MEDS, MARs, and Mastering Meltdowns Pharmacy Alternatives™ BASICS for Survival in the Field.
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MEDS, MARs, and Mastering Meltdowns Pharmacy Alternatives™ BASICS for Survival in the Field By Georgia Swank MS, RN, CDDN Director of Clinical Development Pharmacy Alternatives™ 2009 Objectives To orient new Nurses or staff whose clients or facilities utilize PAL’s services, to pharmacy and medication handling processes To increase familiarity with PAL systems and forms To improve quality of care to our customers by assisting in coordination of processes that effect medications Pharmacy Alternatives™ • • • • • • PAL KY-open 1-2006 PAL TX-open 6-2006 PAL VA-open 7-2007 PAL IL-open 4-2009 PAL GA-open 6-2010 Where next? Doug Russell RPh Senior V.P. Organization: Having Systems Coordinating medication processes is a BIG JOB….on your end and ours! This is why we must BOTH have systems that we follow in all areas of medication ordering, handling, dispensing, disposal, return, and documentation These systems should be written as procedures or operational standards in each of your organizations and used to train staff, nurses, and others as appropriate Communication We pride ourselves in face to face (or voice to voice) communication as much as possible. We offer regular customer conference calls with key people from PAL and your organization as often as you desire them to maintain open communication. If you have a need, a suggestion, or you would like to schedule a conference call, please talk to the pharmacy director for your area. It Goes With the Job… A physician is supposed to give a lecture and carefully writes down his notes in preparation. But that night, as he prepares to give his presentation, he looks down and discovers that he can’t read his index cards. They are illegible! He starts getting nervous since he can’t seem to remember his opening lines….when he suddenly thinks of a remedy and calls out to the crowd….. "Is there a pharmacist in the house?" Medical Records Timing is everything…. in everything •PAL has a variety of medical record formats to choose from •You will be linked to your own Medical Records employee to work with for your facility or operation Tinika, Marcy, Wendy Marcy Mills, Medical Records Manager •Our staff get to know you and how you like your records Physician Order Formatting Insure your P.O.s are formatted in an easyto-read, clear, concise format Use Headings such as Dietary, Activity, Lab/Diagnostics, Adaptive Equipment, History/Surgical You can add new P.O.’s or Nursing Measures to your orders between physician signings AND: date and sign each new entry Organize info under each heading You can handwrite in a new order but you must This is so anyone viewing the orders can quickly see that this was added AFTER the physician signed the original orders This also keeps you organized-by the end of the month, your orders are all updated and ready for Medical Records without any extra effort!! P.O.s - Make Them Work for You Special consideration statements: “Missing one dose of any medication or one treatment of any kind does not impair the health or safety of the individual. (Exceptions, please list: _______)” “Physician Orders are in effect for _____ days” “Client may use any of the following: sun block, lip balm, lotion, cream, makeup, bug repellant, (whatever else you want to add)” Nursing measures Qualifying orders (egs. Wheelchair for long distances only) Medical Records…. MONTHLY: You make changes to medication and ancillary orders according to physician orders or nursing/staff interventions Physician must sign at bottom of each page of orders to signify his/her agreement (according to your state’s guidelines—every 60, 90, or 180 days for example) Mail all updated orders for your area to PAL Medical Records Dept. before the due date (updated orders rec’d AFTER the due date will be added to the subsequent month’s orders) Med Records staff will make changes and new MARs and POs will be shipped out to you prior to the start of the new month Updating Medical Records (MARs) Your MAR monthly updates get mailed to the Medical Records Dept. by the 10th of each month (to be updated for the next month). Mail to : Pharmacy Alternatives Att: Your Medical Records Person 10140 Linn Station Road Louisville, KY, 40223 Medication Updates are made AT the Pharmacy as your new orders come in To discuss or change medication orders, you must contact your PHARMACY By updating monthly POs in a timely manner, you can maintain accurate, high quality records which help to minimize Med Errors for our consumers. Processes for Ordering on Your End Telephone Orders Nurses are the ONLY ones who can give the pharmacy a phone order for a new prescription This must, however, be followed up by a written order, signed by the physician Staff can reorder any meds or items that the pharmacy ALREADY HAS refill orders for FAXing is the preferred method for reordering as this method connects all documents for a specific client together in our Docutrack system FAX….FAX….FAX….FAX….FAX 1. Your faxed order comes in on this computer 2. The new order or reorder is connected to a patient’s history on this computer 3. The order and history are electronically “stapled” together…and kept together forever LOA Meds Medications can be provided for LOA (leave of absence) in separate bubblepacks if you notify the Pharmacy BEFORE your medications are shipped Current day Rx insurances do not allow for extra medication to be paid for beyond the prescribed amount (for example, 30 pills for a once a day med order in a 30-day month) Option to pay out-of-pocket for the extra LOA meds Labeled empty vials can be provided at your request for medications being taken on LOA. Many organizations send all current meds on LOA intact in their packages as received from PAL LOA Meds: But I Can’t Send All the Meds With the Consumer, They Won’t Come Back! If this is an issue you are dealing with, it is wise to develop a system for LOA that requires the consumer/family/friends to sign in and out for meds received and meds returned to the facility Staff also count all meds prior to sending and upon return and sign the statement that counts are correct Determine, as an organization, what the plan will be for meds not returned or incorrect counts…do this ahead of time and be sure to discuss with families This procedure can be discussed with consumers and families ahead of time at team meetings so it is not a surprise at LOA time when they are picking up their loved one for the weekend Clozaril Monitoring Requirements MUST HAVE Baseline WBC and ANC before initiation of treatment, weekly or biweekly labs as stated below, and lab 4 weeks after discontinuation of treatment BY LAW, the Pharmacy cannot send Clozaril (Clozapine) out to a patient without first receiving and confirming blood test parameters per the guidelines TESTING: Weekly for 6 months Every 2 weeks from 6-12 months Every 4 weeks thereafter WBC ≥ 3500 mm3 and ANC ≥ 2000 mm3 Any changes to the WBC or ANC beyond listed parameters require some action. Go to the link below on page 10 of Prescribing Guidelines for requirements for monitoring Interruption of therapy guidelines for restarting a consumer on the med are also found at the following link http://www.pharma.us.movartis.co m/product/pi/pdf/Clozaril.pdf If you did not receive your Clozaril, it is probably because the pharmacy did not receive lab results—call the lab! Pharmacy Quality Checks Each medication order goes through a series of Quality Checks by the Pharmacist and our pharmacy staff at several points in the process….before it is approved to be shipped to you! Shipping & Delivery Timely, efficient delivery systems individualized to customer needs Medication Orders are processed the same day we receive them. You will receive these medications at your next scheduled delivery time unless it is a MUST HAVE medication such as: Antibiotics Seizure meds Pain meds Behavioral meds Our BACK UP PHARMACY system will insure you can pick these up the same day in your local area John Brian, Director of Logistics Exceptional Service, Exceptional People “It’s not just a line to me!” Back Up Pharmacy You are provided a list of Back Up neighborhood pharmacies to meet your important medication needs after hours This is a list of neighborhood pharmacies YOU have chosen and can be changed at any time with your notification of John Brian, Logistics Coordinator. This is for meds that cannot wait until the next delivery day Examples would be meds for seizures, pain, antibiotics for illness or infection, psych meds, etc. It would not be vitamins, cholesterol meds, or other meds that would not affect the overall health or safety of the consumer if it was obtained the next day Use good judgment before ordering from the Back Up Pharmacy. This is not meant to be used for every medication. Back Up Procedure Fax or call order to Pharmacy Alternatives—if it is after hours, you will hear a recording giving you information for contacting the PAL On Call Pharmacist Designate on fax or in call that you need this medication called to Back Up Designate which Pharmacy you will be going to (if more than 1 on your choice list) Wait 2 hours for order to be processed on our end, sent to Back Up, and filled on their end Call the Back Up Pharmacy to be sure it is ready before you go pick it up You will not have to pay any copays or other costs when picking up medications as long as you called Pharmacy Alternatives first to process the order Back Up Pharmacy Questions? Will I get a full supply of meds or only a partial supply? You will get enough medication to get the consumer to the next scheduled delivery time. (example: enough to get to the next day if it is the weekday, or enough to get through the weekend to Monday) Will the meds still be in bubblepacks? The meds from the Back Up Pharmacy will be in vials or bottles for those few doses. The meds delivered by PAL the next delivery time will be packaged in bubblepacks, just like usual. If the Back Up Pharmacist asks for money, what do I do? You tell him or her that the med was already billed through Pharmacy Alternatives and nothing should be due. If you have a card from PAL to show the procedure to them, provide this at this time. What if I have to fill a Controlled Med at Back Up? Then you will have to fill the entire prescription there due to the federal laws binding handling of these medications. You would also have to pay any copays or other costs on behalf of the consumer at that time (since it did not go through PAL). Refer to the Work Flow Guide You’ve Been Provided PHARMACY WORKFLOW GUIDE NEW ORDERS New prescription medication orders or changes should be faxed to the pharmacy once available. The original hardcopy must be maintained with your records….we will utilize our electronic PDF image as our copy. Please follow your Core Office policy and procedure when filing and recording these documents. The best procedure will be to copy the prescription, then document any notes or guidance to the pharmacy on this copy……such as “STAT”, “Call into backup today”, “OK to deliver on next run”, “PROFILE ONLY”, “Renewal copy only-do not fill”, “Send separate noon doses also”, “Label only”, etc. Communication will be the key to guiding pharmacy action with the prescription. ALWAYS call the pharmacy when a fax you have sent is urgent and requires immediate handling. All new orders will be filled per your guidance. Note: Schedule II Narcotics / Controlled Substances: New prescriptions for this class / category of medication require that the pharmacy receive the hard copy of the prescription prior to dispensing. It is critical that orders of this nature follow State Regulation. Please contact us immediately following the receipt of one of these prescription orders….the pharmacist will assist in logistics regarding the hardcopy. REORDERS Reorders / Refills requests are necessary for Bulk items (creams, ointments), Birth Control Pills, most nasal sprays and inhalers, insulin, syringes, etc….basically any item that is not considered a routine maintenance medication included in the monthly exchange. Please make your requests 3-5 days in advance to allow sufficient time for delivery / shipment. EXCHANGE Routine maintenance medications will be cycled via a monthly calendar month exchange. Delivery of these medications will occur at the end of each month…….. PHARMACY ALTERNATIVES™ Consumer Change of Status Notification Instructions: Complete and fax this form to the Pharmacy under a cover sheet for all changes in consumer status that would affect pharmacy services for that consumer. This includes New Admissions, Discharges, and Transfers within an operation, Notification regarding Deceased Persons, and any other pertinent status change situations. A signature and phone number must be included in every communication for the contact person. Full Name of Consumer: ____________________________________________________________________ Date: ________________________ Facility (Main Office): _____________________________________________________________________________________ Change of Status Form Status Change: □ New Admission--Effective Date: _________________ New Address (street/city/state/zip):____________________________________________ Phone #: __________________________________________________________ Date of Birth: Medicaid #: ___________________ _________________________________ __________________________ Medicare #: _______________________ Med Part D Prescription Drug Plan Name: __________________________ID #:_____________________________ Primary Physician: Allergies: (FAX) ___________________________ Phone #: ___________________ __________________________________________________________ Admission Orders Included: YES NO Send Routine Meds □ Discharge--Effective Date: _________________ □ Deceased—Date of Death: __________________ □ Transfer within facility--Effective Date: ________________ Old Address (street/city/state/zip): Don’t forget to fill out Contact information! SS#: Send PRN Meds (Please circle) ____________________________________________ New Address (street/city/state/zip):____________________________________________ New Phone #: □ _______________________________________________________ Other: ______________________________________________________________ (Example: Change of work status, day programming schedule, return from Nursing Home, etc.) Signature of person completing: ____________________________________Print Name: __________________________ Phone #: ________________________________________________________________________________________ Consumer Change of Status Fax to Pharmacy anytime there is an: Admission Discharge Transfer to another address within same organization Hospitalization, Rehab, Skilled Care Complete when sent and when returns Death Workshop, Day Programming, or Work changes effecting med administration Why it is important to use the Change of Status form? So the medications are sent to the correct address So there are no missed doses So the pharmacy does not send medications when it is not appropriate (egs. Client is on LOA, moved, discharged, or deceased) So you do not keep collecting meds when the client is not there To communicate consistently in those situations that may effect client or payer $$ Reorder Form Tear off extra label that came with the med and stick it in one of these boxes—FAX this form to the pharmacy—you can put meds for several consumers on this form You can also print names of meds and consumers on this form if you don’t have a sticker! Reordering of non-cycle fill items These are the medications and some supplies that RUN OUT throughout the month and are NOT on a cycle fill with your other meds This is because these meds come pre-packaged in specified amounts that cannot be broken down into monthly amounts Examples: Birth control pills, creams, drops, ointments, inhalers, Fosamax, blood glucose supplies These must be ordered PRIOR TO running out (3-5 days) Have a system for identifying these meds or items weekly and reordering in a timely manner so the client does not run out before delivery occurs Possible system for reordering of non-cycle-filled meds Who is responsible for reordering? When are they required to do it? Pick a day and time (Egs. Weds by 12:00) that the designated person is to check all meds that run out between cycles and medical supplies that come from the Pharmacy (like blood glucose supplies)….and reorder these if there is not enough to get through another week What is the procedure? Where is it written? Is the staff person trained to do it and the backup plan if they are unable? YOU DECIDE. Is it the Nurse? Program Manager? And what is the backup plan if this person is gone? Create an Operational Standard, 1-2 paragraphs, print it at the top of a sign-in sheet, staff to read and sign Implement it! Make it the expectation. WEBSITE www.palrx.com Download any pharmacy forms, medical forms Find links to internet sites for questions about meds, medical conditions, etc. Archived newsletters Information about drug plans Education Pharmacy Processes Medication Returns Medications of which any portion has been used, cannot be returned Controlled Medications cannot be returned as per Federal Law There are limited circumstances for which the Pharmacy can take returned meds. Please call your Pharmacy Director before sending any meds back to insure these can be returned. Medication Disposal Please refer to the Procedures for your organization for Medication Disposal The PAL Policy & Procedure for Disposal can be found on the website at www.palrx.com Controlled Medications Cannot be returned to the pharmacy—per the Controlled Substances Act Controlled Count Sheet will be attached to every Controlled med you receive labeled with the correct correlating information Ready to use by staff! Disposal/destruction of Controlled Medications that are no longer needed should be done according to your state’s regulations and EPA guidelines Destroyed medications should be well documented with name of med, dosage, total amount, and signatures of responsible parties who destroyed and witnessed med destruction. Method of destruction must also be logged. Billing Processes Billing for services Goes out monthly to your designated person/office Payment is expected prior to the next billing cycle Shirley Maclaine, actress New Billing Form provides more itemized information Prior Authorizations This means you may get a FAX or phone call about one of these… Lisa Schnell Pharmacy Controller Requests to pharmacy * attach a prescription *write a message *send info to go on the patient profile only *designate a med that needs to be called to Back Up This form will come through the Docutrack system and be electronically stapled to the client’s history---with your message, script, or request Pharmacy Forms Communication FAX Change of Status Medication Reorder All of the forms you will use to communicate with the pharmacy can be downloaded from the PAL website at www.palrx.com Education & Resource Georgia Swank MS, RN, CDDN Director of Clinical Development The Post Script- a monthly clinical newsletter to your email FDA Alerts for Nurses Professional Journal articles to your email of issues pertinent to DD and medical news Webinars, Seminars, Speaker Events-periodically in your area Educational Resource for teaching/learning materials Certified DD Nurse—to use as a Resource Marketing Our Services Pharmacy Alternatives is always looking for new opportunities to serve others in the DD field If you know of an organization in need of quality Comprehensive Pharmacy Services, please let us know and refer to us! Contacts for marketing opportunities: Kathy Brown RN, CDDN [email protected] Georgia Swank MS, RN, CDDN [email protected] Nanette Wrobel BS, RPh [email protected] MASTERING MELTDOWNS Now you have all of the information you need to avoid those MELTDOWNS in your daily routine Use this presentation to train new nurses and staff as often as you require it If you have any questions or need clarification for anything you read in this presentation, call us! We will be happy to assist you. Pharmacist Consulting PAL has Consultants who do Medication Regimen Reviews and provide needed insight and expertise into issues of disease states, side effects, interactions, and many other topics Consulting by a non-dispensing pharmacist is required in some areas The cost of consulting is minimal compared to the benefits it provides our consumers If you are interested in consulting services, please contact your Pharmacy Director Nurse Consulting Pharmacy Alternatives is lucky to have 2 Nurses who are Certified Developmental Disabilities Nurses with many years of DD experience as well as Leadership and Training experience Nurse Consulting and providing training and other activities to our customers is free of charge Did you know…. How many pharmacists it takes to change a light bulb? Just one, but he has to do it for ten days, three times a day. If there is a special topic you would like to see addressed in this training for the future, please email [email protected]