Great Care @ Low Cost in SNF-NF Jabbar Fazeli, MD Maine Medical Directors Association
Principles Best interest of the patient (SNF) and resident (NF) comes first. Lowest cost to achieve the same care. Saving allows for more room to spend more when we need to. Process development is more important than individual efforts
At point of entry The Admission process How many fax transfer summaries in lieu of orders? How many fax the doctors the discharge orders to sign and implement as admission orders How many have facility standing orders that they don t duplicate in admission orders
Pharmacy Supply Two weeks supply for all meds meds may change Patients may leave (SNF) Amount of narcotics to send can be included on narcotic Scripts What to stock and what to order? beware of inflated prices (compare to retail options)
Standing orders opportunities Glucagone orders for diabetic patients How often is it used? What happens when the admission orders include PRN glucagone? What happens when standing orders include Glucagone? Is there cost saving derived?
Standing Orders Opportunities Zofran on standing orders What happens when admission orders include zofran? Is there cost saving derived from inclusion on zofran on standing orders?
PPIs Omeprazole vs other PPIs less than 1$ per pill vs >4$ per pill Liquid omeprazole vs zegerid packet 2$ per dose vs >$10 and its easier to take Soltabs QOD vs QD, and General taper strategies Interaction with plavix
Statins The hospital quality measures drive over prescription Technically the quality measures don t include patients over 75, but in practice even hospice patients are on statins Hospital Pharmacy recommendations vs patient centered physician recommendation (collaborative agreements)
When to stop Statins Hospice patients Palliative patients Failure to thrive (technically low cholesterol is one of the diagnostic criteria) Over 100, over 90, over 80? Weakness and falls (underestimated) Elevated LTFs ETOH use?
Supplements we may stop How good is the diet at nursing homes How useful is a MVI Do we need 3x day calcium (vs once a day) Some patients have as many vitamin supplements as prescription drugs (do they need them in an inpatient setting?)
Supplements we may add Thiamin and folate in alcoholics (impact the nervous system) FeSo4 in post op anemia patients (initiation +stop date). Once a day dosage in elderly Vit D (dosage?)
Drugs We may stop on admission of a delirium patients Anti-histamines PRN or scheduled H2 blockers (PPI cost more but safer in delirium) Anticholinergics such as Oxybutynin Benzodiazepines (taper with stop date vs continuation) Narcotics Ultram if in combination with SSRI Timoptic!
Drugs we may want to reduce or stop in the elderly Amitriptyline (taper vs DC) High dose Choline esterase inh (aricept, exelon etc) in an anorexic patient Namenda prescribed for mild dementia without behaviors! Lidoderm patch left over from an old compression fx treatment
Protein Supplements vs house supplements Weight gain objective can be achieved with the adequate calorie supplements regardless of trade marks
streamlining Laxatives and stool softeners Colace Plus Senna= Senna S= one less pill (cheaper and better) miralax is more expensive and often unnecessary Using sorbitol instead of MOM, Why?! When to use lactulose? Ortho patients and patients on narcotics
Minimizing Frequent dosing BID dosing for Tylenol VS QID if pain not primary issue Use of 500 mg Tylenol instead of 650mg = one less pill and minimal difference in effect tid or less Glucoscan instead of tid and HS less night time hypoglycemia and one less finger-stick for the elderly or dementia patients in the middle of the night. many skip snacks and still get coverage.
A word about Sliding Scales Maintenance treatment SNF vs NF patients Glucoscans without Sliding Scale
Novlog vs Humalog SS Who cares?
Insulin Pen vs Vials What s the waste factor Expiration dates and survey issues Post discharge implications
Generic conversions Proscar vs Avodart Various nebs (xopenex vs duoneb) *interaction with spiriva Generic SSRIs, now even lexapro is generic Generic ODTs is the exception to the rule generally not as dissolving as originals. Defeats the purpose when they only work as regular pills BP meds, Diabetic meds, etc.
Eliminating duplicate therapy Nebs and MDIs home vs SNF/NF Scheduled tylenol with scheduled narcotic Sylfonylureas (i.e glipizide) with insulin multiple SSRIs in a frail or FTT patients Narctics and ultram PRN on same patient
Potential useful Combination effects Remeron= SSRI plus Hypnotic plus Appetite stimulant useful in FTT depressed patient with insomnia who take two separate meds Cymbalta= neurontin plus SSRI useful in residents with falls, FTT who are being treated for depression with neuropathy or generalized pain costs less if you factor in eliminating two meds
Crazy (potentially) combinations Ritalin combination with a hypnotic Anti-hypertensives along with Midodrine and florinef (that elevate Blood pressure) Antipsychotics (which cause Parkinsonism) in Parkinson's patients to counteract the side effects of Parkinson's meds. Wouldn t be safer to reduce the dose of Parkinson s meds instead?! (less meds, better care, less cost)
Time limits on high cost items Lovenox or arixtra stop dates If 4 weeks are needed then does it make sense to switch to Coumadin know your orthopedist (they follow different Criteria for anticoagulation)
Easy Antipsychotics Decisions Seroquel 25 QHS with no significant behaviors reported. Technically being used as a very expensive hypnotic easily switched to trazadone 25 QHS PRN antipsychotics can have a stop date on admission which can be revisited
Formulary and wound supplies Do you need Saline spray and wound cleanser spray in the facility? Do you need multiple telfas or gauze types? Can you use large gauze packets for cleaning and reserve single package gauze for dressing? Do you need multiple foam dressings etc. Do you need multiple MVIs (ocuvite and generic MVI covers more than 90% of pts)
Palliative/Hospice patients When to stop curative medications New issue with CMS guidelines and PA denials
CMOs and Medical Directors role If best care can be achieved with the lowest cost then WHY NOT?! Going Cheep doesn t include everything at all times You can t fix what you Can t measure-what s your average patient day pharmacy cost? Mine is $30-35 per patient per day Cost cutting done for sake of cost cutting = substandard care