Long-term Care Transitions: Safe Geriatric Medication Practices after Hospitalization

Monday, June 19, 2017

Rebecca Sommers, BS Pharm

It is one of the most talked about issues in healthcare. The population of the United States (and the world!) is aging. In 2010, 40 million Americans were age 65 and older, and that number is projected to swell to 88 million by 2050.

For those of us working in geriatric medicine, the increasing older population amplifies the care safety challenges that already exist in long-term care. Most of our geriatric population has multiple co-morbidities and therefore patients average 10-12 routine medications per day. That increases the potential for harmful drug interactions and adverse events to occur.

That potential increases even further at times of care transition — moving back and forth between acute hospitalizations and residence in a long-term care facility. During these transitional periods, the switch in location, provider, pharmacist, and the possible confusion of the patient regarding his or her care plan can result in several common medication safety issues:

  • Transcription errors
  • Wrong doses
  • Missing meds
  • Differing formularies leading to duplication of meds or to essential medications dropping off the list

It is incumbent upon consultant pharmacists to keep an eye out for these frequent care transition concerns.

Medication Reconciliation

When a patient comes to long-term care from the hospital, the medication history we receive is often unreliable, due to the source being a family member or geriatric patient reporting from memory. There is often a lack of continuity in care:

  • The family physician cares for the patient when she is alert and mobile.
  • When there is a change in her condition, she is admitted to hospital and cared for by a hospitalist.
  • When she is discharged, she is transferred to an attending physician at a long-term care facility.

She may have duplicated or conflicting prescriptions from these three care sources.

Another issue that arises is that many discharge and transfer orders from the hospital are still handwritten and very difficult to read. Every time the order is transcribed by a different person along the path, it creates another opportunity for errors.

Sliding-scale Medications

When it comes to patients with diabetes, 80-90% of residents get discharged from hospital with a sliding-scale insulin order. The patient is experiencing an acute event in the hospital and may need sliding-scale coverage during that time. However, if the sliding-scale treatment plan continues in the long-term care facility, the patient will need to be stuck for a blood sugar check four times a day in addition to their sliding-scale insulin injections. This is a burden on the patient and creates greater potential for errors to occur.

The pharmacist needs to be ask, “Was this patient on sliding-scale insulin before hospitalization?” If the answer is no, the care team needs to plan to return the patient to a regular maintenance dose schedule upon discharge.

The Pharmacist’s Role

Pharmacist intervention can help mitigate several common long-term care medication safety concerns.

The consultant pharmacist can help make recommendations to adjust dosing of medications based on labs, as well as recommend labs to help screen for and prevent potential adverse effects, sub-therapeutic dosing, or overdosing. The consultant pharmacist can also help create and implement protocols to effectively use expensive medications such as Procrit/ Aranesp.

Diabetes care is a great area in which consultants can help organizations create facility-wide initiatives to help improve care. These can include decreasing incidence of sliding-scale treatments, improving blood sugar control, and decreasing medication costs by decreasing infections and ultimately amputations.

Minimally, the consultant can verify there is a reason — an appropriate diagnosis — to justify the use of all a patient’s medications, thereby helping avoiding unnecessary treatments.

Rebecca Sommers, B.S. Pharm., is vice president of clinical services at Absolute Pharmacy. She has been a clinical manager and consultant pharmacist in long-term care since 1988. A member of the American Society of Consultant Pharmacists, Sommers is a graduate of Ohio Northern University.

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