Raising the Service Level in Long-term Care Pharmacy

Cover Story | Raising The Level

by Will Lockwood

Long-term care (LTC) pharmacies have been, by the very nature of the services they provide, on the leading edge of some important trends in pharmacy. For example, they’ve long been syncing prescriptions in order to provide cycle fills, and they’re the original adherence packagers. Then there are the platforms they’ve built out to create a connected care provider team, including web portals for LTC communities and interfaces between pharmacy systems and digital records platforms such as electronic medication administration records (eMARs). With this history of technology and practice innovations in mind, we checked in with four closed-door long-term care pharmacies to find out how they are continuing to raise the bar in the profession.

Medication Management Partners Crestwood, Ill. 
Labi Avdiu, Pharm.D., FACA, Chief Executive Officer

Closed-door long-term care pharmacy focused entirely on providing comprehensive medication management services to non-skilled, post-acute residential care communities in seven states, including assisted living, supportive living, memory care, group homes, and community integrated living arrangements (CILAs).

Committing to a Service Level

Managing the complex demands of dispensing workflow and patient care effectively is critical at any pharmacy, but the long-term care environment comes with very specific demands that mean these pharmacies really have to be on their game, particularly when there’s a clear growth path at hand. For example, about seven years ago Labi Avdiu and several colleagues saw an opportunity to take on a larger LTC business. So they created Medication Management Partners, which has since grown tremendously — from about a thousand residents its first year, to around 4,300 now. It is now licensed in seven states, soon to be eight. But to get where they are, Avdiu says, he and his partners had to come to terms with committing to the software they’d need to serve these new communities. The pharmacy ultimately selected FrameworkLTC from SoftWriters. “It became very apparent to us that the software we were using in our retail environment could not take on the growth that we wanted,” says Avdiu. “We could see that there’s a great deal of complexity that you have to manage in the LTC world, and the software platform you use needs to be built for this.”

Avdiu’s ready with a number of examples of just how complicated LTC pharmacy gets. “When we first started, we needed to do multidose packaging,” he says, “because that’s what the communities we’d serve wanted. When you do multidose in assisted living, the next step that’s required is managing the days’ supply. Most communities don’t want to go beyond 14 days, because of the need to manage medication changes, which in and of itself is really complex.” This is where a strong set of cycle fill functions comes in, according to Avdiu, so that you can build the rules for pulling medications into the filling queue on certain intervals, with certain start dates and certain packaging configurations.

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A high-performance LTC pharmacy also has to have the ability to layer customizations within its pharmacy management software, both LTC community by community and within a community itself. “An LTC community may have, for example, a memory care wing that wants things a certain way,” says Avdiu, “but also regular assisted living and independent living residents for which it wants things a different way.” Or, he reports, an LTC community may choose multidose for noncontrolled meds, but want all controlled substances or just schedule IIs in bingo cards. It may want specific hours of administration on meds for its assisted living side, but not for its memory care wing; or it may want certain classes of meds or all prescriptions for memory care residents packaged on a shorter cycle, since changes are more frequent.

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Operating in multiple states also brings layers of complexity. For example, states vary in how long a controlled-substance prescription is valid. They also have different reporting requirements for controlled-substance dispensing. “These are just two examples of the regulatory and administrative requirements that your LTC software has to facilitate,” says Avdiu. ”You also have to be able to build the requirements for a wide variety of insurance plans into your software. If you don’t understand the LTC market, then you may not see clearly why truly robust LTC software is critical to success.”

Becoming a Partner

The right software can also drive innovative models, such as the one in use at GoldStar Pharmacy. “The central part of our approach to long-term care pharmacy is to be the patient’s medication management partner,” says A.J. Oben. “Our goal is first and foremost to help our patients stay at home, which is really the natural progression of where the industry is going. GoldStar’s focus is to do more than just fulfill medication orders. We are partners with healthcare providers and the patient.”

GoldStar Pharmacy, College Station, Texas
A.J. Oben, Owner
Closed-door long-term care pharmacy that develops strategic partnerships with patients and healthcare providers such as accountable care organizations (ACOs), assisted living communities, home healthcare, hospice, and group homes, to improve outcomes and quality of care and reduce healthcare costs by using medication adherence management.

To this end, Oben says, the pharmacy assigns a health coach to each patient: “We’ve got a workflow in our pharmacy system from SuiteRx that tells each health coach which patients, for those who are living at home, or which LTC communities he or she needs to be calling that day.” As Oben explains it, six days before a scheduled delivery the SuiteRx system prompts the GoldStar Pharmacy health coach to review everything for that patient or LTC community, and make a phone call to ensure that the pharmacy is capturing any changes or events, such as hospitalizations, that might have happened along the way. And once a month, reports Oben, a clinical pharmacist reviews the entire file for a patient and makes recommendations to the physician. “This way, we know we have an accurate list of medications when we produce that patient’s multidose pack, which we’ve branded as the GoldStarPak,” he says.

“From a management standpoint, having these dedicated health coaches means that we know who to talk to if things haven’t gone according to plan for a patient or a community,” says Oben. “And from the patient’s standpoint, they get to talk to the same person every month, and they build a relationship. Some of our patients live at home by themselves and have family members out of state. Having that health coach call them once a month gives everyone a little bit of comfort, knowing that, hey, that patient has a partner helping him through.”

GoldStar Pharmacy, College Station, Texas Bessem Oben, Pharm.D., Owner

This active role also means that physicians and other healthcare providers come to understand that their patients are in good hands with GoldStar Pharmacy. “When we partner with home healthcare groups,” says Oben, “they give us their top 10% of difficult cases. Most of these people are what we call the frequent flyers, who’ve been going to the hospital and getting admitted often simply because of issues with their medications. When GoldStar becomes a partner for this patient, they end up staying at home, because they’re getting the right medication and the right dose at the right time.”


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Jamie Branshaw has experience with this need to put the right pharmacy technology in play as well, at Harbor Pharmacy. He has found that LTC communities and physicians are concerned that an independent pharmacy may not have invested in the right technology platform to meet expectations. Branshaw is confident that Harbor Pharmacy is ready to provide the highest level of service, based on QS/1’s LTC-focused PrimeCare pharmacy management software and WebConnect LTC community portal.

Keeping Your Head Above Water

Harbor Pharmacy
Oswego, N.Y.
Jamie Branshaw, R.Ph. Owner
Closed-door long-term care pharmacy serving 25 communities and around 3,000 beds.

Branshaw also offers examples of what you need from your LTC software in order to keep up with the demands of the market. He notes that having good visibility into your workflow is critical for avoiding bottlenecks that impede your service level. He points to the dashboard in Harbor Pharmacy’s QS/1 PrimeCare system that color-codes the different process queues — red, yellow, green — and shows how many tasks are currently at such steps as refills, voicemails, error resolution, QA, web portal messaging, and DUR alerts. This is a prime avenue for ensuring that there aren’t any unpleasant surprises and that the pharmacy has its staff and resources deployed correctly.

At Midwest LTC Pharmacy, Cindy Lobeda points to a need for document management software to handle the constant flow of orders and information coming in from and going out to prescribers and LTC communities. “In years past, all this information came in as paper faxes,” says Lobeda. “We used to have to take faxes off our fax machine constantly. And then we’d have to shuffle and reshuffle all that paper to move it through the process and prioritize what needed to be done next.” That’s not a tenable way to really build an LTC business, and Lobeda reports building a software platform centered on SoftWriters’ FrameworkLTC and Integra’s DocuTrack as the pharmacy’s foundation. “Document management is probably my favorite thing that we have implemented here,” says Lobeda. “It automates and prioritizes our inbound and outbound communications. We can automatically link all the paperwork to a prescription, and make it available in all the right work queues.” Lobeda’s staff has access to information at the click on a button, whether it’s to answer a question from an LTC community or in the event of an audit. “We can answer a question in seconds,” she says, “and preparing for an audit takes a few hours, compared to a few weeks.”

Automation and Packaging

Document management isn’t the only driver in managing efficiency, of course. You’ll find that dispensing automation — robotic adherence packaging in particular — plays a crucial role as well. For example, Midwest LTC Pharmacy has two TCGRx ATP automated packaging machines, which produce multidose and unit dose strip packaging. “We use our newer ATP for all our routine fills,” says Lobeda. “The other one we use for new orders or short-term orders. We keep them running constantly.” Lobeda also reports using TCGRx’s InspectRx automation, which she says records an image of every package in the strips dispensed. “We can have that for our records,” she says. “If the nursing staff calls and says, ‘We don’t think we got this med,’ then we can go back and confirm that it was or was not in that strip.” Midwest LTC Pharmacy uses another piece of automation to produce 14-day bubble packs, which supports prepacking between 40 and 50 common cycle fill meds. “When we print a prescription label,” says Lobeda, “regardless of what packaging system we use, we have a barcode on that label that we can scan to verify the dispensing if needed. It’s a huge safety priority for us, knowing that we’ve always got the right meds. LTC communities that are using an eMAR can use these barcodes to confirm details such as patient, meds, and administration time.”

GoldStar Pharmacy is also using multidose packaging automation, in this case from Synergy Medical. “We’ve done multidose packaging from day one,” says A.J. Oben. Before automation pharmacy staff filled cards manually, with one patient’s medications taking about 15 minutes to fill, according to Oben. “Today, with SynMed, we’re ten times as productive,” he says. Oben also points to the benefit of being able to use a variety of packaging cards in SynMed, allowing the pharmacy to better match its output to the needs of patients and LTC communities.

Early Investment in Automation Yields Returns

Midwest LTC Pharmacy
Grand Island, Neb.
Cindy Lobeda, Pharm.D., Co-owner and Pharmacist
Family-owned and operated closed-door long-term care pharmacy serving skilled nursing, assisted living, and mental health communities.

You’ve probably heard rules along the lines of robotics making sense once your volume reaches X or your patient base reaches Y. But both Midwest LTC Pharmacy and GoldStar Pharmacy report finding that these rules were better broken for them. “When we started out and we were filling manually, we couldn’t really absorb a lot of patients,” says A.J. Oben. “We were getting a lot of requests for us to be a part of the community health platform, but doing it manually was just not going to work.” Oben’s response was to make a decision early on to invest in SynMed, even though the pharmacy didn’t technically have the volume for it. The decision has made what Oben calls a night-and-day difference. “We’re using SynMed to efficiently package a variety of multidose cards,” he says, “and we can even use it for unit dose cards, if that’s what an LTC community wants.” Oben’s goal is to run as many prescriptions as possible through the automation, because it allows GoldStar Pharmacy to print important details on the label, such as times of administration and the patient’s photo and room number. “At the end of the day,” Oben continues, “this is the kind of service that reduces med pass times and eliminates errors.”

Midwest LTC Pharmacy
Grand Island, Neb.
Jenny Reisdorph, Marketing Manager

That flexibility to offer the kind of packaging an LTC community wants is important, according to Midwest LTC Pharmacy’s marketing manager, Jenny Reisdorph. “I take our packaging options to show to LTC communities,” she says, “since what they’re going to want really depends on different factors. We may want to start them off with our bubble packaging, just because they’re familiar with it. But if they really understand the benefits of multidose packaging — such as making med passes easier and putting all the key information on the label — they’ll tend to go that route, and we’ll offer them our strip packaging.”

In fact, the results that Midwest LTC Pharmacy saw from its TCGRx ATP packaging automation were so strong that it led to the decision to add a second robot. “When they came out with the new, improved TCGRx ATP,” says Cindy Lobeda, “we knew we wanted it, because it has an upgrade that allows us to use two exception trays without any interruption of dispensing. The newer model is also a little bit faster than the old machine.” But rather than use the older machine as a trade-in to help with the cost of the new ATP, Lobeda realized the pharmacy would be better off

using that older model for short-term orders. “With just one ATP we had to find a time to pause our cycle fills in order to fill acute or emergency orders,” she explains. “It was never convenient, and we might have had to wait 15 to 20 minutes to get to a place where we could pause the ATP and switch over to filling that new order.” Lobeda’s decision to double-down has paid off quickly, too. “We’ve made back what we gave up on the trade-in within the first six or seven months by using our older robot for just those short-term orders,” she says.

Interfaces and Communication

Connectivity, both among systems within the pharmacy and with LTC communities and patients, is another key tool helping LTC pharmacies push the bar higher. Within the pharmacy itself, a strong interface between the pharmacy system and the dispensing automation is crucial, according to Cindy Lobeda. “Whatever we create in FrameworkLTC is exactly what needs to fill in the ATP,” she says. “Fortunately, the interface between the two is excellent, and we’re able to manage the full range of complex orders we’re filling.”

Then there’s connecting with LTC communities, which, not surprisingly, brings layers of complexity. We’ve already heard about moving to a paperless information flow with a tool like document management. eMARs and web portals are two other ways LTC pharmacies are connecting with LTC communities and providing tools for putting prescriptions status, order management, and more in the hands of community staff. This is an area important enough that pharmacies take a multipronged approach, often supporting interfaces between the pharmacy management system and multiple eMARs, as well as providing an LTC community-facing web portal.

For Labi Avdiu electronic records interfaces were a top priority for Medication Management Partners when it ramped up closed-door LTC operations seven years ago. “We wanted to come out of the gate with this,” says Avdiu, “It was a good thing for us that we built all of our processes from scratch at the very beginning to accommodate real-time entry. The bad thing for us, at that time, was that we made a huge investment well before electronic records really took hold with LTC communities. Still, in hindsight it forced us to learn all the intricacies of interfacing with an electronic system: start dates, end dates, and a variety of other fields that are all important in terms of how the order will appear at the LTC community.”

Today, Avdiu estimates that half of the assisted living communities that Medication Management Partners serves are using some form of electronic record system. That’s good, but it leaves the pharmacy looking for a way to serve the other half as efficiently and safely as possible. This is where web portals come in, according to Avdiu. “For that half of the communities that isn‘t ready for eMARs yet, we look to a more basic web portal from SoftWriters called FrameworkLink,” he explains. “This gives a community an opportunity to experience what it’s like to have a web-based product that lets them do pretty much everything from printing records to entering and accepting orders.” It creates what Avdiu calls a crawl, walk, run situation, in which the pharmacy is able to demonstrate the value of electronic records to LTC communities and support them in evaluating their preparedness to then move on to a true eMAR system.

Harbor Pharmacy’s Jamie Branshaw has found that a web portal, QS/1’s WebConnect in this case, is a strong marketing tool. “We’re giving communities access to order refills, patient information, drug interaction checks, and reports on a range of devices with internet connections — everything from tablets to smartphones and workstations,” says Branshaw. He goes on to enumerate a variety of other tasks that the web portal allows, including processing credits or the return of medications and completing such forms as active medication, medication discharge, and medication reconciliation sheets. “Our web portal is proof to our LTC communities that we have the technology that the larger chains have,” he says.

Covering Your eBases

Returning to eMARs, the benefits are worth enumerating in detail and, it turns out, worth the effort for pharmacies to support products from multiple vendors. GoldStar Pharmacy integrates with several different eMAR systems, which according to A.J. Oben, is part of the pharmacy’s focus on medication management. “eMARs, number one, offer the visibility that we need to all the partners in the continuum of care,” says Oben, “and, number two, they really reduce the med pass time in the LTC community, which has a direct impact on efficiency and patient care.”

Cindy Lobeda notes that Midwest LTC Pharmacy integrates with four different eMARs, and concurs that they are a big time saver and play a central role in safety. “Paper MARs easily get out of date and are prone to mistakes,” she says. “An eMAR is correct 100% of the time.” As Lobeda describes the process, orders entered at the pharmacy are pushed out for acceptance by the LTC community in real time, and the community then knows exactly what to expect in a delivery. These interfaces also drive productivity when a resident needs a refill for something like a cream or eye drops. “The LTC community staff can just click a button to submit the request to us,” says Lobeda.

Taking into consideration the number of electronic records platforms out there, and with the trend toward electronic health records continuing, there’s a real need for LTC pharmacies to be neutral or, as Labi Avdiu puts it, “Switzerland,” when it comes to supporting these platforms. “We need to be able to take the approach that we will support all eMARs,” says Avdiu, “and that we’ll let the community pick. Selecting and implementing a digital platform at a community is a big decision and undertaking, just like selecting the pharmacy operating system is for a pharmacy. Therefore, it’s important that the decision is ultimately made by the end user.” The task of supporting a wide range of eMARs at Medication Management Partners is borne by SoftWriters, which Avdiu reports has done critical work in building up a robust interface protocol called FrameworkHL7. “This has been very important for us, because it means we can offer the highest level of service no matter which systems our communities are using,” says Avdiu.

And while we’re talking about electronic transmission of mission-critical information, it’s worth touching on e-prescribing. Jamie Branshaw reports seeing a complete shift into e-prescribing, driven in Harbor Pharmacy’s market by New York State’s requirement that all prescriptions be transmitted electronically. This trend has turned out to be a big boost to workflow efficiency, with a major assist from the ease with which QS/1’s PrimeCare handles these transactions, according to Branshaw. In fact, the switch to e-prescribing has helped increase efficiency so much in terms of entering orders that Harbor Pharmacy has gone from about 1,400 technician hours a month down to just 1,100. “And that’s not eliminating jobs,” Branshaw says. “We were just that much into overtime, late runs, late deliveries, and late orders processing.”

Set the Bar, Then Raise It Higher

As high as these pharmacies have been able to set the bar right now, it’s still not high enough for them. They are all actively looking for ways to push it higher. “What we’ve seen and responded to in the marketplace is the need for that extra level of service from pharmacies,” says A.J. Oben. “We should not be putting the medication management burden on the patient or the caregiver, for example by leaving it to them to call doctors for refills. At GoldStar Pharmacy, our goal is to manage the entire medication life cycle for the patient. This is a powerful message for us. The time is past for thinking of the pharmacy as just a fulfillment center.”

The ability to move to a higher level of partnership can come from new technologies as well as from getting more traction with what’s in play now. “One fundamental step,” says A.J. Oben, “is to make sure that the patients and communities we are serving know what we can do. Sometimes, they’ve done it one way for such a long time that it’s a real opportunity for us to come in and say, ‘Hey, with our technology we can upgrade you to multidose and make your med pass much faster and safer.’ And then, when we help them understand that medication management is at the core of our business, and that what we’re trying to do is make sure there is a continuous loop where the communication flows between patient, caregiver, physician, and pharmacy, well, then we have the ability to really win business across the board.”

Cindy Lobeda returns to a central fact when it comes to aiming high in LTC: It’s critical to have the tools you need to deliver the highest level of service, and to create a growth path. “Getting this right has made a real impact,” she says. “We used to have seven techs working to serve around 400 patients. Now we’ve got 1,100 patients and five techs.” Lobeda’s advice? Don’t be afraid to make investments to find that growth. “We have done very well by getting our packaging automation very early in our growth,” she says.

You also need to have the right interfaces available, notes Jamie Branshaw. With LTC contracts running three to five years, it’s critical for the pharmacy to be able to assure an LTC community that it can satisfy its requirements, fully integrate with its technology, and be ready to take next steps when the time comes over the course of the contract. “It’s an electronic-based world now,” says Branshaw, “so we’ve got to be able to connect with the systems out there.”

And having your operations really nailed down means that there’s more room for strategic thinking as well. For example, Jenny Reisdorph reports that Midwest LTC Pharmacy is rolling out a new program to support residents’ transitions back home, the ever-critical transition of care. “So many times when our residents leave a skilled care home or even assisted living, they have to have a family member go get their meds,” says Reisdorph. “And then, instead of our adherence packaging, there are 12 bottles, and they’re confused and they don’t know where to start. They don’t take the meds correctly, and then they end up back in the home or in the hospital.” As a solution, Midwest LTC Pharmacy will provide a 30-day long-term care discharge plan, with a full month’s worth of a patient’s medications delivered in strip adherence packaging. “We see this as a way to eliminate confusion during this time of transition back home, and to help prevent missed or skipped doses,” says Reisdorph. “Down the road, if this is successful, we would love to offer the same program for hospitals. For now we are focusing on the LTC residents we are serving because of how our pharmacy is licensed.”

Positioning the pharmacy for the future is also on Labi Avdiu’s mind. “One really important area of focus is healthcare quality and value-based reimbursement,” says Avdiu. “LTC pharmacies have an opportunity to drive quality through strong processes, monitoring, and reporting. We need to be able to show the data on how the populations that we’re managing are really doing. I think the foundation is there, the software is there, but there’s work to be done across the industry for us to be able to prove our value so that we’re not just looked at as a cost, but instead as an important component in the value chain.” CT

Will Lockwood is VP, Director of Editorial at ComputerTalk. He can be reached at will@computertalk.com.