Some consultant pharmacists are self-employed and contract directly with a nursing facility, other type of facility, or patients. Some independent, self-employed pharmacists sub-contract with dispensing pharmacies to provide consulting services to their facilities or patients. And, some consultant pharmacists are employed by a pharmacy. If the consultant pharmacist is an employee, the pharmacy that employs him/her often contracts with a facility to provide both the consulting and the dispensing services. In that case, the individual pharmacist is paid a salary by the pharmacy, and the pharmacy collects the payment for the pharmacist’s services from the facility/client based on their negotiated contract.
For pharmacists interested in working directly for a pharmacy, there are many options. First, ASCP maintains a website where employers can post jobs and those seeking jobs can post their resume/interest. That webpage is MyRXCareer.com.
Independent pharmacies sometimes provide services to long-term care facilities. These pharmacies might be retail, community pharmacies that service both walk-in customers along with nursing facilities, group homes, and other institutions. Or, they might be “closed door” pharmacies - meaning they are not open to the public and service only institutional facilities. Check with the local, community pharmacies in your area to ask whether they service nursing facilities and hire consultant pharmacists. Even if they don’t, they often know of other independent pharmacies that are servicing institutions and/or are in need of consultant pharmacists.
There are also larger, chain long-term care pharmacies that are “closed-door” and employ pharmacists for both dispensing and/or consulting. There are two national long-term care pharmacy chains: Omnicare and PharMerica. To find out whether these companies have pharmacies in your area and whether they have job openings, check out their Web sites:
Networking with other consultant pharmacists in your state or area can also be helpful when seeking a job. ASCP has chapters in many states and in Canada, and individuals involved with those chapters can serve as a helpful resource or contact when getting started. Learn more about ASCP’s chapters here.
Consultant pharmacists who are employed by pharmacies are typically paid an hourly or yearly salary, similar to pharmacists in other practice settings. Consultant pharmacists who are self-employed and contract directly with facilities or sub-contract with pharmacies must determine the rate they charge the facility or pharmacy.
Billing for consulting services to institutions or facilities is quite different than third party billing and reimbursement for medication therapy management (MTM) services. When a pharmacist’s consulting services fulfill federal or state regulatory requirements, the facility is simply invoiced for the pharmacist’s services once a month or whatever frequency is determined by the facility and pharmacist/pharmacy. Electronic submission of claims does not occur, unless there is a third party payer paying for MTM services above and beyond the services already being provided to meet the regulatory requirements.
There are various payment methodologies used by consultant pharmacists. Sometimes consultant pharmacists are paid per bed or per resident, per month. If consultant pharmacists use this type of payment methodology, they often charge “extra” fees for additional services, such as committee meetings or med room inspections. Other consultant pharmacists charge an hourly rate, no matter whether they are doing chart reviews, attending meetings, performing med pass observations, or other activities. The actual dollar amounts charged vary depending on the consultant’s experience, educational background, etc.
When comparing a facility’s psychotropic medication utilization with CASPER data, should medications be counted based on their pharmacological class or based on how they are being used? On a similar note, how are psychotropic medications tracked or counted on the Minimum Data Set (MDS)? Example: When amitriptyline is being used for neuropathic pain, does it get counted as an antidepressant or not counted as a psychotropic at all because it is being used as an adjuvant analgesic?
Psychotropic-related data that is compiled and entered into the CASPER database is collected on CMS Form 672. The instructions for Form 672 suggest that only medications classified under the specific pharmacological class be counted. The same guidance is provided in the RAI User’s Manual for filling out the medication section of the MDS, both MDS 2.0 and the new RAI User’s Manual for the upcoming MDS 3.0.
In other words, amitriptyline for neuropathic pain would be counted as an antidepressant because that is the pharmacological class in which it falls, even though it is being used as an adjuvant analgesic. This contradicts the method of identifying and evaluating psychotropic medications outlined in the CMS Interpretive Guidelines for F-329 in Appendix PP of the State Operations Manual. In F-329, the Interpretive Guidelines discuss the importance of evaluating all antipsychotics, sedative/hypnotics, and psychopharmacological medications – where "psychopharmacological" medication is defined as "any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders." F-329 does not direct surveyors to only evaluate those medications that fall under specific pharmacological classes; instead it focuses surveyors to evaluate how medications are being used.
When comparing facility-specific psychotropic utilization data to state and national CASPER data, it is important to count medications according to pharmacological classification, keeping in mind that this will NOT provide a clear picture as to which residents or which medications might be evaluated by a surveyor under F-329.
In contrast, a facility might prefer to have a report that identifies which residents could trigger a closer evaluation by a surveyor due to their use of a psychotropic or psychopharmacological medication – based on F-329 definitions, in which case the consultant pharmacist would count residents taking any antipsychotic, hypnotic or medication used to manage behavior, stabilize mood, or treat a psychiatric disorder.” However, it is important to keep in mind that such a report would be substantially different than a report generated based on CASPER definitions.
When collecting CASPER data related to psychotropic medications, do surveyors count both routine and PRN medications? For PRN medications, are only those PRNs that have been used recently, as evidenced by the MAR, counted?
The CMS Survey & Certification Department has clarified for ASCP the procedure used by surveyors when counting psychotropic medications. Surveyors count psychotropic medication "orders" - both routine and PRN - for all psychotropic classes. Surveyors do not necessarily look at the medication administration record (MAR) to see whether the PRN was used. If there is an order, it is counted.
The most recent national study to identify the average number of medications used per nursing facility resident was conducted in 2003. Results were presented at ASCP’s 2003 Annual Conference and Exhibition. The 2003 study revealed an average of 8.1 routine and 3.2 PRN medications per resident.
The previous study was conducted in 2000, and it revealed an average of 6.7 routine and 2.6 PRN medications per resident.1
A report from the Department of Health and Human Services in 20022 compared medication utilization among nursing facility residents to that of assisted living residents. The results from that report are as follows:
1. Tobias DE, Sey M. General and psychotherapeutic medication use in 328 nursing facilities: A year 2000 national survey. Consult Pharm 2001;16:54–64.
2. U.S. Department of Health and Human Services. “Medication Use by Medicare Beneficiaries Living in Nursing Homes and Assisted Living Facilities”; June 2002.
Is the Quality Indicator (QI) that looks at residents who use nine or more medications still in use by the Centers for Medicare & Medicaid Services (CMS) and surveyors? Are there plans to delete the Quality Indicator (QI) that looks at residents who take nine or more medications? How was the number “nine” chosen or determined in the Quality Indicator (QI) pertaining to residents taking nine or more medications?
Technically, the “nine or more meds” Quality Indicator (QI) is still utilized by the Centers for Medicare & Medicaid Services (CMS) and state survey agencies, along with the other QIs, in preparation for surveys. Unofficial discussion and rumors have circulated for years that the “nine or more meds” QI would be discontinued due to controversy surrounding its usefulness and validity. It is indeed questionable whether this QI will be utilized after implementation of the Minimum Data Set (MDS) 3.0 in October 2010 given that the MDS question used to track the number of medications that each resident receives is not included on the MDS 3.0.
QIs are triggered by specific responses to Minimum Data Set (MDS) elements and identify residents who either have or are at risk for specific functional problems needing further evaluation. QIs are not definitive measures of quality of care, but are "pointers" that indicate potential problem areas that need further review and investigation. These data, at a nursing facility level, are used by state survey agencies to target survey and quality monitoring activities. The data are also shared with the facilities; each facility receives a report of its own data, as well as its statewide data. This report can be used by the facility as a tool to rate its performance compared to the state and to target areas of care for improvement. Because the data reports can be generated for sequential time frames, they are also useful to track trends.
In their research to develop quality indicators for nursing facilities, staff at the Center for Health Systems Research and Analysis at the University of Wisconsin – Madison explored at least 175 potential quality indicators for usefulness in evaluating nursing facilities. These QIs were developed through a systematic process involving extensive interdisciplinary clinical input, empirical analyses, and field-testing.
The QI on use of nine or more medications is intended to identify facilities where medications may potentially be overused and residents may be at increased risk for adverse drug reactions and drug interactions. However, because nursing facility administrators and staff are aware that surveyors are using this indicator, prescribers and consultant pharmacists are often encouraged to reduce the number of medications used by residents.
For the “nine or more medications” quality indicator, the number "nine" was chosen as the break point with input from expert clinical panels and guidance from a thorough literature review. The following information was provided by CHSRA staff as background for the development of this quality indicator.
By 1988, numerous studies had been done on drug utilization. Comparing results of the studies is difficult due to variation in the definition of "drug use." Some studies reported drugs ordered by the physician, including or excluding PRN medications; others reported doses received and included only drugs actually received during the defined time period.
A 1988 article by Robers (Extent of medication use in U.S. long-term care facilities. Am J Hosp Pharm. 45:93-100) summarized the studies and findings to date. She found that the mean number of medications reported ranged from 3.3 to 8.6 medications ordered per resident, or from 5.7 to 6.8 prescriptions per resident, with the majority reporting about 7 medications ordered per resident. These do not identify the number of drugs actually received. An article by Beers M, et al., (Psychoactive medication use in intermediate-care facility residents. JAMA 1988; 260: 3016-3020) reported on a study of 850 residents in 12 intermediate care facilities. These residents were prescribed an average of 8.1 medications each during a one-month period. Based on this information, it appeared that a threshold of 9 or more would identify individuals who were beyond the norm and facilities with a high proportion of such cases.
An Office of Inspector General (OIG) study of Texas nursing facilities in 1996 included a survey of consultant pharmacists, which revealed that consultant pharmacists were concerned about overutilization of medications (Prescription Drug Use in Nursing Homes. OIG Report: OEI-06-96-00081. November 1997). In addition, an article by James Cooper (Cooper, JW Adverse drug reaction-related hospitalizations of nursing facility patients: a 4-year study. South Med J, May 1999) showed that nursing facility residents taking higher numbers of medications were more likely to be hospitalized for adverse drug reactions.
An article by Bernabei et al. (J Gerontology 1999; Vol 54A:M25-M33) indicated that, based on MDS data from the case mix states, the average number of medications was 6.5, with about 20% of the residents having 10 or more medications. Interpolating from the category of 7-9 medications, a reasonable estimate is that about 25% of the residents have 9 or more medications. This is consistent with [CHSRA] estimates, both from earlier data from the case mix states and from data for more than 500 nursing facilities participating in the Provider Initiative Project and Oryx project.
There has been much discussion regarding the validity of the “nine or more meds” QI. Undoubtedly, the correct number of medications for a given patient is determined by the needs of that individual patient. A patient receiving three medications may be getting too many and a patient receiving ten medications may be getting too few. The only way to determine the correct number is by evaluation of each specific patient. In addition, there are no specific survey guidelines for evaluating a facility that triggers this quality indicator. The guidelines given to surveyors to evaluate drug therapy are found in the CMS Interpretive Guidelines, primarily at F-Tag 329. These guidelines apply to all residents in the facility, not just those taking nine or more medications.
Version 3.0 of the Minimum Data Set (MDS) is scheduled to go into effect in October 2010. Initially, the Centers for Medicare and Medicaid Services (CMS) planned to implement MDS 3.0 nationally on October 1, 2009. However, in early 2009, CMS announced that the implementation deadline would be pushed back one full year. ASCP has background information on the MDS, along with links to the new MDS 3.0 and other helpful resources. For further information, visit ASCP’s MDS Web page.
ASCP maintains a list of consulting software companies whose products are geared towards consultant pharmacists practicing in the nursing facility setting. Most of the companies on the list exhibit at ASCP’s Annual and Midyear conferences. Attending the ASCP Annual or Midyear Conference & Exhibition may be a good way to compare and learn about various software options.
In addition, the following are lists of companies that offer medication therapy management (MTM) software, which may be useful for pharmacists performing community-based pharmacy consulting or other types of medication review services:
No, the CGP credential is not required to practice as a consultant pharmacist. While the CGP credential is completely voluntary, it can certainly provide pharmacists with an advantage when seeking consulting jobs or contracts because it instantly demonstrates clinical expertise in geriatric pharmacotherapy.
Keep in mind that some state Boards of Pharmacy do require training or specific licensure/registration prior to working as a consultant pharmacist. Obtaining the CGP credential may or may not count towards state-required training requirements; consult with your state Board of Pharmacy for more information.