Institutional Pharmacy Provider Services Outside the SNF Walls

Patients in skilled nursing facilities (SNFs) receive specialized medication management services from institutional pharmacy providers (IPPs) and consultant pharmacists. These IPP medications management services are needed to address the complex needs of the older adult population who require long-term services and support in SNFs as well as the increasing number of adults with these needs receiving home-based care. This population often has multiple chronic medical conditions and disabilities or impairments, which may require specialized care and coordination. According to the US Centers for Disease Control and Prevention (CDC), up to one in every four (27%) US adults has some type of disability, and just over 18 million US adults have disabilities or impairments that usually require assistance with instrumental activities of daily living. This population typically takes multiple medications, a trend that has sparked a growing demand for outpatient medication management services to ensure optimal care and outcomes.¹

In recent years, there has been a significant increase in postacute (PAC) and long-term care (LTC) services being delivered in the home vs SNFs. This shift is being driven by both changing financial incentives as well as patient preferences. Under new value-based payment models, Managed Care Organizations (MCOs) and Accountable Care Organizations (ACOs) are responsible for PAC costs, which drives motivation to pursue lower-cost home and community-based care options, when appropriate, to reduce spending.² Furthermore, negative perceptions of nursing homes have grown considerably following the COVID-19 pandemic, during which over 200,000 residents and staff died from the virus; facilities were criticized for inadequate infection control and restrictive policies.^3,4 More than 70% of older adults say they are unwilling to live in a nursing home in the future, with most vastly preferring care at home.⁵ In addition to consumer demand, growth in home- and community-based services, which are funded by such sources as Medicaid waiver programs, provide resources to enable care at home rather than in facilities.⁵ New models, such as the Program of All-Inclusive Care for the Elderly (PACE), also aim to meet needs in the community. The combination of financial incentives, patient preferences, and expanding home care options is leading PAC/LTC services to shift dramatically toward home- and community-based settings and away from nursing facilities.

The current medication issues in the PAC/LTC population at home include poor compliance and adherence to medication regimens, medication duplication, inappropriate dosage, drug-drug interactions, low health care literacy, and verification that they are on the most efficacious and cost effective drugs for their disease states.⁶ Many patients with PAC/LTC needs struggle to adhere to their medication schedules, which can lead to suboptimal outcomes and increased health care costs. Some of the challenges in medication adherence result from a lack of understanding of one’s medical conditions or medication regimen. In addition, the high prevalence of polypharmacy among this population poses a risk of adverse drug interactions and medication errors.⁷ There is a need for comprehensive medication review, coordination among prescribers, and person-centered support to address these gaps.

Groups that are at financial risk, such as MCOs, ACOs, and PACE organizations, are responsible for the clinical and financial outcomes for patients who often have complex pharmacy regimens, multiple chronic health conditions, and frequent interactions with health care providers. By addressing medication-related risks and optimizing medication use, IPP services can potentially reduce health care costs and improve outcomes for this at-risk population.

IPPs employ a range of strategies and services to meet the needs of patients with PAC/LTC needs who received care at home and community-based settings. These are discussed below.

IPP are required to provide medication regimen review (MRR) services at least monthly to all SNF residents. Although PAC/LTC patients at home have these same needs, this requirement exists only within the SNF walls. In the community, medication management requirements fall under Medicare Part D, which is limited to medication therapy management (MTM) services, which are far different from MRR. The Table illustrates the significant differences between MRR and MTM in every aspect despite the similar needs they aim to serve. In fact, the case can be made that medication management needs are greater in the home setting because these patients do not have 24/7 nursing care and oversight available within SNFs.

Table. A Comparison of Medication Regimen Review vs Medication Therapy Management

MRRs by consultant pharmacists have been shown to improve health care outcomes across settings, including SNFs. MRRs are associated with reduced rates of adverse drug events, unnecessary medications, polypharmacy, and medication errors for older adults.⁸ By systematically reviewing entire medication regimens monthly, consultant pharmacists can optimize therapy, identify duplications or interactions, adjust dosages, and reduce the risks of inappropriate medication use. A recent study conducted comprehensive medication reviews for older, medically complex home-based primary care patients and found a high rate of potentially inappropriate medications, resulting in many accepted recommendations for deprescribing and dose adjustments. Integrating pharmacists into home-based care may improve outcomes.⁹ Attention to medication reconciliation, polypharmacy, and discontinuation of high-risk medications when not indicated can help reduce readmissions from PAC facilities. Interventions should focus on medication safety both during hospitalization and after discharge to skilled nursing and rehabilitation facilities.¹⁰ One study found that 16% of hospital readmissions within 30 days were medication-related, with 40% of those being potentially preventable, indicating that more attention paid to medication safety could help lower readmission rates.¹¹

Beyond MRR or MTM services, additional necessary services that are available to SNF residents would also benefit PAC/LTC patients receiving home-based care:

• Special medication packaging and delivery: IPP use specialized packaging systems that organize medications by time-of-day to reduce caregiver burden, promote adherence, and minimize the risk of medication errors. They also provide home delivery services through courier services, ensuring timely access to medications.
• Medication synchronization: IPP services synchronize medication refills to reduce complexity and ensure that patients receive all their recurring prescriptions on the same day. This helps improve medication adherence and reduces the risk of missed doses.
• Education: IPP services prioritize patient, family, and caregiver education to enhance medication understanding and adherence. They provide counseling and support, ensuring that all parties involved in medication administration have the necessary knowledge and resources, thereby improving health care literacy.
• Emergency delivery and 24/7 pharmacy services: IPP services include emergency home delivery services to provide rapid access to medications during crises. They also provide round-the-clock access to an on-call pharmacist, ensuring that questions and concerns can be addressed promptly.

IPP medication management services offer a transformative solution for at-risk provider groups. By leveraging comprehensive services such as MRR, specialized packaging, medication synchronization, education, and emergency delivery, IPP services empower providers to enhance care coordination, improve patient outcomes, and reduce health care costs. Implementing IPP services streamlines medication management, reduces errors, increases medication-related knowledge, and improves medication adherence among patients. This leads to better health outcomes, fewer hospitalizations, and cost savings. By partnering with an IPP, providers can tap into specialized expertise, advanced technologies, and personalized care plans that optimize medication regimens.

Moreover, IPPs understand the financial risks associated with suboptimal medication management. By addressing medication-related challenges, they help providers mitigate risks and deliver value-based care. This results in improved patient satisfaction, caregiver support, and reduced emergency department visits and medical expenses.

Incorporating IPP services into the care continuum enables at-risk provider groups to deliver integrated, patient-centered care in home and community-based settings. It enhances medication management, patient safety, and adherence while maximizing operational efficiencies. Partnering with an IPP is an investment in improved patient care, reduced health care costs, and increased operational efficiency. By embracing IPP services, providers can optimize medication utilization and achieve better clinical and financial outcomes for their vulnerable patient population. Given the drive for value-based care and increasing number of PAC/LTC patients in the community, the time is right for IPP services at home.

Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD¹1 • Jen Devinney-Lavsa, BPharm, PharmD, FASCP²

Affiliations:

¹Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, PA

²GraneRx, Pittsburg, PA

Disclosure:

The authors report employment with GraneRx.

Address correspondence to:

Richard G. Stefanacci, DO, MGHm MBA, AGSF, CMD

Email: Richard.Stefanacci@Jefferson.edu

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