Consultant Pharmacy in Long-term Care Brings Challenges

SEPTEMBER 01, 2008
Shane Lawrence, PharmD, CGP, BCPP, FASCP

Dr. Lawrence is director of Clinical Pharmacy Services at Phoebe Services Pharmacy in Allentown, Pennsylvania, and is preceptor for the long-term care elective rotation at the University of Pittsburgh and Wilkes University.

I know what you are probably thinking, ?nursing homes?not much of a clinical challenge.? I know, because I thought the same thing when I was at a career crossroads 9 years ago, stuck between the choices of my staff/clinical position in a teaching hospital or making the leap to a consultant pharmacist position in long-term care (LTC). I took a chance, made the change, and have had the 9 most challenging and rewarding years of my career. The following is a brief look at the role of consultant pharmacists.

The primary responsibility of the consultant pharmacist is the medication regimen review. Omnibus Reconciliation Act guidelines require all residents of skilled nursing facilities (SNFs) to have their medication regimen reviewed by a consultant pharmacist at least once per month. Centers for Medicare & Medicaid Services (CMS) guidelines and requirements for medication use in SNFs are extensive and beyond the scope of this article; however, the consultant can divide a medication regimen review into 3 components.

1. Clinical Review. This is pharmaceutical care. Do all the medications have an appropriate diagnosis or rationale for use? Are the medications monitored appropriately (ie, laboratory studies, vital signs, blood glucose, mood/behavior tracking)? Could any of the medications be contributing to an ongoing problem? Is there a safer alternative to a medication with an unfavorable side effect profile? Are goals of medication therapy being achieved?

2. Regulatory Review. Fortunately, good clinical practice will satisfy most regulatory requirements; however, the consultant always has to look at the medication regimen as if they were a CMS surveyor and ensure compliance with CMS standards.

3. Pharmacoeconomic Review. Consider medication cost as well as nursing administration time in the regimen review. Does the regimen comply with the resident?s prescription drug provider formulary? Although not required, nursing home residents and the facilities will appreciate this.

Any irregularities or recommendations noted in the medication regimen review are reported to the attending physician and nursing staff.

A consultant pharmacist?s responsibilities go beyond the medication regimen review. Consultant pharmacists serve on a number of interdisciplinary committees. Quality Assurance committees establish policies and protocols for medication use, review medication errors, and develop plans to minimize them, review infection control issues, and address any facility-specific issues related to pharmacy services or medication use.

In addition to serving on various committees, consultant pharmacists also are educators, frequently used by SNFs for preparing and delivering in-service education programs. A consultant pharmacist also may undertake medication-pass observations and medication storage audits to ensure appropriate administration and storage of pharmaceuticals. Excellent verbal and written communications skills are essential.

If you are considering a career in consultant pharmacy, here are a few recommendations:

  • If geriatrics is not required in your curriculum, take it as an elective. Medication management for seniors is different from that of a younger adult population.
  • Intern with an LTC provider
  • If you are entering your sixth year, register for an LTC elective rotation that includes exposure to consultant pharmacy
  • Join the American Society of Consultant Pharmacists (ASCP) ( is a tremendous resource
  • Attend an ASCP meeting, especially the ?Orientation: 60 Steps to Success? session. This is an excellent opportunity to network.

My view toward LTC pharmacy 9 years ago was completely wrong. I am challenged every day, and no 2 days are alike. Professionally, I have benefited from having an opportunity to serve a frail, elderly population in need of quality care. Personally, I have benefited from having an opportunity to work closely with nurses, physicians, and other health care professionals whose daily efforts toward caring for our patients are nothing short of heroic. If you are looking for something a little more dynamic, intellectually stimulating, with varied responsibilities and the opportunity to make a difference in a patient?s life, this might be for you.

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