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Pharmacy consultants can help you think through drug policies
Hospices too often find that no single health care professional is coordinating a dying patient’s pharmaceutical needs, including both adequate pain treatment and drugs to alleviate other conditions and symptoms. Without some coordination, it’s difficult to determine which medications should be included within hospice care and which should not, experts note.
"One of the most difficult questions for hospice providers is what is or isn’t related to the terminal illness," says Jeffrey Lycan, RN, president and chief executive officer of the Ohio Hospice & Palliative Care Organization in Upper Arlington. "That’s the one question we don’t like to talk about. It’s difficult to answer." For example, hospices often will be expected to take over the costs of a patient’s medication for chronic conditions that are not related to the terminal illness, but these costs may not be reimbursed under Medicare or Medicaid, Lycan says.
Hospices must coordinate medication use with physicians
"Some programs will say, Gee, I’m sorry, we don’t cover those drugs,’ and others will say, Sure, we cover them if those are things that are needed to provide comfort and symptom support,’" Lycan explains. "That’s an access issue."
Even when hospices are clear about which medications they’ll provide, there can be problems obtaining the best medications for a particular patient when hospices do not work in a coordinated way with physicians.
Palliative Care Consulting Group of Dublin, OH, conducted a study that found a 30% reduction in medication costs for hospices that took a coordinated approach to medication use, including additional nurse education and communication with physicians, says Phyllis Grauer, PharmD, president of Palliative Care Consulting Group. "There are a lot of medications where there are important concerns about side effects and the drug’s appropriateness for long-term use, depending on whether the patient has months or years to live," Grauer says. "As a patient gets closer to the end of life, those concerns become less of an issue, and in maintaining a patient’s comfort we may use medications that we typically wouldn’t use if the patient wasn’t in the final stages of life."
For example, a dying patient who has been on a cholesterol-lowering drug for years may no longer need that particular medication, and it could cause unnecessary expense, side effects, or a drug-drug interaction, Grauer says.
Grauer and Lycan offer these suggestions for how hospices may improve access to and use of medications:
1. Hire a pharmacist consultant to coordinate care.
"Six years ago, most programs in this country had no idea what their drug cost per patient was. Today, hopefully, we’re much further along in knowing what our pharmaceutical costs are per patient," Lycan says. Some hospices use a pharmacy management company to coordinate pharmacy care, he says. The Ohio Hospice & Palliative Care Organization was involved in a study that compared costs of drug utilization among nine small or medium-sized hospices, Lycan says. "We went in and supported them, doing a clinical review of medications and setting up their areas with pharmacies," he recalls.
Among the hospices that received help in coordinating pharmacy care, the average daily drug cost per patient fell from $12-$14 to $6-$8, Lycan says. Part of the solution was just taking the time and energy necessary to understand drug costs and to set up policies and procedures, he explains.
Clinical pharmacists can help
"One of the most effective things that occurred and was included in the price reduction was the use of a clinical pharmacist to help drive the process," Lycan says. "The clinical pharmacists knew how these drugs moved through the system and how the costs of drugs worked and how to effectively use drugs for pain and symptom management."
Some pharmacies will hire a clinical pharmacist to assist in drug coordination; others will hire a clinical pharmacist as a consultant or will have a preferred buying group in which one of the services offered is access to a clinical pharmacist, Lycan says.
The Palliative Care Consulting Group is a pharmacy consulting company that offers a variety of services to hospices, Grauer says. "We coordinate care with respect to a patient’s medication management, which is a big issue in health care today, and there are not a lot of good mechanisms to do that," she says.
Pharmacist consultants will assess a patient’s entire drug regimen and make recommendations about which drugs could be eliminated or changed due to duplication, unnecessary side effects, or expense, Grauer explains. Consultants also educate staff and are available to answer any questions they or the prescribing physicians might have, she adds.
Grauer’s pharmacy consulting organization provides hospice nursing staff with a six-hour educational presentation. "We meet with the medical director separately sometimes, and we introduce what we have to offer, teach them about drug therapy, listen to their concerns, and we talk about communication skills," Grauer says. "From that point, we start with the on-call process. The nurse on admission may call us prior to calling a physician to review all medications, help them review what’s related to terminal illness and what’s not, and receive recommendations."
Consultants can give unbiased advice
"The other thing we do is help balance what drug manufacturers and direct consumer advertising are saying to the public and health care professionals by providing them with the rest of the story," Grauer says. "We have nothing to gain by recommending certain drugs, so we look at a drug unbiased and help hospices, patients, and their caregivers with suggestions for changing drug therapy to provide better care, particularly if finances are an issue."
2. Select a flexible drug formulary.
Lycan says the development and use of a drug formulary can be helpful to a hospice because formularies can give a hospice some structure. The Ohio Hospice & Palliative Care Organization does not advise hospices never to go outside the formulary, because hospices need to be able to provide appropriate care; but a formulary helps ensure that a hospice doesn’t always pick a physician’s favorite drug.
Also, a hospice can advise a pharmacy of the drugs it is using to help ensure those medications are kept in stock, Lycan says. That also can help the hospice negotiate a more competitive price and ensure access to necessary medications, he adds. "Hospices should develop their own formularies, working with the attending physicians in their practice areas," Lycan says. "We believe the formulary helps to provide structure to their decision making and gives the hospice control and balance over increasing cost and knowledge of various drugs for symptom management."
Grauer says she prefers to call it a drug list, rather than a formulary. "We recommend basic drugs that are preferred drugs in our patient population," she says. Having such a list also makes staff training more efficient and patient care more consistent, Grauer adds. "I like having a preferred drug list because it provides an educational tool for staff training," she says. "And if those drugs don’t work, then when you decide to use something that’s not on the drug list, it’s a well-thought-out decision."
For example, a hospice drug list might exclude the drug ondansetron (Zofran), which is commonly prescribed to treat nausea in chemotherapy patients. While this drug may have worked for a patient when that patient was actively seeking a cure for cancer, it is the wrong drug to use for most hospice patients because it has a limited mechanism of action, Grauer says. "It’s appropriate with chemotherapy, but it’s not as effective for hospice patients," she explains. "And it costs at least 10 times more than other drug therapy for nausea."
3. Advise discontinuation of unnecessary medications.
"We have recommended discontinuation of unnecessary drugs related to comorbid conditions," Grauer says. "Also, as patients begin to decline, they typically don’t want to take as many medications."
Drug needs change at end of life
For example, women may be prescribed alendronate sodium (Fosamax) to prevent osteoporosis as they age, Grauer says. "But as a patient becomes bed-bound, one of the problems with this drug is that if it’s not taken correctly, it can cause erosion of the esophagus," she says. Patients who take fosamax have to sit up for a while after taking the drug; for bedridden patients, this may be difficult. Plus, dying patients need not worry about osteoporosis, so alendronate sodium can cause more harm than good, Grauer explains. "Those drugs also are expensive, and you can reduce costs by $5 to $8 per day by eliminating unnecessary drugs that are, in fact, causing them problems," she says.
Other examples of drugs that can be eliminated include diabetes medications and cardiac disease drugs, Grauer says. "My focus is 100% on improving quality of care for the patient," Grauer says. "By reducing the costs to the patient and the hospice, you have the added benefit that by using resources appropriately, you have more resources to put into other areas that promote quality of care and quality of life."