Pharmacy Connection
Long term care (LTC) is a specialized practice setting for pharmacy professionals. Through regular practice assessments of pharmacists working in LTC, College practice advisors have identified some opportunities for improvement in the processes used to deliver patient care. By highlighting specific and common gaps between observed practice and the requirements of standards and legislation, our goal is to help registrants meet their professional obligations while managing the complex care of their patients.
Note: In some cases, the gap will reference specific elements of the Model Standards of Practice for Pharmacists (SOP) and the requirements of the Fixing Long-Term Care Act, 2021 and O. Reg 246/22.
Gap 1: Assessment of New Prescription Orders and Changes to Existing Orders (SOP 1.9 & O. Reg 246/22 s.129.1)
Key requirements: Review each new prescription to ensure that the medication is the most appropriate for the specific patient. A pharmacist must consider relevant information to assess the patient and the patient’s health and medication history.
This could include, but is not limited to:
- Confirming the indication
- Ensuring the dose and instructions for use of the medication are correct
- Ensuring no significant drug interactions or contra-indications are present
- Considering patient specific characteristics (i.e., medical conditions, vitals, laboratory results, etc.)
Gap 2: Quarterly Drug Regimen Reviews (SOP 1.11 & O. Reg. 246/22 s. 146(c))
Key requirements: It is a Standard of Practice that pharmacists assess the appropriateness of therapy for all refill prescriptions. However, a pharmacist is not required to assess a patient’s drug regimen with every refill if the medications are dispensed in regular, lesser quantities to assist with self-administration of medication, or to comply with policies in assisted living facilities. In this scenario, comprehensive assessments must be completed at least quarterly (i.e., every 90 days). Comprehensive assessments are required more frequently with changes in the medication profile (i.e., new medication prescribed, medication discontinued, and dose changes).
Practice Tip: A quarterly review can be achieved by considering the patient’s health and medication history and relevant patient specific characteristics when completing a comprehensive therapeutic check for each medication. The relevant factors include, but are not limited to, the indication, effectiveness, safety, adherence, and proper use of the medication.Related resource:
TIPS AND TOOLS FOR PATIENT ASSESSMENT
Gap 3: Therapeutic Checks for Refill PRN Orders
Key requirements: As noted above, the Standards of Practice state that a pharmacist must assess the appropriateness of each refill of a medication by collecting and interpreting relevant patient specific information. This also applies to PRN reorders in the long-term care setting. Without comprehensive assessments of appropriateness for PRN orders, drug therapy problems could go undiscovered and result in adverse effects for residents.
Practice Tip: A way to begin working towards meeting the SOP is utilizing pharmacy technicians to flag routine use of PRN medications that may suggest an uncontrolled disease state that may require re-evaluation.Gap 4: Follow-Up on Changes and Concerns (O. Reg. 246/22 s.129.2 and s.146(a))
Key requirements: A pharmacist must evaluate the therapeutic outcomes of drugs for residents. This includes following up on therapy changes and previous concerns noted by other healthcare team members. Pharmacists also need to have a plan for follow-up to ensure decisions made were safe and effective for residents. It is important that pharmacists include monitoring parameters when providing recommendations to resolve drug therapy problems. Monitoring plans and the outcomes of patient follow-up must be documented to facilitate continuity of care between colleagues.
Practice Tip: Complete and document necessary patient follow-ups when conducting quarterly reviews. There must be a retrievable and effective means of communication between operational and consultant pharmacists to ensure patient follow-ups are completed and to facilitate the continuity of care for patients.Gap 5: New Admission/Re-Admission Reviews (SOP 1.29 and O Reg. 246/22 s.126b)
Key requirements: A pharmacist must evaluate the appropriateness of each medication upon admission and re-admission of a resident to a LTC facility. This includes individualizing medical directives to a resident’s condition and needs. Pharmacists must also address actual and potential drug therapy problems identified and ensure any potential risks are mitigated. Another healthcare provider can complete follow-up if they have access to the pharmacist’s recommendations to resolve the drug therapy problem.
Practice Tip: Comprehensive assessments for newly admitted/re-admitted residents can be achieved through completing a best possible medication history, medication reconciliation and accessing a clinical viewer to gain an understanding of the patient’s medical history. If drug therapy problems cannot be addressed at the time of admission, the need for follow-up must be communicated to appropriate colleagues.Related resources:
ISMP ONTARIO PRIMARY CARE MEDICATION RECONCILIATION GUIDE, PAGE 11
ISMP MEDICATION RECONCILIATION FORM
Gap 6: Retrievable Documentation
Key requirements: Documentation that is complete, up-to-date, and retrievable for all members of the pharmacy team is important to facilitate continuity of care between colleagues in operational and consultant roles. This allows for improved information gathering for patient assessments, facilitates the completion of patient monitoring and follow-up plans, increases efficiency, and reduces redundancy of work.
Practice Tip: Retrievable documentation can be achieved by evaluating the pharmacy software to determine the most appropriate location and format for the pharmacy team to document.
