Managing Medication and Independence in Assisted Living

Nursing Homes, March, 2000 by Diane B. Crutchfield

For assisted living to keep its federally unregulated status in medication management, facilities must self-regulate on a national scale

Mrs. Jones enjoys her independence residing in an assisted living facility (ALF). One day she complained to the nurse of symptoms common to a urinary tract infection (UTI). The nurse called Mrs. Jones's physician, and the nurse practitioner returned the call with an order for an antibiotic, which was filled by the pharmacy. In the meantime, Mrs. Jones's daughter came to the facility and took her to see a physician, who also ordered an antibiotic for the UTI. On the way back to the facility, they stopped and had the prescription filled at a local pharmacy. Mrs. Jones began taking her medication right away. She continued to take her prescription for three days before reporting it to the staff at the facility. She had also continued to receive a very similar antibiotic during the routine medication administration pass at the facility.

Mrs. Jones's case is an example of a drug-related problem that occurred at an assisted living facility where I consult. Because of the independence of ALF residents, it is difficult to successfully convey the importance of the staffs knowing about all medications that are consumed by every resident, including vitamins or herbal products. Assisted living is unique in that residents are encouraged to live independently and call their room their home. With this in mind, it is a challenge to staff to find out needed information without interfering with an individual's right to privacy.

On the other hand, the facility has a responsibility to ensure that each resident receives his or her medications safely. This delicate balance between independence and quality care presents a definite challenge to assisted living facilities. The pharmacist can play a significant role in helping ALFs meet those challenges.

Providing medications and medication monitoring is significantly different in ALFs than in traditional nursing homes. Unlike nursing homes, which usually have one or two pharmacy providers within a facility, the ALP might have as many pharmacies as there are residents in the facility. There might also be a variety of medication delivery systems within one ALP. Most assisted living facilities that I have worked with do not require residents to choose a particular pharmacy. There might be a range of providers, including mail order plans, which complicates the medication management system for the facility even more.

Another major difference, of course, is that the nursing home industry is highly federally regulated, whereas assisted living is not. Assisted living is state regulated, and the regulations vary widely from state to state. In Tennessee, for example, consultant pharmacists are not required to review medications on a regular schedule. Other states require a quarterly review of medications, as a minimum.

The lack of standardization might prove to be a major problem for the assisted living industry in the future. Many residents come to ALFs for assistance with medication management. However, even the terms for assisted living and medication management are loosely defined. Is there a licensed nurse on staff who administers medication, or "assists" with medication? Does the nurse or unlicensed staff member simply remind residents when it is time to take medications? Some states require a nurse to "administer" medicine; that is, to remove it from the packaging and hand it to the resident. Others allow a trained medication technician to "assist" with medication administration.

When choosing a medication management system, it is important to consider the training of the staff. It is equally important to consider the cognitive function of the residents. Are they capable of self-administration? Do they need minimal assistance or total assistance, such as in an Alzheimer's unit?

Another consideration involves comparing services offered by different pharmacies. Make sure that the provider pharmacy can meet the needs of the facility and residents. This includes the labeling of medications--particularly whether medications are labeled individually. Record keeping and documentation are important, as well. Many pharmacies will print medication administration records. Again, the type of documentation required will depend on the residents' level of care.

Assisted living facilities should question the pharmacy about medication storage. Some ALFs do not want to use traditional medication carts that are seen in long-term care facilities because they connote a more institution like setting. Question delivery frequency and times. Will a pharmacist be available seven days a week? What about provisions for emergency deliveries? Are pharmacy policies and procedures for medication delivery, administration and therapeutic monitoring available for review?

Once an assisted living facility enacts policies and procedures for medication administration and storage, they should be explained to the residents and their families upon admission. The need for this becomes apparent if a resident begins to have a decline in cognitive function. Perhaps upon admission the resident was capable of self-administration or asking the staff for the medication, but over time the resident's memory might have declined, rendering the resident incapable of any form of self-administration. Giving up this independence is very difficult for a resident and sometimes for families, as well. It is a great advantage to have a protocol in place where all residents are reevaluated periodically to assess for any changes that might make them incapable of managing medications on their own, or even with minimal assistance.