We’ve heard from a lot of our members about the need for payment to align with the service level that they’re providing for patients who are aging in place.”
Morris notes that NCPA’s LTC division has been taking a leading role and working with other national LTC associations and with LTC GPOs (group purchasing organizations) in efforts at the federal and state levels to ensure that pharmacy reimbursements for LTC patients will move to being defined by service level.
This is critical work. As ASCP’s Arnie Clayman points out, the problem for people aging at home is that they end up having to pay for LTC pharmacy services out of pocket. Add to this the fact that individual patients and their caregivers may also not really understand the value of the medication management services that LTC pharmacists can provide. When they are asked to pay for these services themselves, you can see how significant this financial barrier can be.
Pharmacy has gained attention for this matter in Congress, fortunately. Arnie Clayman notes that the last two sessions of Congress have seen the bipartisan Long-Term Care Pharmacy Definition Act introduced into the Senate, with 12 cosponsors for the current version S.1574.
“The goal of the Long-Term Care Pharmacy Definition Act is to create a statutory definition of LTC pharmacy based on the ability to, as the act summary says, ‘provide enhanced pharmacy and clinical services to individuals who have certain comorbid and medically complex chronic conditions and who reside in skilled nursing facilities, nursing facilities, or any other applicable setting (as determined by the CMS),’” explains Clayman. The summary goes on to note:
“The term enhanced pharmacy and clinical services includes medication dispensed in special packaging, drug utilization review, and 24-7 availability of medication delivery and on-call pharmacists.”
“It’s of the utmost importance that we have a uniform definition of LTC pharmacy that can be applied across a range of federal programs and agencies,” says Clayman.
THE LTC SERVICE LEVEL
It’s useful to take a closer look at the areas proposed to define LTC pharmacy in the act and consider the technology implications for providing these services not just to residents of traditional facilities, but to those aging at home as well.
The act lists the following as defining LTC pharmacy services:
- Medications dispensed in specialized packaging.
- Drug utilization review.
- Medication reconciliation services at the transition of care and other necessary clinical management and medication services.
- Medication delivery 24 hours a day, 7 days a week.
- Pharmacist on-call availability to provider dispensing and clinical services 24 hours a day, 7 days a week.
- Emergency supplies of medication.
All of these items are addressable by current LTC pharmacy technology and workflows when patients are residents of facilities. For example, adherence packaging is standard in LTC pharmacy and is even becoming more and more common for retail-focused pharmacies. This is a very good thing because, according to Paul Shelton, almost 60% of patients served by LTC pharmacies have a cognitive impairment, Alzheimer’s disease, or dementia. Drug utilization reviews — even multidrug interaction reviews — and medication reconciliation are both well within the scope of practice for pharmacies with the right technology platforms. But several items stand out as potentially requiring a significant rethink of processes by pharmacies serving patients at home.
DELIVERY MODELS CHANGING
For example, delivery is an area in which Paul Shelton sees a need for pharmacies to upgrade their processes. He sees a need to create what he terms an active delivery model. “It’s not just FedEx, UPS, USPS, or even your driver dropping meds off at the door,” he says. “It could even extend to the delivery person crossing the threshold into the patient’s home and confirming the positive receipt of the medication. Short of that, you will want a way for the driver to observe and record that a person has received the delivery, with perhaps a geofenced photo or signature for proof. What we’re talking about here is a true, engaged delivery process.”
LTC pharmacies have also recently been moving from using one delivery method, for example either in-house delivery drivers or an outsourced courier service, to using multiple methods in what you can call a hybrid model. Which method is used can be a factor of distance from the pharmacy or be determined by time, with one service used during the week and others used after hours or on weekends or for stat deliveries. When it comes to on-demand delivery, for example for emergency orders, one interesting wrinkle is that pharmacies can now adopt the social style of delivery dispatch familiar to anyone who has used a ride hail service. In this case, the pharmacy has a group of drivers who are available on demand. When there’s a delivery ready, the pharmacy can offer this up to the drivers through an app, and the first driver to reply gets the delivery.
What’s important for pharmacies to realize is that while delivery is a core service for them, planning and managing routing is not. And the delivery-planning aspect is only becoming more complex as pharmacies need not just to manage a hybrid model of delivery methods, but also to plan routes for deliveries to both facilities and to patients in the home. This is where a strong technology base for delivery comes in, one that goes beyond a device carried by drivers or an integration with courier system platforms.
LTC pharmacies now need services that can pull in data on deliveries and produce optimized routing, taking into account factors such as historical traffic patterns and potentially even an optimized allocation of deliveries among the different methods. A pharmacy also has to consider the need for defined delivery windows that can be communicated to facilities and patients at home. In the latter case, it’s particularly important to be sure there will be someone available at a residence to sign for a delivery. “Delivery coming sometime today” does not cut it.
THE CARE TEAM CONNECTED
Another area that requires attention is ensuring that pharmacy, prescribers, caregivers or facility staff, and patients are all connected as efficiently as possible. Again, there are tools for this, and LTC pharmacies and their technology vendors have been building out connectivity with facilities over the years — for example, eMARs (electronic medication administration records) and digital paperless care team communications channels.
However, there are still problems to solve here, notes Arnie Clayman. “We continue to see challenges in LTC pharmacy around interoperability and bidirectional exchange of information,” he says. “Reducing the number of siloed IT [information technology] systems and creating standards-based data exchange remain two of the greatest needs we have.” Clayman notes that a consultant pharmacist may have to interact with three or more different EHR systems and have consulting software that connects to only some of them. “And then you may have an e-prescribing connection between the prescriber and the pharmacy,” Clayman continues, “but you don’t necessarily have a three-way connection that includes the facility.” If the pharmacy ends up having to recommend any changes to an order, Clayman says that it remains a challenge to ensure that the facility is updated efficiently so that staff there can match up deliveries with the order records in their systems and that nursing has a valid order to administer the medication.
None of this specifically addresses patients aging at home, though, and of course standards-based data exchange will be crucial here as well. For patients at home, pharmacies are going to have to be able to implement more one-to-one communications processes that allow them to manage this decentralized patient population and work with caregivers who may not be healthcare professionals.
THE LATEST IN-HOME APPS
One impact of the pandemic has been that people have grown increasingly familiar and proficient at interacting remotely, including for healthcare. This is as true of older populations as of anyone else, notes Paul Shelton. “The 75-year-old of today is not the 75-year-old of a few years ago,” says Shelton. “Parents and grandparents may be on social media and making video calls more than their children are. This is a demographic central to LTC pharmacy, and they’re constantly online.” This means that pharmacies should be looking for ways to create secure telepharmacy connections with patients, even to the extent of supporting ad hoc consultations if a question or concern arises.
Shelton has also been keeping his eye on various remote patient monitoring products that sit inside a patient’s home and bring data back into the pharmacy. “This could be something like a smart scale,” says Shelton, “and it’s going to alert the pharmacy that a patient on Lasix has now gained four pounds in 48 hours.”
Shelton has also seen a variety of small countertop home dispensing devices that come with an app that contains the medication list and schedule, among other details. This kind of setup can provide patients and caregivers with structured access to medications and create a record of adherence that’s available to the pharmacy. This is essentially the home version of the eMARs and dispensing cabinets at an LTC facility. There’s one such solution out there with a $30 monthly subscription cost, which is an interesting price point, in Shelton’s view. That’s because, while payers typically have been reluctant to fund these devices, $30 a month is a cost level that can be within reach for many people. There are more expensive options out there as well.
This is just one example of the technology, whether apps or hardware-app combinations, being developed to support care for patients aging at home. “This technology is very intriguing,” says Shelton. “Some of these companies are seeing real uptake, and the companies developing them are growing exponentially.” And while the biggest barrier to getting such technology into the patient’s home is consistently who pays for it, COVID-19 has led some payers to understand better the value of remote monitoring and a pharmacy’s role in managing the information coming from these technologies. Of course, we circle back here to the need for standards-based data feeds so that pharmacy technology systems can interact with as many apps and devices as possible. “It is going to be really critical over the next 12 to 24 months to see where this in-home monitoring market goes,” says Shelton. “Pharmacy needs to keep a close watch on these technologies, continue working to extend pharmacy services into the patient’s home, and demonstrate the value of these services.”
MANAGING CHANGES IN CARE LEVEL
Another area to watch is transition of care. “We’re seeing short-term rehab facilities start to fill back up as people have the elective procedures that have been postponed during the pandemic,” says Paul Shelton. “And there is a need for pharmacies to manage and reconcile a patient’s medication regimen to ensure that it’s appropriate, safe, and that there aren’t unnecessary or redundant drug therapies.” Interestingly, however, Shelton also predicts that we are entering a time when we will see the care level shift without requiring a change in provider or care setting. Even without a change in setting, every time there’s a change in care level, there’s a risk of medication mismanagement. The flip side of this risk, notes Shelton, is the opportunity for a pharmacy to provide the services that reconcile the patients medications and manage the transition of care.
COMBO SHOP OUTLOOK
There is a great deal of opportunity in these LTC trends for pharmacies that operate as a retail-LTC combo shop, notes NCPA’s Bri Morris. “You don’t have to be a closed-door pharmacy serving a large number of patients and facilities,” she says. “Especially when it comes to providing LTC services for patients at home, this is a whole new market share that combo shops haven’t touched yet. There’s going to be new technology that you want to invest in, certainly, but it’s also as much about looking at what you are doing now and seeing how that applies as opportunities for care expand.”
For example, Morris sees a strong med sync program helping pharmacies tailor their delivery programs to serving LTC patients aging at home. “Pharmacies that have truly adopted med sync will find it much easier to create a sophisticated delivery program for patients at home,” she says. “And when I say truly adopted med sync, I mean pharmacies that have 80% to 90% of their prescription volume in the program. Think about how this will allow your pharmacy to create a rationalized delivery schedule that works through the delivery area, for example by dividing your delivery area into quadrants and delivering to each quadrant one day a week.”
And then Morris sees pharmacies that are part of a CPESN (Community Pharmacy Enhanced Services Networks) network being well placed for care at home. Many of the enhanced pharmacy services that are part of the CPESN model can address the needs of patients aging at home. Pharmacies that have developed these programs already have experienced staff and the right workflows and technology for providing services, in addition to dispensing prescriptions. “I think it’s really about making sure you’re meeting the patient where they are,” says Morris. Pharmacies should keep a close eye on how CPESN can evolve into a way specifically to address LTC care needs too.
GETTING READY FOR WHAT’S AHEAD
No pharmacy, no matter what its level of experience in LTC, should be resting on its laurels right now, however. “The trends in the number of people who need LTC pharmacy are going to mean a significant increase in workload, frankly,” says Paul Shelton. “This will be particularly true as we find ways to allow patients to age at home. Instead of interacting with several facilities, pharmacies will be helping manage care for many more patients individually. There will be myriad challenges that come from having different levels of health, education, or medical understanding and different types of caregivers.”
Arnie Clayman sees the medical at-home model undergoing a real evolution in the near term. “We’re talking more and more about how critical long-term care pharmacy services are,” he says. “Dispensing medications will continue to be a central part of the pharmacy offering, but to set yourself apart it can’t just be about the product. Patients do best when there’s a high service level as well.” So the question that Clayman wants pharmacies to ask is, how will they provide the same service level to patients at home as they do to residents in skilled nursing and assisted living facilities?
Pharmacies that want to stay ahead of these trends and provide what the market is demanding can do a few things. Bri Morris emphasizes being plugged into what your associations are doing to support you. “I think that there are quite a few independent pharmacies that don’t even realize that NCPA has a separate LTC division that’s working to build new models for members,” she says.
Arnie Clayman notes that ASCP is working broadly to support LTC pharmacies in this evolving environment — from participation in the Pharmacy HIT Collaborative on standards to drive systems interoperability, to working with the DEA (Drug Enforcement Administration) on the issues surrounding electronic prescriptions for controlled substances in LTC pharmacy, and keeping a finger on the pulse of efforts to shift the payment model to focus on service level rather than location.
Closed-door and combo-shop LTC pharmacies also need to stay up to date with the latest technology marketed to patients and facilities, as well as the capabilities of their own pharmacy technology platforms. Those pharmacies that develop a clear understanding of both the tools and processes they already have that can address trends, while also identifying any gaps that they need to address, will be the ones best equipped to lead in the market and provide the highest service levels no matter where LTC patients reside. CT