Medication Management: Assisted Living & Memory Care

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Dispensing drugs is one of the most important functions in Assisted Living (AL) and Memory Care (MC) communities, as the average AL resident takes 11 pills a day. In this video I’m going to give you the basics of medication management, with the caveat there are minor differences from community to community. Then I’m going to give some advice on how a resident’s power of attorney can better handle the medication management  process.

Custodial Care 

The first thing to recognize is that the only person who can prescribe a medication is the resident’s doctor. It is important to know that AL and MC are “custodial care” facilities, meaning they are not health care organizations. Therefore they cannot prescribe or change a doctor’s orders. The community must give all the medications prescribed, and do so on time. They can’t say “oh, he’s better today, I’m not going to give this medication.” Nor can they decide to double up a medication just because they think it’s a good idea.

When a drug prescription changes, the doctor’s office is supposed to consult with the medical power of attorney and inform them of the recommend change to the prescription, and ask if the power of attorney approves. The prescription change can not happen without proper consent. Next the doctor’s office will send the new prescription to the community. Upon receiving the prescription change, the community will also call the power of attorney and check that they have approved the medication change. At least that is the way things are supposed to happen. A prescription change should never be a surprise.

Pharmacy

Drugs are delivered to the AL or MC community by a licensed pharmacy, one chosen by the community.  In Austin the most common pharmacies I see used are Omnicare, a nationwide firm owned by CVS, and Northwest Hills Pharmacy, a local establishment, but there are probably a dozen other providers. Both will deliver the medications daily, and sometimes twice a day if a medication change is made early enough in the day.  A resident’s family can choose to use their own pharmacy, but a community may charge extra for the additional hassle.

Drugs are often delivered in blister packs, which are often easier to use than pill bottles. What has become more common in recent years is a “pillow pack.” This is where the pharmacy delivers multiple medications in a single sealed plastic bag, according to an individual resident’s prescriptions. So the pharmacy might deliver for a resident one pillow pack with five pills for the morning, a second with three pills at lunch, and a third pillow pack in the evening with a different mix of six pills. This further simplifies the medication management process for a community.

Medication Aides

Drugs are almost always dispensed in a community by a Medication Aide, interchangeably referred to as a Med Tech. To become a Med Tech, first you must be a Certified Nurses Assistant (CNA), which requires a caregiver to take 60 hours of classroom work, 40 hours of practical experience, and pass a test.  Then the additional requirements to be a Medication Aide are another 100 hours of classroom work, 40 hours of demonstration laboratory work, and a 100 question multiple choice test. A Med Tech must be supervised by a nurse. A Med Tech usually makes a few dollars an hour more than a caregiver.  A Med Tech is often the most senior caregiver with supervisory responsibilities when a nurse is not present. Also a Med Tech will double as a caregiver when the medication duties are done.

The Drug Cart

The Drug Cart or Med Cart is a rolling chest of drawers containing all of the medications a Med Aide will need as they make their rounds dispensing medication. Only the community nurse or a Med Tech can access the Drug Cart, and it must be locked at all times, unless the Med Aide is standing next to it. On top of the Med Cart is a computer connected to a medication management system. This computer will pull up a mug shot of the resident, and have both a list of the medications that resident is supposed to receive, the time they should receive them, and a photo of what all the pills should look like so that the Med Aide can double check the accuracy of the drugs to be delivered. The medication management system will automatically order new pills when they run out, so the entire process is quite automated.

The Med Tech cannot pre-arrange the medications: think of a tray with twenty small pill cups filled with different medication and with the residents’ names written on the side. At one time this was the method used in long term care settings. But you can imagine how many times Mrs. Smith got Mrs. Jones cup by mistake, or what would happen if multiple cups spilled by accident and the pills got mixed up. 

So now, by regulation, a Med Aide must first find the resident, then individually prepare their medications, deliver them in a cup along with a cup of water, and watch them take the medications. The Med Tech can not force a resident to take the medications, so this might require a little cajoling or coaxing. Eventually if the resident refuses the medications—and this should be very rare—the Med Aide will make a notation in the record and move on. At this point the family and the doctor need to be notified.

If the community is managing someone’s medications, then all pills a resident is taking must be dispensed from the Drug Cart. Therefore, even over the counter pills such as vitamins, fish oil, herbal supplements and even aspirin all have to be managed by the community, because loose pills need to be managed for everyone’s safety.

Self Administration

In an Assisted Livings setting Medication Management will cost from $400 to $850 per month. For this reason a family may want to pick up the medications themselves and have the resident take their pills without the community’s help. This is awkward for the community for two reasons. 

First, the community is responsible for a resident’s health. If the resident isn’t taking their medications properly, it is difficult for the community to know, and to therefore properly help the resident manage their care. 

Second, by its very nature an Assisted Living has between 50% and 75% of its residents with memory problems. These residents, who shouldn’t be going into anyone else’s room, often do wander where they shouldn’t, and they are a danger to take someone’s medications inappropriately, so as I mentioned, loose meds are a problem.  But some Assisted Living communities will allow residents to manage their own pills—if the resident can pass some sort of test monthly, just to ensure safety. 

Medication management is mandatory in all Memory Care communities, and is most often included in the base price, though not always.

PRN Medications

Occasionally a doctor will prescribe medications to be taken PRN, which means they can be given as needed.  I’m not a fan of PRN medications. First, I’ve seen too many cases where PRN medications are simply given every time possible, just as a normal prescription. This results in over-medication. Second, I wouldn’t want my family member to be given drugs by a Medication Aide who only has a couple of hundred hours of training.

A Precaution

Finally, I recommend as a good idea that all families check the community’s drug records at least on a quarterly basis. Too often there are times where a prescription is mismanaged in error. For example, a doctor changes an antidepressant medication from 50 to 75 milligrams. The pharmacy delivers an extra 25 milligram pill for the remainder of the month, but the increase doesn’t make it into the system for the following month. Or a heart medication is changed from one drug to another, but the first drug prescription mistakenly isn’t cancelled and the resident ends up getting a double dose.  These type of errors are rare, but since they do happen occasionally, everyone should do a drug review with some regularity.