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KEEPING TABS

Absolute Pharmacy is the prescription for what ails you.In each quarterly edition, you’ll find the latest news about pharmacy, new medications, technology and more – all through the lens of what is pertinent to the long-term care (LTC) industry.

Absolute Pharmacy has been serving the LTC industry since 1994. We’re a part of a dynamic circle of care that consists of rehabilitation, home health care services, hospice care and much more. We have a rich perspective, and we’re thrilled to share what we’ve been learning from industry leaders, our employees and our customers – you!

We are confident you’ll find the information useful. If you have a suggestion for a topic you’d like to learn about, let us know at [email protected].

Q3 July 2019 Newsletter

Table of Contents

KEEPING TABS

Industry- The Impact Act and Medication Reconciliation Transitions of Care

Drug News- Medication Expiration Charts

Absolute Insights- Time Study - Packaging Methods- Put a Face to a Name: Beth Husted- Take our survey for a chance to win $50!

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2 Absolute Pharmacy

The Impact Act and Medication Reconciliation Transitions of Care

INDUSTRY

The medication reconciliation domain was implemented in SNFs, IRFs, and LTCHs October 1, 2018. The Impact Act of2014 included medication regimen reviews (aMRRs) closely following admission. Extensive revisions made by CMS tothe Requirements for Participation under the Medicare and Medicaid Programs: Reform of Requirements for the LTCFacilities. Because of this, F Tag 756 stipulates the requirement for the aMRR applies to all residents (whether short or long-stay) without exception. Recent additions of the new Section N items of the Minimum Data Set 3.0 (MDS) specifically address if an aMRR was performed timely and how its inclusion impacts the facility’s Quality Measures. All of these factors highlighted the need for Absolute Pharmacy to add an expanded aMRR service.

The program’s success involves multiple parties.

Pharmacist:• Admission review service - Complies with ”Interim” DRR

requirement for change in status• Ensures MDS documentation from all sources - Fulfills

IMPACT Act intent• Considers discharge solution - Education for the

discharging resident/family

Pharmacy• Adds procedure to document interventions - Directly to

the facility or via the consultant pharmacist• Creates MDS documentation to reporting - Fulfills

IMPACT Act intent• Considers discharge solution - Meds to home

Nursing Center• Schedules in-services and staff training on the

IMPACT Act• Develops IMPACT specific communication and

documentation• Aligns the pharmacy, the pharmacists and the nurses• Documents clinically significant recommendations in

a common manner so the MDS coordinator is clear on documentation

Data collection is the key to success. Data collection can be done federally with rules and regulations, personally with your residents and families, locally with your referring hospitals, and regionally and nationally with press and publications.

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Steps of Completing an aMRR

Gather admissions• Discharge summary• Current medication list• Labs and significant data

Perform Medication Reconciliation• CMS defines Med Rec as the process of identifying the

most accurate list of medications that a patient is taking. That includes name, frequency, dosage and route, by comparing the medical record to an external list of medications obtained from a patient, hospital or other provider.

> Common potential issue findings: • Not transmitting • Inappropriate route • Details in dosing • Duplicate therapy • Skipped orders

The reason these issues are occurring are due to hospital omission, nurse omission, EHR misunderstanding, confusing hospital orders, picking incorrect drug or form in EHR, and entering incorrect directions.

Perform Drug Regimen Review (DRR)• Clarifications• Allergies or previous adverse effect issues• Missing diagnoses• Monitoring recommendations such as INR,

IV antibiotics, Potassium level, and kidney function and stop dates related to antibiotics, Lovenox and Heparin, medications with a stop date that should be continued

• Stop dates• Drug interactions to minimize fall risks and ensure proper

administration times• Avoiding potential duplicate therapy including multiple

antihypertensive agents and GI agents

Q3: July 2019 Newsletter | #3 3

34% of Clinical Significant Interventions Identified were Considered High Risk

Advantages, Goals, and Value of an aMRR programAn aMRR program could be completed through developing a nursing center’s own policy and procedures. However,there are advantages of the pharmacy performing aMRR. Pharmacists are medication specialists, which is ideal foridentifying drug interactions, appropriate dosing, and routes of administration. Having the pharmacy perform theaMMR provides an extra set of eyes to look for details, the potential to resolve issues before consultant visits, and anadditional form of communication regarding pending issues.

The overall goals of aMRR are to avoid adverse events, patient harm and associated consequences, optimize quality and safety of the medication care plan for all SNF residents, improve SNF regulatory compliance, manage medication costs, decrease re-hospitalization due to adverse medication events, support inclusion into ACO’s, and impact SNF Quality Measure.

Absolute Pharmacy continues to work on collecting data to demonstrate the value of an aMRR program. As thisprogram continues, we’ll share information and findings.

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0DOSE/FREQ MISMATCH

WRONG DRUG COUNT OF OMISSION

POSSIBLE PREVENTION OF

MED ERRORS

References:“The Impact Act and Medication Reconciliation Transitions of Care” presenta-tion by Chad Worz , Pharm. D., BCGP, Chief Executive Officer, The American Society of Consultant Pharmacists, Casey Persinger, R.Ph., Assistant Director of Pharmacy Operations, Absolute Pharmacy, and Becky Sommers, R.Ph., Vice President of Clinical Services, Absolute Pharmacy

Potential value of aMRR:Maximize Medicare A rate: $$$6,000 skilled days x 2% = $60,000/ year

Avoid readmissions: $$$$Loss of revenue and penalty to nursing center and hospital

Quality improvement: $$$Reduce medication error, avoid patient harm, reputation, liability, preserve star rating

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DRUG NEWS

Medication Expiration Charts Non-InsulinMEDICATION EXPERATION DATE REFERENCEACETYLCYSTEINE (MUCOMYST® SOLUTION) 96 hours after opening Package insert

Advair Inhaler 30 days once foil opened. Package insertAnoro Ellipta Discard 6 weeks after opening the foil tray Package insert

Aranesp Injection Need to be refrigerated. Once removed (unopened) from refrigerator must be discarded after 7 days Package insert

Arnuity Ellipta Discard 6 weeks after opening the foil tray Package insert Azithromycin Ophthalmic Soln Refrigerate until open. Discard after 14 days. mtsBacteriostatic Normal Saline And Water For Injection Should not exceed 30 days after first use. Package insert / USP

Banzel Oral Suspension Discard after 90 days of opening. Package insert Breo Ellipta 6 weeks after opening foil tray. Package insertBudesonide Inhalation Suspension Once the foil has been opened, use vials within 2 weeks. Package insertCombivent Respimat Discard 3 months after insertion of cartridge into inhaler Package insert Cyclosporine Oral Solution Use within 2 months after opening. Store at room temperature. mtsDabigatran (Bottle) Discrad 4 months after opening. mts

Epogen Alfa Injection Single dose: one dose per vial; dioscard excess. Multidose: 21 days after initial use in fridge or 1 week at room temperature. Do not shake. mts

Furosemide Oral Solution 90 days after opening. Medication Therapy Solutions (mts)

Forteo Store in refrigerator. Discard 28 days after first injection. Package insertGabapentin Oral Solution Store refrigerated at all times. See label on bottle for expiration date. mtsGlucose Control Solutions and Tests Strips Manufacturer's date; most 90 days after opening. mts

Ipratropium/Albuterol Inhalation Solution Once removed from foil pouch, use vials within a week. Package insert

Incruse Ellipta 6 weeks after opening foil tray. Package insertIrrigation Solutions -Sterile Water, Sterile Sodium Chloride, Sterile Acetic Acid

24 hours after opening Recommendation from manufacturer (Baxter)

Lasix Oral Solution (Furosemide) 60 days after opening Package insertLatanoprost (Xalactan®) Eye Drops 6 weeks after opening- at room temperature Package insert

Levalbuterol Inhalation Solution Once foil pouch is opened, use vials within 2 weeks. Once removed from the foil pouch, use vials within a week. Package insert

Liquids In Original Bottles Manufacturers expiration date Consensus from several manufacturers

Lorazepam Intensol Solution (Refrigerated) 90 days after opening Package insert


Non-Insulin (Continued)MEDICATION EXPERATION DATE REFERENCE

Lorazepam Injectable Intact vials should be refrigerated. Discard after 60 days at room temperature. mts

Miacalcin Nasal Spray 35 days after opening Package insertMultiple Dose Vials/Pen For Injection (Non-Insulin) Should not exceed 30 days after first use. Package insert/ USP

Nasal Preparations Manufacturers expiration date Consensus from several manufacturers

Neosporin Gu Bladder Irrigation 48 hours after opening Package insertNitroglycerin Tablets Manufacturers expiration date Package insert/ USPOnfi Oral Suspension 90 days after opening Package insert/ LexicompOphthalmic Preparations Manufacturers expiration date Package insert

Otic Preparations Manufacturers expiration date Consensus from several manufacturers

Oxydose Oral Concentrate Solution 90 days after opening Package insertOxcarbazepine Oral Suspension 7 weeks after opening. mts

Procrit Injection Need to be refrigerated. Once removed (unopened) from refrigerator must be discarded after 7 days Package insert

Prolia Store unopened in refrigerator. Use within 14 days once at room temperature Package insert

Risperdal Consta InjectionMust be used within 6 hours of suspension. Recommended to store in refrigerator – only good for 7 days out of refrigerator Package insert

Serevent Inhaler 6 weeks after package opened Package insert

Single Dose Vials For Injection 24 hours after use Consensus from several manufacturers

Spiriva Handihaler Once the foil has been removed the capsule must be used immiediately or it should be discarded. Lexicomp

Suppositories Manufacturers expiration date Consensus from several manufacturers

Topicals In Original Container Manufacturers expiration date Consensus from several manufacturers

Trelegy Inhaler Discard 6 weeks after opening the foil tray Package insertTubersol Store in refrigerator. Discard within 30 days of opening. Package insertTudorza Pressair Discard 45 days after opening pouch. Package InsertVentolin Inhaler Discard 12 months after foil pouch was opened Package InsertVimpat Solution 7 weeks after opening. LexicompXopenex Inhalation Solution 2 weeks in pouch after foil opened/1 week out of pouch Package insertYupelri Inhalation Solution Once the foil pouch has been removed and use the vial immediately Package Insert

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DRUG NEWS

MEDICATION DISCARD DATE 10 Days 14 Days 21 Days 28 Days 30 Days 31 Days 40 Days 42 Days 56 DaysINSULIN VIALS Novolog (aspart)Humalog (lispro)Apidra (glulisine)Humulin R (regular)Novolin R (regular)Humulin R U-500Humulin NNovolin NHumulin 70/30Novolin 70/30 Humalog 75/25Humalog 50/50Novolog 70/30Lantus (glargine)Levemir (detemir)INSULIN PENS Humalog KwikPen (lispro)Novolog FlexPen (aspart) NovoPen Echo (aspart)Apidra Solostar (glulisine)Apidra OptiClikHumulin R U-500 KwikPenHumulin N pen Novolin N pen

Rapid-Acting Insulin

Short-Acting Insulin

Intermediate-Acting Insulin

Pre-Mixed Insulin

Long-Acting Insulin

Incretin/Insulin Mixtures

Incertin Mimetics

Amylin Analogs

KEY

Insulin


MEDICATION DISCARD DATE 10 Days 14 Days 21 Days 28 Days 30 Days 31 Days 40 Days 42 Days 56 DaysINSULIN PENS Humulin N pen Novolin N pen Lantus SoloStarLantus OptiClikLevemir FlexPen Novolog Mix 70/30 FlexPen Tresiba FlexPen (degludec)Toujeo (glargine)BasaglarHumalog Mix KwikPen 50/50Humalog Mix 75/25 KwikPenHumulin 70/30 Pen Ryzodeg 70/30MIXED LONG-ACTING INSULIN / INCRETIN MIMETICSXultrophy (degludec/liraglutide)Soliqua (glargine/lixisenatide)INCRETIN MIMETICS Byetta (exenatide) Bydureon (exenatide)Victoza (liraglutide)Tanzeum (albiglutide)Trulicity (dulaglutide)Adlyxin (lixisenatide)AMYLIN ANALOGSSymlin (pramlintide) vial and pen




Pre-Mixed Insulin

Long-Acting Insulin


Incertin Mimetics

Amylin Analogs

KEY

Continued from previous pageInsulin (Continued)

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DRUG NEWS

MEDICATION EXPIRATION DATE REFERENCE

Novolog (aspart) All unopened vials of insulin are recommended to be stored in the refrigerator. Whether stored in a refrigerator or at room temperature, insulin vials must be discarded 28 days after opening. ADA guidelines

Humalog (lispro) All unopened vials of insulin are recommended to be stored in the refrigerator. Whether stored in a refrigerator or at room temperature, insulin vials must be discarded 28 days after opening. ADA guidelines

Apidra (glulisine) All unopened vials of insulin are recommended to be stored in the refrigerator. Whether stored in a refrigerator or at room temperature, insulin vials must be discarded 28 days after opening. ADA guidelines

Humulin R (regular) All unopened vials of insulin are recommended to be stored in the refrigerator. Whether stored in refrigerator or at room temperature, insulin vials must be discarded 31 days after opening. Lexicomp and DiabetesinControl.com

Novolin R (regular) All unopened vials of insulin are recommended to be stored in the refrigerator. Stored at room tem-perature, insulin vials must be discarded 42 days after opening. DO NOT refrigerate after opening. Lexicomp and DiabetesinControl.com

Humulin R U-500 All unopened vials of insulin are recommended to be stored in the refrigerator. Whether stored in refrigerator or at room temperature, insulin vials must be discarded 40 days after opening. Lexicomp and DiabetesinControl.com

Humulin N All unopened vials of insulin are recommended to be stored in the refrigerator. Whether stored in refrigerator or at room temperature, insulin vials must be discarded 31 days after opening. Lexicomp and DiabetesinControl.com

Novolin N All unopened vials of insulin are recommended to be stored in the refrigerator. Stored at room tem-perature, insulin vials must be discarded 42 days after opening. DO NOT refrigerate after opening. Lexicomp and DiabetesinControl.com

Humulin 70/30 All unopened vials of insulin are recommended to be stored in the refrigerator. Whether stored in refrigerator or stored at room temperature, insulin vials must be discarded 31 days after opening. Lexicomp and DiabetesinControl.com

Novolin 70/30 All unopened vials of insulin are recommended to be stored in the refrigerator. Stored at room tem-perature, insulin vials must be discarded 42 days after opening. DO NOT refrigerate after opening. Lexicomp and DiabetesinControl.com

Humalog 75/25 All unopened vials of insulin are recommended to be stored in the refrigerator. Whether stored in refrigerator or at room temperature, insulin vials must be discarded 28 days after opening. Lexicomp and DiabetesinControl.com

Humalog 50/50 All unopened vials of insulin are recommended to be stored in the refrigerator. Whether stored in refrigerator or at room temperature, insulin vials must be discarded 28 days after opening. Lexicomp and DiabetesinControl.com

Novolog 70/30 All unopened vials of insulin are recommended to be stored in the refrigerator. Whether stored in refrigerator or at room temperature, insulin vials must be discarded 28 days after opening. Lexicomp and DiabetesinControl.com

Lantus (glargine) All unopened vials of insulin are recommended to be stored in the refrigerator. Whether stored in refrigerator or at room temperature, insulin vials must be discarded 28 days after opening. Lexicomp and DiabetesinControl.com

Levemir (detemir) All unopened vials of insulin are recommended to be stored in the refrigerator. Whether stored in refrigerator or at room temperature, insulin vials must be discarded 42 days after opening. Lexicomp and DiabetesinControl.com

MEDICATION EXPIRATION DATE REFERENCE

Byetta (exenatide) Prior to use store under refrigeration. After initial use may store at room temperature and must discard after 30 days. Lexicomp and DiabetesinControl.com

Bydureon (exenatide) Prior to use store under refrigeration. After initial use may store at room temperature and must discard after 28 days. Lexicomp and DiabetesinControl.com

Victoza (liraglutide) Prior to use store under refrigeration. After initial use may store at room temperature and must discard after 30 days. Lexicomp and DiabetesinControl.com

Tanzeum (albiglutide) Prior to use store under refrigeration. After initial use may store at room temperature and must discard after 28 days. Use within 8 hours of reconstitution. Lexicomp and DiabetesinControl.com

Trulicity (dulaglutide) Each single use pen can be stored in refrigerator. Pens can also be stored at room temperature but must be discarded 14 days. Lexicomp and DiabetesinControl.com

Adlyxin (lixisenatide) Prior to use store under refrigeration. After initial use may store at room temperature and must discard after 14 days. Lexicomp and DiabetesinControl.com

MEDICATION EXPIRATION DATE REFERENCEXultrophy (degludec/liraglutide)

All unopened pens need to be stored in refrigerator. Whether stored in refrigerator or at room temperature, pens must be discarded 21 days after opening. Lexicomp and DiabetesinControl.com

Soliqua (glargine/lixisenatide)

All unopened pens need to be stored in refrigerator. After opening, pens should be stored at room temperature and must be discarded after 28 days. DO NOT refrigerate after opening. Lexicomp and DiabetesinControl.com

Incretin Mimetics

Mixed Long-Acting Insulin/Incretin Mimetics

Insulin Vials





Pre-Mixed Insulin

MEDICATION EXPIRATION DATE REFERENCEHumalog KwikPen (lispro)

All unopened pens of insulin are recommended to be stored in the refrigerator. Stored at room tem-perature, insulin pens must be discarded 28 days after opening. DO NOT refrigerate after opening. Lexicomp and DiabetesinControl.com

Novolog FlexPen (aspart) All unopened pens of insulin are recommended to be stored in the refrigerator. Stored at room tem-perature, insulin pens must be discarded 28 days after opening. DO NOT refrigerate after opening. Lexicomp and DiabetesinControl.com

NovoPen Echo (aspart) All unopened pens of insulin are recommended to be stored in the refrigerator. Stored at room tem-perature, insulin pens must be discarded 28 days after opening. DO NOT refrigerate after opening. Lexicomp and DiabetesinControl.com

Apidra Solostar (glulisine)


Apidra OptiClik All unopened pens of insulin are recommended to be stored in the refrigerator. Stored at room tem-perature, insulin pens must be discarded 28 days after opening. DO NOT refrigerate after opening. Lexicomp and DiabetesinControl.com

Humulin R U-500 KwikPen


Humulin N pen All unopened pens of insulin are recommended to be stored in the refrigerator. Whether stored in refrigerator or at room temperature, insulin pens must be discarded 14 days after opening. Lexicomp and DiabetesinControl.com

Novolin N pen All unopened pens of insulin are recommended to be stored in the refrigerator. Whether stored in refrigerator or at room temperature, insulin pens must be discarded 28 days after opening. Facts and Comparison

Lantus SoloStar All unopened pens of insulin are recommended to be stored in the refrigerator. Stored at room tem-perature, insulin pens must be discarded 28 days after opening. DO NOT refrigerate after opening. Lexicomp and DiabetesinControl.com

Lantus OptiClik All unopened pens of insulin are recommended to be stored in the refrigerator. Stored at room tem-perature, insulin pens must be discarded 28 days after opening. DO NOT refrigerate after opening. Lexicomp and DiabetesinControl.com

Levemir FlexPen All unopened pens of insulin are recommended to be stored in the refrigerator. Stored at room tem-perature, insulin pens must be discarded 42 days after opening. DO NOT refrigerate after opening. Lexicomp and DiabetesinControl.com

Novolog Mix 70/30 FlexPen


Tresiba FlexPen (degludec)

All unopened pens of insulin are recommended to be stored in the refrigerator. Whether stored in refrigerator or at room temperature, insulin pens must be discarded 56 days after opening. Lexicomp and DiabetesinControl.com

Toujeo (glargine) All unopened pens of insulin are recommended to be stored in the refrigerator. Stored at room tem-perature, insulin pens must be discarded 42 days after opening. DO NOT refrigerate after opening.

DiabetesinControl.com and Pharmacotherapy: A Pathophysiologic Approach, 10e. Dipiro JT, et al.

Basaglar All unopened pens of insulin are recommended to be stored in the refrigerator. Stored at room tem-perature, insulin pens must be discarded 28 days after opening. DO NOT refrigerate after opening. Lexicomp and DiabetesinControl.com

Humalog Mix KwikPen 50/50


Humalog Mix 75/25 KwikPen


Humulin 70/30 Pen All unopened pens of insulin are recommended to be stored in the refrigerator. Stored at room tem-perature, insulin pens must be discarded 10 days after opening. DO NOT refrigerate after opening. Lexicomp and DiabetesinControl.com

Ryzodeg 70/30 All unopened pens of insulin are recommended to be stored in the refrigerator. Whether stored in refrigerator or at room temperature, insulin pens must be discarded 28 days after opening. Lexicomp and DiabetesinControl.com

MEDICATION EXPIRATION DATE REFERENCESymlin (pramlintide) vial and pen

All unopened pens or vials are recommended to be stored in the refrigerator. Whether stored in refrigerator or at room temperature, pens must be discarded 30 days after opening. Lexicomp and DiabetesinControl.com

Amylin Analogs

Insulin Pens

Long-Acting Insulin


Incertin Mimetics

Amylin Analogs

KEY

Continued from previous page

10 Absolute Pharmacy

ABSOLUTE INSIGHTS

Time Study – Packaging Methods

Punch card = 43.21 secondsflexPOD card = 10.18 seconds

Difference = 33.03 seconds

ObservationsTime to remove/replace med card to and from cart

Time to remove medication from packaging

FindingsThe Time Study identified the difference in

nursing time between punch card and flexPOD multi-dose packaging card:

A time savings of 33.03 seconds per patient, per med pass, utilizing flexPOD Cards!

12 Absolute Pharmacy

ABSOLUTE INSIGHTS

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Put a Face to a Name: Beth HustedQ: How long have you worked for Absolute Pharmacy?A: 3 Months

Q: What do you do for Absolute Pharmacy? A: I am the Director of Retail Services. As long-term care

continues to evolve with the aging population, it is important to maintain the continuum of care, even when a patient is no longer in a facility. We will be launching a Follow Me Home program where patients being discharged from a facility or those trying to stay in their homes can receive their medications in our flexPOD packaging, which are sorted by time of day. This will help our patients by simplifying complicated medication regimens, improving compliance, and reducing the risk of hospital re-admissions."

Q: What do you absolutely love about working for Absolute Pharmacy?

A: Customer service and improving the health of the patients we serve are the core elements of our business. Everyone I have encountered here is kind and willing to teach you anything. There are no egos because we want to be a successful team to continue to serve our customers!

Q: What’s your favorite quote or saying?A: “If at first you don’t succeed, try, try, try again.”

- William Edward Hickson

Q: What do you love doing the most? A: Spending time with my husband and three kids, playing

outside, going on walks or going outlet shopping. If I am by myself (which rarely happens with three little ones), I enjoy reading and running.

Q: What did you want to be when you grew

up as a child?A: I always wanted to make people feel better, so I thought

a clown or a pharmacist would be great options.Once I figured I couldn’t make a living as a clown, the pharmacist career choice stuck (and I’ve been one for nine years now)!

Q: What is your favorite animal and why? A: Monkeys have always been my favorite animals because

they are cute, seem so happy, and love bananas!