Taking the Pain Out of Compliance with F-Tag 329: Meeting the Challenges Through Collaboration, Part II
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Dana Saffel, PharmD, CGP, and Steven Levenson, MD, CMD
This is part II of a two-part article. Part I appeared in the
October issue of the Journal.
Nursing facilities and physicians are still trying to interpret and address the expectations related to CMS’ December 2006 update of the Unnecessary Drug Surveyor Guidelines (F-TAG 329). Numerous medications are available, and the medication regimens of most nursing home residents are lengthy. The challenge for the practitioner is to identify a safe, effective medication regimen that minimizes the risk of having adverse consequences. In addition, both the practitioner and facility are expected to identify and address significant adverse medication consequences. This two-part article reviews several strategies for compliance, based on effective use of the care delivery process and a productive alliance between the practitioner, the consultant pharmacist, and other key facility leadership. (Annals of Long-Term Care: Clinical Care and Aging 2008;16:11-16)
Dr. Saffel is a certified geriatric pharmacist and President of Pharmacare Strategies, Santa Rosa Beach, FL; and Dr. Levenson is a multi-facility medical director in Baltimore, MD.
In December 2006, the Centers for Medicare & Medicaid Services (CMS) issued updated guidance for nursing home surveyors on the topic of medications.1 This update was a comprehensive overhaul of previous guidance on the subject.
The F329 guidance emphasizes the use of medications in the proper context, to try to provide the greatest possible benefit with the least possible harm. It promotes scrutiny of the entire medication regimen, for both short-stay and long-stay residents. It directs surveyors to seek more specific information about the clinical basis for a decision to use medications, not just a diagnosis or a declaration that the patient needs it. In addition, it reinforces the intent of the original regulation to balance the risks and benefits of all medications, not just psychopharmacologic medications.
Although physicians and consultant pharmacists are the primary disciplines involved in selecting and evaluating medications, the guidance emphasizes a facility-wide responsibility for safe and effective medication use. An interdisciplinary approach is desirable because medications impact all aspects of care, and the input of various disciplines can provide additional insights into the patient’s need for and response to medications.
To these ends, the F329 guidance promotes the care process, including pertinent discussions among the staff, patients, families, and practitioner about the causes of symptoms and the potential benefits and risks of medications, and a thorough search for, and review of, the background for a medication regimen (ie, when and why a medication was initiated, added, or changed).
Part I of this article discussed managing the challenges to healthcare practitioners, reviewing and understanding the surveyor guidance, and respecting the evidence about medications. Part II discusses the care process, including considerations related to tapering medications, and provides case examples related to improving F329 compliance.
Managing the F329 Challenge
The F329 surveyor guidance challenges nursing home staff and healthcare practitioners to consider medications in the context of the whole patient care process, rather than being a distinct activity. Although the F329 guidance was written to guide surveyors, the staff and practitioners can use the principles and information in the guidance to improve compliance while giving optimal care.
Part I of this article discussed two of the three key approaches that can make compliance with F329 feasible and relatively painless: reviewing and understanding the F329 surveyor guidance, and respecting the evidence about medications. The third key approach, thinking about care process, is discussed below.
1. State operations provider certification. Centers for Medicare and Medicaid Services Website. http://www.cms.hhs.gov/transmittals/downloads/R22SOMA.pdf. Accessed June 11, 2008.
2. Preface. Acute Change of Condition Clinical Practice Guideline. Columbia, MD: American Medical Directors Association; 2003.
3. Roshan M, Rao AP. A study on relative contributions of the history, physical examination and investigations in making medical diagnosis. J Assoc Physicians India 2000;48(8):771-775.
4. Levenson SA, Saffel DA. The consultant pharmacist and the physician in the nursing home: Roles, relationships, and a recipe for success. J Am Med Dir Assoc 2007;8:55-64.
5. Metoclopramide (metoclopramide hydrochloride) Solution. Daily Med Website. http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=3450. Accessed June 11, 2008.
6. Silva CCR, Saconato H, Atallah AN. Metoclopramide for migration of naso-enteral tube. Cochrane Database of Systematic Reviews 2002; Issue 4.