Managing Medication and Independence in Assisted Living.

For assisted living to keep its federally unregulated status in medication management, facilities must self-regulate on a national scale

Mrs. Jones enjoys her independence residing in an assisted living facility (ALF). One day she complained to the nurse of symptoms common to a urinary tract infection (UTI). The nurse called Mrs. Jones's physician, and the nurse practitioner returned the call with an order for an antibiotic, which was filled by the pharmacy. In the meantime, Mrs. Jones's daughter came to the facility and took her to see a physician, who also ordered an antibiotic for the UTI. On the way back to the facility, they stopped and had the prescription filled at a local pharmacy. Mrs. Jones began taking her medication right away. She continued to take her prescription for three days before reporting it to the staff at the facility. She had also continued to receive a very similar antibiotic during the routine medication administration pass at the facility.

Mrs. Jones's case is an example of a drug-related problem that occurred at an assisted living facility where I consult. Because of the independence of ALF residents, it is difficult to successfully convey the importance of the staffs knowing about all medications that are consumed by every resident, including vitamins or herbal products. Assisted living is unique in that residents are encouraged to live independently and call their room their home. With this in mind, it is a challenge to staff to find out needed information without interfering with an individual's right to privacy.

On the other hand, the facility has a responsibility to ensure that each resident receives his or her medications safely. This delicate balance between independence and quality care presents a definite challenge to assisted living facilities. The pharmacist can play a significant role in helping ALFs meet those challenges.

Providing medications and medication monitoring is significantly different in ALFs than in traditional nursing homes. Unlike nursing homes, which usually have one or two pharmacy providers within a facility, the ALP might have as many pharmacies as there are residents in the facility. There might also be a variety of medication delivery systems within one ALP. Most assisted living facilities that I have worked with do not require residents to choose a particular pharmacy. There might be a range of providers, including mail order plans, which complicates the medication management system for the facility even more.

Another major difference, of course, is that the nursing home industry is highly federally regulated, whereas assisted living is not. Assisted living is state regulated, and the regulations vary widely from state to state. In Tennessee, for example, consultant pharmacists are not required to review medications on a regular schedule. Other states require a quarterly review of medications, as a minimum.

The lack of standardization might prove to be a major problem for the assisted living industry in the future. Many residents come to ALFs for assistance with medication management. However, even the terms for assisted living and medication management are loosely defined. Is there a licensed nurse on staff who administers medication, or "assists" with medication? Does the nurse or unlicensed staff member simply remind residents when it is time to take medications? Some states require a nurse to "administer" medicine; that is, to remove it from the packaging and hand it to the resident. Others allow a trained medication technician to "assist" with medication administration.

When choosing a medication management system, it is important to consider the training of the staff. It is equally important to consider the cognitive function of the residents. Are they capable of self-administration? Do they need minimal assistance or total assistance, such as in an Alzheimer's unit?

Another consideration involves comparing services offered by different pharmacies. Make sure that the provider pharmacy can meet the needs of the facility and residents. This includes the labeling of medications--particularly whether medications are labeled individually. Record keeping and documentation are important, as well. Many pharmacies will print medication administration records. Again, the type of documentation required will depend on the residents' level of care.

Assisted living facilities should question the pharmacy about medication storage. Some ALFs do not want to use traditional medication carts that are seen in long-term care facilities because they connote a more institution like setting. Question delivery frequency and times. Will a pharmacist be available seven days a week? What about provisions for emergency deliveries? Are pharmacy policies and procedures for medication delivery, administration and therapeutic monitoring available for review?

Once an assisted living facility enacts policies and procedures for medication administration and storage, they should be explained to the residents and their families upon admission. The need for this becomes apparent if a resident begins to have a decline in cognitive function. Perhaps upon admission the resident was capable of self-administration or asking the staff for the medication, but over time the resident's memory might have declined, rendering the resident incapable of any form of self-administration. Giving up this independence is very difficult for a resident and sometimes for families, as well. It is a great advantage to have a protocol in place where all residents are reevaluated periodically to assess for any changes that might make them incapable of managing medications on their own, or even with minimal assistance.

The use of multiple pharmacies within a facility should be discouraged as much as possible. It is much more difficult for staff to manage medications from different sources. It helps if facilities encourage the use of one or two primary pharmacies--and even better if the pharmacies use the same type of medication delivery system.

Confusion caused by the use of different types of medication management systems can be problematic for the staff. Systems vary from the traditional prescription vial to unit-dose systems to more sophisticated systems that, for example, package all morning medications in one package. Pharmacy pricing will also vary depending on the packaging system that is used; for example, the advanced systems that place all medications for each medication administration time into one package are extremely expensive and labor-intensive for the pharmacy. However, they are very easy for the staff to use, especially unlicensed staff. Safety and efficiency, as well as storage requirements, are issues for facility administration to consider.

The most common concern for facility residents is typically the cost of medications. Some ALF residents might have private insurance coverage for medications, while others depend on state Medicaid programs to provide medications.

Facilities and pharmacies might be limited on choices for medication packaging systems based on reimbursement constraints. For more details on the advantages and disadvantages of the more commonly used systems, including cost issues, refer to the table.

The consultant pharmacist can play an important role in helping assisted living facilities evaluate the options for an appropriate medication management system. This includes training the staff, as well as providing education for the residents and their families.

Another important issue involves adverse drug reactions (ADRs). Recognition and avoidance of ADRs by the consultant pharmacist are not only important to the quality of life of the resident, but also to the facility in financial terms. For example, a resident who takes an antianxiety medication and a hypnotic could experience oversedation leading to a fall, fracture and hospitalization. Afterward, the resident might no longer meet the requirements for staying in an ALF and might need extended nursing home care. The cost of losing a resident and having to fill an empty bed is very significant to ALFs.

Another example of an ADR is the drug-induced increase in confusion that commonly occurs in elderly residents taking a number of unmonitored medications. This could be misinterpreted as a worsening of Alzheimer's or other dementia and could cause the resident to be prematurely released from the ALF setting. Often, medications can be adjusted to allow the resident to remain in the assisted living facility.

There tends to be a general consensus that managing medications in the ALP setting remains a challenge for facilities, residents and pharmacists. The industry wants residents to remain independent and at the same time avoid costly federal mandates. The development of standards by the national ALF organizations that better define the gray area of medication management would be of value to the industry, and likely help to delay federal regulations. Meanwhile, the American Society of Consultant Pharmacists (ASCP) has a manual for assisted living facilities that contains many policies and procedures for medication management. These can provide a basic framework for facilities to build upon. Another excellent resource is an ASCP publication entitled Assisted Living Facilities: A Resource Manual for Pharmacists, which contains a wealth of information for pharmacists, as well as for facility administration.

Balancing quality care and resident independence in medication management is a particular challenge for assisted living facilities. Facilities can rise to the challenge with an organized approach supported by the expertise and intervention of consultant pharmacists.

Diane B. Crutchfield is the president of Pharmacy Consulting Care in Knoxville, Tennessee. For more information regarding the ASCP policies and procedures manual for assisted living or the book Assisted Living Facilities: A Resource Manual for Pharmacists.

                  Advantages and Disadvantages of Various
                     Medication Packaging Systems. [*]
                         Advantages
Traditional Multidose    Probably least expensive system for
Vial System              both the resident and the pharmacy
Unit-Dose System         Reduced risk of medication errors;
                         some systems may allow return and
                         re-use of medications, which pro-
                         vides a cost savings to the resident;
                         convenient for staff administration;
                         saves administration time
Multiple Medication      Reduced risk of medication errors;
Packaging System         convenient and safe for staff admin-
                         istration or self-medication; increased
                         compliance for residents who self-
                         administer
Hybrid Systems           Easy to identify discontinued medi-
                         cation and remove from prepack-
                         aged container; decreased risk of
                         medication errors by staff and resi-
                         dent; less financial investment for
                         pharmacy compared with automated
                         packaging machines
Patient Reminder Systems Maintain resident independence
                         Disadvantages
Traditional Multidose    Labor-intensive for the facility staff to
Vial System              administer or assist with administra-
                         tion; increased risk of medication er-
                         rors, particularly with the use of unli-
                         censed staff; lack of accountability for
                         controlled substances or for other
                         medications; increased cost to resi-
                         dent if numerous medication changes
                         occur; difficult to monitor compliance
                         for residents who self-administer
Unit-Dose System         Increased initial cost of medication to
                         the resident (compared with vial sys-
                         tem); potential increased costto phar-
                         macy if there is a need to purchase
                         additional medication carts, unit-dose
                         packaging equipment or unit-dose
                         stock
Multiple Medication      Increased risk of medication errors if
Packaging System         filling is not 100% accurate when
                         medication changes are made; some
                         systems are labor-intensive for phar-
                         macy; additional cost to pharmacy
                         for equipment and supplies; increased
                         cost to resident compared with vial
                         system
Hybrid Systems           Labor-intensive for pharmacy, in-
                         creased cost to resident compared
                         with vial system
Patient Reminder Systems Depend on resident's ability to self-
                         administer, manipulate packaging,
                         and understand and respond to pager
                         system or telephone reminders; use
                         is limited to residents capable of self-
                         administering medications; may in-
                         crease or decrease compliance, based
                         on ability of resident to use; increased
                         risk of errors with reminder contain-
                         ers, based on who is responsible for
                         refilling the containers

(*.)Crutchfield DB. Medication management and the role of the consultant pharmacist in assisted living facilities. Clinical Consult Supplement 10A to the Journal of the American Society of Consultant Pharmacists 1998;13:10A-5. Reprinted with permission.