2. PHARMACY MANAGEMENT Laura Williams, MSN, RN, CHPN Area Vice President Hospice Clinical Operations Chair Pharmacy Advisory Committee

3. Objectives Review the importance of determining related and unrelated diagnoses to understand how it impacts covered and uncovered medication decisions Discuss approval process for non-formulary and high cost medications Discuss Formulary use Review how to mitigate delivery costs Understand the role of the Regional Clinical Pharmacist Review documentation of medication oversight

4. Related or Not Related? NHPCO Terminal Prognosis Process Flow

5. Determining Relatedness A CLOSER LOOK – Physician uses all available information to evaluate for: 1.Terminal prognosis of 6 months or less 2.Terminal and related diagnoses that contribute to the terminal prognosis 3.Symptoms caused or exacerbated by terminal diagnosis, related diagnosis or treatment of terminal and related diagnoses (NHPCO, 2014)

6. Fill it (NHPCO, 2014)

7. Determining Relatedness NOTE: The decision about relatedness is determined by the hospice physician and is individualized based on the patient’s clinical status. (patient-by-patient, case-by-case) Decisions about relatedness change as the patient’s condition changes (NHPCO, 2014) Why is this important?

8. Covered and Uncovered Once relatedness has been determined by the hospice medical director, the nurse will mark “Hospice Covers” on the medication profile for all related medications. Medicare Part D pharmacy plans will pursue payment of uncovered medications they feel are related to the hospice diagnosis.

9. Admissions At the time of admission, leave the “Hospice Covers” box unchecked on the medication profile. During the admission provide an explanation, to the patient, of the Hospice’s responsibility to cover medications related to the Hospice diagnosis. Explain that the Hospice Medical Director will determine what is related.

10. Admissions (continued) Ensure the patient has enough meds to get to the first IDG. –If the patient is running low on ANY medication, this should be discussed with the Hospice Medical Director on the initial phone call. –The Hospice Medical Director will need to make a decision, with the information he or she has up to that point, as to whether the medication is related.

11. Admissions (continued) –If a medication needs to be ordered and is determined to be related, mark the “Hospice Covers” box, save, and call pharmacy to order medication. Once the patient is reviewed at the first IDG and final related medications are determined, mark the “Hospice Covers” column on the Medication Profile and save. –HMD will document why diagnosis/diagnoses is/are not related to the terminal illness and does not contribute to the terminal prognosis. –Inform patient of what medications hospice will cover

12. Formulary Considerations After relatedness has been determined: –Are there any non-formulary medications? If so, can medication/s be changed to formulary medication/s? If not, obtain coverage authorization from program leadership. –Are there any expensive medications >$400.00? Can these medication/s be changed? If not, contact program leadership for coverage authorization for regular medications costing > $400.00 per fill, or compounded medications costing > $100.00 per fill.

13. Admission (continued) Contact the National Hospice Medical Director for the following: All injectable (SQ/IV/IM/ETC) Medications –i.e. insulin, vaccines, etc. –IV Flushes and Vitamin K excluded –Does not apply to IPU’S Any continuous infusions (excluding hydration) –Does not apply to IPU’s Any medication exceeding $1,000.00 - per fill

14. Admission (continued) Document the name of the person from whom you obtained coverage authorization in the clinical record. o i.e. “non-formulary verbal coverage authorization obtained from Jane Doe MCP” o i.e. “high-cost medication verbal coverage authorization obtained from Dr. Crossno, NHMD” Fill in Medication Profile and mark medication “Hospice Covers”

15. HospiScript Kindred at Home works with HospiScript as a Pharmacy Benefit Manager Kindred at Home utilizes the HospiScript Calisto Formulary HospiScript interfaces with our EMR, once medications are entered into the medication profile and marked “Hospice Covers’, medications can be ordered from a contracted local pharmacy. A HospiScript Clinical Pharmacist is dedicated to each region to provide: −Clinical education −Advice on patient symptom management and specific medication concerns −Improve medication utilization and cost management

16. Formulary The Calisto Formulary can be found in the Resources section under My Forms menu in Kindred Link Keep a copy of the Calisto Formulary on hand at all times - Refer to it often The Calisto Formulary: – Is in compliance with current hospice industry standards concerning medication coverage, and promotes the use of clinically appropriate and cost effective medications. –Is a continually updated list of medications supported by current evidenced-based medicine. –Is a great educational tool for hospice staff to encourage hospice clinical best practice. –Includes Clinical Pearls – Hospice specific clinical information designed to encourage best practice

17. Key Considerations At times and for various reasons, high cost and/or non- formulary medications are ordered. It is the responsibility of the Manager of Clinical Practice and Case Manager to monitor high-cost and non- formulary medications prescribed, and obtain orders to discontinue or change the medication/s at first opportunity, if appropriate to do so.

18. Medication Delivery By Staff Per Hospice Policy 03-21 medications delivered by staff may only occur in “extreme emergencies.” –When there are cases of extreme emergency and medications cannot be delivered or picked up by a caregiver or designated representative, clinicians may transport medications. –All other delivery options should be explored first prior to a clinician making a medication delivery. –If unavoidable, Form – Medication Pick Up and Delivery (I- HOS3000) must be completed by obtaining the pharmacy representative’s signature, the patient or patient’s representative’s signature and the signature of the clinical delivering the medication.

19. Delivery Decision Tree

20. Pharmacy Delivery Considerations: Refill synchronization –Group medication refills –Keep in mind the 50% refill rule to help determine what meds can be ordered together Anticipate symptoms –Order meds ahead of symptoms to avoid after- hour and stat delivery fees –Tuck your patients in for the weekend – make sure they have everything they need

21. Documentation – Medication Oversight The EMR Medication Profile is a list of medications entered by the nurse and signed electronically. The signature at the end of each medication entry provides proof that the medication was reviewed by the nurse. –Make sure ALL medications are included on the profile: Prescriptions, over-the- counter, herbals and alternative treatments. –The Medication Profile is not an order form. The Medication Profile is created at admission by the nurse who enters the medications, then clicks the ‘sign’ button to apply their electronic signature to each line entry.

22. Medication Documentation The medications entered on the Medication Profile at admission flow over to the Hospice Initial Order which is signed by the Hospice Medical Director. There is no requirement that the HMD sign each line entry on the Medication Profile. After admission, new medications or medication changes are: 1)Entered in the Medication Profile 2)Documented in a Physician Order that the HMD signs 3)Reviewed and signed (electronically) at the bottom of the form by the MCP

23. Medication Documentation After admission, the Manager of Clinical Practice (MCP) reviews the Medication Profile and applies their electronic signature at the bottom of the form by selecting the Sign/Save button. - There is no requirement that the MCP sign each line entry.

24. Medication Documentation For re-certifications, the current Medication Profile is closed, and a new one created (using the recertification packet). –The current medications flow over to the new Medication Profile. –Medication changes are documented on the Medication Profile and Physician Orders as outlined in the previous slide.

25. Medication Oversight Mark the top box on the left after reviewing the medications with the Hospice Medical Director – who is “an individual with palliative care training…” In the next section, select the individuals that participated in the medication review. The HMD should be one of them, and select the date the review was completed.

26. Medication Documentation Medication changes completed between Clinical Visits are to be noted on the Clinical Note in the IDG Changes Since Last Visit section:

27. Medication Documentation Medication changes and review are also noted on page one of the IDG POC Review/Update form.

28. Questions?