Monthly Archives: October 2014

Golden Living Unveils Preferred Medication List

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Over the past several years, it has been virtually impossible to practice in an office or hospital without encountering formularies. While they initially were met with skepticism and felt like barriers to freedom of choice in care, eventually most physicians came to see them as necessary evils, then as reflections of the realities of practice of medicine in a world of expensive choices. Many doctors now see formularies as what they have become – a list of thoughtful choices about drugs in classes made by pharmacy and therapeutics committees. These choices ultimately have become evidence-based clinical decisions about what medications are best, and for drugs with equivalent proof of efficacy, medications that reflected best negotiated prices by hospitals or insurance organizations.

While at this point Golden Living is not instituting a closed formulary, the clinical, pharmacy, and medical leaders have developed a preferred drug list.  This list does not cover all drug classes, but does have some preferred medications in some of the most commonly prescribed classes. Unlike some drug lists, there won’t be complicated tiers, or pages or pages of medications.  It will be able to fit on two sides of one sheet of paper.

At Golden Living, guides will be available to help you make some of these decisions regarding medications. While you are free to make your own choices about what is best for your patients, I ask that you take a look at the list to see some of our recommended medication substitutions for several classes of drugs. Some will have an equivalent therapeutic effect but at a significantly reduced cost. Others simply will be the best medication in their class. For those facilities with automated drug dispensing units (ADUs), the list also will help you prescribe medications which are most readily available to the patient because they are already in the facility.

We will do our best to get these lists to you via e-mail and in print, which will be available to you at the nursing stations. We also will make sure that the nursing supervisor has extra copies. If you have questions, comments, or suggestions about the list, please feel free to discuss the items with your consultant pharmacist.

Down the road, it may be possible to have an automated list, which will prompt nurses entering initial orders to request substitutions or alternative medications. Ultimately (in states where this is permitted), you may even be able to sign a list ahead of time which allows for automatic substitutions of medications. Until then, please help us right now with your own prescription activity.

If your patient comes from the hospital with some medications which are of dubious value or unclear indication, I hope that when clinically appropriate you will be willing to consider discontinuation or a gradual dosage reduction. If not, then consulting the list ultimately may result in a safer, more efficacious, and cost-effective regimen for your patients. It may even save you from some phone calls and fax requests down the road.

Dr. Lilly Manages Complex Patients in West Virginia

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Having gone to medical school at the Joan C. Edwards School of Medicine at Marshall University, Dr. Jonathan P. Lilly has a deep knowledge of the culture and population in West Virginia. Armed with this understanding, Dr. Lilly serves as medical director for two LivingCenters – GLC – Glasgow and GLC – Riverside and was recognized as one of Golden Living’s Medical Directors of the Year earlier this year.

First Monday’s editor recently sat down to visit with Dr. Lilly about his approach to serving these two facilities.

“Even though they are 30 minutes apart, they might as well be worlds away,” Dr. Lilly said of the two facilities.

One facility serves a large population that includes many coal miners, and the other facility serves many people who spent their careers in the chemical industry. However, one thing both facilities have in common is that they both serve populations that are complex. Many patients have multiple chronic diseases with obesity and diabetes rates being very high in West Virginia overall.

Dr. Lilly went on to talk about how almost everyone in one of his LivingCenter’s battles diabetes, so managing insulin and related care regimes is a core focus of the medical team there. At the other LivingCenter, a number of residents and patients suffer from a combination of COPD, black lung disease and heart disease. He stressed how the team approach was critical to navigating the changes in the healthcare approach for both facilities.

In his nomination, Jennifer Jeffrey, executive director of GLC – Riverside noted how much Dr. Lilly thinks beyond his medical role at his LivingCenters.

“Dr. Lilly is always ready and willing to represent the facility as well as the residents,” she said.

He enjoys helping the facility staff and has purchased food for staff, paid for parties for the team and even ordered ice cream for staff and residents to have an ice cream social. When there is a health scare or crisis with staff, he is one of the first to help, answer questions and listen to concerns.

“Both LivingCenters are so proud to call Dr. Lilly our medical director [as he illustrates a] substantial amount of loyalty, dedication and hard work upon both facilities,” Jeffrey continued.

Insulin Pens Rolling Out to LivingCenters

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It is rare when we can institute an intervention that can achieve the triple aim of simultaneously improving patient health, improving the patient experience and reducing cost of care.  Such an opportunity exists with the automatic substitution of insulin pens in our LivingCenters which begins this month.

Studies repeatedly have demonstrated that using insulin pens is safer and more convenient for patients.  In settings like hospitals and skilled nursing facilities, insulin pen usage decreases dosing errors. Patients do better upon discharge with insulin pens because the dose markings are easier to see and less manual dexterity and visual acuity is necessary to self-administer doses.

In addition to this, there is less chance of running out before a refill is obtained because the pens clearly indicate remaining doses.  This takes the guesswork out of estimating how much is left in a vial.  Finally, using 3 mL insulin syringes and in some patients, 3ml vials decreases insulin waste when a patient is discharged.  This results in less medicine cost to facilities and payer sources.  Ultimately, this benefits everyone.

As a physician, you do not need to change your order or do anything for this to occur.  The necessary steps to execute this initiative will be done at the nursing and pharmacy level.  It is important to notify you because this will enhance your patient care, post discharge adherence, and because your patients may have questions.  If you’d like to know more about this, your Director of Nursing should be able to help you.

Medical Director Town Hall Meetings

Last month, Golden Living held three “Town Hall” phone conferences.  Multiple times were provided so that physicians could find time within their busy schedules.  Given the positive feedback we have received about these calls, and the active discussions that ensued, we are likely to continue to have these periodically.  Keep an eye out for e-mail notices about these events, where your Medical Leadership will provide timely news and tips, as well as encourage your input as to your concerns as well as best practices within your LivingCenters.  Topics covered in the last Town Hall meetings included updates on FDA rescheduling of hydrocodone and tramadol, as well as the Medical Director/Director of Nursing/Executive Director annual facility meeting concept.

Controlled Substance CII Signature Compliance

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As you are aware, Federal DEA Regulations require physicians to provide written or faxed prescriptions to cover verbal orders for CII class controlled substances within 7 days.  AlixaRx has worked together with Golden Living to develop a system to help remind physicians that a written, signed prescription is needed.  This includes multiple attempts to contact the doctor’s office or preferred phone # as well as your fax #.  After 4 days the Director of Nursing at the LivingCenter (DNS) will be contacted as well to assist in obtaining the prescription.  The DNS may require your assistance in making sure that these prescriptions are obtained in accordance with regulation.  Once a week is passed and the prescriptions become overdue, the AlixaRx pharmacy or backup pharmacy must report out of compliance prescriptions and physicians to the DEA.  You may be contacted by me or your Regional Medical Director asking for your help in getting the doctor to comply.  PharMerica and OmniCare also have been taking similar steps to comply with Federal Law.

Pharmacies have the right to decline to fill controlled substances for physicians who are repeatedly non-compliant with this law.  At Golden Living, we recognize the importance of following the law so that our patients receive their medications in a timely fashion.  Please double check to make sure that your pharmacy and LivingCenter have the preferred contact information including fax and phone numbers of your office and that of your medical staff.  Call coverage arrangements should be clear so as to avoid delays in communications.

If you have any questions about this, please do not hesitate to contact your Regional Medical Director or me.

AMDA Conference to Be Held in Louisville in March

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Medical Directors are encouraged to attend next year’s American Medical Directors Association Long-Term Care conference in Louisville, Kentucky, held March 19-22, 2015.

Because this will coincide with the NCAA Final Four in the same town, hotel space will be at a premium, so it pays to register early this year.  As usual, Golden living plans to hold our Medical Director Gala on Friday Night.  You will get a chance to meet other Golden Living Medical Directors, your Regional Medical Directors, and other Golden Living leadership.  The Annual Golden Living Medical Directors of the Year will be presented as well.  We look forward to seeing you there!

2014-15 Flu Vaccine Will Be Available Soon

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For the 2014-15 influenza season, national suppliers have had some difficulty getting dosages ready.  This week, however, the vaccine should be available for both our patients and staff.  Please encourage staff to get vaccinated.  Studies have demonstrated that in facilities where influenza vaccine has been mandated among staff, that mortality from influenza can be cut as much as 40% among residents.  While Golden Living currently does not have a company-wide mandate, it is strongly urged, and if rates do not improve, this situation may change, particularly as CMS looks to include staff immunization rates as a quality measure in the future.

This year’s trivalent vaccine is the same as last year’s.  As you know, antibody rates will not carry over from last flu season to this flu season.  The CDC recommends that individuals get the flu shot as soon as it becomes available.

You can keep up with the latest information about the flu prevention and treatment by going to the CDC http://www.cdc.gov/flu/professionals/index.htm and http://www.cdc.gov/flu/weekly/ for weekly updates. It’s also possible to subscribe to weekly e-mail updates through the site.