David K. Buerger
For the nation's estimated 800,000 residents of assisted living facilities, a population with high rates of poly- pharmacy and chronic disease, wellness programs offer a new way to assume a greater measure of control over their own health, to stave off functional decline, and to stay in a residential care setting as long as possible.
For owners and operators of assisted living facilities, wellness programs represent nothing less than a vital link to continued profitability. By partnering with health services companies with proven track records in senior care, they can offer residents a level of preventive services and pharmaceutical care far beyond the scope of their own clinical, technological, and staff resources. Already a top drawing card for attracting and retaining new customers, wellness programs are also viewed by assisted living providers as a key pathway to enhanced operating efficiency and reduced overall treatment costs-increasingly important considerations as more states move to implement or expand Medicaid reimbursement for their services.
Diversified pharmacy services providers are proving to be willing and able partners in the wellness arena. For these companies-NCS HealthCare, NeighborCare, Omnicare, PharMerica, and others-wellness programs present an exciting opportunity to integrate their impressive clinical databases and medication management capabilities, a chance to pioneer and refine innovative strategies for prospective medical review and proactive pharmacist intervention still not feasible in the skilled nursing care setting.
For individual pharmacists, wellness programs offer an opportunity to be at the very center of an innovative team approach to comprehensive health promotion and disease prevention.
Pharmacy providers, while sensitive to the need to operate within a broad multidimensional definition of "wellness," naturally are emphasizing the clinical side of wellness and the paramount importance of adept medication management and monitoring and compliance-enhancing education in the overall equation. They're convinced, and are now working to convince assisted living purchasers, that optimization of drug therapy for assisted living residents is an essential prerequisite for progress in all the other areas.
Chuck DiTrapano, vice president of Omnicare's operations group, says the Covington, Kentucky-based company has built its new "HealthyOutlooks" wellness program on several basic premises: "that assisted living residents are an at-risk population, with relatively high rates of inappropriate prescription and over-the-counter medication use; that many suffer from one or more chronic illnesses but have not been receiving coordinated medical care; and that many may also have one or more undiagnosed disorders." Bringing these residents up to speed, DiTrapano says, entails a three-pronged process of data gathering and risk assessment, initial and ongoing drug use evaluation (DUE) to ascertain the appropriateness of current drug therapy, and continual assessment and modification of various risk factors for physical, mental, and functional decline.
Because assisted living residents often have the same chronic diseases that are common in nursing facilities, Omnicare's wellness program, like others developed to date, has strong elements of resident assessment, medication review, and disease management. "Essentially, we're taking what we've learned about disease management in the skilled nursing facility and bringing it into the assisted living setting," DiTrapano says.
But it's DUE and disease management with a new twist. "In the skilled nursing facility, disease management involves refinement of appropriate treatment. In assisted living, it involves risk identification and refinement of preventative approaches," he explains.
Initial assessment, or "move-in," services begin with a face-to-face consultation with a pharmacist. Residents are asked to complete a health questionnaire eliciting information such as nutritional status, body mass index, functional status, activities of daily living (ADL) deficits, and other information used to develop a "probability of [resource] utilization score," Daschner said. The goals of initial assessment are to appraise general health risk, to assess ability to self-manage medications, to categorize the risk of adverse drug reactions, and to identify undiagnosed or poorly controlled chronic diseases and conditions such as diabetes, hypercholesterolemia, hypertension, and memory loss. Residents whose assessments reveal polypharmacy are scheduled for a follow-up consultation and "brown bag" medication review. Those identified as being at high risk for medication problems are referred to a "Wellness Center" for general prevention-oriented education and, if appropriate, disease-specific intervention.
| "Essentially, we're taking what we've learned about disease management in the skilled nursing facility and bringing it into the assisted living setting." |
Another wellness program developed by Daschner's company is geared toward prevention of debilitating fractures-a common cause of nursing facility placement. Central components include identification of residents who may benefit from osteoporosis treatment, environmental risk screening to identify fall hazards, education of residents regarding appropriate preventive strategies, and outcomes monitoring to measure the impact of these coordinated interventions. So far, Daschner reported, 47% of all residents at high risk for falls have been enrolled in the program, with impressive results: a 20% reduction in the occurrence of falls; 100% compliance with prescribed treatment regimens; no new hip fractures among program participants-compared with a 26% rate of new hip fractures in a control group of residents not participating in the program-and a 66% reduction in other types of new fractures (12% versus 37%).
Linda Drummond, director of growth markets for Tampa, Florida-based PharMerica, believes her company's "Well Care" assisted living service package, including its wellness components, is unique in that it is the result of more than two years of intensive, data-driven market research, including a three-month on-site pilot study conducted jointly with two major assisted living chains. In addition, she says, assisted living providers have been very responsive to the flexibility offered by PharMerica's three assisted living service packages: "Well Care Basic," which offers the core services of move-in medication review, biannual pharmacist consultations, distribution of drug information sheets, medication ordering, and medication administration documentation; "Well Care Plus," which augments those services with quarterly quality improvement visits by specially trained nurses, pharmacist attendance at quarterly family nights, various wellness programs, and on-site training for certified nursing assistants (CNAs); and "Well Care Complete," a full-spectrum program including on-site all-staff training, monthly reporting of utilization trends, computerized outcomes management, and a full complement of wellness programs.
DiTrapano believes Omnicare's program is distinguished from others by its "strong clinical orientation." With its extensive database of Minimum Data Set (MDS) information on geriatric drug use, its proprietary geriatric drug therapy guidelines, and its ownership of contract research organizations, Omnicare is ideally positioned to link clinical data with disease management activities and clinical research initiatives to achieve and document improved outcomes-and resultant cost savings-in wellness program participants, says DiTrapano.
In marketing its "Live Well" program, NCS HealthCare points to its use of pharmacist-trained nurse counselors for "rounding" and on-site problem solving, as well as the cost advantages conferred by the company's new centralized packaging facility, which helps ensure fast, accurate medication distribution to all NCS assisted living sites nationwide.
Levitt stresses the importance of avoiding what he calls a "partial-loop" approach to wellness education. "Our program is all-inclusive, covering the spectrum of clinician and non-clinician caregivers, as well as residents and families. It's also ongoing and repetitive, not a one-time 'shot in the dark.' It's structured, occurring on a monthly or quarterly basis, so if any caregiver misses a particular seminar, they'll be included next time around. Without ongoing reinforcement, there can be resistance from nurses, physicians, staff development personnel, and other team members," he notes. "You must get a firm buy-in from all these parties, or an important link in the chain will break down. You can't just focus on consultant pharmacists, or physicians, or nurses. You also need to target residents, family members, and especially CNAs, who spend the most time with the residents." The idea, says Levitt, is "to build a more effective, efficient team. The glue that binds it all together is education."
| "You need to be part of a team approach to care. Assisted living providers have very high expectations. They really want you to be an integral part of their community." |
"The nurses typically receive much less training than those in nursing facilities. This creates a great need and opportunity for the pharmacist to educate," Drummond notes. "Also, there's no chart review, and drug therapy recommendations are conveyed not through chart notations, but through one-on-one interaction with physicians. The pharmacist needs to be able to teach, to coach, to serve as an information resource, to coordinate therapeutic interventions. The responsibility for coordination of care lies squarely with the consultant pharmacist," she says. "You need to be part of a team approach to care. Assisted living providers have high expectations. They really want you to be an integral part of their community."
Omnicare's DiTrapano agrees that clinical skill alone is not enough to ensure success in the wellness arena. "It's a given that our pharmacists have the requisite clinical acumen." But beyond that, he says, they need to be skilled communicators and educators. "They need to be able to relate well to people-not just to residents, but also to family members, physicians, and other health care team members."
Levitt notes that NeighborCare consultant pharmacists are at the forefront of implementing both the educational and clinical components of the company's wellness initiatives, serving as speakers and lecturers at its various seminars and marshaling other staff development activities.
Daschner said crucial first steps for pharmacy providers interested in getting involved in the wellness area include: deciding on standardized screening and assessment instruments; developing criteria for identifying target populations; crafting protocols for documentation and interdisciplinary communication; and developing appropriate treatment guidelines and pathways. She encouraged pharmacies to base the pricing of these and other related services on the downstream value they represent to the purchaser in terms of increased operational efficiency and overall cost savings.
PharMerica's Drummond also sees a bright future for pharmacists in this fast-expanding field. "Wellness is already at the core of assisted living," she says. "Over the next 10 years or so, I think we're going to see wellness take on even greater importance, with increased use of telephonic care management and information technology. There will be more 'telepharmacy' interventions and more self-education tools for computer-literate seniors"-for example, computerized educational "kiosks" in assisted living facilities and senior centers. She notes that one large continuing care retirement community in Colorado is moving to open an "ADL product store" offering assistive devices and equipment to meet the needs of residents with various sorts of functional limitations.
A philosophy of prevention versus treatment. A social rather than medical model of disease management. Prospective drug regimen review and proactive pharmacist intervention. Self-empowerment through education. All these threads are converging to make wellness one of the hottest areas of health care. "It's all about encouraging and enabling residents to take charge and take responsibility for their own health," Drummond says. "Wellness is not a program, or a series of programs; it's a way of life, a healthy state of being."
Copyright © 1999, American Society of Consultant Pharmacists, Inc.