ALTC Newsletter Header

April 30, 2012 

Mission Statement 

The mission of the Academy of Long Term Care is to promote pharmacy practice in the long-term care setting by enhancing the quality of practice through education and establishment of professional and ethical standards.

ALTC Board  

Larry Reis, Trustee


Janice Hoffman, Chair  


Charles Brown 


Catherine Chan 


Chen Chen 


Elizabeth Gross  


Joseph Woelfel 

Paige Talley
Staff Lead
(916) 779-4546

Events & CE

Diabetes Care Certificate Training Program

April 28, 2012

Sacramento, CA


APhA's Pharmacy-Based Immunization Delivery 

May 12, 2012 


Sacramento, CA


APhA's Pharmacy-Based Immunization Delivery 

June 23, 2012 


San Diego, CA


LTC Weekend

September 8-9, 2012

Town & Country Resort

San Diego, CA 


Local Association
Events Calendar

Important Links


Sponsorship of this newsletter is available. Please contact Jamie Carota at (916) 779-4511 or

I am the Chair of your Academy and want to thank you for all your efforts in caring for our LTC patients. My experience in LTC spans decades and currently I'm teaching geriatric care to student pharmacists at Western University of Health Sciences. As you may know, each year the ALTC Board plans and hosts Long Term Care Weekend, and this year is no exception. However, we've changed the Saturday programming to be more interactive case-based active-learning while allowing plenty of time for networking. We will have the regulatory section on Sunday plus a session on new drugs in the elderly and changes in the Beer's list. Please mark you calendar for September 8-9 in San Diego, CA!


As times are changing rapidly in our practice-setting, ALTC wants to keep you informed, so our newsletter:

  • Will be going out bi-monthly 
  • Will contain a couple of articles addressing issues in LTC
  • Will list upcoming events from various organizations that support LTC

If you have any articles or announcements to make, please send to Paige Talley at 




Janice Hoffman
ALTC Chair 


Serving the Needs of Ambulatory Medicare Beneficiaries - Drug Cost Savings, Immunizations, and Medication Therapy Management


By Raj A. Patel, Pharm.D., Ph.D and Joseph A. Woelfel, Ph.D., FASCP, R.Ph.


Part D Cost Savings

Students, faculty, and volunteer pharmacist preceptors from the University of the Pacific's Thomas J. Long School of Pharmacy and Health Science provided annual Medicare Part D assistance to beneficiaries in Northern and Central California during Part D's Open Enrollment period in 2011. Thirteen outreach events in five different cities were conducted. A total of 540 beneficiaries were assisted with their Part D plan at the various outreach events.


The specific language needs of 116 (21%) beneficiaries were provided in a language other than English using translators and language-specific documents.  


There were 166 (31%) low-income (i.e., dual-eligible [Medicare & Medicaid] or Low-Income Subsidy receiving) beneficiaries assisted. Nineteen new low-income subsidy beneficiaries were identified and enrolled on-line at the outreach events. Additionally, 199 individuals were enrolled into a new Part D plan during one of our outreach interventions.


The total potential Part D plan cost savings to beneficiaries assisted was $368,660 corresponding to an average of $813.82/beneficiary.



In total, 429 individuals were vaccinated with flu, pneumococcal, or shingles vaccines by students under pharmacist preceptor supervision.


Medication Therapy Management (MTM)

Medicare beneficiaries attending the outreach events were offered MTM services by students working with a pharmacist preceptor. The average number of medications taken by outreach attendees was 5.3 (range 0-23). Of the 540 beneficiaries, 413 (86%) had not previously received MTM services from their Part D plan and therefore received MTM service for the first time from us.  


Severe medication-related issues were identified in 148 patients. The number of patients and corresponding medication-related problems (MRPs) included:    


  • 47 (9.5%) patients were taking a medication on the Beers list
  • 37 (8%) patients had a severe drug-drug interaction that was identified
  • 25 (5%) patients had one or more untreated conditions
  • 20 (4%) patients had therapeutic duplications in their medications profiles
  • 19 (4%) patients were taking a drug that was contraindicated for them.

Some of these patients had multiple MRPs.


The patient's prescriber was contacted for 103 (22%) patients with suggested therapy recommendations based on our findings.


What Ever Happened to Maalox and Mylanta

By Charles D. Brown, PharmB

As the body ag
es and people become less active some of the body's systems are less tolerant of the foods and beverages we ingest. This leads to indigestion, dyspepsia and Gastroesophageal Reflux (GERD), conditions which make a person uncomfortable and would want to take the easiest route to relief.


In the past, Maalox and Mylanta were utilized to relieve the symptoms associated with gastrointestional changes and reactions. These medications were administered 1-6 times daily depending on frequency and severity of the symptoms. Although the taste was not always pleasant, most of the time antacids relieved the problems. Then came the advent of the H-2 Blockers: Tagamet(R), Zantac(R) and Pepcid(R). These medications reduced the acidity and most of the symptoms associated with hyperacidity, and did not have the taste issues associated with the antacids. However, after its entry to the market we found many drug interactions associated with the use of Tagamet(R), and some that were suspected with the other H-2 blockers, specifically those competing within the Cytochrome P450 enzyme systems.


The drug industry kept working diligently on new products to combat the gastrointestional acid related issues such as ulcers and reflux , with improved adherence using once daily dosing and turning off the acid pump completely thus, the "birth" of the PPIs (Proton Pump Inhibitors).


PPI medications, inhibit the production of acid in the stomach, therefore reducing many of the symptoms associated with hyperacidity. They are intended for short term therapy (12 weeks) for most conditions such as prevention of stress ulcers in the acute hospital setting. Those 12 weeks extend to years in most cases and overuse began.


Many medications are designed to be dissolved and absorbed either in the acidic media of the stomach or in the basic media of the intestines. With long-term therapy, we have now changed the acidity of the stomach and some medications are not dissolved and absorbed in the stomach as intended. Calcium is an example. It has been shown that when Calcium is administered to a patient on long-term PPI therapy the absorption may be reduced greatly. As we bring the stomach acidity close to a neutral pH of 7, many of the medications that should have dissolved in the intestine may now be absorbed partially in the stomach. These medications may cause nausea or not be absorbed at all.


Studies are now being conducted to determine the full effects of altering the pH of the stomach on medication absorption and efficacy. Overuse of the newer antibiotics, especially the Fluoroquinolones (Ciprofloxacin, Levafloxacin, etc.), particularly in the acute hospital setting, has been a well-published fact. We know that one of the effects of of these medications is that some of the intestinal flora is destroyed by the use of these extremely effective and powerful newer antibiotics. However, when the intestinal flora is compromised it allows the overgrowth of "bugs" that are kept in check by the Acid/Base/Flora equilibrium. When this equilibrium is compromised, the organisms flourish and are able to overtake the system and create problems that are difficult to eradicate such as resistant strains of organisms like E.Coli, Entercoccus and Staphylococcus Aureus.


Is there any question why we have seen such an insurgence of C. Diff over the past several years?

It may be time that we start focusing on changes in diets and restore the use of temporary measures to reduce the acidity of the stomach instead of immediately resorting to use of a PPI. In addition, using antibiotic therapy in a more rational way may decrease the development of overgrowth of more resistant bacterial strains. Perhaps, re-visiting the use of PPIs and routine use of antibiotics in the elderly may reduce the incidence of C. Difficile in the long-term care setting.


 CMS Update


The American Health Care Association (AHCA) sent the following message to its members regarding CMS and its decision not to move forward with the proposed delinking of the consultant pharmacists from the contracted LTC pharmacy.  However, CMS will reconsider its proposal if the industry does not move to prevent overprescribing and reduce the use of antipsychotic drugs in LTC.   


"In a welcome response to comments submitted by AHCA and other stakeholder groups, The Centers for Medicare and Medicaid Services (CMS) reported yesterday that they will not move forward in the immediate term with a proposal to require LTC facilities to hire independent consultant pharmacists, while reserving the possibility of doing so in the future if reductions in "inappropriate prescribing," including the off-label use of antipsychotic drugs, are not observed. This decision was reflected in a final rule with comment period for the Medicare Advantage and prescription drug benefits programs for Calendar Year 2013.  


In an October, 2011 Federal Register Notice, CMS discussed a potential new requirement for LTC consultant pharmacists to be independent of any affiliations with the facility's pharmacies, pharmaceutical manufacturers and distributors, or any affiliates of these entities. CMS reasoned that such a requirement was necessary to ensure that consultant pharmacist decisions were objective, unbiased, and in the best interest of nursing home residents.  CMS now indicates that, "From comments received on this issue, we now believe a more targeted and less disruptive approach is warranted."


In December 2011, AHCA submitted comments to CMS on this proposal, which the AHCA Pharmacy Workgroup was instrumental in shaping.  In our comments, AHCA agreed that it is important to minimize the potential for a conflict of interest on the part of the consultant pharmacist and argued that current regulations and Guidance to Surveyors provides adequate support for CMS to deal with potential conflicts.   We also provided 6 alternative suggestions to minimize potential conflict of interest, provided data from the one state that requires an independent pharmacist that suggests "independence" does not necessarily result in reduction of use of antipsychotics and listed (with supporting information) advantages to having the consultant pharmacist associated with the dispensing pharmacy.

CMS is now soliciting additional comments to help determine a more comprehensive approach to eliminate overprescribing and reduce the use of antipsychotic drugs in LTC. CMS also strongly encourages the LTC industry to voluntarily adopt the following changes to increase transparency:

  • Separate LTC consultant contracting for dispensing and other pharmacy services;
  • Pay fair market rates for consultant pharmacist services; and
  • Disclose to LTC facilities any affiliations of consultant pharmacists that pose potential conflicts of interest (this may include the execution of consultant pharmacist integrity agreements.)

CMS adds that if the expected improvements in prescribing behavior and antipsychotic drug use do not occur through voluntary practice changes, they will use a future notice and comment rulemaking to propose requirements to comprehensively address these concerns."