Vicki Meade

Today, consultant pharmacists focus not so much on where patients receive care, but on the goal of improving patients' health and quality of life, wherever they are. With pressure to provide efficient, cost-effective care and avoid devastating medication-related problems growing stronger every day, they're finding niches they never considered when consultant pharmacy first emerged as a distinct sector of pharmacy 30 years ago.

For years in long-term care I was looking at charts, very rarely talking to residents. Now, in assisted living, we need to involve residents in their care.

Assisted Living: The Sky's the Limit

Although traditionally in the long-term care market, nurses have been heavily relied upon to communicate consultant pharmacists' recommendations to physicians, in assisted living, pharmacists must "go directly to the doctor to get anything accomplished," Darling explains. This is especially challenging given that physicians typically see the residents at their offices, not at the assisted living facilities; thus pharmacists have no opportunity to confer with them where the patient resides. Also pharmacists who consult for assisted living facilities must remember to get residents' approval for access to their medical records-a step that skilled nursing facilities handle themselves.

"Getting closer to the resident again is exciting," Darling says. "For years in long-term care I was looking at charts, very rarely talking to residents. Now, in assisted living, we need to involve them in their care." She also enjoys offering wellness clinics to explain how residents can better care for themselves. "I find this 'well' model, as opposed to the 'sick' model, very positive," she says.

Roger Klotz, FASCP, president and chief executive officer of Tustin, California-based Specialized Clinical Services, Inc., is "aggressively marketing to a number of senior centers and assisted living programs because I believe this is a great opportunity to provide enhanced care in this growing area." He notes that many for-profit organizations and entrepreneurs are building new facilities because they recognize that the aging of the baby boomers will create an increased need for senior apartments and assisted living.

"As therapy improves, but becomes more complex, there will be increased need for supportive care, but not with the intensity of a skilled nursing facility," Klotz says, noting that this trend will expand the need for consultant pharmacists' services. Even when the elderly have chronic diseases, they and their families will want to maintain independent living and avoid places that have an institutional appearance. "Assisted living allows seniors to maximize their independence and, at the same time, receive much-needed supportive care." Unlike in nursing facilities, where pharmacists are accustomed to a consulting format based on chart review, assisted living calls for a personal-care, community-based practice format, Klotz says. He points out that moving into this new area will allow pharmacists to market more clinically focused services, such as laboratory services, immunization programs, and direct patient consulting.

Mark Rhoads, FASCP, consultant pharmacist manager for SunScript Pharmacy, Tempe, Arizona, also believes that assisted living will continue to offer many opportunities for consultant pharmacists. "Until recently, most states have not required a consultant pharmacist review in assisted living facilities, but some states are now requiring at least a quarterly review of each resident's medications." These reviews allow pharmacists to monitor the level of psychotropic medication use and help prevent related falls and fractures. They also increase the likelihood of detecting adverse drug reactions, he explains.

Rhoads, like Darling, is finding that assisted living facilities are developing wellness centers that provide an opportunity for pharmacist involvement. He believes that more pharmacists will also take part in disease state management and patient education in the assisted living population, helping to control such chronic conditions as diabetes. (For more information on wellness programs, see the January 1999 issue of The Consultant Pharmacist.)

Among the challenges associated with consulting in assisted living facilities, medical records available on site are not as extensive as in skilled nursing facilities. "Many times," Rhoads says, "diagnoses for medications are not found in the records. Laboratory findings may be at the provider's office but are not in the resident's medical record at the assisted living facility." Communication between the facility and the provider's office is not as direct as in traditional nursing facilities, and in some states, staff at assisted living facilities do not need to be licensed.

A great area of concern, Rhoads notes, is the need to develop new mechanisms for reimbursing consultant pharmacists for their services. He emphasizes that "outcomes will need to be collected that demonstrate our overall impact in the assisted living environment."

There's high use of consultant pharmacist services in subacute care units already, but how they are used will change.

Subacute Care: Proving Ground for Prospective Review

Freeman expects that growth in the number of subacute care units will slow down, but the need for such care outside of hospitals will continue. "There's high use of consultant pharmacist services in subacute care units already, but how they are used wi0ll change. In the past, pharmacists reviewed the medication regimen after the fact, but what must happen now with subacute care is a prospective look. For each patient, pharmacists will need to pre-plan with the facility-looking to see what kind of drug therapy the patient is receiving, what the projected length of stay is, and what the cost of drug therapy will be over time. This is definitely an opportunity for pharmacists to have more input into the patient's care, and they will work more closely than ever with the facility."

The greatest challenge in subacute care, Freeman says, is finding the best drug therapy for patients while keeping costs firmly in mind. "The pharmacist has to help the facility determine the most cost-effective medication," he says, "which means looking at factors such as route of administration. For example, if a doctor orders an I.V. drug, you may want to recommend discontinuing it and going to an oral drug. But you've really got to look closely at the whole picture, because sometimes the cheapest drug is not the best."

Armon Neel, Jr., FASCP, president of Griffin, Georgia-based Institutional Pharmacy Consultants, characterizes subacute care as "a wonderful place to toot your horn so it is heard loud and clear." He predicts that it will be a high-growth area of practice because "input in the delivery of cost-effective drug therapy management can only be done consistently by the consultant pharmacist." However, key players in the health care system need to get the message that "the drug doesn't control the cost as much as expert clinical intervention" by consultant pharmacists. "If pharmacists can't convey this message effectively," he adds, "we will be hurting for jobs."

For subacute care to be an important area of expansion for consultant pharmacists, they must "become more aggressive in their approach to consulting, looking at the drug therapy and determining what combinations of chemistry will provide optimal outcomes at the lowest cost," Neel says. He recommends that consultant pharmacists earn credentials validating their expertise in specialized areas of drug therapy and that they become "facilitators of drug utilization," giving advice on all aspects of care that relate both to drug therapy and other interventions that have a bearing on therapeutic response. A skilled consultant pharmacist should be able to return to the facility as much as 10 times what each of his or her visits cost, Neel says. "The positive outcomes demonstrated by this aggressive approach to pharmacist care and the tremendous amounts of health care dollars saved as a result will bring about a renewed perception in the solid value of consultant pharmacist services."

For Neel, the pluses of practicing in the subacute care area are many. He feels rewarded by "seeing positive patient outcomes from the decisions I make, being paid appropriately for the services I render, receiving respect and appreciation from the patient and families, proving to the system how much they need the valuable services of the consultant pharmacist, and knowing that I am a true member of the professional health care team."

Outcomes Research: Documenting Value

In his own outcomes-focused research, Cooper is concentrating on the areas of adverse drug reactions (ADRs) that often lead to hospitalization of nursing facility residents: NSAID-induced gastropathy, psychotropic-related falls and injuries, diabetes mellitus treatment, hypoglycemia and hyperglycemia, and dehydration due to overuse of diuretics.

But ADRs are far from the only problem in elderly patients that consultant pharmacists can help solve. Making sure that patients are not undertreated and that they do not receive the wrong drugs for preventing stroke, heart attack, heart failure, depression, dementia, osteoporosis, and malnutrition are also crucial areas for consultant pharmacist input-and documentation of outcomes to demonstrate their value. "Research clearly establishes in specific areas that without consultant pharmacist intervention-and acceptance of those interventions by other health care providers-patients do not receive the best possible pharmacotherapy," Cooper says.

He admits that it is challenging for consultant pharmacists not only to follow up on the recommendations they have made, but also to measure the outcomes, such as gains or losses in quality of life and cost, associated with the acceptance or rejection of their recommendations. The rewards of such work include "simply observing patients' improved cognition when their psychoactive drug load is reduced," Cooper says, as well as adding to knowledge that helps reduce adverse consequences of drug therapy, prolong patients' lives, improve quality of life, and save money for the health care system.

Cooper admits that it is challenging for consultant pharmacists not only to follow up on the recommendations they have made, but also to measure the outcomes.

Infusion Care: Small Providers Welcome

To provide home infusion therapy, consultant pharmacists may need additional, specialized training, or they may need to bring on a new staff member with infusion expertise, but the payoff, besides expansion of services, is taking part in collaborative care planning in which the pharmacist interacts as a team member with physicians and with nurses who do the hands-on home care.

Tortorici, who has been involved in home infusion therapy for 15 years, notes that reimbursement has changed recently, reducing compensation. Although this is a major issue for large home infusion companies, "I see the regional and local providers really capitalizing on this," he notes. "They don't have shareholders expecting growth and earning statements, there are no analysts watching their performance, and they can function with margins that are significantly lower than the large corporations." He says that third-party payers may look for organizations that can provide services to both long-term care and home care populations. "If they're looking to contract with pharmacy providers, you can offer a nice package."

The most common drugs administered in home infusion therapy are antibiotics, followed by agents for pain management and enteral and parenteral nutrition formulations. "There may be a resurgence of chemotherapy, as well, since Medicare is changing reimbursement to physicians for this," Tortorici notes. The key reward of providing home infusion care is "you can actually see your patients get better," Tortorici notes. One success he's most proud of is providing total parenteral nutrition for five months to a woman with hyperemesis during pregnancy. "She delivered a full-term, healthy baby," which made him feel great. He cites the feeling of accomplishment, the chance to monitor patients, and in some cases, to get to know them personally, as motivations for providing home infusion therapy. "You have the opportunity to be involved with patients if you're comfortable with that, but you have the choice." He also believes that demonstrating patient care skills and knowledge by providing home infusion helps "elevate the practice of pharmacy to a higher level."

Disease Management: A Nice Fit

A few years back, when disease management was a new concept, getting physicians to accept the approach was a hurdle many pharmacists had to overcome. Now the challenge is remembering to document activities and results appropriately so they add to the body of knowledge about the benefits of specific activities and therapies. "It's a time issue more than anything," Hollenack says. A big payoff is "finally being able to show clinical significance for what we're doing on a day-to-day basis and just knowing that we're improving patient care," she notes. Studies involving two of her programs-one for congestive heart failure and the other for osteoarthritis-have shown favorable results in terms of reducing costs and complications.

Michael Geeslin, of Managed HealthCare Pharmacy, a division of OmniCare based in Springfield, Missouri, notes that his company has implemented four disease management programs in its nursing facilities targeting residents with congestive heart failure, depression, atrial fibrillation, and osteoporosis. The programs focus on clinical assessment and evaluation, treatment options, current standards of care, and outcomes data. "I expect that this trend will continue to develop in the next few years and will change the face of how we consult in nursing and assisted living facilities." He lists an alphabet soup of health care organizations that are intensely interested in documenting the value of disease management. "The PPS payers, Medicare fiscal intermediaries, assisted living provider sponsored organizations, and the Joint Commission on Accreditation of Healthcare Organizations will invariably all require outcomes data for payment and accreditation."

To implement disease management programs effectively, you need solid acceptance from the top down, Geeslin says. "The consultants and operations staff must be on the same page or else the system will have many complications and barriers to overcome. The facility must also embrace this new direction and understand that we are able not only to provide valuable information for the staff, but also to improve the residents' care."

However, as Hollenack notes, time is a challenge. "To successfully implement a program that includes appropriate data collection and individual resident assessment, your time to devote to disease management is limited," Geeslin says. "You must schedule in-services, meet with physicians to explain programs and goals, take time to meet individual residents and family members to facilitate communication and compliance, and collect outcomes data."

The rewards of implementing a disease management program hinge on how well the above steps are put into effect, as well as the cooperation offered by providers and nursing facility administrators. Gaining trust from a facility, provider, or resident is an intangible reward; more concrete is the competitive advantage that providing disease management and collecting outcomes data will ultimately give a facility, Geeslin says.

The consultants and operations staff must be on the same page or else the system will have many complications and barriers to overcome.

Correctional Facilities: A Stable Market

In correctional facilities, health care takes place in two primary settings: jails and prisons. Except when prisons become overcrowded, jails generally house inmates waiting to be sentenced. The usual length of stay is under two weeks. Prisons contain inmates who have committed crimes that lead to lengthy sentences, averaging four to six years. "This in itself causes a unique challenge," Steres says. "If a consultant pharmacist reviews a chart while the inmate is incarcerated in a jail, it is likely that by the time a physician can respond to the pharmacist's recommendation, the inmate is out on bond. Therefore, most consultant pharmacists who practice in a correctional setting are usually involved with prisons. The most effective pharmaceutical consulting for a jail setting is to incorporate it as a part of prospective review of medication orders prior to dispensing."

The primary reward of consulting in correctional facilities, Steres says, is "the ability to share our clinical knowledge in caring for a sector of our population that usually doesn't have the luxury of receiving necessary clinical input from other qualified health care professionals."

The primary challenge in treating ICMR patients stems from their problems with language, communication, cognition, and environmental perception.

ICMR: An Area of Unmet Needs

Kidder believes that savvy pharmacists could find niches and fill important needs as deinstitutionalization moves forward. "Say you have a patient with a seizure disorder who is moved from the suburbs to a rural area, where the local family practitioner isn't familiar enough with the intricacies of this condition. A knowledgeable pharmacist could prevent that seizure disorder from getting out of control." Although the number of drugs dispensed in the ICMR population is declining, Kidder believes "there will be a lot of need for pharmacy consultation. It won't be mandated, however," which suggests that pharmacists must identify unmet needs and step in to fill them.

The primary challenge in treating ICMR patients stems from their problems with language, communication, cognition, and environmental perception. "This gives rise to behavioral symptoms, so the big challenge is to figure out what's causing those symptoms-Is the room temperature too high? Is there too much noise?- before you start drugging the resident. Pharmacists can make a major contribution in this area," Kidder says. "And overall, the reward is that you're serving humankind."

Elizabeth Emma, FASCP, a consultant pharmacist with Pharma-Care, Inc., Clark, New Jersey, who serves an all-male developmental center in nearby Woodbine, agrees that ICMR will not be a growth area in any classic sense, but may still provide opportunities. "The philosophy behind moving individuals out of institutions and into the community is to allow them a more natural living situation and to save money. The responsibilities of pharmaceutical care then fall to the community pharmacist. Although I mean no disrespect to my friends and colleagues in retail pharmacy, their scope of practice may not always accommodate the needs of my more fragile clients."

So far, Emma says, efforts to sell consulting services to community settings that care for developmentally disabled people have been mostly unsuccessful. "But Pharma-Care has provided services to individuals in group homes in cases in which the client's family saw the value of the service we provide and were willing to pay for it out of pocket."

Emma loves working in her developmental center, "mostly for the intangible benefits," she says. "First of all, the clients tend to live in the facility for decades, so I really get to build caring relationships with many special patients. Many have little or no family contact, so staff and consultants like myself become the resident's surrogate family. Second, there are numerous opportunities for expanding and utilizing my clinical skills. Many other professionals-dietitians, physical therapists, speech therapists, occupational therapists, physicians, nurses, and others-are willing to share what they know for the common good of the client. The residents present with a huge variety of diagnoses, syndromes, and complications, so I must constantly expand my own knowledge to optimize my contribution to each man's care. Many of my clients do not have the ability to communicate verbally, and it is often difficult or impossible to find literature with answers to problems that a client's condition raises. So there's plenty of opportunity for creative problem solving.

"Finally," Emma says, "unlike my colleagues who practice in nursing facilities, I work full-time in one developmental center with 600 residents. Being in only one location allows me the time to get really involved in the facility and the lives of the residents. I can initiate programs that are time intensive whenever I feel that clients will significantly benefit. I make morning rounds with the doctors, round weekly with the consultant psychiatrist, am actively involved in many committees that directly affect the care of the clients, and I conduct drug use evaluations that generally result in modification and improvement in client care."

Voids in health care become new areas of practice for pharmacists willing to move into new territories and demonstrate their value.

Seizing Opportunity

Neel, for one, is very excited about the broad palette of practice options open to consultant pharmacists today. His comment on each of the settings described here was the same, like a mantra: "Great place to prove your worth."

Copyright © 1999, American Society of Consultant Pharmacists, Inc. All rights reserved.