Long term acute care hospital (LTACH) pharmacy

[xiphoid2010]

Well, still learning as I go, but here's some basics for pharmacists, residents, students not familiar with this less known pharmacy setting.

(1) LTACH is an acute care setting, pharmacy operate by the rules and regulation of a hospital pharmacy.

(2) There are 2 types of settings. Stand-alones (in it's own facility) or Hospital within a hospital (purchased or leased a part of a bigger hospital).

(3) Patients are in for a long term. For facility licensing purposes, the average length of stay per patient needs to be at least 25 days.

(4) in term sickness, patients falls somewhere between ICU and med-surg. Patients are typically on 2+ IV antibiotics, on ventilators, or have stage 4 wounds.

(5) Pharmacist's regular duties are the same as most hospital pharmacists. Process orders, dispense IVs, kinetic dosing, formulary maintenance, answer questions... etc.

(6) Pharmacy is not always 24 hours, at least mine isn't. Automated dispensing cabinets, PRN pharmacists, on-call and remote order entry is used during off-hours.

(7) With smaller facilities, there won't be specialist/clinical positions. Bad if you just want to clock in/out process orders all day, good if you want learn all aspect of pharmacy.

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Now for some early opinions.

The good:
(1) Workload: 2 pharmacist + 2 techs, PRNs on weekends, taking care of 25-30 patients 12 hours a day. Remote order processing for another 4 hours after. PRNs cover shortened weekend hours and time off.

(2) Setting: mine is a hospital within a hospital, and we have contract to access their services. I can order all the labs and the turn around is about the same as my old job. The borrowing meds is just a call and a jog down the stairs. Their DOP is a pretty cool guy as far as I can tell.

(3) Pay: I'm not going to disclose mine. But my staff pharmacist is paid about $3-$5/hr higher than a similarly qualified staff at my old place. Same for the techs. Benefits, pretty standard fairs.

The bad:
(1) on-call. If something after-hour can't be handled remotely, someone has to come in. I'm told that's rare. Keeping my fingers crossed.

(2) Small staff. Hard to plug holes and can't stretch for long. The PRNs I inherited all have full time jobs, meaning weekday holes are probably hopeless. Once I settle in, probable need to get more PRNs that can be available during weekdays.

(3) quality of care and accountability. I hate to say it, but I am a little surprised at the lax attitudes in many of the staff here, from nursing, MD to pharmacy. Maybe it's just this one, or maybe it's because LTACH is not under as much scrutiny as hospitals. I'm gonna watch a while longer, but clearly there is room for improvement.

Well, it's still early yet. But it's a practice setting that's not widely known, but some might find it an interesting setting. Definitely don't confuse it with LTC pharmacy.

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[rph3664]

It's not a Select or Kindred facility, is it? Those are two fairly well-known chains (what a horrible word, but that's what they are) that do this. There's a Select facility a couple miles from my house; it's in a building that housed a small independent hospital for many years and looks like an elementary school.

 

[xiphoid2010]

It's not a Select or Kindred facility, is it? Those are two fairly well-known chains (what a horrible word, but that's what they are) that do this. There's a Select facility a couple miles from my house; it's in a building that housed a small independent hospital for many years and looks like an elementary school.

Not one of those. But they are two of our competitors in this area. There are couple of others out there as well. I haven't got a grasp on just who are the big dogs in the business, definitely something I'll have to learn sooner rather than later.

 

[pharm B]

Good summary, Xiphoid. I'm seeing a lot of that first hand on my current rotation. There's definitely a lot of room for improvement in care, and I think pharmacy can definitely play a leading role in that aspect.

Are there limitations on the labs you can order? For example, we have a phenytoin patient currently whose albumin has fluctuated in the past, and we haven't seen a new level in two weeks, but her phenytoin came back at like 5.3 (adjusted activity around 7.5).

 

[xiphoid2010]

Good summary, Xiphoid. I'm seeing a lot of that first hand on my current rotation. There's definitely a lot of room for improvement in care, and I think pharmacy can definitely play a leading role in that aspect.

Are there limitations on the labs you can order? For example, we have a phenytoin patient currently whose albumin has fluctuated in the past, and we haven't seen a new level in two weeks, but her phenytoin came back at like 5.3 (adjusted activity around 7.5).

Currently, pharmacy can order labs pertinent for a consult. So far I have only seen your typical vanc, gent, coumadin consults. But yes, there is definitely plenty of room for improvement. But the first step I want to do is build up a relationship with the staff. Once there is rapport and trust, can you get the buy-in for changes you want to make.

 

[PharmDstudent]

Currently, pharmacy can order labs pertinent for a consult. So far I have only seen your typical vanc, gent, coumadin consults. But yes, there is definitely plenty of room for improvement. But the first step I want to do is build up a relationship with the staff. Once there is rapport and trust, can you get the buy-in for changes you want to make.

You were probably hired, because you'll do a good job - not because the place needs to be turned upside down on its head.

Since you're fairly new to this type of work, get settled in and learn the ropes and then just take things one day at a time. Although it's an acute care setting, it's also long-term care, so things will move at a different pace, ie LTACHs are lax in a beneficial sort of way, because you can work for an LTACH long-term without experiencing too much burn out.

I'm totally jealous...

 

[type b pharmD]

I have a lot of personal experience with this setting and I would say it is an understatement to describe quality of care as "lax" lol. But on the bright side, it is possible to really make a big difference as a pharmacist here.. and especially as a director.

Ours had > 40 beds and at one point, desperate hospital admin had filled them all with drug resistant infection pts.. terrible move on their part but certainly kept things interesting for us! We went through more cubicin and tygacil in a single day than I've ever seen a normal hospital go through in several months.

Needless to say .. that "ceo" was fired shortly thereafter.

Just a snapshot.

When you have everyone either on vents or with mdr organisms, the job of the pharmacist gets very interesting very quickly! Especially when you are basically one of the most educated and professionally experienced people in the whole facility. (We had 2-3 hospitalists, very smart folks, but apart from them, pharmacy was one of the last barriers against mortality in the whole joint... certainly not quality nurses and administrators)

 

[Travex]

What type of experience do you need to get the job?

 

[xiphoid2010]

What type of experience do you need to get the job?

All my staffs here all have hospital pharmacy background before coming here. Me and 2 PRN pharmacists have had residency training, the others including the former DOP don't.q

 

[joetrisman]

Sounds like a sweet gig. I'll agree with the other posters in that ltc experience I had makes me shudder in fear if I ever end up in such a place with the level of care they get. I personally couldn't dig ltc as the patient contact was nonexistent (unless your a consultant) or at least that was like that at the big place I was at

 

[xiphoid2010]

Sounds like a sweet gig. I'll agree with the other posters in that ltc experience I had makes me shudder in fear if I ever end up in such a place with the level of care they get. I personally couldn't dig ltc as the patient contact was nonexistent (unless your a consultant) or at least that was like that at the big place I was at

That's the thing. I was trying to spread some info on this less known pharmacy setting, and one to be confused with LTC. My wife works LTC, sweet gig in its own right, but their job is to dispense outpatient to various nursing homes and what not.

LTACH is actually classified as a hospital, so it's pure inpatient care. Mine is actually a floor of a larger hospital. But what raises my eye brow at the moment is that the patients we have is on average sicker than your med-surg patients. We have 2 rooms that's dedicated to ICU level patients (intubated, on propofol + ativan drip, titrating levophed to keep MAP >65, on Vanc + Zosyn + flagyl + diflucan to cover all basis) that kind of all out patients. The rest are mostly bed bound, very few are ambulating.

But at the same time, I don't see the same kind of MD, nursing, pharmacy care expected in a hospital. The pulmonologist would swing buy maybe in the afternoon after he's done with all the main hospital patients, nurses chatting at the nursing station, pharmacy not checking why patients have been on vancomycin for 4 weeks.

I found out that we are joint commission accredited. Ok then. Maybe I won't be able to do much about what nursing or MDs do, but there are few things in the pharmacy I plan to change when the time is right.

 

[joetrisman]

That's the thing. I was trying to spread some info on this less known pharmacy setting, and one to be confused with LTC. My wife works LTC, sweet gig in its own right, but their job is to dispense outpatient to various nursing homes and what not.

LTACH is actually classified as a hospital, so it's pure inpatient care. Mine is actually a floor of a larger hospital. But what raises my eye brow at the moment is that the patients we have is on average sicker than your med-surg patients. We have 2 rooms that's dedicated to ICU level patients (intubated, on propofol + ativan drip, titrating levophed to keep MAP >65, on Vanc + Zosyn + flagyl + diflucan to cover all basis) that kind of all out patients. The rest are mostly bed bound, very few are ambulating.

But at the same time, I don't see the same kind of MD, nursing, pharmacy care expected in a hospital. The pulmonologist would swing buy maybe in the afternoon after he's done with all the main hospital patients, nurses chatting at the nursing station, pharmacy not checking why patients have been on vancomycin for 4 weeks.

I found out that we are joint commission accredited. Ok then. Maybe I won't be able to do much about what nursing or MDs do, but there are few things in the pharmacy I plan to change when the time is right.

I'm still very wet behind the ears. Sorry for the confusion. I've heard of hospitals doing this before (having floors that are run by outside facilities). Sounds very interesting

 

[xiphoid2010]

A few more things learned about LTACHs.

1. There is a host-admit ratio. An LTACH can not take more than 50% of the medicare pts from the host hospital (defined as one located within 250 yards of the facility). This is especially something a hospital within a hospital like mine has to watch for.

2. General rule of thumb, a stand alone LTACH can not succeed unless it has 40+ bed capacity and maintain a high census to spread the cost over. A hospital-within-a-hospital can manage with a much lower census, but has to deal more with point #1.

3. Wound care and vent wean is the cash cow. Debridements/flaps/grafts drives up DRG and reimbursement and carries long length of stay to support the average length requirement of 25+ days. A pneumonia pt might come in with a relative weight of 0.7, but stays on vent for 96 hrs it goes up to 1.5ish, and if gets trached it goes up to 3+.

4. Medicare reimbursement formula, a rough estimate is $37k x relative weight of the DRG. So if you know your monthly census, and relative weight, you can estimate revenue. And if you know your average length of stay and other cost, you can figure out the profit.

5. Without giving out exact numbers, pharmacy drug cost + pay is 1/2 of nursing cost, and together they are 1/3 of the total operating expense. The other 1/3 being leasing/rental cost, and the rest being divided among other services (MD, RT, PT/OT/speech, business development, HR, managerial..) In term of pharmacy cost, 2/3 is drug, 1/3 is salary. In fact, high census makes us look better as salary cost is fixed, and help to divide the few high patients over a large census.

Anyway, its a very interesting setting, and I'm trying to learn abound wound care which I previously knew almost nothing about. But God! Those stage 4 wounds look ugly, and how can the wound care nurses eat is beyond me. forget what I learned about empiric treatment duration of antibiotics, keep it as long as the MD wants....

All-in-in all, it's a pretty cushy job, I'm actually feeling a little guilty coming from my previous post. But of my staff would never say that.