Helpful Ideas

Tooling Around the State Survey

Problem: Recent revisions to the Health Care Financing Administration’s (HCFA) Nursing Home Survey Procedures and Interpretive Guidelines have made our client facilities nervous that the usual drug regimen review is not enough when it comes to reviewing for inappropriate medication use in the geriatric patient. Solution: To help nursing facilities gain the upper hand on inappropriate medication use, we’ve developed a new reference tool listing all medications deemed generally inappropriate for elderly patients and their potential for causing severe adverse reactions in various clinical situations.

One of the most significant events in the practice of consulting pharmacy in 1999 was the revision of the HCFA Nursing Home Survey Procedures and Interpretive Guidelines. One of the second most significant events of 1999 was our creation of the “HCFA Tool” to sort out the revisions; specifically, the sections on medications deemed inappropriate for the geriatric patient and the “Beers list.”

In 1997, Mark Beers, MD, published “Explicit Criteria for Determining Potentially Inappropriate Medication Use by the Elderly” in Archives of Internal Medicine. His article validated the criteria for medication use deemed inappropriate in the elderly population (defined as all persons more than 65 years old). In addition, he discussed medication use deemed inappropriate in the elderly known to have any of 15 common medical conditions. Dr. Beers validated in practice what consultant pharmacists have long employed in theory with regard to the monthly drug regimen review (DRR)—even before HCFA decided to modify its regulatory guidelines to surveyors.

Tool Time

New state surveyor quality targets that went into effect July 1, 1999, created a need in our nursing centers for assurance that pharmacy was doing something beyond the routine DRR. We developed the “HCFA Tool” for use in identifying the medications deemed inappropriate for the elderly and the reasons underlying such inappropriate use.

The tool merged HCFA’s revisions with known risks and the rationale behind the risks (e.g., potential adverse outcomes). HCFA exemptions also were defined, where applicable, and emphasis was placed on medications with a high potential for severe adverse outcomes (Unnecessary Medications—F329) and a high potential for less severe adverse outcomes (Pharmacy Services—F428, F429).

In July of this year, consultant pharmacists circulated the tool in our nursing centers, and a mailing went out to all of our prescribing physicians. As a pharmacy provider, we have already begun to experience the focus of state surveyors on many aspects of the new revisions in the regulatory guidelines and, in fact, have learned some lessons the hard way.

HCFA Tool Hammers Home the Lesson
With more responsibility falling on the consultant pharmacist to report any and all deficiencies or trends, it is more important than ever that we understand all aspects of the revisions, including:

• Medications deemed inappropriate for the elderly
• Patients on more than nine routine medications
• Medication errors during the medication pass
• Medication pass in the dining room

We have found that the key to understanding revisions to the guidelines lies in our “HCFA Tool.” It seems that others agree, as the response to our “HCFA Tool” has been positive from nurses and physicians—and even some consultant pharmacists beyond Heartland Healthcare Services. We trust you will find it useful, as well.

Pamela Black, PharmD, CGP, FASCP
Manager of Clinical Services
Heartland Healthcare Services
Toledo, Ohio

Share Your Great Ideas! Have you developed a novel patient care technique, a time-saving documentation form, a new aid to inservice education or interdisciplinary collaboration, or some other innovative practice tool or program? If so, why not share it with your colleagues in Helpful Ideas? Send contributions to Senior Editor Barbara Eilenfield, 1321 Duke Street, Alexandria, VA 22314; or call 703-739-1300, ext. 134, for assistance in turning your great idea into a practical article that will help others in the field.

Editor's note: The medication monitoring reference tool presented in this article represents one consultant pharmacist's approach to helping client nursing facilities achieve compliance with medication-related provisions of the recently revised HCFA survey procedures. While this reference tool has proven to be a valuable aid to medication management in the author's practice, its publication in The Consultant Pharmacist is intended only to provide broad guidance to others seeking to develop similar monitoring tools and does not constitute endorsement by ASCP.