Senior Service
Demographic changes make the strongest case for a specialty in geriatric pharmacy
BY KRISTAN WOLFE
Iris Krawchenko, pharmacist manager of Dell Rosedale Pharmacy in Hamilton,
Ont., is just entering the world of geriatric pharmacy. Krawchenko
earned her Certified Geriatric Pharmacist designation last
August. She is now educating her colleagues about the importance
of the designation, and determining how she can best apply her new specialization
to her practice.
“I’ve got the knowledge now and the skills,” says
Krawchenko. “Now I have to develop a market around them. My gut
feeling is that it’s the right thing to do because our population
is aging and people are using more medications. There are going to
be more and more issues identified with that.”
Statistics show Krawchenko’s gut feeling is probably right.
Projections indicate that by 2026 one Canadian in five will have reached
the age of 65. Also, Canadians aged 60-79 had 35 prescriptions dispensed
per capita in 2005, according to IMS Health’s Canada Rx
Report . This means pharmacists will be increasingly caring for
patients who have multiple drug therapies and disease states, often
a source of confusion and adherence difficulties. Moreover, physical
changes in seniors—such as slower organ function and blood circulation—can
affect the way medication is absorbed, distributed, retained and metabolized
by the body. Given these facts, the demand for pharmacists with a specialized
focus in geriatric care is sure to rise in the coming decades.
More than 130 Canadian pharmacists—working across the country
in community pharmacies or in dispensaries catering exclusively
to long-term and assisted-living facilities—have earned the Certified
Geriatric Pharmacist (CGP) designation through the Commission
for Certification in Geriatric Pharmacy in Alexandria, Virginia. The
non-profit commission (www.ccgp.org),
founded in 1997 to oversee the certification of geriatric pharmacy
practise, conducts sit-down exams across the U.S., and also offers
the three-hour exam online at more than 150 testing locations across
the U.S., Canada and Australia.
A CGP has gained in-depth knowledge about appropriate medication
use in the elderly and about other issues specific to the population.
For one, geriatric patients are the biggest consumers of prescription
and over-the-counter medications and are more likely to be taking multiple
medications at the same time. In addition, changes in physiology place
them at greater risk of adverse reactions.
To prepare for the exam, Canadian pharmacists can attend six-day
courses offered through the Ontario Pharmacists’ Association’s
Drug Information and Research Centre (DIRC). The Alberta Pharmacists’ Association
offered the program in 2006, and will likely do so again when there’s
demand.
DIRC’s biannual Certified Geriatric Pharmacist Preparation
Course (www.opatoday.com/CertificatePrograms_CGPPC.asp)
covers more than 25 therapeutic topics and offers a “comprehensive review
of common medical issues that afflict older persons and how to best
manage and treat these conditions,” according to Janice Tang,
OPA’s education coordinator.
Most pharmacists come into contact with geriatric patients either
by working in a community retail setting, or through institutional
establishments such as long-term care homes.
For pharmacist Sandy Posnikoff and her colleague James Ng, the former
is true. The two began a novel outreach program at their Vancouver
pharmacy seven years ago to provide specialized care to seniors in
the community. Posnikoff meets with patients referred to her, to review
their medication regimen. She removes all old medications from the
patient’s home, and creates a customized blister pack for current
medications. Customization might mean a bilingual blister pack, with
instructions, dates and times written in both English and the patient’s
native language, or pre-loaded insulin syringes for patients who are
visually impaired.
Posnikoff says she will never forget the day she met one elderly
patient suffering from dementia. Four months earlier, six different
drugs had been prescribed, packaged in individual medication cards
for use at home. By the time she was referred to Posnikoff, the patient
had already been to the emergency room several times. Posnikoff began
a review of the medication by asking the patient how she took her pills.
The patient replied that she’d complete one card of medicine
before moving on to the next card.
”She had no clue that every card had a different drug in it,” says
Posnikoff. “I was able to take all those cards away and blister-pack
them. She didn’t go into the hospital again. That was a huge
thing for me.”
In contrast, the pharmacists at Toronto-based GeriatRx Pharmacy have
little direct interaction with patients. The company chose to focus
its energies exclusively on long-term care and retirement homes, says
CEO Randy Goodman. In this model, GeriatRx clinical consultants—who
are out on the road making calls to client facilities—have more
direct contact with physicians and nursing staff than with patients.
“In long-term care we’ve had the privilege of having
these interactions with other members of the healthcare team,” says
Goodman. “We’ve been permitted as pharmacists to go to
the nursing stations and pull a patient’s chart, take a history,
speak to the nurses and healthcare aid staff about a resident in the
facility to ask how they’re doing with their medications… look
at all the data and lab tests.”
Goodman adds that a GeriatRx pharmacist will sometimes accompany
physicians on rounds during their quarterly reviews of patients’ medications.
This consultation with the whole healthcare team creates a well-rounded
picture of the patient’s situation.
When Posnikoff and Ng began their outreach program, their marketing
strategy involved meetings with homecare nurses at all of the city’s
health units.
“We didn’t tell them to switch to our pharmacy,” says
Posnikoff. “We explained what we could do for their clients.”
Posnikoff also made presentations at community centres and assisted-living
facilities. She says this tactic is more effective than the in-store
clinics many pharmacies host because elderly patients are frail or
immobile. It’s easier for patients if the clinic comes to them.
To secure contracts with long-term care facilities, however, Goodman
has a different approach. GeriatRx, for example, sets up booths at
industry-specific trade shows, bids on calls for tender, sends literature
to area nursing homes and also relies on word-of-mouth. Contracts can
run from one to five years, he says, but are generally set at three
years.
Staffing is probably the biggest investment for geriatric pharmacy.
When servicing long-term-care homes, for example, both the staff pharmacist
and clinical consultant are working from one dispensing fee. No extra
payment is received for providing drug regimen reviews, clinics and
counselling services on location at the facilities.
“The payment model is actually the same as it is in community
pharmacy,” says Goodman. “We’re paid as we dispense
prescriptions on a per-script basis.”
This may change, however, as initiatives like Ontario’s MedsCheck
program are developed. Once Phase II is complete, for instance, clinical
pharmacists will be paid for providing the cognitive services that
up until now have been provided for free “as part of providing
good service,” says Goodman.
Posnikoff, on the other hand, was hired by her employer specifically
to act as a consultant pharmacist for the retail pharmacy. She does
not fill prescriptions or counsel patients who visit the dispensary.
Her responsibility is to patients who are referred to her. She says
it took several years before the cost of her salary was covered by
the business earned through the referrals. “We don’t charge
for my service,” says Posnikoff. “I work off the dispensing
fee. But by offering this service, we get the business and referrals.”
Inventory is another cost to consider. While the drug list for a
geriatric patient base is fairly straightforward, keeping a good selection
of home healthcare and personal-care items is key to remaining competitive
in a retail setting.
Stephen Pearson, Senior Vice-President, Long Term Care Services,
for Medical Pharmacies of Pickering, Ont.—which counts 20 CGPs
among its 150 pharmacists—has witnessed the evolution of this
niche over the past three decades, and the burgeoning costs of treating
an aging population. He says that in addition to staff and inventory
costs, geriatric-focused pharmacies should expect to make substantial
investments in technology. A blister-packing machine, for example,
can cost more than $200,000.
Given the time and money needed, you might wonder why a pharmacist
would delve into geriatric pharmacy. The bottom line, says Pearson,
is that the rewards of such a practice are priceless.
“You get to practise the type of pharmacy you learn in school
and see significant outcomes,” he says. “When you go into
a home, suggest something and then see the improvement of the patient,
it’s a fantastic feeling.”
“It’s wonderful to think that you can actually make a
difference,” agrees Posnikoff. “These people wouldn’t
be able to stay in their home if they didn’t have support from
everyone—nursing, doctors, home-support workers, pharmacy. I’m
very lucky; I have the best pharmacy job in the world.”
- Canadians aged 60-79 have 35 prescriptions dispensed per capita,
according to IMS Health’s Canada Rx Report 2005 . Those
aged 80 and up held 74 prescriptions.
- The majority of patients over 65 taking five or more medications
have three or more drug-related issues (Lau E, Dolovich LR. “Drug-related
problems in elderly general practice patients receiving pharmaceutical
care.” International Journal of Pharmacy Practice 2005 ).
- The Canadian Pharmacists Association estimates that 25 percent
of hospital visits by people over age 65 are due to medication
errors.
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