Sending a patient's medication orders to the nursing facility may seem straightforward. It may even give you a sense of reassurance that the challenges of polypharmacy,¹ medication timing, administration, and picking up medications from the pharmacy will no longer be the patient's responsibility, but instead will be handled by health care professionals. Unfortunately, just prescribing the medications to the facility doesn't guarantee the patient will receive them as ordered, on time, and as you intended.

When it comes to procuring and administering medications, nursing facilities (meaning both skilled and long-term care environments for the purposes of this article) have protocols and rules that may not be familiar to physicians who haven't worked in such settings. Here's what family physicians need to know.

MEDICATION ORDERING AND DELIVERY

To avoid delays in care, nursing facility clinicians need to approve admission medication orders from the hospital on the same day the patient leaves the hospital, prior to the patient's arrival at the facility. Best practice is for the hospital clinician to send their hospital discharge summary to the nursing facility at the same time the admission medication orders are sent. Unfortunately, the physician discharge summary is not always ready when a patient leaves the hospital (federal law only requires that hospitals make the discharge summary available within 48 hours). This opens the door for medical error. When the physician discharge summary is received after the day the patient is discharged from the hospital, there are often changes to the medication list or further clarifications to the recommended treatments. Such discrepancies can't always be avoided, so reviewing the discharge summary and updating facility orders to reflect any changes is an important step in admitting a patient to the nursing facility. If the hospital physician discharge summary is not available at the time the nursing facility clinician performs the initial visit and review of hospital documentation (within 24–72 hours), the review of the discharge summary and final verification of hospital orders may not be possible until the next visit. Depending on the acuity of the patient and availability of the clinician, the next visit could be in one day or 28 days. Thus, having the hospital clinician complete the discharge summary as soon as possible assures continuity of care and prevents medication errors during the transition from one medical setting to another.

The first step in obtaining medications for the patient is receiving the signed admission medication list from the hospital. All medications (even over-the-counter drugs) must be prescribed and linked to a diagnosis, or the patient will not have access to them (see “Pearls for successful prescribing in nursing facilities”). Nursing facilities contract with a pharmacy that delivers their medications. The delivery process typically takes a few hours but can take days if there are delays at any step.

The most frequent delay is when controlled substances are prescribed. For controlled substances, e-prescribing is usually required. (Per the SUPPORT Act of 2018, all schedule II–V medications covered by Medicare Part D or a Medicare Advantage plan must be e-prescribed to the pharmacy unless the prescriber has a waiver approved to write controlled substance prescriptions by hand. Most states also have laws requiring e-prescribing for controlled substances, whether the patient is covered by Medicare or any other payer.^2,3) The most efficient way to assure the patient has access to a controlled medication is for the hospital clinician to e-prescribe a three-day supply of the medication to the facility's contracted pharmacy, not the patient's usual outpatient pharmacy, as part of the discharge process. The facility clinician will manage further prescribing once they evaluate the patient. If the patient is not discharged with a prescription for the controlled substance, the facility nurse and the facility pharmacist must speak with the nursing facility clinician to obtain a prescription. This means the controlled substance will probably require a separate delivery, after the other admission medications. That can take several hours and cause delay of care for the patient.

MEDICATION ADMINISTRATION

The timing of medication administration in the nursing facility can differ from what clinicians anticipate because it is based on efficiency for facility staff. For instance, if an antibiotic is prescribed as “TID” (three times daily), a clinician might assume the facility staff will give the medication every eight hours. But in a nursing facility, staff will give it with meals, which means it could be more than 12 hours from the last dose of the day to the first dose the following morning. To avoid this, clinicians should order the specific time interval they desire rather than how many times a day the medication should be taken.

Here's another complicating factor: Nursing facilities are allowed certain wiggle room for medication administration. If you write a prescription for the facility to give a medication at a specific time (e.g., noon) or at a specific interval (e.g., every four hours), the allowable window for delivery is one hour before or one hour after. That means two hours is the narrowest window, regardless of how specific your instructions are. The broadest window is for a medication to be given during a nursing shift, which could be a span of anywhere from 8–12 hours, and could be a different time each day. You should avoid that unless you're OK with that kind of variability.

Medication administration details are important because nursing facilities can interpret them differently. Do not assume they will follow standard administration procedures unless you specify them in the order. Here's an example: “levothyroxine 25 mcg/PO/q AM.” With this order, the facility will likely give the levothyroxine with all other medications at the morning med pass. If that's not what you want, it's best to write “take one hour prior to eating/other meds.” Likewise, if you write a prescription for a statin to be dispensed “once daily,” the facility will probably give it at the morning med pass unless you specify the standard bedtime administration.

Another thing to consider when writing medication orders is that “prn” (as needed) orders can result in patients not receiving medications due to staff constraints or the inability of patients to effectively advocate for their needs. This is particularly important with pain medications such as acetaminophen. Clinicians often write these as “prn” for patients at home or in the hospital but may need to schedule them more specifically in a nursing facility to ensure reliable pain control (unless the patient is able to self-administer, which some facilities allow for patients they deem able). Work with your patients to determine a reasonable schedule and then ask at their next visit whether the schedule needs to be revised.

SPECIAL RESTRICTIONS FOR ANTIPSYCHOTIC AND PSYCHOACTIVE DRUGS

Federal guidelines restrict nursing facilities' use of psychoactive medications. The guidelines require clear documentation of the diagnosis and target behaviors for these drugs, including antidepressants, anxiolytics, and antipsychotics. The goal is to have nursing facilities instead use non-pharmaceutical measures to treat conditions such as delirium or adjustment reactions to being in the facility. The only indication for antipsychotic use is psychosis that causes risk of harm to self or others, and you must document specific examples of the psychotic behavior causing that risk. Patients or their surrogates also must give permission for the facility to use antipsychotics, after being informed of the “black box” warning that their use is associated with increased risk of heart attack and stroke.

Psychoactive medications, such as benzodiazepines, used as needed can only be prescribed in nursing facilities for a maximum of 14 days. After 14 days, the facility must reassess the patient with the goal of stopping the medication or adjusting the nursing home environment to better manage the target symptoms.

These regulations align with overall goals of deprescribing any unnecessary medications for nursing home residents, partly in response to past reports of overmedication among this population.⁴ One of the priorities for physicians practicing in nursing facilities is to assure that each medication has a clinical indication and is tolerated by the patient. Nursing facility physicians are often vigilant about deprescribing unsafe or unnecessary medications and assuring the patient is prescribed only the lowest effective dose. For this reason, it is important to review the medication list the nursing facility sends with the patient when they arrive at outpatient appointments or if the patient is sent to the emergency room. Federal guidelines require facilities to send the most recent medication list with the patient when they leave the nursing facility for medical care.

WORKING TOGETHER TO HELP PATIENTS

As you can tell, prescribing in a nursing facility is different than prescribing in a hospital or clinic setting. But we all have the same goals: getting patients the medications they need when they need them, without overmedicating them. Understanding the various idiosyncrasies of nursing facility medication procurement and administration should make it easier for you to work with the facilities that are taking care of your patients to keep them well.