CMS Proposes Mandatory Consultant Pharmacist Independence

Inside This Issue:

CMS Proposes

Mandatory

Consultant RPh

Independence

Page 2 –3

Déjà vu

A Short

Story

Page 4

Are You Singing the

Blues?

Page 5

Conclusion: Are You

Singing the Blues

Conclusion: CMS

Proposal on Consultant

Independence

Pages 6-7

Quiz:

Why are these

Medications

Used?

Page 8

NMG

Contact

Information

March/April

2012 Neil Medical Group: The Leading

Volume 12, Issue 2

PHARM NOTES

PHARM NOTES Volume 15, Issue 2

March/April

2012 Neil Medical Group: The Leading Pharmacy Provider in the Southeast

In October 2011, a proposed rule was published in the Fed-

eral Register that has the potential to dramatically change

the delivery of consultant pharmacist services to skilled

nursing facilities. This rule, if enacted, would prevent a

long-term care pharmacy from having a financial relation-

ship with a consultant pharmacist. The proposed basis for

this action is the fear that consultant pharmacists may en-

courage increased drug utilization and/or utilization of more

expensive medications to increase the profits of his em-

ployer, the long-term care pharmacy. In addition, the pro-

posed rule commented that many long-term care residents

receive expensive, potentially dangerous, atypical antipsy-

chotics despite a FDA warning concerning their use in de-

mented elderly patients. The Centers for Medicaid seem-

ingly assumes that by separating the consultant pharmacist

from the pharmacy that antipsychotic drug utilization may

decrease.

Available drug utilization data does not support the theory

that independent consultant pharmacists are more effective

in reducing drug use or lowering drug costs. All consultant

pharmacists in New Jersey are prohibited from having a

financial relationship with a long-term care pharmacy pro-

vider. Despite this prohibition, data reveals that New Jersey

nursing home residents have higher drug utilization across

eight major therapeutic categories than the average of any of

the other twenty states with the most nursing home resi-

dents. These therapeutic classes include anti-dementia, anti-

depressant, anti-platelet, antipsychotic, diabetes, dyslipide-

mia, osteoporosis, and respiratory inhalers. While higher

drug utilization does not necessary correlate with greater

inappropriate drug utilization, this data does refute the the-

ory that consultant pharmacist independence will reduce

drug utilization or drug costs.

Neil Medical Group is also concerned that the proposed

change may further fragment the delivery of care in the

nursing home setting. Currently, most consultant pharma-

cists employed by a long-term care pharmacy have elec-

tronic access to pharmacy records. If the employment rela-

tionship is severed, it is unclear if pharmacies will continue

to grant this access to consultants. In addition, consultant

pharmacists that visit facilities served by unaffiliated phar-

macy providers may become less familiar with an individual

Neil Medical Group is strongly opposed to

this potential change for several reasons.

Continued on page 5

Page 2

Déjà Vu

Neil Medical Group—Pharmacy Services Division

Mrs. Matthews looked down at her watch, impatiently tapping her foot. “Where are the children?”

she asked furiously, with her arms crossed. “They should be here by now!”

Sarah Matthews had been a teacher of home economics in the public high school system for over

thirty years. She was known to be a strict disciplinarian and one who made the students “toe the line”. A

petite woman with graying hair, her face bore the wrinkles of age and wisdom. Her eyes, kind but stern,

had seen much in their day.

Suddenly the intercom popped to life. “May I have your attention please, for the morning an-

nouncements!” The intercom was loud and full of static. It had always been a source of irritation for Mrs.

Matthews. “Today is Monday, November 5th” the voice continued. Today‟s weather will be continued rain

and wind, with a high temperature of only 45 degrees. This is just a reminder that there will be a current

events class for Seniors in the main dining room at 11:00.” The voice continued on with the „thought for

the day‟ as Mrs. Matthews complained, “Can‟t they turn that blasted volume down!”

Mrs. Matthews continued to monitor the activities in the hallway. There was always a lot of activity

during this time of day. With her watchful eyes, she was careful to make sure nothing was out of the ordi-

nary. Suddenly, her attention was drawn to a young teen hurrying down the hall. Mrs. Matthews was con-

vinced that the young man was not in class where he needed to be.

“Young man, young man!” she called as she quickly stepped out into his path. “May I see your hall

pass?” A lively discussion followed which ended with the young man going on his way and leaving Mrs.

Matthews disgusted and stomping noisily back into her room.

Quickly forgetting the incident, Mrs. Matthews remembered her promise to her students that she

would have their test papers graded by today. “Oh, dear me,” Mrs. Matthews cried out worriedly. “Where

are my test papers? I can‟t believe I have lost them! This is so unlike me.” Mrs. Matthews proceeded to

look all over her room and could not find the papers. “Oh, the children will be so upset. I promised them

I would have them graded by today!” Mrs. Matthews was thoroughly upset. She had been teaching for

over thirty years and this had never happened.

Mrs. Matthews‟ thoughts were interrupted by the irritating intercom as it clicked on. “Linda Rob-

bins, please call extension 64,” the voice said.

After the brief interruption, Mrs. Matthews resumed her search for the lost test papers, continuing

to rummage through her room. Mrs. Wall, whose room was across the hall, stopped by with a pleasant

greeting.

“Hello, Mrs. Matthews!” she called out. “How are you today?”

“Dear me, I‟m not doing well, not well at all,” Mrs. Matthews answered, with a worried look on her

face. “It does seem that I have misplaced my test papers and cannot find them anywhere!”

“Well, good luck,” Mrs. Wall responded. “I hope you find them.”

At noon, the intercom popped to life again. “Lunch for the 200 Hall is now being served in the

main dining room.” Mrs. Matthews hurried out of her room and headed for the dining room. “Oh me, I

must get going,” she exclaimed. “The cafeteria will be in an uproar if I‟m not there to control the chil-

dren.”

As she entered the noisy dining room, Mrs. Matthews was greeted by Carol Dixon. Carol was en-

couraging Mrs. Matthews to eat some lunch herself, but Mrs. Matthews was too intent on patrolling every-

one else in the dining room. She finally stopped long enough to grab a quick bite.

On the way back to her room, the intercom once again buzzed on. “The quarterly meeting sched-

uled for today will begin in 15 minutes in the conference room.” Mrs. Matthews, hearing the announce-

ment, hastily walked into the hallway. On her way to the conference room, she stopped by Mrs. Barrett‟s

room. Mrs. Matthews asked Mrs. Barrett, “Aren‟t you coming to the teachers‟ meeting this afternoon?”

Mrs. Barrett, appearing somewhat confused, responded by saying, “I don‟t know of any meeting”.

Mrs. Matthews, now thoroughly perplexed, continued to travel in search of the meeting until the

A Short Story by Lauren Matthews

Neil Medical Group – Pharmacy Services Division Page 3

fire alarm sounded. Total confusion followed, with Mrs. Matthews, in her usually manner, trying to super-

vise everyone and everything. When things finally returned to normal, Mrs. Matthews quickly forgot the

teacher‟s meeting and went back to her room to resume the search for the lost test papers.

Nancy King stopped and knocked on Mrs. Matthews‟ door. As she entered the room, she noticed Mrs.

Matthews sitting in her chair, in a lonely corner of her room. She was smiling happily and clutching a stack

of papers to her chest.

Nancy asked kindly, “How are you today, Mrs. Matthews?” Mrs. Matthews looked back at her with

weary buy relieved eyes, and responded, “I finally found them! I have been looking for these test papers all

day. Now I can get them graded for the children.”

Nancy looked down at the papers that Mrs. Matthews was clutching so tightly in her lap. The stack

consisted of an odd assortment of old birthday cards, tattered letters sent by friends and family from years

gone by, and several issues of The War Cry, a complimentary magazine brought in by volunteers from the

Salvation Army. This stack represented many old memories that Mrs. Matthews had accumulated while be-

ing a patient at Shady Creek Nursing Home over the last three years.

Nancy looked down at Mrs. Matthews with a knowing smile. “Here are you bedtime medications, Mrs.

Matthews,” said Nancy as she tucked her in. “Good night…..”

…...for all the “Mrs. Matthews”…….. While the above story is a “short-story”, it is factually based on an actual resident in one of my facilities many years ago. When I told my daughter, Lauren, how Mrs. Matthews’ confusion was compounded by the long term care environment...Lauren turned it into a short-story. The story won an award at High Point University and is re-printed here to hopefully give us a different perspective on all the “Mrs. Mat-thews” that we may have in our own facilities.

Your “Mrs. Matthews” may not have been a teacher…..perhaps she was a nurse and is now trying to “care” for your other residents…..or a homemaker that needs to “get home” to care for her children. Or maybe it is a “Mr. Matthews”...that wanders out in the parking lot because he used to sell cars…..or worked third shift all his life and won’t fit into our mold of what his bedtime should be. Perspective and information about our residents is empowering….and since their “reality” is not likely to change…sometimes…..OUR perspective needs to.

Cathy Fuquay, Consultant RPh & PharmNotes Editor

Neil Medical Group – Pharmacy Services Division Page 4

Have you ever felt down in the dumps during the winter sea-son? Now is the time of year many become depressed as the days get shorter and the holidays bring back negative memo-ries. Don’t brush off that feeling as simply a case of the “winter blues”- you may have Seasonal Affective Disorder (SAD). In any given 1-year period, about 18.8 million American adults suffer from a depressive illness. Seasonal Affective Disorder is a type of depression that occurs at the same time every year. Most people’s symptoms start in the fall and continue into the winter months, then go away during the sunnier days of spring and summer. Less often, people have the opposite pattern and become depressed with the onset of spring or summer. In either case, problems start out mild and become more severe as the season progresses.

How Does SAD Develop? The specific cause of Seasonal Affective Disorder remains un-known. It’s said that genetics, age, being female, and your body’s natural chemical makeup all play a role in developing the condition. The most difficult months for SAD sufferers seem to be January and February. SAD may begin at any age, but the main age of onset is between 18 and 30 years. A few specific factors that may come into play include: Shorter daylight hours and a lack of sunlight in winter can cause a biochemical imbalance in the brain. This affects your biological clock or circadian rhythm. Just as sunlight affects the seasonal activities of animals, SAD may be an effect of this seasonal light variation in humans. As seasons change, people experience a shift in their biological internal clock that can cause them to be out of step with their daily schedule. Melatonin, a sleep-related hormone, also has been associated with SAD. This hormone, which has been linked to depression, is produced at increased levels in the dark. When the days are shorter and darker, more melatonin is produced. Researchers have proved that bright light makes a difference in the brain’s chemistry, although the exact means by which sufferers are affected is not yet known. Some evidence suggests that the farther someone lives from the equator, the more likely they are to develop SAD. Serotonin levels may also be a factor. Serotonin is a brain chemical that affects mood. Reduced sunlight can cause a drop in serotonin, perhaps leading to depression. Symptoms Symptoms of SAD usually appear during the colder months of fall and winter, when there is less exposure to sunlight during the day. Depression symptoms can be mild to moderate, but they can become severe. Those who work long hours inside office buildings with few windows may experience symptoms all year, and some individuals may note changes in mood dur-

ing long stretches of cloudy weather. Symptoms can include, but are not limited to:

Fall and winter Seasonal Affective Disorder (Winter Depres-sion):

●Depression ●Hopelessness ●Anxiety ●Loss of energy ●Social withdrawal ●Oversleeping ●Loss of interest in activities you once enjoyed ●Craving foods high in carbohydrates ●Weight gain ●Difficulty concentrating

Those with SAD may not experience every symptom. For ex-ample, energy levels may be normal while carbohydrate crav-ing may be extreme. Sometimes a symptom is opposite the norm, such as weight loss as opposed to weight gain.

As mentioned earlier, in a small number of cases, annual re-lapse can occur in the summer instead of the fall and winter, possibly in response to high heat and humidity. During this period, the depression is more likely to be characterized by:

Spring and summer Seasonal Affective Disorder (Summer De-pression):

●Anxiety ●Insomnia ●Irritability ●Weight loss ●Poor appetite ●Increased sex drive

Continued on page 5

♪ ♪ ♪ Are You Singing the Blues? ♪ ♪ ♪

Neil Medical Group – Pharmacy Services Divi-

Page 5

Treatment

Increased exposure to sunlight can improve symptoms of SAD. This

can be a long walk outside, opening blinds, adding skylights, trim-

ming tree branches that block sunlight, or arranging your home or

office so that you are exposed to a window during the day. If your

depressive symptoms are severe enough to significantly affect your

daily living, light therapy (phototherapy) has been proven to be an

effective treatment option. Researchers have proved that bright light

makes a difference to the brain chemistry, although the exact means

by which sufferers are affected is not yet known. This form of ther-

apy involves exposure to very bright light (usually from a special

fluorescent lamp) between 30 and 90 minutes a day during the win-

ter. Light therapy mimics outdoor light and appears to cause a

change in brain chemicals linked to mood. This treatment is easy to

use and seems to have few side effects. You may be able to engage

in routine activities, such as reading, while undergoing light therapy.

Additional relief has been found with psychotherapy sessions. Al-

though SAD is thought to be related to biochemical processes, your

mood and behavior can also add to symptoms. Psychotherapy can

help you identify and change negative thoughts and behaviors that

may be making you feel worse. You can also learn healthy ways to

cope with stress.

In some cases, a prescribed antidepressant can be of benefit, espe-

cially if symptoms are severe. Medications commonly used to treat

SAD include: bupropion (Wellbutrin), venlafaxine (Effexor), or Se-

lective Serotonin Reuptake Inhibitors (SSRI’s) such as paroxetine

(Paxil), fluoxetine (Prozac), or sertraline (Zoloft). Your doctor may

recommend starting an antidepressant before your symptoms typi-

cally begin each year. He or she may also recommend that you con-

tinue to take an antidepressant beyond the time your symptoms nor-

mally go away.

Several alternative supplements and mind-body techniques are also

commonly used to relieve depression symptoms. It’s not clear how

effective these treatments are, but they may help. These include sup-

plements such as St. John’s Wort, SAMe, Melatonin, and Omega-3

Fatty Acids. Mind-body techniques include Acupuncture, Yoga,

Meditation, and Massage Therapy.

Tips to Help Manage SAD

●Stick to your treatment plan.

●Take care of yourself. Get enough sleep, exercise regularly,

and eat regular, healthy meals.

●Practice stress management.

●Socialize. Make an effort to be around people you enjoy. They

can offer support.

●Take a trip. If possible, go to sunny, warm locations if you

have Winter SAD or to cooler locations if you have Summer

SAD.

If you feel you are suffering from SAD, it is important to seek the

help of a trained medical professional. SAD can be misdiagnosed as

hypothyroidism, hypoglycemia, infectious mononucleosis, and other

viral infections, so proper evaluation is necessary. For some people,

SAD may be confused with a more serious condition like severe de-

pression or bipolar disorder. It’s normal to feel down some days, but

if you feel down for days at a time and you can’t seem to get moti-

vated to do activities you normally enjoy, see your doctor. This is of

special importance if you notice your sleep patterns and appetite have

changed or if you feel hopeless, think about suicide, or find yourself

turning to alcohol for comfort or relaxation.

There’s no way to prevent the development of SAD; however, if you

take steps early on to manage symptoms, you may be able to prevent

them from getting worse over time. If you can get control of your

symptoms before they get worse, you may be able to head off serious

changes in mood, appetite, and energy levels.

Article by Heather Eaton-Erskine, PharmD, CGP, FASCP

CMS Proposes Mandatory Consultant Pharmacist Independence…………continued from page One

pharmacy’s policies and procedures over time. This may negatively impact the consultant pharmacist’s ability to appropri-

ately advise the facility as required by CMS guidelines.

Lastly, employed consultant pharmacists are able to access pharmacy resources that are already in place to support dispens-

ing operations. This may include electronic drug information software, clerical support, IT services, etc. The independent

consultant could obtain these services separately from a long-term care pharmacy, but those increased expenses are likely to

be passed along to the nursing homes in the form of higher consultant fees. Ironically, this could produce precisely the oppo-

site financial impact than what is intended.

The Centers for Medicare and Medicaid Services accepted public comment on this proposed rule through mid-December

2011. At the time of this newsletter printing, it is unclear when CMS may request additional information or make a determi-

nation regarding finalizing the proposed rule. Neil Medical Group will continue to update all facilities as new developments

emerge. As always please feel free to contact your Neil Medical Group Pharmacist with any questions.

Robert Smith, Pharm D, CGP, FASCP

Director of Clinical Services

Neil Medical Group – Pharmacy Services Division

Page 6

Why are these Medications used?

1. Atrial Fibrillation

A. Digoxin

B. Coumadin

C. Lopressor

D. Cordarone

E. All of the above

2. Benign Prostatic hyperplasia (BPH)

A. Flomax

B. Proscar

C. Adcirca

D. All of the above

3. Seizures /epilepsy/ anticonvulsants

A. Dilantin

B. Depakote

C. Tegretol

D. All of the above

4. Schizophrenia/ Demented illness related

behaviors

A. Risperdal

B. Seroquel

C. Haldol

D. All above

5. Depression

A. Lexapro

B. Celexa

C. Zoloft

D. All of the above

6. Alzheimer’s Dementia

A. Aricept

B. Namenda

C. All of the above

7. Overactive bladder

A. Ditropan

B. Remeron

C. Demerol

8. Anxiety

A. Ativan

B. Buspar

C. Klonopin

D. All of the above

9. Anorexia

A. Megace

B. Marinol

C. Periactin

D. All of the above

Quiz by Stuart Booker, Consultant Pharmacist

Neil Medical Group

Neil Medical Group – Pharmacy Services Division Page 7

1. E. all the above. Both Digoxin and Cordarone are antiarrhymics that affect the heart’s conductive

pathways. Both need close monitoring of labs and vital signs. Digoxin requires a digoxin level every 6

months and daily pulses. Cordarone labs include TSH, LFT and CBC . Lopressor is a Beta-blocker and blunts

the effect of catecholamine’s, thus reducing heart rate. Lopressor is effective at lowing pulse rate as well as

blood pressure. Coumadin is indicated for A fib to prevent embolic clot formation and stroke.

2. D. Flomax and Hytrin are alpha 1-blockers, Adcirca is a selective phosphodiesterase inhibitor.

All of these medications increase blood flow to the prostate and ease urination. Adcirca

(Tadalafil) is also indicated for erectile dysfunction and is also marketed as Cialis. These medica-

tions may increase the risk of hypotension and priapism.

3. D. (Anticonvulsants) These medications stabilize neurons in the CNS and reduce seizure activity. These

medications all require close monitoring of blood levels and side effects. Depakote and Tegretol have also

been used to treat agitated behaviors.

4. D. (drug class Antipsychotic) These drugs block the effect of dopamine (sometimes known as the mas-

ter neurotransmitter) in the brain. These medications have a block box warning for use in dementia related

psychosis in the elderly. Haldol should be used in caution with cardiac patients. Side effects include, excess

sedation, falls , cognitive decline and diabetes. Monitoring includes Lipid panel, blood sugar and Discus or

AIMS every 6 months. Target behaviors need to be monitored and documented to support continued use.

5. D. ( Antidepressants) These are SSRI’s and increase the neurotransmitter serotonin. These drugs have also

been shown to be effective in anxiety disorders.

6. C . Aricept is a cholinesterase inhibitor and Namenda is a NMDA receptor antagonist. Both of these

medications may help preserve cognitive function in Alzheimer’s disease. Side effects of the cholinesterase

inhibitors include Nausea, dizziness, confusion and agitation. Aricept is recommended to be dosed in the

evening.

7. A. Ditropan is an anticholinergic and helps the detrusor muscle to relax and decreases urgency . This

medications has anticholinergic side effects such as dry mouth, blurred vision, constipation and orthostasis.

8. D. (Anxiolytics) Both Ativan and Klonopin are benzodiazepines and are used to treat anxiety and agita-

tion. They have many side effects , including sedation, falls and cognitive impairment. Buspar’s effect is on

Serotonin and it has low incidence of sedation.

9. D. (Appetite stimulant) Marinol is a synthetic preparation of THC. It may cause psychosis and cardiac

effects. it is a CII and needs refrigeration. Megace has a hormonal effect and has shown to increase ap-

petite. Periactin is a H1 antihistamine and is very sedating. Remeron is indicated for depression, but low

doses are often ordered as an appetite stimulant.

Answers

Mooresville Pharmacy

947 N. Main Street

Mooresville, NC 28115

Phone 800 578-6506

Fax 800 578-1672

Kinston Pharmacy

2545 Jetport Road

Kinston, NC 28504

Phone 800 735-9111

Fax 800 633-3298

Pharm Notes is a bimonthly publication by Neil Medical Group Pharmacy Services Division.

Articles from all health care disciplines pertinent to long-term care are welcome. References

for articles in Pharm Notes are available upon request. Your comments and suggestions are

appreciated. Contact:

Cathy Fuquay (cathyf@neilmedical.com)

1-800-862-4533 ext. 3489

Note: Periodically, we are asked to add a name to our distribution list. At this time, copies of

Pharm Notes newsletters are distributed in bulk to Neil Medical Group customers only.

Neil Medical

Group

Pharmacy Services

Save the Date!

The 9th Annual Neil Medical Education Summit will be held on June 20th & 21st

at the Embassy Suites in Winston Salem, NC. Ten hours of CE Credit will be provided

for NC Administrators and Nurses. Additional program information will be distributed

soon…..but plan now to attend this outstanding event!

On a personal note...many thanks to all who sent me e-mails regarding my note in the

last newsletter on the passing of my Mom. I really appreciated all the kind words and

condolences and shared them with my family.

This month, I will leave you on a lighter note……

“A positive attitude may not solve all your problems, but it will annoy

enough people to make it worth the effort.”

Till next time…..

Cathy Fuquay

...a note from the Editor