Spring 2005 - University of the Sciences in Philadelphia

Caring Where Seniors LiveThe pharmacist’s role in caring for theelderly continues to growBY RICHARD G. STEFANACCI, DO, MGH, MBA, AGSF, CMDPHARMACISTS HAVE BEEN PROVIDINGcare beyond the reach of the corner drugstore counter for quite some time. Theirservices in skilled nursing facilities (SNF)were mandated as a result of OmnibusBudget Reconciliation Act of 1987 (OBRA). 1This presence has resulted in improvedoutcomes for residents of SNF for most ofthe last two decades. 2, 3 But what about thosesimilarly frail seniors living outside ofnursing facilities? How can they have accessto these same valuable services that pharmacistshave been providing in SNF?While the number of seniors will doubleover the next several years along with anexpansive growth in the number of our “oldold,” those over the age of80, it is anticipated thatthese seniors will be housedin facilities other than SNF.This movement from thesefacilities to home andhome-like settings willresult in a growing numberof seniors living in assistedlivingfacilities (ALF) as wellas in their own homes, wellbeyond what is commonplacetoday. As a result, theacuity level of ALF residentswill grow beyond the typicalresident. Even today, theaverage ALF resident looksmore like a SNF resident ofa few years ago—80 years and older, withmultiple chronic illnesses and cognitiveimpairment, and receiving, on average,between 5.1 and 6.1 prescription medica-BUT HOW CANPHARMACISTSDELIVER CARETO SENIORSREGARDLESS OFWHERE THEYLIVE?tions daily. 4, 5 But despite the fact that ALFresidents are looking increasing like thoseof SNF, ALFs have fought and won the battleagainst the intrusion of federal regulationsinto their business. Combined with the typicaloperator philosophy that ALFs are nothingmore than real estate ventures, ALFs arelargely void of most pharmacist medicationtherapy management services (MTMS) thathave become required for similar residentsliving in nursing facilities.A recent article by Dr. Philip Sloane illustratedmedication undertreatment in assistedlivingsettings, and a previous article showedgeneral inappropriate medication prescribingin this same setting. 6, 7 In a correspondingeditorial, Dr. Jerry Gurwitz proposed thatthese findings were the result of severalfactors, including the need for systems ofcare that improve drug safety and enhanceadherence in elderly persons on complexmedication regimens and the persistence offinancial barriers to access the medications. 8Clearly greater pharmacist involvement inALFs and other places where seniors will beliving would be a major benefit.So what’s being done to fix this problem?OBRA-2005? No, actually the MedicareModernization Act includes many sectionsthat are aimed directly at thefactors Dr. Gurwitz has highlighted,the most obviousof which is the new MedicarePrescription Drug Benefit—Medicare Part D—which startson January 1, 2006, and willprovide for partial drugcoverage for most seniors. Inaddition, a section encouragesevidence-based medicine toexamine pharmaceuticaleffects in seniors. But perhapsthe most significant sectionfor pharmacists was the inclusionof MTMS. MTMS targetsbeneficiaries with multiplechronic conditions, using multiple prescriptions,and incurring significant drugspending. These services are provided bypharmacists and include both dispensing andmonitoring. And while MTMS is a positive