Hospice Pharmaceutical Care2015 and Beyond

Mary Mihalyo, PharmD, CGP, BCPS, CDEOregon-Washington Spring Intensive

Vancouver, Washington23 March 2015

Pharmaceutical Care

The direct, responsible provision of medication-related care for the purpose of achieving definite outcomes that improve a patients quality of life.

Medication related + Care related + Outcome related

04/19/23 ASHP Statement on Pharmaceutical Care Am J Hosp Pharm 1993;50,1720-3 2

Medication related

Includes decision to or not to use medications as well as judgements regarding medication selection, dose, route, frequency and method of administration plus patient education.

04/19/23 ASHP Statement on Pharmaceutical Care Am J Hosp Pharm 1993;50,1720-3 3

Care related

The pharmacist providing direct personal concern (i.e. care) for the well-being of another person just as nursing and medicine does.Integrated, collaborative and cooperative domains of care including medical care, nursing care and pharmaceutical care.

ASHP Statement on Pharmaceutical Care Am J Hosp Pharm 1993;50,1720-3

Outcome related

• Identifying potential and actual medication-related problems

• Resolving actual medication-related problems• Preventing potential medication-related

problems

04/19/23 ASHP Statement on Pharmaceutical Care Am J Hosp Pharm 1993;50,1720-3 5

Medication-related problems

• Untreated indication• Improper medication selection• Subtherapeutic dosage• Failure to receive medication• Overdosage• Adverse drug reaction• Drug–Drug and Drug-Food Interaction• Medication use without an indication

ASHP Statement on Pharmaceutical Care Am J Hosp Pharm 1993;50,1720-304/19/23 6

Hospice CoPs 2008

• Defined the role of the pharmacist for Hospice.

• As an industry, have we met the CoPs ?• Let’s take a look at select sections…

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Medicare Part D & Hospice

• Was reform necessary? • Has continuity improved?• Have outcomes improved?• Medicare Part D reform affirmed the right of

hospices to use a formulary and resulted in approximately 25% increase in the cost of medications for the hospice industry.

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Medication Cost

What is cost?

Cost is defined by the buyer!PharmacyHospice

Cost is NOT average wholesale price !

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Are Medication Costs Rising?

Yes, at rates never seen before….

Brand name medications:

Generic medications:

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Why Medication Prices Are Rising

• Industry consolidation • Drug shortages• Raw material shortages• Unanticipated demand• Manufacturing difficulties• Regulation• Business and economic issues

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Medication Price IncreasesMedication Approximate Hospice Cost

2013 Approxiate Hospice Cost 2014

Amitriptyline 100mg Tablet $4.00 $91.00

Atropine Opth. Soln 1%-5 $9.00 $21.00

Erythromycin Estolate Susp400 mg/5ml; 240 ml

$25.00 $350.00

Morphine 60 mg ER; #100 $75.00 $125.00

Morphine 20 mg/ml; 30ml $9.00 $18.00

Nystatin Susp 100,000 U240 ml

$25.00 $42.00

Oxycodone 20 mg/ml;30ml $57.00 $284.00

Tetracycline 250 mg cap #100

$3.50 $236.00

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Necessary Hospice Infrastructure

Pharmacotherapeutic Support System

3 Essential Components:

a. Pharm Db. Preferred Drug List

c. Pharmacy & Therapeutics Committee

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PharmD

“My Hospice can’t afford to hire a pharmacist!”

Really?

“Your Hospice can’t afford not to hire a pharmacist!”

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Hospice PDL

Composed by symptom and by medication.

Must be a dynamic document

Patient specific!

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P & T CommitteeMultidisciplinary hospice stakeholders meet on a scheduled basis to oversee all issues relative to hospice medication use.•Adding or deleting medications from PDL•Adverse drug reaction reporting•e-Prescribing protocol•Medication diversion and error review•Medication cost per patient day•Patient education tools•Pharmacy QA•Symptom management algorhythms•Therapeutic interchange

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Hospice Preferred Drug List

Please see sample provided

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Adverse Drug Reaction Reporting

Required by JCAHO!

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e-Prescribing Protocol

e-Prescribing of controlled substances, including CII is now legal is 48 states.

Regulations may vary, state by state.

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Medication Diversion & Error Review

• Individual states are now imposing new regulations aimed at preventing diversion of opioids from the home of hospice patients.

– Example: State of Virginia now requires hospice to report patient death to the distributing pharmacy of record.

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Benchmark Medication Costs

• National PPD goal = $8.00 – Post Medicare Part D reform = $10.00 ?

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Patient Education Tools

• Hospice patient population medication specific written material left in the home for patient and care giver education.

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Pharmacy QA

• Pharmacy dispensing error reporting• Patient satisfaction• Nurse satisfaction

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Therapeutic InterchangeDefined as the dispensing of a drug that is therapeutically equivalent to but chemically different from the drug originally prescribed by a physician or other authorized prescriber.

Example: Substitution of ipratropium bromide inhalation solution(Atrovent)® for Spiriva® or Tudorza®

Example: Substitution of oral prednisone 10 mg per day for Pulmicort® nebulization solution.

04/19/23 24ACCP Position Statement: Guideline for Therapeutic Interchange 2004

Therapeutic Interchange

• Although usually of the same pharmacologic class, drugs appropriate for therapeutic interchange may differ in chemistry or pharmacokinetic properties, and may possess different mechanism of action, adverse-reaction, toxicity, and drug interaction profiles.

• In most cases, the interchanged drugs have close similarity in efficacy and safety profiles.

04/19/23 ACCP Position Statement: Guideline for Therapeutic Interchange 2004 25

Symptom Management Algorhythms

Please see sample provided

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Remember:

“It is neither immoral nor unethical to think about the cost

of therapy!”

-Methadone Mary, 1998

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Questions?mary.mihalyo@deltacarerx.com

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