presented by: dr. william c. hallett, pharm.d., mba, cgp, c-mtm president/ceo guardian consulting...

Presented by:

Dr. William C. Hallett, Pharm.D., MBA, CGP, C-MTM

President/CEO

Guardian Consulting Services, Inc.

[email protected]

F425 Update Medication Regimen Review (MRR)

for Short Term/Short Stay and Residents who Experience

Significant Decline/Change in Condition

mailto:[email protected]

Presented by: Dr. William C. Hallett, Pharm.D, MBA, CGP, C-MTM

2F425 UpdateLet’s get right into it….

Text of F425 Guidance

F425 requires that the facility work with the Consultant Pharmacist to:

“Establish procedures that address medication regimen reviews for residents who are anticipated to stay less than 30 days; or

when the resident experiences an acute change of condition as identified by facility staff.”


3F425 Update

Text of F425 Guidance, continued…

“Facility procedures should address how and when the need for a consultation will be communicated, how the medication review will be handled if the pharmacist is off-

site, how the results or report of their findings will be communicated to

the physician, expectations for the physician’s response and follow up, and how and where this information will be documented.”

Guidance issued: December, 2006


4F425 Update

Why the focus now on guidance that

was issued over 6 years ago?

CMS Memorandum S&C 13-02NH – Guidance Related to

Medication Errors and Pharmacy Services Issued to all State Survey Agency Directors on November 2nd, 2012 Targets 7 specific areas in Pharmacy for increased survey focus Specifically cites Medication Regimen Reviews for Stays under 30

days and Changes in Condition:

“The requirement for the medication regimen review applies to

all residents, including residents receiving respite care, residents at

the end of life or who have elected the hospice benefit, residents

with an anticipated stay of less than 30 days, or residents who have experienced a change in condition.”


5F425 Update

Why the focus now on guidance that

was issued over 6 years ago?

It all comes back to Preventable Hospitalizations.The expectation of CMS is that, for New Admissions, the Consultant Pharmacist can identify: Poorly or incorrectly written orders and other “reconciliation” issues Important Meds ordered with no monitoring parameters Incorrect dosing based on age, weight, renal function, etc.

For Change of Condition: The Consultant Pharmacist should evaluate for Medications that

may be inducing the change and recommend changes before the resident gets expensive tests, consults, or ER visits!


6F425 Update

New Admission Medication Regimen Review (MRR)

The Issue: Scenario 1: Resident admitted to Unit on the 1st, discharged on the 20th,

monthly MRR occurs on that Unit on the 23rd. Outcome: Resident missed, no MRR performed.

Scenario 2: Resident admitted to Unit on the 1st, discharged on the 20th, monthly MRR occurs on that Unit on the 17th. Little to no value to the MRR review!

CMS does not specify exactly when the MRR must be performed during a short stay, just that it must be done.

Logic dictates the sooner the better.


7F425 Update


Best Practice: Develop a system where the Consultant Pharmacist reviews

New Admission Orders within 1 to 3 days of admission. Leverage Technology:

Log in to EMR or Pharmacy Vendor System remotely to access Med Profile and perform Medication Regimen Review (MRR)

Communicate Findings via email to DNS, cc the ADNS/Supervisor, Medical Director and Administrator

Understand the “Time Sensitive” nature of these MRR’s By nature, these require immediate attention Insist on 100% response rate within 24-48 hours of receipt!


8F425 Update


Best Practice, continued…. Understand the “cost” of failing to address these MRR’s

Promptly Survey Implications: A system was implemented, but it did not

meet the intent of F425, which calls for the following:

“….how the results or report of their findings will be communicated to the physician, expectations for the physician’s response and follow up, and how and where this information will be documented.” Another Survey (and also Medical-Legal) Implication

Failing to address promptly may result in actual, avoidable harm!


9F425 Update


Best Practice, continued…. Why send MRR findings and recommendations via email?

Provides a time and date stamp of when the reviews were performed

Quickly and easily retrievable in the event it is questioned during Survey

Consider using a simple Cover Letter, and attach findings Cover letter should clearly indicate the purpose of the review, the

names of any residents for whom new reviews were performed, and whether or not there were recommendations for that resident.


10F425 UpdateSample Email Cover Letter


11F425 Update


Common Findings of New Admission MRR’s Narrow Therapeutic Index Drugs ordered with no monitoring

(e.g., Coumadin, Dilantin, Digoxin, Carbamazepine) Inappropriate or poorly written insulin or sliding scale insulin

orders Inappropriate route of administration (e.g., a non-crushable

ordered via G-Tube) (Often expensive) medications for acute conditions written

without stop dates Drug-Disease State interactions or contraindications Medication Cost Issues


12F425 Update


The Unintended (GREAT) Benefit of New Admission MRR’s:

MEDICATION COST SAVINGS Most all short stay admissions (and in some facilities, most

every admission) comes in under Medicare Part A or an HMO This means that the facility is responsible for 100% of the drug costs

New Admission MRR’s provide the perfect opportunity to quickly and efficiently Identify and make Formulary Changes Discontinue Unnecessary Medications right away

Our internal analysis: The cost savings FAR exceeds the cost of performing the MRR’s!

The F425 Requirement is for Short Term/Short Stay – can and should facilities expand it to ALL admissions, regardless of intended length of stay?


13F425 Update


Best Practice, continued…. The “Cost Savings” Element reinforces again how TIME

SENSITIVE these MRR’s are – MUST act on them right away!

Who can respond to New Admission MRR’s? Nurse Practitioner Physician’s Assistant Medical Director Attending Physician Nursing Supervisor, via T/O from the Physician


14F425 Update


One final important note on New Admission MRR’s:

New Admission MRR’s can not and should not replace

normal monthly Medication Regimen Reviews Monthly MRR’s serve as an immediate QA on the New

Admission MRR’s Are the reviews being responded to PROMPTLY? Are the findings valid, relevant, and being accepted?

Monthly MRR’s have the benefit of new and more information, and often lead to additional changes.


15F425 Update

Supplemental MRR for Residents Experiencing Significant Decline/Change in Condition

What defines “Significant Decline”? Different than the MDS definition of Significant Change

Consider a Supplemental MRR to rule out medications as a cause for an UNEXPLAINED change in condition such as those listed in F329: Recent/multiple Falls Weight Loss Seizure Activity Mood/behavior change Constipation/Impaction Sleep Disturbance Rash/Pruritus

And other unexplained changes


16F425 Update

Supplemental MRR for Residents Experiencing Significant Decline/Change in Condition

Best Practices Tie the process into Morning Report.

Unexplained Change? Submit a request to your consultant Pharmacist for review via Fax, email, phone.

Consultant Pharmacist logs in remotely to your EMR or Pharmacy Vendor System, performs review, and emails response.

Look for a 1 business day turnaround on Supplemental MRR Requests

Request a response regardless of the outcome of the review. Possible responses include: Highly likely to be caused by a medication, consider change Possibly likely to be caused by a medication, consider change Unlikely to be caused by a medication, consider other causes


17F425 Update

Questions and Answers

Thank you!

Dr. William C. Hallett, Pharm.D., MBA, CGP, C-MTM

[email protected]

mailto:[email protected]

presented by: dr. william c. hallett, pharm.d., mba, cgp, c-mtm president/ceo guardian consulting...

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