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Care Points

1 S T Q U A R T E R 2 0 1 6

Welcome to Care PointsWelcome to the 1st Quarter 2016 edition of the Care Points Newsletter. This quarter’s newsletter will focus on the following items:

Industry Hot Points:

•Medicare-MedicaidPlans

•PayrollBasedJournal

•FocusonSignificantChanges in the 2015 AGSBeersCriteria

What’s new at Omnicare:

•CVSHealthUpdate:FocusonBack-upPharmacyProcess

•WelcomePackets

Customer Focus Point:

•ePrescribing

•EnhancedAssisted Living Program

Infusion Focus Point:

•SIGMASpectrumSmartPumpUpdates

©2016Omnicare CarePoints|FirstQuarter2016

IndustryHotPoints

> Medicare-Medicaid Plans

TheMedicare-MedicaidPlandemonstrationseekstoimprovethebeneficiaryexperienceof“dualeligibles”(personsthatqualifyforbothMedicareandMedicaid)withanintegratedapproachdesignedtoimprovequalityandcoordinationofcare.OutlinedbelowisanupdateregardingtheRhodeIslandDualDemo:IntegrityProgram.

Opt-In Enrollment

March31,2016(tentative) Firstopt-innoticestoeligible RhodeIslandersmailed

May1andJune1,2016 Effectivedatesoftwowavesof opt-inenrollment

Passive Enrollment

April15,2016(tentative) Firstpassiveenrollmentnoticesmailed

July1–December1,2016 Effectivedatesofpassive enrollment waves

January1,2017 Steadystateenrollment

> Payroll Based Journal

TheAffordableCareActrequiresallnursingfacilitiestoelectronicallysubmitdirectcarestaffinginformation(includingagencyandcontractstaff)toCMSbasedonpayrollandotherdata.Whencombinedwithfacilitycensusinformation,thedatacanthenbeusedtoreportonthelevelofstaffineachnursingfacility,andalsoprovideinformationonemployeeturnoverandtenure,whichcanimpactthequalityofcaredelivered.ThesedatacollectingandreportingrequirementsbecomeeffectiveonJuly1,2016.

Tofulfillthisrequirement,CMShasdevelopedasystemforfacilitiestosubmitstaffingandcensusinformationknownasa“Payroll-BasedJournal”(“PBJ”).ThisreportingmustalsoincludedirectcareprovidedbyConsultantPharmacists.

Omnicarewillbeprovidingcustomerswithoptionsforreceivingthisdata.ItisourgoaltohavetheseoptionsavailablebyJuly1,2016,andmoreinformationwillbeprovidedasthisdateapproaches.PleasecontactyourConsultantPharmacistwithanyquestions.

> Focus on Significant Changes in the 2015 AGS Beers Criteria

Since1991theBeersCriteriahaveprovidedhealthcareprofessionalsingeriatricslistsofpotentiallyinappropriatemedications(PIMs).InOctober2015theAmericanGeriatricsSociety(AGS)publishedthefifthversionoftheCriteria(hereafterreferredtoas“the2015Criteria”),whichupdatestheinformationAGSfirstbegantoprovidein2012.The2015AGSupdateincludesfiveliststhatcomprisethe2015Criteriaaswellasthreeothersupportingdocuments.Theseincludemorethan40potentiallyproblematicmedicationsorclassesof medications.

Lists Comprising 2015 Data

• PotentiallyInappropriateMedication(PIM)Use

• PIMUseDuetoDrug-DiseaseorDrug-SyndromeInteractions

• PIMstoBeUsedWithCaution

• ClinicallyImportantNon-Anti-InfectiveDrug-DrugInteractionsThatShouldBeAvoidedNEW!

• Non-Anti-InfectiveMedicationsThatShouldBeAvoidedorHaveTheirDosageReducedBasedonKidneyFunctionNEW!

Supporting Documents

• How-to-UseGuide

• EvidenceTables(625pages)

• SuggestedAlternativesNEW!

Inadditiontostatingthatthe2015CriteriaareNOTintendedforuseinolderadultsinpalliativeorhospicecare,AGS’underlyingprinciplesforuseofthe2015Criteriaincludethefollowing:

• Medicationsincludedarepotentiallyinappropriate,notdefinitelyinappropriate. (TheyareNOTuniversallyinappropriate)

• Readtherationaleandrecommendationsforeachcriterion —thecaveatsandguidanceareimportant• Understandwhymedicationsareincludedandadjustyourapproachtothesemedicationsaccordingly.• OptimalapplicationinvolvesidentifyingPIMsand,whereappropriate,offersafernonpharmacologicaland

pharamcologicalalternatives• TheCriteriashouldbeastartingpointforacomprehensiveprocessofidentifyingandimprovingmedication

appropriatenessandsafety• AccesstoincludedmedicationsshouldNOTbeexcessivelyrestrictedbypriorauthorizationand/orhealthplan

coveragepolicies

Theremainderofthisarticlewillfocusonthesignificantadditionsand changes within the 2015 Criteria.

©2016Omnicare CarePoints|FirstQuarter2016

IndustryHot Points

AccordingtoAGS,the2015

Criteria “serve as a ‘warning

light’toidentifymedications

thathaveanunfavorable

balanceofbenefitsand

harmsinmanyolderadults,

particularlywhencompared

withpharmacologicaland

nonpharmacologicalalternatives.”

Changes in the 2015 AGS Beers Criteriacontinuedonnextpage.

The 2015 AGS Beers Criteria and other resources are available for FREE at: http://geriatricscareonline.org

IndustryHot Points

©2016Omnicare CarePoints|FirstQuarter2016

Significant Updates

Althoughnotasextensiveasthe2012revisions,the2015Criteriaincludeseveralupdates.Whilesomemaybedeemedminor(e.g.,nolongersayingtoavoidtrimethobenzamide),importantchangesinthePIMlistaresummarizedbelow.

Drug or Category New Update Guidance Why Included?

Nitrofurantoin

•

ChangedguidancetoavoidinCrCl<30mL/mininsteadofavoid<60mL/min;Long-termuseshouldbeavoidedduetopulmonary,liver,andnervetoxicity

Morerecentclinicaltrialsdemonstraterelativesafetyandefficacywithshort-termuseinthosewithurinarytractinfectionsandCrCl≥30mL/min

ClassIa,Ic,IIIAntiarrhythmicsinAFib •

Removed“entireClass”;amiodaroneand dronedarone are now listed individually

Newevidencesuggestsrhythmcontrol can have equal or even favorableoutcomescomparedtorate control

Digoxin

•AvoidasfirstlinetherapyforAFiborHF;Avoiddoses>0.125mg/day(anyindication)

Possibleincreaseinmortality;questionableeffectsonhospitalizations

Non-benzodiazepineHypnotics(e.g.,zolpidem)

•Changed“Avoidchronicuse(>90days)”to“Avoid”regardlessofduration

Evidenceshowsanincreaseinharmwithminimalimprovementinsleeplatencyandduration

Desmopressin • Avoid for treatment of nocturia or nocturnalpolyuria

Highriskofhyponatremia;saferalternativesavailable

ProtonPumpInhibitors(e.g.,omeprazole) •

Avoidroutineusefor>8weeksexceptinhigh-riskpatients(e.g.,NSAIDuse,Barrett’sesophagitis)

RiskofClostridium difficileinfection,boneloss,andfractures

SlidingScaleInsulin

•Clarifieddefinition=“referstosoleuseofshort-orrapid-actinginsulinstomanageoravoidhyperglycemiainabsenceofbasalorlong-actinginsulin”

**Guidance to Avoid use of sliding scale insulin remains**

CrCl=creatinineclearance;AFib=AtrialFibrillation;HF=HeartFailure;NSAID=NonsteroidalAnti-inflammatoryDrug

AfewchangeswerealsomadeinthePIMlistinvolvingspecificdiagnoses.

Disease or Syndrome Drug/Drug Class New Update Description of Change

Delirium Antipsychotics(e.g.,quetiapine) • Avoidunlessnonpharmacologicaloptions(e.g.,behavioralinterventions)havefailedorarenotpossibleANDtheolderadultisthreateningsubstantialharmtoselforothers

Dementiaorcognitiveimpairment

Antipsychotics(e.g.,quetiapine)

•

Dementiaorcognitiveimpairment

Eszopicloneandzaleplon • AvoidduetoriskofadverseCNSeffects

Changes in the 2015 AGS Beers Criteriacontinuedonnextpage.

IndustryHot Points

©2016Omnicare CarePoints|FirstQuarter2016

Disease or Syndrome Drug/Drug Class New Update Description of Change

Constipation Drugsassociatedwithconstipation(e.g.,anticholinergics)

DELETEDConsidered“commonknowledge”andnotspecifictotheelderly

Historyoffallsorfractures

Opioids

•

Maycauseadditionalfallsorimpairpsychomotorfunction.Mayuseforpainmanagementduetorecentfractureorjointreplacement.Ifmustbeused,considerreducinguseofotherCNS-activemedications(e.g.,sedatives,anticonvulsants,antipsychotics,antidepressants)andimplementfallriskreductionstrategies.

UrinaryIncontinence(alltypes)inwomen

Peripheralalpha-1blockers (e.g.,doxazosin) • Combinedfromthe2012categoryfor

“Stressormixedurinaryincontinence”

Clinically Important Drug-Drug Interactions **New**

Oneofthenewadditionsinthe2015Criteriaisalistof13selectdrug-druginteractions(excludinganti-infectivemedication-relatedinteractions).Althoughthislistisnotmeantto“diminishtheclinicalimportanceof[other]known-knowninteractions”,theseinteractionshave“evidenceinolderadults…ofseriousharmif…thedruginteractionisoverlooked”.

Drug A Drug B Interaction Risk Recommendation

ACEInhibitors Amiloride or Triameterne

⬆ riskofhyperkalemia Avoid routine use (unlesstheyhavehypokalemia)

Anticholinergics Anticholinergics ⬆ riskofcognitivedecline Avoidorminimizenumberofagents

Antidepressants

TwoormoreCNS-active drugs

⬆ riskoffalls

AvoidthreeormoreCNS-activedrugs;minimizeuse

Antipsychotics ⬆ riskoffalls

Hypnotics ⬆ riskoffalls

OpioidAnalgesics ⬆ riskoffallsandfractures

Corticosteroids (oralorparenteral)

NSAIDs ⬆ riskofGIbleeding/pepticulcerdisease

Avoid.Ifmustuse,alsouseGIprotection

Lithium ACEInhibitors ⬆ riskoflithiumtoxicity Avoid.Ifuse,monitorlithiumconcentrationLithium LoopDiuretics

PeripheralAlpha-1Blockers

LoopDiuretics ⬆ riskofurinaryincontinenceinolder women

Avoid in older women

Theophylline Cimetidine ⬆ riskoftheophyllinetoxicity Avoid

Warfarin Amiodarone ⬆ riskofbleeding Avoidwhenpossible.Monitorcloselyforbleeding(e.g.,INR)Warfarin NSAIDs ⬆ riskofbleeding

Changes in the 2015 AGS Beers Criteriacontinuedonnextpage.

IndustryHot Points

©2016Omnicare CarePoints|FirstQuarter2016

PIMs Based on Kidney Function **New**

Beyonddruginteractions,the2015Criteriaalsoidentifyaselectgroupofchronicmedicationsthatshouldbeavoidedorhavetheirdosereducedbasedontheindividual’skidneyfunction.SomerecommendationsmaydifferfromtheFDAlabeling.

Drug Category MedicationCrCl

(mL/min)Rationale

Action

Avoid Reduce

Potassium Sparing Diuretics(Amiloride,Spironolactone,Triamterene)

<30 ⬆ potassium±⬇︎ sodium X

Ant

ico

agu

lant

s

Apixaban < 25 ⬆ riskofbleeding X

Dabigatran <30 ⬆ riskofbleeding X

Edoxaban

30-50 ⬆ riskofbleeding X

<30or>95 ⬆ riskofbleeding(<30);⬆ riskofstroke(>95)

X

Enoxaparin <30 ⬆ riskofbleeding X

Fondaparinux <30 ⬆ riskofbleeding X

Rivaroxaban30-50 ⬆ riskofbleeding X

<30 X

CNS Analgesics

Duloxetine <30 ⬆ riskofGIsideeffects X

Gabapentin < 60 CNSadverseeffects X

Levetiracetam ≤80 CNSadverseeffects X

Pregabalin < 60 CNSadverseeffects X

Tramadol <30 CNSadverseeffects X(ER) X(IR)

H2 Antagonists(Cimetidine,Famotidine,Nizatidine,Ranitidine)

< 50 Mentalstatuschanges X

GoutMeds

Colchicine<30 GI,neuromuscular,and

bonemarrowtoxicitiesX

Probenecid <30 Loss of effectiveness X

Applying the 2015 AGS Beers Criteria Update

AGSprovidesvarioussuggestionsforapplyingthe2015Criteria:

• Avoidabruptstoppingofmedications.UsetheCriteriaasa“warninglight”forclosereviewandmonitoring.• Closelyassessforpotentialadverseeffects(manymaybesubtleyetimportant).• UsetheCriteriaasastartingpoint“intoalargerreviewanddiscussionofmedicationprescribingquality.”• Addressingthemanagementofthesemedicationsshouldbeinterdisciplinary(e.g.,prescribers,nurses,pharmacists).• TheCriteria“arereasonabletouseforperformancemeasurementacrosslargegroupsofpatientsandprovidersbutshould

notbeusedtojudgecareforanyindividual.”• TheCriteriashouldnotdistractcliniciansfromattendingtootherimportantaspectsofpharmaceuticalcareinolderadults.• Throughoutthecareprocess,alwaysdeterminewhythepatientistakingthedrug,ifitistrulyneeded,andwhethersaferor

more-effectivealternativesareavailable.

Ashealthcareprovidersbecomeincreasinglyfamiliarwiththe2015Criteria,theAGS’goal“tosupport,ratherthansupplant,goodclinicaljudgment”canbeaccomplished.

©2016Omnicare CarePoints|FirstQuarter2016

What’s New at Omnicare

> CVS Update: Focus on Back-up Pharmacy Process

NowaspartofCVSHealth,wehaverapidlyembracedourroleasapharmacyinnovationcompanyandremaincommittedtoreinventingpharmacyforthebenefitofourcustomers.AswebecomemoreintegratedwithinCVSHealth,youwillseemanyexcitingnewaswellasenhancedservicesandsolutions.

ThefirstnewdevelopmentwewouldliketosharewithyouisourbackuppharmacyprograminwhichweutilizetheCVS/pharmacyretailfootprinttoextendournetwork.

WebegantestinganewprocessinDecemberinwhichCVS/pharmacieswereusedasourbackuppharmacyinColumbus,Ohio,andtheresultshavebeenfantastic.

WeweresuccessfulduringthetestbecausewewereabletoinstillaseamlessprocessatOmnicareandCVS/pharmacy,somethingwecouldnotdobeforebecomingpartofthelargerenterpriseofCVSHealth.Wehavebeguntolaunchthisinitiativeinselectmarkets,andweexpecttohaveitimplementedacrossthemajorityofournetworkinlessthantwomonths.Andwiththe10,000CVS/pharmacylocations,weexpecttodeploythisprocessforthemajorityofourbackuppharmacyneeds.Weareintheprocessofdevelopinganameforthisgreatnewprogram.Staytuned!

WehaveanumberofnewinitiativesindevelopmentthatutilizethemanycapabilitiesofCVSHealthtobringnewpatientcaresolutionstoourcustomers.WelookforwardtosharingmoreoftheseserviceswithyouinfutureeditionsofCarePoints!

> Welcome Packets

AnelectronicversionoftheupdatedResident Admission Welcome PacketthatisavailableonOmniviewaswellasMyOmniview.

Theupdatedversioncontainstimelyresidenttopicsincludingbutnotlimitedto:

• OmniPlanFinder• MedicarePartD• PharmacyStatementInformation• Online and Over the Phone

PaymentOptions

Path for Omniview Access:ReferenceLibrary>PharmacyBillingGuidelines>OmnicareToolsforFacilities>WelcomePacketforNewResident

Ofnote,whenresidentsregisterforMyOmniview,theyreceiveanelectronicversionofthewelcomepacketintheirinbox.

©2016Omnicare CarePoints|FirstQuarter2016

> ePrescribing

Committedtechnologyofferingsresultingreateraccuracy,speedandconsistencyofservice.Thisleadstoimprovedpatientcare,increasedefficienciesandreducedcost.

Earlylastyear,OmnicarebeganreceivingElectronicPrescribingofControlledSubstances(EPCS)viaSurescripts.Surescriptsisthenation’slargestePrescriptionnetwork.ThisallowsanyprescribertoaccessanypharmacyconnectedwithinthisnetworkusingtheirofficesoftwarepackagesviatheSurescriptstransmissiongateway.Prescribersusingthisoptionincludephysicians,specialists,nursepractitionersandphysicianassistantswhohavecommunityofficepracticesandcontinuetocarefornursinghomeandassistedlivingpatients.

Omnicareiscommittedtosupportingtechnologyastheindustryadvancestoamoreelectronicprocess.

> Enhanced Assisted Living Offering

CustomerFocusPoint

> SIGMA Spectrum Smart Pump Updates

©2016Omnicare CarePoints|FirstQuarter2016

InfusionFocusPoint

Omnicare’scommitmenttobringinnovativeandbestinclasstechnologytoourcustomers,directedourdecisiontobeginthenationwideconversionofourfleetofBaxter6201Flo-GardinfusionpumpstoSIGMASpectrumSmartPumpTechnologyin2012.DuringthepastthreeyearswehaveexperiencedunforeseendelayscausedbypumpavailabilityfromthemanufacturerandstringentFDArequirementsformedicalequipment.

WebelievetheSigmaSpectrumisthebesttechnologyavailabletomeettheneedsofourcustomerswhoareadmittinghigheracuitypatentsasaresultoftheeverchanginghealthcareenvironment.TheSIGMASpectrumInfusionSystemDoseErrorReductionSoftware(DERS)canhelpreducepumpprogrammingerrorsandadversedrugeventsby:

• StartingdoseratesandconcentrationscustomizedspecificallyforOmnicarecustomerswiththeOmnicareMasterDrugLibrary(MDL)

• HardandsoftdrugdosinglimitsestablishedbyOmnicarePharmacists and Clinicians

• CheckFlowatStartoftheinfusionhelpsensuretherearenoclosedclampsorkinksintubingthatmaypreventtheflowofcriticalmedications

• SecondaryInfusionContainerCheckpromptsthecliniciantoverifymedicationflowfromthesecondarycontainerandnottheprimarycontainer

OurgoalistocontinuemovingforwardwiththeSigmaSpectrumconversioninawell-plannedprocessoverthenext24months,withatargetcompletiondateofDecember,2017.Belowisamaprepresentingthecurrentconversionplan.

Current Conversion Plan

SIGMA SpectrumInfusion System

Pink:Conversioncompleted

Purple: Planned for 2016

Blue:Plannedfor2017

Managing Pump Returns to Omnicare

Omnicaremanagesafleetofover15,000infusionpumpsnationwide.OurpumpfleetrepresentsanextremelyvaluableassettoOmnicareandanimportantresourceforourcustomers.Weemploytheuseofanelectronicassettrackingandpumpmanagementsystemthatallowsustotrack:usage,location,maintenance,identification,andqualitychecksbetweeneachpatientuse.TheinfusionpumpisthepropertyofyourOmnicarePharmacy.Pleasereturnthepumptothepharmacywhenthetherapyisdiscontinuedorwhenthepatientistransferred/discharged.

Pumps must be returned to the pharmacy between each patient for terminal cleaning, disinfection and testing per manufacturer’s recommendations and FDA regulation.

Omnicarecourierservicedriversareroutinelyatyourfacilityandwillpickuppumpswhenpickingupmedicationsforreturn.Intheeventofloss,assesseddamageordestructionoftheequipment;thelongtermcarefacilitymaybechargedthereplacementcostoftheinfusionpump.

OmnicareInfusionServicesstrivetoprovideyouwiththebestserviceandstateoftheartequipmenttosafelymanageyourpatient’sinfusionneeds.

EditorialBoard

BethCoryea,PharmD-SeniorEditorSeniorDirector,AccountManagement

BarbaraConnolly,MS,RPhSeniorDirector,ClinicalServices

KathleenEarly,RPhSeniorDirector,Operations

JeffWoodside,RPhSeniorDirector,AccountManagement

Contributing Authors for this Issue:

CoreyBishop,RN,CRRN,CRNINationalDirectorofInfusionNursing

MelanieKincerProductManager,OmnicareDigital

PatrickLeeVicePresident,LTCProduct&BusinessDevelopment

AllenL.Lefkovitz,PharmD,CGP,FASCPDirector-ClinicalPharmacyEducationandDrugData,Omnicare,Inc.

TerryO’Shea,BSPharm,PharmD,CGPSeniorDirector,ConsultantPerformance

ColinUphamSeniorDirector,PayerRelations

HollyVenezianoSeniorManager,BillingDepartment

JimVett,SeniorDirectorALMarketingandCommunication

InfusionFocusPoint

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