Even if the Centers for Medicare & Medicaid Services didn’t have a monthly medication regimen review (MRR) requirement for residents of skilled nursing facilities, having a periodic review of each resident’s medications in a focused, methodical way invariably results in better care for the residents we serve.
The heightened awareness of the increased risks for adverse drug events (ADEs), prescribing cascades, falls, and hospitalizations have caused concern about the use of potentially problematic or unnecessary combinations of drugs in our senior population (P.A. Rochon, “Drug Prescribing for Older Adults,” UpToDate
, Apr. 26, 2021, https://bit.ly/38DDGsY
). The Centers for Disease Control and Prevention estimates the number of emergency department visits related to ADEs to be at more than 1.3 million annually (Medication Safety Program, “Program Focus,” https://bit.ly/3EavFHG
) with 450,000 visits per year for adults aged 65 or older (Medication Safety Program, “Adverse Drug Events in Adults,” https://bit.ly/3KAOqGG
Readers may be familiar with the minimum requirements to see newly admitted residents of SNFs at specific intervals every 30 days for the first 90 days after admission and at least every 60 days thereafter (see F712 in the State Operations Manual on frequency of physician visits: https://go.cms.gov/3JEz5Ub
). These assessments are the ideal opportunity to examine the status of residents in all areas of progress.
AMDA – The Society for Post-Acute and Long-Term Care Medicine published its position statement on collaboration with consultant pharmacists in 2007 (“Physician-Consultant Pharmacist Roles and Collaboration in the Nursing Home,” Mar. 1, 2007, https://bit.ly/3xoegtE
) and has recognized the value that pharmacists bring as members of the care team. In many cases, pharmacists have advanced doctor of pharmacy degrees and certifications in geriatric pharmacy (BCGP) by the Board of Pharmacy Specialties, which lend additional credibility to their consultations. Pharmacists have most recently partnered with the Society in its well-publicized and highly successful Drive to Deprescribe initiative, including identifying the need to optimize the anticholinergic burden (https://paltc.org/d2d-meeting-archives
One of the most impactful reviews of medications occurs during the transition of care from one setting to the next. Medication reconciliation at facility admission establishes residents’ baseline needs at that specific point in time with respect to their pharmacological interventions. Medication reconciliations at this time can also be critical in identifying both errors of omission and errors of commission.
The initial MRR can capture these opportunities to set or reset expectations regarding drug therapy, until the provider gets to know the resident. A helpful resource in this process comes from the American Society of Consultant Pharmacists: “5 Things Physicians and Patients Should Question” (May 17, 2021, https://bit.ly/3M1pXdR
Once a resident has settled in, perhaps after the first 90 days, the focus should shift to a more nuanced review of medications. This is an opportunity to assess whether each medication is still necessary — an assessment that should occur at regular intervals during a long-term stay. (The unnecessary medication requirement is in the “Pharmacy Services” section § 483.45(d) of the U.S. Code of Federal Regulations “Requirements for Long Term Care Facilities,” available from https://bit.ly/37Cum8P
.) Because providers may become victims of “clinical inertia” during monthly routine orders signing, recapitulation, and authentications, medications require a focused review with attention to detail, often best provided by the consultant pharmacist.
The MRR, or drug regimen review (DRR), is a monthly (or more frequent) requirement. This is essentially a “time-out” that pharmacists perform with a critical eye for all possibilities associated with medications. Not only does the review encompass a snapshot of the medication list, but it also allows the pharmacist to review key nursing, dietary, and therapeutic activities, rehabilitation progress, and medical notes. The pharmacist can then provide a recommendation for optimizing key medication regimens or for suggested clinical monitoring such as laboratory work.
Drugs that are high-risk medications or cited as potentially inappropriate medications (see the American Geriatrics Society’s Beers Criteria: https://bit.ly/3xlwPPj
) are a high priority for falls risk mitigation strategies. Nursing and risk management team members also may call on pharmacists to review medications after a fall, including recommendations on medication adjustment or additional interventions such as orthostatic blood pressure recordings or fingerstick monitoring, as indicated (see Figure 1
for a sample template note).
Figure 1. Sample Template Note After Fall Incident
MRR Consultant Pharmacist Note - Med Review Post Fall; requested by nursing; reviewed BP monitoring results, reviewed recent lab results, reviewed SBAR note
MRR - FALLS
Current medications reviewed; meds that increase risk for falls include: (list)
[ ] orthostatic BP monitoring, sitting->standing, every day [ ] evening [ ] shift for 1 week. Notify MD for systolic drop more than 20
[ ] fingerstick for blood sugar in morning and evening for 1 week, notify MD for FS <70 or >300
[ ] medication regimen adjustment to include:
[ ] other:
Abbreviations: BP, blood pressure; FS, fingerstick; MD, physician; SBAR, Situation, Background, Assessment, Recommendation.
Pharmacists’ MRR recommendations tend to have some core elements of repetition. As these recommendations are considered part of the resident’s medical record, it’s prudent to pay more attention to MRRs that are reported to the attending physician and/or providers, the medical director, and the director of nursing. Medical directors should discuss these reports with the pharmacist.
Pharmacists can also use trends to create strategies or protocols to encourage best practices among medical providers. The following includes a short, priority list of recommendations pharmacists typically offer, with rationales for requesting.
Recommending laboratory testing and clinical monitoring. Most drugs are affected by a resident’s ability to metabolize them; many medications require adjustment based on therapeutic levels and hepatic and renal function, which change as the resident ages. Pharmacists look for the basics — basic metabolic panel, comprehensive metabolic panel, liver, and thyroid — and for any drug level measures that the manufacturers recommend having performed “periodically.” The facility should have a policy for minimum laboratory test frequencies that is reviewed at least annually by the medical director and consultant pharmacist. In addition, the pharmacist will review provider notes to ensure acknowledgment of results requested but not performed (laboratory test refusal, quantity insufficient to test, results not found in electronic health records [EHR] or chart) or results outside the normal ranges. Providers are encouraged to comment on all outlier results with a relevant progress note.
Requesting a medication be reduced, tapered, or discontinued. Quite often there are opportunities to simplify the number of drugs in a regimen or to reduce dosages or frequencies; these would include both routinely scheduled and as-needed (PRN) medications. Enrollment in hospice benefits or a palliative care regime is also a key opportunity for modifications. Pharmacists review the monitoring data provided in the EHR or chart/medication record for clinical parameters — including blood pressure, heart rate, fingerstick monitoring results, and the medication administration record — to identify medications that are being refused, held, or not administered due to lack of demand. This focused time spent reviewing may not be a priority for the provider, so these specific pharmacist recommendations should prompt a more in-depth probe into the resident’s status.
Identifying concerns related to electronic order entry and acknowledgment. Such concerns may include clarification of directions, scheduling of administration times, monitoring protocols, missing stop dates, and any auxiliary warnings related to a drug prescription order. Any of these data entry points can be considered clinically significant and require time-sensitive attention for correction and error avoidance.
Simplifying regimens with multiple drugs in the same category; avoiding the prescribing cascade; using shared decision-making to promote medication regimen optimization. Avoiding therapeutic duplications, adding a drug to counteract side effects of a drug, and encouraging resident engagement are all relevant strategies that pharmacists should highlight and call to a provider’s attention. The adoption of shared decision-making as a strategy for having informative discussions with patients and caregivers that lead to medication reductions has become a more accepted intervention.
Addressing the elephant in the room: the gradual dose reduction (GDR).
With GDR for any psychotropic medication, it’s best to acknowledge that we should avoid the statement “We can’t reduce!” More and more evidence points to GDR as a successful medication discontinuation strategy. Reducing psychotropics in conjunction with programming and nonpharmaceutical interventions promotes the resident’s best quality of life. It also addresses the facility’s need to maintain an active program for monitoring where the facility compares with national and state benchmarks as an indicator of quality (see F758 on psychotropic drugs: https://go.cms.gov/3JEz5Ub
Robert C. Accetta, RPh, is a board-certified geriatric pharmacist and the president/owner of Rivercare Consulting, LLC, a care strategy and consulting business for care organizations.