From sophisticated formulary management to nuts-and-bolts compliance expertise, today's best consultant pharmacists have an arsenal of proven capabilities to help ensure positive outcomes and cost-effectiveness of patient care in long-term care facilities. But do physicians, nurses, and facility administrators really listen to their consultant pharmacists? A cross-section of fellow healthcare professionals talks about how they view consultant pharmacists' expanding role in the new, outcomes-based long-term care environment.

The evidence has been mounting for several years: The best consultant pharmacists have demonstrated the ability to move well beyond traditional drug regimen review to act as pivotal figures in orchestrating cost-effective, outcome-enhancing medication decisions for long-term care residents in a variety of settings.

Mounting research data and anecdotal evidence support the effectiveness of the consultant pharmacist in helping to fine-tune prescribing patterns, spark initiation of more cost-effective drug therapies, contribute to formulary design, and pave the way for the introduction of the best new pharmaceutical products-all critical functions in maintaining the balance between optimum pharmaceutical care for long-term care residents and sensible cost containment for facilities struggling to adapt to new health care realities.

Influencing Drug Choices

Much of the evidence of the profession's strategic importance has been gathered during the past few years. In a study of 10,207 long-term care facility residents conducted in 1995, Alison M. Johnston, RPh, et al. documented a 68 percent rate of acceptance among prescribers of consultant pharmacist recommendations regarding changes in drug therapy. Forty-three percent of these interventions resulted in cost savings, leading to a total cost reduction for the facilities of $15,111 in a one-month period, or $18.70 for each accepted pharmacist recommendation. Accepted recommendations resulted in favorable health outcomes in 99.5 percent of cases.

The list goes on: A study published in the May 1990 issue of the Journal of the American Geriatrics Society concluded that face-to-face educational interventions between consultant pharmacists and physicians can effectively improve prescribing patterns. A report published in the July 1995 issue of the American Journal of Health-System Pharmacy documented the effectiveness of a team of consultant pharmacists in encouraging more economical and effective anti-infective prescribing among physicians. Results of a prospective open-label, repeated-measures study of diabetes mellitus patient outcomes published in the January 1995 issue of The Consultant Pharmacist concluded that consultant pharmacist interventions regarding drug therapies significantly reduced rates of hyper- and hypoglycemia in two nursing facilities.

And in a study published in the June 1994 issue of The Consultant Pharmacist, the frequency with which prescribing physicians accepted consultant pharmacists' recommendations to alter patients' drug therapies was determined in a non randomized, prospective study of all patients admitted to a skilled nursing facility over a 12-month period. In 63 percent of the cases examined, physicians altered patients' drug therapies as recommended by pharmacists.

"Consultant pharmacists are a definite influence in shaping physician prescribing habits in the nursing facility," says one manager of industrial affairs for a major pharmaceutical manufacturing company. "The typical physician doesn't spend very much time in the nursing facility due to the number of patients he sees in his private practice. He often looks to the registered nurse and the consultant pharmacist for advice in selecting medications."

The Double-Team Approach

Eugene Bonham, MD, a psychiatrist working with long-term care facilities, corporations, and consultants in the Dallas-Fort Worth area, says that his close professional relationship with consultant pharmacist Fred Wendt, RPh, FASCP, has been a valuable asset in working with long-term care nurses and facilities. "Fred and I 'double-team,'" explains Bonham. "We complement one another's functions, consult on clinical aspects of medication issues, and lend weight to one another's recommendations."

Bonham points out that by working together as patient advocates, he and the pharmacist have made a dramatic difference for residents. Bonham adds that though OBRA regulations happen to be his area of expertise, "most physicians look to the consultant pharmacist to back them up with a thorough knowledge of the regs."

Nancy Cotharn, RN, director of nursing at the 120-bed Wedgewood Nursing Center in Fort Worth, agrees that Wendt has been instrumental in helping the facility moderate the use of psychotropic medications and secure good follow-up documentation for medications that are working. "Fred really knows his regs," says Cotharn, "and he's right there if he sees something, but he's not just trying to lower dosages-he looks at the whole patient, the whole situation. Fred is not there simply to see if our narcotic count is right-he goes way, way beyond that, not only in his personal attention, but in his ability to help nursing staff access the latest medication information and other experts. Nurses are hungry for information, and Fred is a key part of giving us that information."

Bruce Ferrell, MD, who works with the Veterans Administration in Los Angeles, includes some home visits in his practice. "I count on consultant pharmacists to sort out compliance issues for my patients," says Ferrell. "They sit down with the patients and their grocery sacks full of medications, find out what medications they are taking, and build a total medication profile. I find this essential in helping me provide the best patient care."

Nancy Zytkowicz, RN, director of nursing at Lakeview Gardens, a nursing facility in Kirkland, Washington, counts on her consultant pharmacist to act as another set of eyes in areas such as looking at costs, organizing information for audits, and making sure that medication therapy is the most effective possible to ensure shorter stays. "I have to compare costs," says Zytkowicz, "and I absolutely can't waste money, since state assistance is so limited. I really depend on the cost analyses from my consultant pharmacist."

Cotharn concurs: "We see managed care and possibly Medicaid block grants coming, along with capitated payment systems, and our consultant pharmacist helps us control costs by making sure that all medications and dosages are necessary. He makes sure there's a diagnosis for every medication."

Don't Just Sit There

Rick Smith, MD, who works at the Jewish Homes for the Aging in Los Angeles, says he appreciates consultant pharmacists who "come up with ideas for drug use evaluations on their own, actually do the DUE, and then document its usefulness." He expects pharmacists to collect and present data to the physician in a meaningful manner. "Come up with ideas, take the lead," he suggests. "Drug regimen review is just a monitoring function. I expect a lot more, such as computerized quality improvement data presented graphically via spreadsheets, histograms, and control charts."

Smith points out that many physicians don't have a good grasp of new medications, and they look to consultant pharmacists to fill the gap. Zytkowicz agrees: "We have a large facility with a lot of complicated patients receiving multiple medications. We count on our consultant pharmacist to keep us informed about the latest new drugs, to keep up with the literature in the field of pharmacy, and to communicate that information to us. We can't learn this out of books-we need a human being out there."

Grant Lawless, MD, PharmD, who works in a managed care environment, counts on his consultant pharmacists to help implement disease management programs, create physician profiles, and provide strong input on formulary development. He suggests that consultant pharmacists have a unique role to play in the new health care arena: "Become experts in the newest drugs and in pharmaco-economics," he urges, "and develop ways to share this information with the physician and the facility."

Making the Most of Formulary Management

Strong anecdotal evidence suggests that one of the most effective strategies today's consultant pharmacists use to minimize costs and maximize effectiveness of drug therapies in long-term care is formulary management. A prototype study conducted in 17 long-term care facilities in 1993 by Marcia Palmer, RPh, et al., "Introducing a Formulary System in Long-Term Care Facilities," formed one of the bases for a number of subsequent studies, many of them proprietary, documenting consultant pharmacists' effectiveness in directing medication choices in nursing facilities. The Palmer study was published in the March 1994 issue of The Consultant Pharmacist.

"The responsibility of the consultant pharmacist for containing costs in the long-term care facility is rapidly resembling that assumed by pharmacists for some time in most hospitals," concluded the study's authors. "When the therapeutic factors are comparable and several drugs in a selected category can effectively produce the same outcomes, the determinant may be the drug with the lowest cost"-an area in which the consultant pharmacist holds the key to guiding the facility toward effective management of drug costs.

However, Palmer cautions that formulary management systems should not be allowed to minimize the collegial relationship among pharmacists, physicians, and nursing staff. "One concern of mine centers around the tendency in the long-term care setting to push for immediate results," says Palmer. "My original work in hospitals with form-ulary development took time, and we insisted on emphasizing and developing the colleague-to-colleague relationship between pharmacist and physician."

Palmer says that physicians and nurses must be able to have confidence that the pharmacist has the patient's interest at heart-difficult to do under the influence of a mentality that concentrates too much on quantifiable, quickly achievable results.

"The physician must have some contact with the reasoning behind the pharmacist's recommendation," says Palmer. "You need that relationship with the docs, in order to help them understand the clinical basis of your formulary choices."

Up Close and Personal

Cotharn has made a personal effort to make sure that her consultant pharmacist and her physicians have more than a speaking acquaintance. "Once every six months, we all go out to lunch-administrators, physicians, and consultant pharmacists." The consultant pharmacist may update the physicians on the regs, or remind staff that they've overlooked a lab, but the meeting is primarily an informal one. "I've heard about consultant pharmacists not being seen as a friend, or being looked at as if they're 'checking up' on a facility," says Cotharn. "We don't hide from our consultant pharmacist; in fact, he teaches us all."

Kathleen Y. Riley is Associate Editor.

Copyright © 1996, American Society of Consultant Pharmacists, Inc. All rights reserved.