by Becky Agar RPh, BSc.Phm
With the improved homecare supports available in Ontario, seniors are much older than they used to be when finally moving to long-term care facilities, and they are often transferred directly from acute-care facilities, after a crisis incident such as a fall, or rapid decline in cognition.
As a result, elder pharmaceutical care has changed dramatically over the last 30 years and polypharmacy predominates. 83% of adults over the age of 65 take prescription medications, and 30% of these elders take more than five medications each day. And among seniors older than 80, the number of prescriptions rises to 10 or more per day.
For at least the last 30 years, long-term pharmacy service has operated under a central distribution model, structured on transactional compensation for pharmacy service providers. And until 2015, all long-term care (LTC) pharmacies operated this way. In 2015, Darryl Moore and Jeff Churchman founded Hogan Pharmacy Partners Ltd. with the mission to “offer an unprecedented approach to pharmacy services with a collaborative model that integrates operations, technologies and quality programs.”
They believed having pharmacy truly partner with their homes and focus on providing pharmacy services would allow nurses to spend more time with residents, instead of supervising the medication management system, and that everyone would benefit from improved outcomes.
Hogan Pharmacy Partners focuses on resident safety and wellness outcomes first and foremost. Hogan’s provides a level of medication safety and oversight comparable to those seen in today’s hospitals. The use of automated dispensing cabinets in hospitals has been an industry standard for more than 20 years, and the long-term care sector is grossly overdue for the same level of control and oversight for all medications, not just high-alert drugs and opioids.
Since the company’s beginnings in 2015, Hogan’s has provided automated dispensing cabinets with full biometric control to all of our partner homes. We have eliminated the traditional unsupervised “emergency boxes” provided by the rest of the sector. This ensures that nurses are always supported by pharmacy and significantly restricts access to high-alert and potentially fatal medications like insulin and narcotics. These cabinets are managed by Regulated Pharmacy Technicians who come on site to their partner homes to restock and audit the cabinets multiple times per week. Hogan dispensing cabinets use resident-profiled medication lists, which ensures that nurses can only access medications prescribed for the resident, that have been clinically reviewed by a telepharmacist, for each and every dose. The Hogan cabinets use fingerprint biometric technology to control access to the cabinets.
Insulin access is also highly restricted in the Hogan pharmacy model. Nurses, under fingerprint control, can only remove one insulin pen at a time from the locked fridge, controlled by the automated dispensing cabinets. This access is tracked and audited at least weekly.
Control of narcotics
The use of the automated dispensing cabinets also significantly reduces the ability for narcotic diversion in their partner homes, because of the just-in-time inventory and alerts that the cabinets provide. Registered staff can only access a new fentanyl patch when they return a used one, keeping in line with the provincial patch-for-patch guidelines. This level of oversight for fentanyl patches cannot be achieved without the dispensing cabinets. Traditional pharmacies provide a large sheet of paper, upon which nurses are supposed to affix used fentanyl patches. While this piece of paper may be locked in a medication cart, it makes the supervision and protection of this sheet the nurse’s responsibility, which is truly not in their scope of practice. Our system not only significantly reduces the risk of fentanyl patch diversion, it also keeps the home’s staff and residents safer, and returns the responsibility of medication waste management to pharmacy, where it belongs.
Our dispensing cabinets also ensure a quicker time-to-first dose for our residents. In the traditional pharmacy model, sometimes a resident can wait a minimum of eight hours to get the first dose of an antibiotic for infection. Those eight hours of waiting can mean the difference between a resident’s infection turning to sepsis and requiring a transfer to hospital. Because we house our antimicrobials, even some injectables, in our cabinets, residents get their first doses of antimicrobials much faster than the traditional model.
Hogan Pharmacy Partners also eschews the traditional intermittent “Visiting Consultant Pharmacist” model utilized by the other pharmacy service providers, preferring to ensure they provide clinical pharmacist services 24/7/365 for every medication order, before it is even given. My previous l experience in acute-care telepharmacy has allowed me to develop a team of geriatric-focused clinical telepharmacists that ensures that every medication order is the most clinically appropriate medication order, in real time. Hogan Pharmacy Telepharmacists have access to the most up-to-date references and clinical tools to support the home’s prescribers, at any time of day. Homes need never wait for a clinical pharmacy assessment for their residents, unlike the other system, where they must wait for the next scheduled consultant pharmacist visit before any recommendations for medication changes are made.
Hogan telepharmacists operate under a guiding principle of deprescribing and reducing medication load for all residents, which I believe is in the best interests of residents and their home partners.
Multiple studies and reports have been published over the last five years, highlighting the significant number of medications that today’s elderly patients are taking, and the potential for serious drug interactions and poor outcomes. However, today’s LTC pharmacy providers are still incentivized to fill more prescriptions, not fewer, based on the way the province reimburses pharmacy. My team and I strongly believe that by working with our partner homes to reduce the amount of medications each resident takes, our clinical operating philosophy is better for residents – and the province.
Because Hogan’s packages all medications in unit-dose format and dispenses just-in-time from the automated dispensing cabinets, the overall amount of medication waste is drastically reduced.
Allowing nurses to do what they do best
From inception, we have recognized that the medication reconciliation process at resident admission and readmission took nurses away from residents at a very crucial transition point, and that this task was better managed by pharmacy, as evidenced by multiple studies in the acute-care sector. Working with our first client, peopleCare Communities Inc., we developed a pharmacy-led medication reconciliation process that not only gives more time to nurses to spend with residents, but now has also been shown to improve resident outcomes on a number of fronts, including decreased time to first dose, less report errors, and an increased rate of deprescribing at admission, compared to the nursing-led model. These findings have been independently confirmed by the University of Windsor and helped Hogan Pharmacy Partners and peopleCare Communities Ltd. receive the largest ever grant from the province’s Healthcare Technologies Fund, in the amount of almost $500,000. Hogan Pharmacy Homes now have a 100% compliance rate with medication reconciliation at admission and discharge.
Unlike other LTC pharmacy providers, Hogan Pharmacy does not segregate operational pharmacists and clinical pharmacists. I believe it is crucial for our telepharmacists to have a full understanding of both the distribution roles of the pharmacist, as well as being clinical experts in eldercare pharmacy. Our team of clinical telepharmacists are specially trained in geriatric pharmacy, with access to the best medication resources in North America. Yet, they also can, and do, work in the dispensary as well.
Hogan Pharmacy also utilizes the latest technologies to support our model. One of my key goals is to have as little paper as possible in our system. Working again with peopleCare Communities, Hogan pharmacy uses electronic forms for their medication reconciliation and pharmacy clinical consults, as well as reordering medications, and supports computerized prescriber order-entry in their homes. They have also eliminated faxing medications and the digital pen system by using the DocuScripts® medication order management system in all of their homes.
Hogan’s is dedicated to a higher level of visibility and partnership in all of our homes, because when everyone is on the same page, the resident ultimately benefits the most.
Becky Agar, RPh, BSc.Phm, Vice President of Hogan Pharmacy Partners Ltd., is a 20+ year clinical pharmacist with multiple awards for patient safety initiatives.