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Pharmaceutical Postline
Home Health Agencies and the Pharmacist* By R. Paul Baumgartner Jr., Janice F. Glascock, Rita M. Smith and Alan Martin Weissman
H
ome health care has been practiced in many communities in the United States for the last few decades; however, during this time pharmacist involvement with home health care has been minimal. The subject has received scant attention in the pharmacy literature and a role for the pharmacist has been referred to only recently.1-6 This is not surprising since it was not until the advent of Medicare in 1965, which made home health agencies more feasible from a financial standpoint, that they achieved prominence in health care delivery. Progressive Patient Care Home health care is but one of the levels of progressive patient care provided by the Appalachian Regional Hospitals (ARH)-a system of ten nonprofit, voluntary hospitals in the mountain areas of West Virginia, Kentucky and Virginia. Pharmacy services at ARH have been discussed previously. 1-2 The fundamental conviction of ARH as set forth in the corporate plan is that community hospitals and health centers, particularly in rural settings, can best serve their communities by providing appropriate levels of health care. There are many variations, but basically there are six recognized levels of care 5 (listed in order of increasing involvement of the patient in the rpanagement of his own health needs)-intensive care, intermediate care, extended care, home care, ambulant care and self-care. These levels of care are on a continuum ranging from total staff management of the patient's needs to almost total control by the patient of his own health needs. At one end of the continuum is "intensivecoronary care" which is emergency and lifesaving in nature where even the patient's simple bodily functions such as respiration and elimination may be controlled by hospital staff and/or by
*
Adapted from a presentation to the Academy of General Practice of Pharmacy at the APhA Annual Meeting in Houston, Texas, April 24, 1972.
machines; at the other end is "self-care" where such "care" as may be provided a person by health personnel is in the nature of guidance and support given at the request of the patient. Each of the levels of care is described here briefly as followsIntensive Care-Intensive care/coronary care units serve a life-saving function, a proper level of care for those so seriously ill or injured that they need minute-byminute monitoring. Typically, patients only need this level of care for short periods of time at which point they either expire or begin to recover. Intermediate Care-Intermediate (acute) care is that function traditionally performed by community hospitals. It is represented by a core of medical, surgical, pediatric and obstetric inpatient beds, facilities and services within the hospital for those who require it. Extended Care-Extended care services meet the needs of those patients whose requirements are such that they do not need to enter or remain in an intermediate (acute) care bed, but who still must have some skilled nursing and medical treatment. Very often extended care also provides many rehabilitation services. Extended care facilities are extensions (both before and after) of hospital care, and are an appropriate level between the intermediate (acute) care hospital and home care. Home Care-Home care is an element of patient care that provides medical, nurs- · ing, social, rehabilitative and related services on an intermittent basis in the home. Home care is a desirable alternative to institutionalization for the patient whose requirements can be met in the home. This level of care can prevent hospitalization and provide the patient with the therapeutic climate inherent in recovery at home. This therapeutic climate is a healing climate and to the home health patient includes familiar surroundings such as family and home environment. Another feature of home care is that it is focused on removing social and environmental obstacles which may deter the recovery of the "total patient"; thus, the patient is
either restored to full health or achieves maximal rehabilitation with the least possible disruption of his (and his family's) usual pattern of daily living. Ambulant Care-Ambulant care (or outpatient) is a level of care for patients who require diagnostic and therapeutic services not conveniently provided in the home. Ambulant (outpatient) services ordinarily are sufficient to meet the needs of most people. Group practice physicians' clinics, satellite health clinics and emergency rooms are basic ambulant care components and these facilities are very often the patient's point of entry into the health care system. Self-Care-As a level of care, self-care has a twofold meaning. First, self-care units in hospital settings can provide overnight . accommodations for patients who can care for themselves, but whose presence in the hospital is required for one reason or another. Second, through preventive health methods and educational processes, self-care facilitates the ability of people to manage their own health needs.
At ~ach of these levels of care the principles of rehabilitation are constant-to reduce the physical impairment of the illness or injury; to cope with other obstacles (such as social factors) which may prevent maximal functioning; to maintain a therapeutic climate, and to insure that care is continuing and complete. At Appalachian Regional Hospitals we have placed particular emphasis on individualizing the level of care that is appropriate to each patient's needs. Home Health Agencies
Home health care services are furnished to any patient who may require them; however, it is readily apparent that the geriatric population with its preponderance of chronic illness and the permanently disabled will be the major recipients of home health care services. These services may be paid for by the Medicare program if they are provided by certified home health agencies. As a result the Medicare program has had Vol. NS14, No.7, July 1974
355
R. Paul Baumgartner Jr. is director of pharmaceutical services for Appalachian Regional Hospitals, South Williamson, Kentucky and an assistant clinical professor at the University of Kentucky college of pharmacy. Since 1972 he has been principal investigator for West Virginia Regional Medical Program grant, "A Project to Improve Drug Therapy for Home Health Care Patients." He is also a member of the Kentucky Comprehensive Health Planning Council. Baumgartner holds a BS in pharmacy from the University of Pittsburgh. His professional associations include APhA, Academy of General Practice of Pharmacy, AACP and he is president-elect of ASHP. Baumgartner has previously published several articles.
Janice F. Glascock is a staff pharmacist at Williamson Appalachian Regional Hospital, South Williamson, Kentucky. She received her BS in pharmacy from the University of South Carolina in 1970. Glascock is a member of APhA, ASHP and the Kentucky Society of Hospital Pharmacists.
Rita M. Smith is coordinator of home health services at Williamson Appalachian Regional Hospital, South Williamson, Kentucky. She is a graduate of St. John's Hospital School of Nursing, Lowell, Massachusetts and earned a BS in nursing education at West Virginia University. Smith is a United States Army veteran.
Alan Martin Weissman is special projects clinical pharmacist for Appalachian Regional Hospitals, South Williamson, Kentucky and pharmacist researcher on the West Virginia Regional Medical Program grant, "A Project to Improve Drug Therapy for Home Health Care Patients." He has BS and PharmD degrees from Columbia University college of pharmaceutical sciences. Weissman was formerly Public Health Service pharmacy chief at Indian Health Service Hospital, Browning, Montana.
a great deal of influence on the conception of home health services and has had a considerable effect upon those who provide the services, as well as the methods by which these se(vices are provided. To become certified a home health agency must meet the "24 Conditions of Participation for Home Health Agencies" put forth by the Social Security Administration, Department of Health, Education, and Welfare. These conditions are somewhat comparable to the requirements that must be complied with by hospitals and extended care facilities in order to participate in the Medicare program. Some of the basic requirements for agency participation are the following-7 The agency's primary function is to include the provision of intermittent skilled nursing services and other therapeutic services on a visiting basis in a' place of residence used as the patient's home. In addition to skilled nursing services the agency must provide at least one ef the following therapeutic 356
' services-physical, speech or occupational therapy; medical social services, or home health aide services. The home health agency designates a physician or registered professional nurse to supervise the agency's performance in providing home health services in accordance with the orders of the physician responsible for the care of the patient and under a plan of treatment established by such physician. The agency's policies covering skilled nursing and other therapeutic services, and the professional health aspects of other policies are established with the approval of, and subject to regular review by, a group of professional personnel which includes a licensed physician and a registered professional nurse. Written standards regarding the qualifications, responsibilities, state licensure and conditions of employment for each type of person employed by the agency are required. The agency also must have procedures which provide for systematic evaluation of its program at least once every two years
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
and be approved by any state or local licensing agency if agencies of this type are required to be so licensed. Skilled nursing service in a home health agency must be provided by or under the supervision of a registered professional nurse(s) currently licensed in the state. One interesting requirement for participation is that the original orders of a physician and all changes in orders for the administration of dangerous drugs are signed by the physician and incorporated in the patient record maintained by the agency. All other changes -in orders are to either be signed by the physician or by a registered professional nurse in the agency if such changes are received verbally by her, but must be co-signed by the physicians within seven days. This requirement does not recognize the traditional role of the pharmacist in health care delivery. In all other areas of pharmaceutical practice, the pharmacist can accept verbal orders from a physician, reduce it to writing and the order then becomes a bona fide prescription. However, when third parties such as Blue Cross audit the records of a home health agency, such prescription orders might be grounds for elimination of the agency from Medicare funding. The home health agency also has written policies to be followed in determining the desirability and practicality of accepting various patients for care. These decisions are to be based on medical, nursing and social information provided by the patient's physician, by institutional (hospital) personnel and by the staff of the home health agency. For each patient, the agency maintains a clinical record covering the services which the agency provides directly and those which it furnished through arrangements with other agencies. This record contains the pertinent past and current medical, nursing, social and other therapeutic information concerning the patient, and includes the plan of treatment. Additional conditions for participation relate to the agreements between agencies, the provision of other professional services, and the selection, training .and supervision of home health aides, if any are utilized. Certain services such as "meals on ' wheels," services of a domestic or other housekeeping services unrelated to patient care, ambulance service, dental service (other than surgery of the jaw), and drugs and biologicals are currently excluded . from Medicare reimbursement. Problems Although Medicare has had a great positive impact on the provision of home health care services, it has also limited the duration of services by restricting
the total number of visits which can be reimbursed. While this policy has the desirable effect of emphasizing rehabilitation principles, it also precludes provision of long-term chronic care to those who require it. The complexities of administration and rei~bursement by insurance carriers acting on behalf of Medicare have placed many home health agencies in financial jeopardy~ The process by which claims are submitted, interpretations made, lengthy correspondence initiated over details of wording and difference in visit counts place an enormous burden on the providers. This has resulted in a great deal of "needless" administrative overhead costs to the home health agencies. 8 Until recently, the retroactive denial of payments which had been practiced by many insurance carriers had also severely crippled some home health agencies. 8 However, Medicare is in the process of setting up rules for advance approval of Medicare payments for post-hospital patients requiring home health services. These rules will be designed to help assume payment for a specific number of home health visits. 9 Another of the major problems of the Medicare-oriented h0me health agency is ' difficulty in providing services to patients who only have Part A coverage under Title XVIII. With Part A coverage the patient must first be hospitalized for a minimum of three days and the physician must complete a plan 'of treatment within 14 days ot discharge from the hospital before the agency can be reimbur~ed. Under Part A the patient is entitled to full Medicare coverage for 100 visits within one year of discharge. If the patient is not hospitalized, and has the 'optional Part B coverage, Medicare pays the full amount of the reasonable charges for 100 home health visits per calenda~ year following payment by the patient of the first $60. Therefore if a patient does not take Part B 'coverage he must be hospitalized, often needlessly, for Medicare to' pay for the home health services received. Pharmacist's
~articipa~ion
Nine ARH hospitals now operate home he~lth agencies. Several of our pharmacists have become involved to varying degrees with this exciting new concept of health care delivery. At present two of the' hospital-based pharmacists provide a pharmacist to to the agency Monday through Friday for one or two hours each day. It is unclear whether the pharmacist cost component to the agency is reimbursable under the 'Medicare conditions of participation of the agencies. Nevertheless, as we are primarily concerned with determining both the needs of home
health patients and the pharmacist's role in helping to meet these needs, shortterm funding is relatively unimportant. However, for continued pharmacist p~r ticipation, 'funding by Medicare is definitely desirable. The finding of our preliminary studies leads us to believe that problems with drug therapy occur frequentiy with home health service patients. This has deepened our inter'est in further exploration of the role for the pharmacist with the agency. Toward that end we have received funding from the West Virginia Regional Medical Program in the amount of $18,000 to study pharmacist involvement with the patients of ~ home health agency. At present this study is ongoing and we are evaluating roles for the horrie health pharmacist such as patient interview and consultation, home evaluation, assistance in the formulation pf drug policies, participation in daily case conferences, provision of formal and informal in service training, and improved medication record systems and controls. It is planned that the pharmacist will interview and consult with each patient discharged from the hospital who is scheduled to be continued as a home health patient. We feel this function to be one of an absolute necessity if the patient is to be continued on drug therapy at home. In practice the pharmacist by utilizing outpatient medication profiles determines what drugs the patient used prior to hospitalization. This information, together with drug therapy during hospitalization, can be related to the pharmacotherapy planned on discharge from the hospital. Prescription orders written by the physician are taken to the patient's bedside. If the patient prefers, the prescription is dispensed from the hospital pharmacy. During this discharge consultation, the patient is educated regarding pertinent aspects of each drug entity. Drllg-r~ lated information that the pharmacist relays to the patient includes how and when to self-administer the medication, what effect should Qe expected, possible side effects, storage requirements, fooddrug interactions, special dietary instructions and prescription renewal information. At present, consultations of this nature take place in the privacy of the patient's room often with the horrie health nurse in attendance'. " We have found that it is occasionally necessary for the pharmacist to assess certain factors in the home by making personal visits with or without other home health personnel. The decision to make a home visit by the pharmacist is determined during the daily case conference based on individual patient needs. Factors which might predispose a patient to a home visit by the pharmacist would include-the need to determine all medications potentially available to the patient other than pre-
scribed by the physician such as o-t-c medications, previously prescribed drugs, medications borrowed from friends and neighbors, compliance with the physician-directed drug therapy, understanding the rationale of therapy and the occurrence of side effects. In essence any drug-related problem concerning the patient which needs the pharmacist's attention would prompt the attending nurse or physician to suggest a pharmacist visit. ' After the pharmacist's visit the pertinent aspects of ' the interview are recorded in the patient record of the home health agency for future referral. Participation in case conferences has been particularly rewarding in terms of the pharmacist making a contribution to the care of the patient and perhaps 'this is a prime example of the team approach to health care. Following the return of nursing personnel from daily visits, each patient is jointly reviewed by team members of the agency. It is then possible for various individuals present such as the coordinator', nurses, aides, pharmacist, dietitian, medical social worker, physical t~erapist and others to apply their specialized knowledge to each case. At this time, patient progress is evaluated and specific problems can be identified. A consensus is reached for any modifications that may be necessary in the plan of treatment. It is perfectly ' within the purview ' of the ph'armacist to recommend changes in drug therapy such as change in dose, route of administration, dosage form and addition or deletion of specific drugs. ' The pharmacist' also may suggest that particular laboratory studies be conducted to monitor various drug toxicities - or ' side effects. If changes in drug therapy or if laboratory tests are advisable,'i t is the pharmacist's responsibility to follow through on the case~ i.e., contact the physician and obtain from him the necessary prescription orders or laboratory requisitions. It should be apparent that these daily case conferences are an excellent opportunity for 'the pharmacist to provide either ' formal or informal continuing education relative to drug therapy to the other team members. In like manner it affords the pharmacist an opportunity to learn from other health care workers and to work effectively in a multidisciplinary group. It is not uncommon for some cases to involve all members of the agency such as the physician, nurse, medical social worker, nutritionist, chaplain, physical therapist, inhalation therapist and pharmacist. , Our last objective for involving the ph~rmacist with the home health agency is to assist in the development and maintenance of adeqpate, accurate and sirpplified medication records and profiles for each patient. This particular phase (continued on pa~e 377) Vol. NS14, No.7, July 1974
357
Women's Auxiliary
Let's Participate Would you like to know in detail some of the events that are planned to assure you an entertaining and informative seven days at the APhA Annual Meeting in Chicago, August 3- 8? We do hope that you plan to come along with your husband this year and participate in the varied events that are planned for you after a year of hard work on the part of local committees. We will begin our ladies activities Monday morning, August 5, with the Auxiliary's Second Annual Welcoming Coffee. After a brief get-acquainted time over coffee and rolls, we will have panel discussions on various problems that face all organizations. The panels WIll be made up of women from throughout the U.S. with suggestions on how their particular groups handled a given situation. The panel discussions will be followed by a general discussion so that each person attending can participate. Monday afternoon will find the ladies on a tour of Chicago. Mrs. Richard Struzynski and Mrs. Roger Cain are serving as co-chairladies of this event. Tuesday morning the 'Women's Auxiliary will honor the local and state presidents and the student wives at our annual coffee. This will be followed by the First General Session. Mrs. Philip Sacks, chairlady of women's activities, will be introduced and bring greetings from the Local Hospitality Committee. This will be followed by the 1973-74 annual reports of the Auxiliary officers and
Home Health Agencies (continued from page 357)
of pharmacist input was very well described by Eastman 3 and we would urge the serious review of this excellent article for any pharmacist considering involvement with a home health agency. As previously stated, we are currently involved in a research project to determine the role of the pharmacist with the home health agency. One of the goals of the project is reimbursement of a pharmacy cost component to the home health agency. This reimbursement will relate, hopefully, with the pharmacist's ability to provide health care as a member of the home health agency and not necessarily be related to drug dispensing activities. This project will quantitate the needs of home health patients which can be adequately met by the addition of a pharmacist to the home health agency. Relating this to any additional direct costs incurred, such as the pharmacist's salary, should provide much of the data necessary to determine if a favorable cost-to-benefit ratio exists. If it does this information will be presented to various third parties such as state welfare agencies and social security administration personnel, with the expectation that the home health
chairladies. Tuesday afternoon there will be a meeting between the student wives, sponsors and board members. Wednesday at noon the ladies will once again be treated to a very special luncheon by Eli Lilly and Company. The entertainment will be provided by Elizabeth Arden. They have designed a very appealing program, involving the application of cosmetics. The commentator will be Glenn Roberts, Elizabeth Arden's creative training director. A showing of the latest creations in fashion apparel will open and close the program. Thursday morning brings the Women's Auxiliary Brunch and Second General Session with Mrs. Marvin Graber as chairlady. There will be greetings from APhA and from the Local Hospitality Committee. This will be followed by an entertaining program entitled "Ileene's Quick Tricks for Fun, Figure and Fashions." This is being presented by Ileene Abrams of Chicago. After the business meeting, Mrs. William Bacon will present the Achievement Awards and the Nominating Committee will make its report. The meeting will be closed with the election and instal~ation of officers for 1974-75. The installing officer will be Mrs. Reginald Lowe, former president. Mrs. William J. Sheffield, President 2204 Langford Cove Austin" TX 7872?,
agency will be fully reimbursed for a service which we believe only a pharmacist can provide. In doing so, we plan to develop standards of pharmaceutical service which may then be adapted by others. . In this preliminary report we hope to acquaint many pharmacists with home health agencies. There is a strong probability that these agencies represent an unmet need for pharmacists to provide a clinical service to those 'patients who are only one 'step away from ambulant care and, hopefully, complete recovery. At the present time, home health patients are largely denied availability of a pharmacy component to their services, a factor which may unnecessarily increase health care costs. It is hoped that our experiences will stimulate an interest on the part of other pharmacists to investigate this rewarding way of meeting health care needs. • References ' 1. Ba umgartner , R. P. Jr., "A Regiona l Concept of Hospital Pha rma cy Services," Am. J. Hosp. Pharm., 28,670 (Sept. 1971) 2. Baumgartner, R. P . Jr.; L and, M. J. and Hauser, L. D., "Rura l Hea lth Care-Opportunity for Innova tive Pha rmacy Service," Am. J. Hosp. Pharm., 29, 394 (M a y 1972) 3. Eastman, P . F.," Pharmaceutical Services for Home Health Agencies," JAPhA, NSll, 391, (July 1971) 4. Ellis, E. F., "The Pharmacist's Role in Home Health Care," Nurs. Hom:s, 22, 15, (Feb. 1973)
5. Levels of Care and Rehabilitation Principles Applied to Appalachian R eg ional Hospitals, Ccntinuing Objective #3, Appalachian Regiona l Hospitals (Revised Aug. 15,1972) 0. Silverman, H. M. , and Simon, G . 1., "Clinical Forum-Physician Rea ction to A Clinical Pharmacist," Am. J. Hosp . Pharm., 28, 361 (May 1971) 7. H ealth Insurance For the Aged-Conditions of Participation for Home Health Agencies, U .S. Dept. of Health, Education and Welfare, Social Security Administration, U.S. Govt. Printing Office, Washington, D.C., HIM-2 (3-66) 8. Home Health Services in the United States-A Report to the Special Committee on Aging, United States Senate, U.S. Govt. Printing Office, W ashington, D.C., 74331 0,p.13 (April 1, 1972) 9. Highlights of 7972 Medicare Changes, U.S. Dept. of Health, Educa tion and Welfare, Socia l Security Administra tion, U.S. Govt. Printing Office, Washington, D.C., (SSA) 73-10329 (Dec. 1972)
Pharmacy Administration A candidate is sought to teach pharmacy administration at the undergraduate and graduate levels and to conduct research alone and in a team. The position requires a research background in one of the social sciences and the ability to apply these skills to problems dealing with health care delivery with particular emphasis on pharmacy and the drug use process. Interested parties should send a C.V. to: Dr. Albert I. Wertheimer College of Pharmacy University of Minnesota Minneapolis, MN 55455
Vol. NS14, No.7, July 1974
317
H
ome health care has been practiced in many communities in the United States for the last few decades; however, during this time pharmacist involvement with home health care has been minimal. The subject has received scant attention in the pharmacy literature and a role for the pharmacist has been referred to only recently.1-6 This is not surprising since it was not until the advent of Medicare in 1965, which made home health agencies more feasible from a financial standpoint, that they achieved prominence in health care delivery. Progressive Patient Care Home health care is but one of the levels of progressive patient care provided by the Appalachian Regional Hospitals (ARH)-a system of ten nonprofit, voluntary hospitals in the mountain areas of West Virginia, Kentucky and Virginia. Pharmacy services at ARH have been discussed previously. 1-2 The fundamental conviction of ARH as set forth in the corporate plan is that community hospitals and health centers, particularly in rural settings, can best serve their communities by providing appropriate levels of health care. There are many variations, but basically there are six recognized levels of care 5 (listed in order of increasing involvement of the patient in the rpanagement of his own health needs)-intensive care, intermediate care, extended care, home care, ambulant care and self-care. These levels of care are on a continuum ranging from total staff management of the patient's needs to almost total control by the patient of his own health needs. At one end of the continuum is "intensivecoronary care" which is emergency and lifesaving in nature where even the patient's simple bodily functions such as respiration and elimination may be controlled by hospital staff and/or by
*
Adapted from a presentation to the Academy of General Practice of Pharmacy at the APhA Annual Meeting in Houston, Texas, April 24, 1972.
machines; at the other end is "self-care" where such "care" as may be provided a person by health personnel is in the nature of guidance and support given at the request of the patient. Each of the levels of care is described here briefly as followsIntensive Care-Intensive care/coronary care units serve a life-saving function, a proper level of care for those so seriously ill or injured that they need minute-byminute monitoring. Typically, patients only need this level of care for short periods of time at which point they either expire or begin to recover. Intermediate Care-Intermediate (acute) care is that function traditionally performed by community hospitals. It is represented by a core of medical, surgical, pediatric and obstetric inpatient beds, facilities and services within the hospital for those who require it. Extended Care-Extended care services meet the needs of those patients whose requirements are such that they do not need to enter or remain in an intermediate (acute) care bed, but who still must have some skilled nursing and medical treatment. Very often extended care also provides many rehabilitation services. Extended care facilities are extensions (both before and after) of hospital care, and are an appropriate level between the intermediate (acute) care hospital and home care. Home Care-Home care is an element of patient care that provides medical, nurs- · ing, social, rehabilitative and related services on an intermittent basis in the home. Home care is a desirable alternative to institutionalization for the patient whose requirements can be met in the home. This level of care can prevent hospitalization and provide the patient with the therapeutic climate inherent in recovery at home. This therapeutic climate is a healing climate and to the home health patient includes familiar surroundings such as family and home environment. Another feature of home care is that it is focused on removing social and environmental obstacles which may deter the recovery of the "total patient"; thus, the patient is
either restored to full health or achieves maximal rehabilitation with the least possible disruption of his (and his family's) usual pattern of daily living. Ambulant Care-Ambulant care (or outpatient) is a level of care for patients who require diagnostic and therapeutic services not conveniently provided in the home. Ambulant (outpatient) services ordinarily are sufficient to meet the needs of most people. Group practice physicians' clinics, satellite health clinics and emergency rooms are basic ambulant care components and these facilities are very often the patient's point of entry into the health care system. Self-Care-As a level of care, self-care has a twofold meaning. First, self-care units in hospital settings can provide overnight . accommodations for patients who can care for themselves, but whose presence in the hospital is required for one reason or another. Second, through preventive health methods and educational processes, self-care facilitates the ability of people to manage their own health needs.
At ~ach of these levels of care the principles of rehabilitation are constant-to reduce the physical impairment of the illness or injury; to cope with other obstacles (such as social factors) which may prevent maximal functioning; to maintain a therapeutic climate, and to insure that care is continuing and complete. At Appalachian Regional Hospitals we have placed particular emphasis on individualizing the level of care that is appropriate to each patient's needs. Home Health Agencies
Home health care services are furnished to any patient who may require them; however, it is readily apparent that the geriatric population with its preponderance of chronic illness and the permanently disabled will be the major recipients of home health care services. These services may be paid for by the Medicare program if they are provided by certified home health agencies. As a result the Medicare program has had Vol. NS14, No.7, July 1974
355
R. Paul Baumgartner Jr. is director of pharmaceutical services for Appalachian Regional Hospitals, South Williamson, Kentucky and an assistant clinical professor at the University of Kentucky college of pharmacy. Since 1972 he has been principal investigator for West Virginia Regional Medical Program grant, "A Project to Improve Drug Therapy for Home Health Care Patients." He is also a member of the Kentucky Comprehensive Health Planning Council. Baumgartner holds a BS in pharmacy from the University of Pittsburgh. His professional associations include APhA, Academy of General Practice of Pharmacy, AACP and he is president-elect of ASHP. Baumgartner has previously published several articles.
Janice F. Glascock is a staff pharmacist at Williamson Appalachian Regional Hospital, South Williamson, Kentucky. She received her BS in pharmacy from the University of South Carolina in 1970. Glascock is a member of APhA, ASHP and the Kentucky Society of Hospital Pharmacists.
Rita M. Smith is coordinator of home health services at Williamson Appalachian Regional Hospital, South Williamson, Kentucky. She is a graduate of St. John's Hospital School of Nursing, Lowell, Massachusetts and earned a BS in nursing education at West Virginia University. Smith is a United States Army veteran.
Alan Martin Weissman is special projects clinical pharmacist for Appalachian Regional Hospitals, South Williamson, Kentucky and pharmacist researcher on the West Virginia Regional Medical Program grant, "A Project to Improve Drug Therapy for Home Health Care Patients." He has BS and PharmD degrees from Columbia University college of pharmaceutical sciences. Weissman was formerly Public Health Service pharmacy chief at Indian Health Service Hospital, Browning, Montana.
a great deal of influence on the conception of home health services and has had a considerable effect upon those who provide the services, as well as the methods by which these se(vices are provided. To become certified a home health agency must meet the "24 Conditions of Participation for Home Health Agencies" put forth by the Social Security Administration, Department of Health, Education, and Welfare. These conditions are somewhat comparable to the requirements that must be complied with by hospitals and extended care facilities in order to participate in the Medicare program. Some of the basic requirements for agency participation are the following-7 The agency's primary function is to include the provision of intermittent skilled nursing services and other therapeutic services on a visiting basis in a' place of residence used as the patient's home. In addition to skilled nursing services the agency must provide at least one ef the following therapeutic 356
' services-physical, speech or occupational therapy; medical social services, or home health aide services. The home health agency designates a physician or registered professional nurse to supervise the agency's performance in providing home health services in accordance with the orders of the physician responsible for the care of the patient and under a plan of treatment established by such physician. The agency's policies covering skilled nursing and other therapeutic services, and the professional health aspects of other policies are established with the approval of, and subject to regular review by, a group of professional personnel which includes a licensed physician and a registered professional nurse. Written standards regarding the qualifications, responsibilities, state licensure and conditions of employment for each type of person employed by the agency are required. The agency also must have procedures which provide for systematic evaluation of its program at least once every two years
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
and be approved by any state or local licensing agency if agencies of this type are required to be so licensed. Skilled nursing service in a home health agency must be provided by or under the supervision of a registered professional nurse(s) currently licensed in the state. One interesting requirement for participation is that the original orders of a physician and all changes in orders for the administration of dangerous drugs are signed by the physician and incorporated in the patient record maintained by the agency. All other changes -in orders are to either be signed by the physician or by a registered professional nurse in the agency if such changes are received verbally by her, but must be co-signed by the physicians within seven days. This requirement does not recognize the traditional role of the pharmacist in health care delivery. In all other areas of pharmaceutical practice, the pharmacist can accept verbal orders from a physician, reduce it to writing and the order then becomes a bona fide prescription. However, when third parties such as Blue Cross audit the records of a home health agency, such prescription orders might be grounds for elimination of the agency from Medicare funding. The home health agency also has written policies to be followed in determining the desirability and practicality of accepting various patients for care. These decisions are to be based on medical, nursing and social information provided by the patient's physician, by institutional (hospital) personnel and by the staff of the home health agency. For each patient, the agency maintains a clinical record covering the services which the agency provides directly and those which it furnished through arrangements with other agencies. This record contains the pertinent past and current medical, nursing, social and other therapeutic information concerning the patient, and includes the plan of treatment. Additional conditions for participation relate to the agreements between agencies, the provision of other professional services, and the selection, training .and supervision of home health aides, if any are utilized. Certain services such as "meals on ' wheels," services of a domestic or other housekeeping services unrelated to patient care, ambulance service, dental service (other than surgery of the jaw), and drugs and biologicals are currently excluded . from Medicare reimbursement. Problems Although Medicare has had a great positive impact on the provision of home health care services, it has also limited the duration of services by restricting
the total number of visits which can be reimbursed. While this policy has the desirable effect of emphasizing rehabilitation principles, it also precludes provision of long-term chronic care to those who require it. The complexities of administration and rei~bursement by insurance carriers acting on behalf of Medicare have placed many home health agencies in financial jeopardy~ The process by which claims are submitted, interpretations made, lengthy correspondence initiated over details of wording and difference in visit counts place an enormous burden on the providers. This has resulted in a great deal of "needless" administrative overhead costs to the home health agencies. 8 Until recently, the retroactive denial of payments which had been practiced by many insurance carriers had also severely crippled some home health agencies. 8 However, Medicare is in the process of setting up rules for advance approval of Medicare payments for post-hospital patients requiring home health services. These rules will be designed to help assume payment for a specific number of home health visits. 9 Another of the major problems of the Medicare-oriented h0me health agency is ' difficulty in providing services to patients who only have Part A coverage under Title XVIII. With Part A coverage the patient must first be hospitalized for a minimum of three days and the physician must complete a plan 'of treatment within 14 days ot discharge from the hospital before the agency can be reimbur~ed. Under Part A the patient is entitled to full Medicare coverage for 100 visits within one year of discharge. If the patient is not hospitalized, and has the 'optional Part B coverage, Medicare pays the full amount of the reasonable charges for 100 home health visits per calenda~ year following payment by the patient of the first $60. Therefore if a patient does not take Part B 'coverage he must be hospitalized, often needlessly, for Medicare to' pay for the home health services received. Pharmacist's
~articipa~ion
Nine ARH hospitals now operate home he~lth agencies. Several of our pharmacists have become involved to varying degrees with this exciting new concept of health care delivery. At present two of the' hospital-based pharmacists provide a pharmacist to to the agency Monday through Friday for one or two hours each day. It is unclear whether the pharmacist cost component to the agency is reimbursable under the 'Medicare conditions of participation of the agencies. Nevertheless, as we are primarily concerned with determining both the needs of home
health patients and the pharmacist's role in helping to meet these needs, shortterm funding is relatively unimportant. However, for continued pharmacist p~r ticipation, 'funding by Medicare is definitely desirable. The finding of our preliminary studies leads us to believe that problems with drug therapy occur frequentiy with home health service patients. This has deepened our inter'est in further exploration of the role for the pharmacist with the agency. Toward that end we have received funding from the West Virginia Regional Medical Program in the amount of $18,000 to study pharmacist involvement with the patients of ~ home health agency. At present this study is ongoing and we are evaluating roles for the horrie health pharmacist such as patient interview and consultation, home evaluation, assistance in the formulation pf drug policies, participation in daily case conferences, provision of formal and informal in service training, and improved medication record systems and controls. It is planned that the pharmacist will interview and consult with each patient discharged from the hospital who is scheduled to be continued as a home health patient. We feel this function to be one of an absolute necessity if the patient is to be continued on drug therapy at home. In practice the pharmacist by utilizing outpatient medication profiles determines what drugs the patient used prior to hospitalization. This information, together with drug therapy during hospitalization, can be related to the pharmacotherapy planned on discharge from the hospital. Prescription orders written by the physician are taken to the patient's bedside. If the patient prefers, the prescription is dispensed from the hospital pharmacy. During this discharge consultation, the patient is educated regarding pertinent aspects of each drug entity. Drllg-r~ lated information that the pharmacist relays to the patient includes how and when to self-administer the medication, what effect should Qe expected, possible side effects, storage requirements, fooddrug interactions, special dietary instructions and prescription renewal information. At present, consultations of this nature take place in the privacy of the patient's room often with the horrie health nurse in attendance'. " We have found that it is occasionally necessary for the pharmacist to assess certain factors in the home by making personal visits with or without other home health personnel. The decision to make a home visit by the pharmacist is determined during the daily case conference based on individual patient needs. Factors which might predispose a patient to a home visit by the pharmacist would include-the need to determine all medications potentially available to the patient other than pre-
scribed by the physician such as o-t-c medications, previously prescribed drugs, medications borrowed from friends and neighbors, compliance with the physician-directed drug therapy, understanding the rationale of therapy and the occurrence of side effects. In essence any drug-related problem concerning the patient which needs the pharmacist's attention would prompt the attending nurse or physician to suggest a pharmacist visit. ' After the pharmacist's visit the pertinent aspects of ' the interview are recorded in the patient record of the home health agency for future referral. Participation in case conferences has been particularly rewarding in terms of the pharmacist making a contribution to the care of the patient and perhaps 'this is a prime example of the team approach to health care. Following the return of nursing personnel from daily visits, each patient is jointly reviewed by team members of the agency. It is then possible for various individuals present such as the coordinator', nurses, aides, pharmacist, dietitian, medical social worker, physical t~erapist and others to apply their specialized knowledge to each case. At this time, patient progress is evaluated and specific problems can be identified. A consensus is reached for any modifications that may be necessary in the plan of treatment. It is perfectly ' within the purview ' of the ph'armacist to recommend changes in drug therapy such as change in dose, route of administration, dosage form and addition or deletion of specific drugs. ' The pharmacist' also may suggest that particular laboratory studies be conducted to monitor various drug toxicities - or ' side effects. If changes in drug therapy or if laboratory tests are advisable,'i t is the pharmacist's responsibility to follow through on the case~ i.e., contact the physician and obtain from him the necessary prescription orders or laboratory requisitions. It should be apparent that these daily case conferences are an excellent opportunity for 'the pharmacist to provide either ' formal or informal continuing education relative to drug therapy to the other team members. In like manner it affords the pharmacist an opportunity to learn from other health care workers and to work effectively in a multidisciplinary group. It is not uncommon for some cases to involve all members of the agency such as the physician, nurse, medical social worker, nutritionist, chaplain, physical therapist, inhalation therapist and pharmacist. , Our last objective for involving the ph~rmacist with the home health agency is to assist in the development and maintenance of adeqpate, accurate and sirpplified medication records and profiles for each patient. This particular phase (continued on pa~e 377) Vol. NS14, No.7, July 1974
357
Women's Auxiliary
Let's Participate Would you like to know in detail some of the events that are planned to assure you an entertaining and informative seven days at the APhA Annual Meeting in Chicago, August 3- 8? We do hope that you plan to come along with your husband this year and participate in the varied events that are planned for you after a year of hard work on the part of local committees. We will begin our ladies activities Monday morning, August 5, with the Auxiliary's Second Annual Welcoming Coffee. After a brief get-acquainted time over coffee and rolls, we will have panel discussions on various problems that face all organizations. The panels WIll be made up of women from throughout the U.S. with suggestions on how their particular groups handled a given situation. The panel discussions will be followed by a general discussion so that each person attending can participate. Monday afternoon will find the ladies on a tour of Chicago. Mrs. Richard Struzynski and Mrs. Roger Cain are serving as co-chairladies of this event. Tuesday morning the 'Women's Auxiliary will honor the local and state presidents and the student wives at our annual coffee. This will be followed by the First General Session. Mrs. Philip Sacks, chairlady of women's activities, will be introduced and bring greetings from the Local Hospitality Committee. This will be followed by the 1973-74 annual reports of the Auxiliary officers and
Home Health Agencies (continued from page 357)
of pharmacist input was very well described by Eastman 3 and we would urge the serious review of this excellent article for any pharmacist considering involvement with a home health agency. As previously stated, we are currently involved in a research project to determine the role of the pharmacist with the home health agency. One of the goals of the project is reimbursement of a pharmacy cost component to the home health agency. This reimbursement will relate, hopefully, with the pharmacist's ability to provide health care as a member of the home health agency and not necessarily be related to drug dispensing activities. This project will quantitate the needs of home health patients which can be adequately met by the addition of a pharmacist to the home health agency. Relating this to any additional direct costs incurred, such as the pharmacist's salary, should provide much of the data necessary to determine if a favorable cost-to-benefit ratio exists. If it does this information will be presented to various third parties such as state welfare agencies and social security administration personnel, with the expectation that the home health
chairladies. Tuesday afternoon there will be a meeting between the student wives, sponsors and board members. Wednesday at noon the ladies will once again be treated to a very special luncheon by Eli Lilly and Company. The entertainment will be provided by Elizabeth Arden. They have designed a very appealing program, involving the application of cosmetics. The commentator will be Glenn Roberts, Elizabeth Arden's creative training director. A showing of the latest creations in fashion apparel will open and close the program. Thursday morning brings the Women's Auxiliary Brunch and Second General Session with Mrs. Marvin Graber as chairlady. There will be greetings from APhA and from the Local Hospitality Committee. This will be followed by an entertaining program entitled "Ileene's Quick Tricks for Fun, Figure and Fashions." This is being presented by Ileene Abrams of Chicago. After the business meeting, Mrs. William Bacon will present the Achievement Awards and the Nominating Committee will make its report. The meeting will be closed with the election and instal~ation of officers for 1974-75. The installing officer will be Mrs. Reginald Lowe, former president. Mrs. William J. Sheffield, President 2204 Langford Cove Austin" TX 7872?,
agency will be fully reimbursed for a service which we believe only a pharmacist can provide. In doing so, we plan to develop standards of pharmaceutical service which may then be adapted by others. . In this preliminary report we hope to acquaint many pharmacists with home health agencies. There is a strong probability that these agencies represent an unmet need for pharmacists to provide a clinical service to those 'patients who are only one 'step away from ambulant care and, hopefully, complete recovery. At the present time, home health patients are largely denied availability of a pharmacy component to their services, a factor which may unnecessarily increase health care costs. It is hoped that our experiences will stimulate an interest on the part of other pharmacists to investigate this rewarding way of meeting health care needs. • References ' 1. Ba umgartner , R. P. Jr., "A Regiona l Concept of Hospital Pha rma cy Services," Am. J. Hosp. Pharm., 28,670 (Sept. 1971) 2. Baumgartner, R. P . Jr.; L and, M. J. and Hauser, L. D., "Rura l Hea lth Care-Opportunity for Innova tive Pha rmacy Service," Am. J. Hosp. Pharm., 29, 394 (M a y 1972) 3. Eastman, P . F.," Pharmaceutical Services for Home Health Agencies," JAPhA, NSll, 391, (July 1971) 4. Ellis, E. F., "The Pharmacist's Role in Home Health Care," Nurs. Hom:s, 22, 15, (Feb. 1973)
5. Levels of Care and Rehabilitation Principles Applied to Appalachian R eg ional Hospitals, Ccntinuing Objective #3, Appalachian Regiona l Hospitals (Revised Aug. 15,1972) 0. Silverman, H. M. , and Simon, G . 1., "Clinical Forum-Physician Rea ction to A Clinical Pharmacist," Am. J. Hosp . Pharm., 28, 361 (May 1971) 7. H ealth Insurance For the Aged-Conditions of Participation for Home Health Agencies, U .S. Dept. of Health, Education and Welfare, Social Security Administration, U.S. Govt. Printing Office, Washington, D.C., HIM-2 (3-66) 8. Home Health Services in the United States-A Report to the Special Committee on Aging, United States Senate, U.S. Govt. Printing Office, W ashington, D.C., 74331 0,p.13 (April 1, 1972) 9. Highlights of 7972 Medicare Changes, U.S. Dept. of Health, Educa tion and Welfare, Socia l Security Administra tion, U.S. Govt. Printing Office, Washington, D.C., (SSA) 73-10329 (Dec. 1972)
Pharmacy Administration A candidate is sought to teach pharmacy administration at the undergraduate and graduate levels and to conduct research alone and in a team. The position requires a research background in one of the social sciences and the ability to apply these skills to problems dealing with health care delivery with particular emphasis on pharmacy and the drug use process. Interested parties should send a C.V. to: Dr. Albert I. Wertheimer College of Pharmacy University of Minnesota Minneapolis, MN 55455
Vol. NS14, No.7, July 1974
317