Many independent pharmacists have heard about the growing opportunity to offer long-term care (LTC) services, especially to patients residing in their own homes over the past few years. LTC pharmacy services are a natural extension over the services you already provide to your retail pharmacy patients, and the opportunities are growing as the population ages.
For the first time in recorded history, people aged 65 years and older outnumber children aged 5 years and younger worldwide, according to the U.S. Census Bureau report An Aging World: 2025. You know your customers, and now they may need your assistance to age in place or transition to a setting that can better support their quality of life. Offering enhanced services to licensed facilities – including assisted living, personal care homes, group homes, and others – as well as people living in their own homes, can help decrease costs for patients, families and healthcare insurance programs, particularly Medicare and Medicaid.
Pharmacies and pharmacists need to be able to provide both dispensing and additional services to patients qualifying for long-term care pharmacy services. When Medicare Part D began in 2006, CMS developed LTC Pharmacy criteria in order to distinguish retail dispensing services from LTC pharmacy services [1].
So, what services do you need to provide in order to qualify as an LTC pharmacy?
- Comprehensive Inventory and Inventory Capacity
You must have the ability to obtain medications not normally stocked in your retail pharmacy such as liquid formulations of drugs usually dispensed as tablets or capsules. Inventory must be available to deliver within four hours for urgent prescription needs or within 24 hours for new maintenance prescriptions. Obtaining services from an additional wholesaler in addition to your primary one or working with a service such as CareServices to help find specialty or hard-to-find medications can assist you in providing these services. This requirement is necessary for all long-term care settings including Long-term Care Pharmacy at Home patients.
- Pharmacy Operations and Prescription Orders
LTC pharmacy operations are different than retail pharmacy operations. You should have a policy and procedure manual for your retail pharmacy operations, as well as a policy and procedure for your long-term care pharmacy workflow and operations.
Many of the retail operations and standard operating procedures (SOPs) such as disaster planning, medication ordering, and storage and handling procedures, can be incorporated into your long-term care policy and procedures.
You must also ensure you have pharmacy software capable of accepting both electronic and written prescriptions, completing drug utilization reviews (DURs), and performing other routine tasks associated with your LTC prescriptions.
Pharmacies servicing nursing homes must also perform tasks and follow the guidelines from the State Operations Manual Appendix PP on pharmacy services. [2] Pharmacies should work with facilities – including assisted living and group homes – to establish facility-specific policies and procedures medication ordering, after-hours questions and urgent prescriptions, storage and handling, and other related processes.
- Special Packaging
Pharmacies must supply oral solid medications, including tablets and capsules, in compliance packaging every 30 days or less for maintenance medications.
Packaging can include punch cards or bingo cards, Dispill cards (with multiple medications in each bubble), pouch or pillow packages with one or multiple medications in each package. Other products such as insulin, creams and ointments, and ophthalmic medications can be provided in supplies of more than 30 days. Medication required, per the package insert, to be dispensed in the original container should be dispensed as such.
You should make sure special instructions are given to the facility staff or caregiver or patient for patients living at home to understand why these medications may arrive in different types of packaging.
All oral solid medications including PRN (as needed), should be in compliance packaging. Patients with unstable chronic conditions many need to have medication dispensed for less than 30 days to avoid deliver of separate packaging for new orders and repackaging of other medications.
- IV Medications
Pharmacies must have the capacity to provide IV medications to all LTC patients, wherever they reside, including patients receiving LTC Pharmacy at Home services.
Therefore, you need to have the capability to prepare IVs at your pharmacy using a clean room or appropriate IV hood, establish an agreement with a local home infusion company or hospital, or contract with a service company that can obtain IV medication and supplies for your patients.
- Compounding/Alternative Forms of Drug Composition
LTC pharmacies can often prepare simple compound medications. If your pharmacy is not able to prepare a complex or sterile compound, you need to have a contract with a compounding pharmacy to supply any needed complex compounds. Alternatively, you can contract with a service company to provide these needed services. Again, compounding medications must be provided by all LTC pharmacies to all patients regardless of where they reside, including LTC Pharmacy at Home patients.
- Pharmacist On-Call Service
Pharmacies must have a pharmacist on-call 24/7, 365 days a week. An after-hours phone number or transferring a call from your pharmacy number to one of your pharmacists can be an easy way to provide this service. This service applies to all LTC patients, including LTC Pharmacy at Home patients.
You must be able to get medication to the patient when there is an urgent need such as an antibiotic. A four-hour response time is typical for a stat order. Again, a service that assists with obtaining and delivering urgent medications to the patient can be an easy way to fulfill this requirement.
- Delivery Service
You should provide deliveries to facilities as needed. Most facilities should have a delivery at least daily with nursing home often requiring at least two deliveries per day. Delivery can be made by your pharmacy’s delivery driver(s) or by a courier service. Mailing prescriptions to patients is not permitted under most PBM contracts.
Delivery also includes your patients under LTC Pharmacy at Home services. Most pharmacies deliver to facilities at least once a day. LTC Pharmacy at Home should generally receive at least one delivery each month, with extra deliveries when medications change during the month.
- Miscellaneous Reports, Forms and Prescription Ordering Supplies
Many facilities are now using electronic medication administration records (eMARs), but the pharmacy should be engaged with the facility’s electronic MAR system or provide paper records when required. This may include documentation for reordering medication.
Patients receiving LTC Pharmacy at Home services should be given special instructions for storage and handling for refrigerated medications or for products that must be kept in their original containers, such as Linzess. Instructions for other medications that require special storage and handling should also be received by a patient receiving LTC Pharmacy at Home services.
- Emergency boxes and logs
Emergency boxes and logs are required for all nursing homes and ICF-IID facilities under federal regulations. They are not required for assisted living and group homes in most states. Check your state’s regulations regarding both what may be included in emergency boxes and who is responsible for selecting or approving the medications in the emergency box in nursing homes.
Pharmacies not servicing nursing homes must still have the capacity to provide emergency boxes and logs if they are to operate as an LTC pharmacy, even if they are only servicing LTC Pharmacy at Home patients. PBM on-site auditors have asked to see the pharmacy’s emergency box in the pharmacy.
You can fulfill this requirement by purchasing a tackle or toolbox from a hardware or sporting goods store, or an online retailer. The box should include disposable plastic locks, provided to alert the staff at a facility to see if the box has been opened and medication has been removed. A logbook should also be included; you can purchase one or create a binder to track when medications are removed and who receives them along with the staff member that administered them.
You should add the pharmacy’s logo, name, address and phone number to the outside of the box. The empty emergency box, along with the log, can then be stored in the pharmacy to fulfill this requirement.
Conclusion
LTC pharmacy is a vital part of assisting our aging population in maintaining and enhancing your patients’ quality of life. With the growing aging population, pharmacists have an important opportunity to help people aging at home or in a facility receive the medications, service, and support they need to achieve the best possible quality of life.
GeriMed
Founded in 1983, GeriMed continues to support independent pharmacies servicing LTC patients. GeriMed strives to be a leader in service by developing programs to help improve their customers’ patient care. Partnering with GeriMed positions your pharmacy for optimal growth and success through their purchasing and reimbursement services. Contact GeriMed at info@gerimedgso.com or call 800-456-4374 for more information.
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