I would like people, who practice in these areas, to share their experiences. Why did you choose it? What's your typical day? What are pros and cons? Thanks.
Home infusion, LTC pharmacists
- Thread starter konkan
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I managed an home infusion pharmacy for 7 months. I hated it. Making IVs for patients at home meant someone had to be on call 24 - 7...just incase the pump malfunctions..and since we relied on UPS for deliveries..who knew when the IV were delivered..etc. Hated it passion.
Never did LTC.
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Are you talking bad about UPS?
(Mr. All4MyDaughter is a manager at UPS worldport in Louisville)
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Are you talking bad about UPS?
(Mr. All4MyDaughter is a manager at UPS worldport in Louisville)
No..I love UPS..after all, MY DME business relies heavily on UPS...
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My stepdad used to work for UPS. Then he got fired for failing two drug tests in a row.....
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Yeah, they don't like that.
Here in Louisville the UPS facility is located entirely within the restricted zone of Louisville international airport, so everyone has to pass the super-strict TSA background check. Many people quit rather than take it.
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I don't know anyone on here that is in either field. We just had guest speakers cover both topics. Here is the study guide a classmate made about both careers: It may be a little boring.
Study Questions for Long Term Care and Home Infusion Pharmacy
Remingtons Chapters 129-130
1. What legislation mandated that a consultant pharmacist be retained by nursing facilities and why was this considered necessary at that time?
The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) required that all nursing facilities certified by Medicare retain the services of a consultant pharmacist to ensure that all medication regimens provided to residents were periodically reviewed. When Medicare and Medicaid were created in 1965 to provide government health insurance, payments to nursing facilities exploded, causing Medicare to restrict nursing home coverage. Decreased payments to nursing homes caused a diminished number of staff to care for a growing number of residents and the quality of nursing home care became a concern.
2. What are the primary duties of a long term care consultant pharmacist?
Primary duties include practicing in a long-term care facility to provide drug regimen review (DRR), medication storage and administration oversight, staff and resident education. Pharmacists must be cognizant of guidelines, manage patients with multiple disease states and medications, and be aware of the quality of life of the patient when recommending drug therapy interventions, including the complexity of the medication regimen, compliance issues and side effect profiles of therapy.
3. What is the primary need that causes patients to be admitted to nursing facilities?
The most common need for admission into a nursing facility is assistance with activities of daily living (ADLs), such as bathing, dressing, toileting and eating. Sometimes residents are unable to follow a medication regimen.
4. Who is the primary payer for nursing home services?
The primary payer for nursing home services was Medicare, comprising 39% of payments.
5. What are Beers criteria? Give an example and describe how this impacts pharmacy services in a nursing facility.
Beers criterion includes inappropriate drugs for use in the elderly due to detrimental side effects of little evidence of efficacy. Examples include antipsychotics and sedative / hypnotics and impacts pharmacy services in a nursing facility by limiting what medications can be used and laying responsibility on the pharmacy to help uphold such standards.
6. What is drug regimen review (DRR)? Describe what the consultant pharmacist must do.
Drug regimen reviews encompass nearly all clinical activities of the consultant pharmacist and occur to ensure safe medication use. Each drug regimen must be reviewed at least monthly by the pharmacist when servicing a nursing facility. Irregularities must be reported to the attending physician and director of nursing of the facility. The pharmacist is only responsible for documenting the irregularity and making a recommendation for resolution.
7. Give several examples of the types of irregularities that a consultant pharmacist is looking for in a DRR.
Multiple orders for the same drug by the same route
Drugs administered without regard to stop order policies
PRN drug orders administered routinely for more than 30 days
Residents receiving three or more laxatives concurrently
8. What is the acceptable rate for medication errors in a nursing facility?
A facility must monitor for medication errors and ensure an error rate of less than 5%.
9. What is a medication pass observation and how often should it be done?
The objective of a medication pass survey is to observe preparation and administration of medications in order to assess compliance with 42 CFR 483.25(m) for medication errors. The pharmacist should observe a minimum of 20-25 opportunities for error (both doses administered and doses ordered by not administered). The medication passer should adhere to the five rights, right resident, right drug, right dose, right time, and right route.
10. What are the quality of life considerations that a consultant pharmacist must take into account when making recommendations for patients?
The pharmacist should take into account the presence of a durable power of attorney or healthcare representative, advance directives such as DNR or full code status, and the emotional wellbeing of patient in an institution.
11. What types of facilities qualify as home care sites?
Patient homes, long-term care, skilled nursing facilities, assisted living and subacute facilities, home care, diagnostic centers, outpatient clinics, ambulatory surgery, rehabilitation facilities and emergency service markets (under the expanded definition of home / alternate site healthcare).
12. What is home infusion therapy and what types of medications are commonly administered this way?
Home infusion therapy involves the preparation, delivery, and administration of parenteral and enteral therapy in alternate settings (rather than an inpatient setting). Commonly administered therapies include antibiotics, chemotherapy, pain management, parenteral nutrition (TPN), enteral nutrition (feeding tubes) and immune globulin. Home therapy involves the prolonged and usually repeated injection of pharmaceutical products most often delivered intravenously, subcutaneously, intramuscularly, enterally, or epidurally. Other common therapies include corticosteroids, inotropics, hydration, tocolytics, human growth hormone, blood clotting factors, and colony-stimulating factors.
13. What factors have driven the move to home care from institutional care?
The main reason for the dramatic increase in alternate site healthcare has occurred largely to the nationwide effort to control healthcare costs.
14. What is aseptic technology?
Aseptic technology is the application of a scientific understanding of the characteristics of viable microorganisms, applied in such a manner that the microorganisms are eliminated, with a high probability of success, from all of the process steps involved in compounding sterile pharmaceutical dosage forms.
15. What issues are involved in providing home infusion therapy that is safe and effective for patients?
Issues requiring the attention of a pharmacist include the use of sterile products before completion of quality control testing, potential exposure of products to temperature changes during shipping and delivery, administration of products by persons lacking professional skills, administration through devices that may not be adequately protected against contamination, and the lack of definitive evidence of stability for the 30 to 60 day shelf life often required.
Study Questions for Long Term Care and Home Infusion Pharmacy
Remingtons Chapters 129-130
1. What legislation mandated that a consultant pharmacist be retained by nursing facilities and why was this considered necessary at that time?
The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) required that all nursing facilities certified by Medicare retain the services of a consultant pharmacist to ensure that all medication regimens provided to residents were periodically reviewed. When Medicare and Medicaid were created in 1965 to provide government health insurance, payments to nursing facilities exploded, causing Medicare to restrict nursing home coverage. Decreased payments to nursing homes caused a diminished number of staff to care for a growing number of residents and the quality of nursing home care became a concern.
2. What are the primary duties of a long term care consultant pharmacist?
Primary duties include practicing in a long-term care facility to provide drug regimen review (DRR), medication storage and administration oversight, staff and resident education. Pharmacists must be cognizant of guidelines, manage patients with multiple disease states and medications, and be aware of the quality of life of the patient when recommending drug therapy interventions, including the complexity of the medication regimen, compliance issues and side effect profiles of therapy.
3. What is the primary need that causes patients to be admitted to nursing facilities?
The most common need for admission into a nursing facility is assistance with activities of daily living (ADLs), such as bathing, dressing, toileting and eating. Sometimes residents are unable to follow a medication regimen.
4. Who is the primary payer for nursing home services?
The primary payer for nursing home services was Medicare, comprising 39% of payments.
5. What are Beers criteria? Give an example and describe how this impacts pharmacy services in a nursing facility.
Beers criterion includes inappropriate drugs for use in the elderly due to detrimental side effects of little evidence of efficacy. Examples include antipsychotics and sedative / hypnotics and impacts pharmacy services in a nursing facility by limiting what medications can be used and laying responsibility on the pharmacy to help uphold such standards.
6. What is drug regimen review (DRR)? Describe what the consultant pharmacist must do.
Drug regimen reviews encompass nearly all clinical activities of the consultant pharmacist and occur to ensure safe medication use. Each drug regimen must be reviewed at least monthly by the pharmacist when servicing a nursing facility. Irregularities must be reported to the attending physician and director of nursing of the facility. The pharmacist is only responsible for documenting the irregularity and making a recommendation for resolution.
7. Give several examples of the types of irregularities that a consultant pharmacist is looking for in a DRR.
Multiple orders for the same drug by the same route
Drugs administered without regard to stop order policies
PRN drug orders administered routinely for more than 30 days
Residents receiving three or more laxatives concurrently
8. What is the acceptable rate for medication errors in a nursing facility?
A facility must monitor for medication errors and ensure an error rate of less than 5%.
9. What is a medication pass observation and how often should it be done?
The objective of a medication pass survey is to observe preparation and administration of medications in order to assess compliance with 42 CFR 483.25(m) for medication errors. The pharmacist should observe a minimum of 20-25 opportunities for error (both doses administered and doses ordered by not administered). The medication passer should adhere to the five rights, right resident, right drug, right dose, right time, and right route.
10. What are the quality of life considerations that a consultant pharmacist must take into account when making recommendations for patients?
The pharmacist should take into account the presence of a durable power of attorney or healthcare representative, advance directives such as DNR or full code status, and the emotional wellbeing of patient in an institution.
11. What types of facilities qualify as home care sites?
Patient homes, long-term care, skilled nursing facilities, assisted living and subacute facilities, home care, diagnostic centers, outpatient clinics, ambulatory surgery, rehabilitation facilities and emergency service markets (under the expanded definition of home / alternate site healthcare).
12. What is home infusion therapy and what types of medications are commonly administered this way?
Home infusion therapy involves the preparation, delivery, and administration of parenteral and enteral therapy in alternate settings (rather than an inpatient setting). Commonly administered therapies include antibiotics, chemotherapy, pain management, parenteral nutrition (TPN), enteral nutrition (feeding tubes) and immune globulin. Home therapy involves the prolonged and usually repeated injection of pharmaceutical products most often delivered intravenously, subcutaneously, intramuscularly, enterally, or epidurally. Other common therapies include corticosteroids, inotropics, hydration, tocolytics, human growth hormone, blood clotting factors, and colony-stimulating factors.
13. What factors have driven the move to home care from institutional care?
The main reason for the dramatic increase in alternate site healthcare has occurred largely to the nationwide effort to control healthcare costs.
14. What is aseptic technology?
Aseptic technology is the application of a scientific understanding of the characteristics of viable microorganisms, applied in such a manner that the microorganisms are eliminated, with a high probability of success, from all of the process steps involved in compounding sterile pharmaceutical dosage forms.
15. What issues are involved in providing home infusion therapy that is safe and effective for patients?
Issues requiring the attention of a pharmacist include the use of sterile products before completion of quality control testing, potential exposure of products to temperature changes during shipping and delivery, administration of products by persons lacking professional skills, administration through devices that may not be adequately protected against contamination, and the lack of definitive evidence of stability for the 30 to 60 day shelf life often required.
I've done Home Infusion via a hospital based home infusion service & filled in for vacationing pharmacist at a private facility.
The days are like those of the IV pharmacist in any hospital. You get the orders, process them, have the tech make them, check them & get them ready for delivery. We always delivered them via the hospital courier - never had a private firm like DHL or Fed Ex...altho...I can't see why that can't be done well. After all DHL delivers our vaccines.
It can be interesting...you get a terminal child who needs narcotic management (depressing as well!!!). But...mostly you are completing therapy which has been started & stabilized elsewhere. The only real interventions which involved much highly sophisticated cognitive skills are hospice management. You do not only narcotic infusions, but chemo, tpn & antibiotics as well. If your tech calls in sick or quits - you mix! It can be boring....a long term tpn pt doesn't change for months & months & months.
The other posters have previously mentioned the call - 24hrs/7days - its awful!!! Usually, there is only one pharmacist. If you're good - you get everything done & get the nursing staff to not admit pts over the weekend. But, your Fridays are not your own - ever. You will only get the most complicated admit on Friday about 3:45. Also....the last morphine bag will be contaminated on Saturday night & you'll have to go in, mix it & deliver it - I've been in some scary places at night & lost more times than I can remember - this was before cell phones!
As for long term care....I only know this because as a hospital pharmacist, I used to have to rotate at our hospital owned snf which was across the street. I don't have to do that anymore (that goodness!!!!). That is different from a long term care consultant who comes in monthly for chart review & does it for many nursing homes. I've never done that, but I know some who have. They say its boring, but you get quick so can make pretty good money.
It has become a paperwork quagmire! You basically do chart review daily. You review for all the medication details which All covered & much, much more. Anytime a family member complains to the state about care...you get a descent of state inspectors who go thru everything with a fine tooth comb. So...every drug with a prn...whatever (pain, anxiety, nausea, etc) must have the response charted. In our facility...it was the pharmacist responsibility (who knew why??) to make sure daily the previous 24hr prn doses had the response charted. It was little stuff like that which drove you crazy. Also....there can not be dose ranges (ie MS 2-4 mg q 4 hr prn pain) So the pharmacist had to rewrite every order MS 2 mg q 4 hr prn mild pain, MS 3 mg q4h prn moderate pain, MS 4mg q 4h prn severe pain....you'd get it all rewritten, as I just did & realize you didn't include something (like the route) then have to rewrite it all over again. These are not rules which are used in the acute side because over there, the nurses are all RNs who can make that judgement. On our snf side, there were LVNs who, for whatever reason, the state said they could not.
Finally, there was the weekly multidisciplinary conference where pts who would be discharged within 5 days were discussed. The physician was supposed to be there, but never was. I can see why. We had every other discipline represented & you have never heard such minutae discussed as in that meeting...ie Mrs Jone's daughter is supportive of having the area rugs picked up, but her son feels it would change the look of the house (oh gawd...please...can't outpt OT work with the family??????)
So....it was little stuff like that which drove me crazy. Not to say all this is not good for the pt. My mom was just in a rehab for a broken hip & I'm sure all this was discussed at length. I thought about the poor pharmacist & figured he/she just blew off my mom since I was there for the last 3 days & day of discharge. The discharge counseling about her medications consisted of "here's your list of medications...you can call your dr if you have any questions" . (Also...a couple of the pharmacists there I know from school, so not really bashing actually).
But...I'd say...if you have the opportunity, as I did, since they were both part of my hospital job...try them to see if you like it. I have been recruited several times for Home Infusion jobs & I've always turned them down because of the call. I'll fill in for friends, but thats about it.
The days are like those of the IV pharmacist in any hospital. You get the orders, process them, have the tech make them, check them & get them ready for delivery. We always delivered them via the hospital courier - never had a private firm like DHL or Fed Ex...altho...I can't see why that can't be done well. After all DHL delivers our vaccines.
It can be interesting...you get a terminal child who needs narcotic management (depressing as well!!!). But...mostly you are completing therapy which has been started & stabilized elsewhere. The only real interventions which involved much highly sophisticated cognitive skills are hospice management. You do not only narcotic infusions, but chemo, tpn & antibiotics as well. If your tech calls in sick or quits - you mix! It can be boring....a long term tpn pt doesn't change for months & months & months.
The other posters have previously mentioned the call - 24hrs/7days - its awful!!! Usually, there is only one pharmacist. If you're good - you get everything done & get the nursing staff to not admit pts over the weekend. But, your Fridays are not your own - ever. You will only get the most complicated admit on Friday about 3:45. Also....the last morphine bag will be contaminated on Saturday night & you'll have to go in, mix it & deliver it - I've been in some scary places at night & lost more times than I can remember - this was before cell phones!
As for long term care....I only know this because as a hospital pharmacist, I used to have to rotate at our hospital owned snf which was across the street. I don't have to do that anymore (that goodness!!!!). That is different from a long term care consultant who comes in monthly for chart review & does it for many nursing homes. I've never done that, but I know some who have. They say its boring, but you get quick so can make pretty good money.
It has become a paperwork quagmire! You basically do chart review daily. You review for all the medication details which All covered & much, much more. Anytime a family member complains to the state about care...you get a descent of state inspectors who go thru everything with a fine tooth comb. So...every drug with a prn...whatever (pain, anxiety, nausea, etc) must have the response charted. In our facility...it was the pharmacist responsibility (who knew why??) to make sure daily the previous 24hr prn doses had the response charted. It was little stuff like that which drove you crazy. Also....there can not be dose ranges (ie MS 2-4 mg q 4 hr prn pain) So the pharmacist had to rewrite every order MS 2 mg q 4 hr prn mild pain, MS 3 mg q4h prn moderate pain, MS 4mg q 4h prn severe pain....you'd get it all rewritten, as I just did & realize you didn't include something (like the route) then have to rewrite it all over again. These are not rules which are used in the acute side because over there, the nurses are all RNs who can make that judgement. On our snf side, there were LVNs who, for whatever reason, the state said they could not.
Finally, there was the weekly multidisciplinary conference where pts who would be discharged within 5 days were discussed. The physician was supposed to be there, but never was. I can see why. We had every other discipline represented & you have never heard such minutae discussed as in that meeting...ie Mrs Jone's daughter is supportive of having the area rugs picked up, but her son feels it would change the look of the house (oh gawd...please...can't outpt OT work with the family??????)
So....it was little stuff like that which drove me crazy. Not to say all this is not good for the pt. My mom was just in a rehab for a broken hip & I'm sure all this was discussed at length. I thought about the poor pharmacist & figured he/she just blew off my mom since I was there for the last 3 days & day of discharge. The discharge counseling about her medications consisted of "here's your list of medications...you can call your dr if you have any questions"
. (Also...a couple of the pharmacists there I know from school, so not really bashing actually).But...I'd say...if you have the opportunity, as I did, since they were both part of my hospital job...try them to see if you like it. I have been recruited several times for Home Infusion jobs & I've always turned them down because of the call. I'll fill in for friends, but thats about it.
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I'm at my home infusion rotation right now. Thankfully this is one of the good rotations that lets you have total access to the internet, otherwise I would be boared out of my mind (you can only play so much solitare on your pda). The pharmacists here seem pretty happy and pretty impressed with themselves that they get to look at charts and such and they say they wouldn't do anything else. It's also extremely laid back. It probably changes from location to location but I'll go over some of the things I've observed over the past month:
1. My preceptor bringing her 1 year old son to work half a dozen times and letting him run around knocking over medications
2. Lengthy debates on what to eat
3. Inviting an ex employee womanizer to come down and see the "hot new students". She failed to mention to him that we were male.
4. One of the employees spending 6 hours on the phone trying to figure out why cingular messed up her cell phone order.
Don't get me wrong this company does a pretty good amount of business, and I give these people credit for finding a pretty solid gig, but what im getting at is that it seems pretty easy.
1. My preceptor bringing her 1 year old son to work half a dozen times and letting him run around knocking over medications
2. Lengthy debates on what to eat
3. Inviting an ex employee womanizer to come down and see the "hot new students". She failed to mention to him that we were male.
4. One of the employees spending 6 hours on the phone trying to figure out why cingular messed up her cell phone order.
Don't get me wrong this company does a pretty good amount of business, and I give these people credit for finding a pretty solid gig, but what im getting at is that it seems pretty easy.
I've done Home Infusion via a hospital based home infusion service & filled in for vacationing pharmacist at a private facility.
The days are like those of the IV pharmacist in any hospital. You get the orders, process them, have the tech make them, check them & get them ready for delivery. We always delivered them via the hospital courier - never had a private firm like DHL or Fed Ex...altho...I can't see why that can't be done well. After all DHL delivers our vaccines.
It can be interesting...you get a terminal child who needs narcotic management (depressing as well!!!). But...mostly you are completing therapy which has been started & stabilized elsewhere. The only real interventions which involved much highly sophisticated cognitive skills are hospice management. You do not only narcotic infusions, but chemo, tpn & antibiotics as well. If your tech calls in sick or quits - you mix! It can be boring....a long term tpn pt doesn't change for months & months & months.
The other posters have previously mentioned the call - 24hrs/7days - its awful!!! Usually, there is only one pharmacist. If you're good - you get everything done & get the nursing staff to not admit pts over the weekend. But, your Fridays are not your own - ever. You will only get the most complicated admit on Friday about 3:45. Also....the last morphine bag will be contaminated on Saturday night & you'll have to go in, mix it & deliver it - I've been in some scary places at night & lost more times than I can remember - this was before cell phones!
As for long term care....I only know this because as a hospital pharmacist, I used to have to rotate at our hospital owned snf which was across the street. I don't have to do that anymore (that goodness!!!!). That is different from a long term care consultant who comes in monthly for chart review & does it for many nursing homes. I've never done that, but I know some who have. They say its boring, but you get quick so can make pretty good money.
It has become a paperwork quagmire! You basically do chart review daily. You review for all the medication details which All covered & much, much more. Anytime a family member complains to the state about care...you get a descent of state inspectors who go thru everything with a fine tooth comb. So...every drug with a prn...whatever (pain, anxiety, nausea, etc) must have the response charted. In our facility...it was the pharmacist responsibility (who knew why??) to make sure daily the previous 24hr prn doses had the response charted. It was little stuff like that which drove you crazy. Also....there can not be dose ranges (ie MS 2-4 mg q 4 hr prn pain) So the pharmacist had to rewrite every order MS 2 mg q 4 hr prn mild pain, MS 3 mg q4h prn moderate pain, MS 4mg q 4h prn severe pain....you'd get it all rewritten, as I just did & realize you didn't include something (like the route) then have to rewrite it all over again. These are not rules which are used in the acute side because over there, the nurses are all RNs who can make that judgement. On our snf side, there were LVNs who, for whatever reason, the state said they could not.
Finally, there was the weekly multidisciplinary conference where pts who would be discharged within 5 days were discussed. The physician was supposed to be there, but never was. I can see why. We had every other discipline represented & you have never heard such minutae discussed as in that meeting...ie Mrs Jone's daughter is supportive of having the area rugs picked up, but her son feels it would change the look of the house (oh gawd...please...can't outpt OT work with the family??????)
So....it was little stuff like that which drove me crazy. Not to say all this is not good for the pt. My mom was just in a rehab for a broken hip & I'm sure all this was discussed at length. I thought about the poor pharmacist & figured he/she just blew off my mom since I was there for the last 3 days & day of discharge. The discharge counseling about her medications consisted of "here's your list of medications...you can call your dr if you have any questions"
But...I'd say...if you have the opportunity, as I did, since they were both part of my hospital job...try them to see if you like it. I have been recruited several times for Home Infusion jobs & I've always turned them down because of the call. I'll fill in for friends, but thats about it.
Do you know are LTC pharmacists on salary or they are paid per chart? Or both?
Privately contracted - a negotiated monthly amount - doesn't matter if all beds are full or only 1 bed is full, pts have been there 6 months or 6 days.
