Nursing Home Medications

Nursing home residents require medications, whether they’re staying short-term in order to receive rehabilitation or remaining in the facility on a long-term basis. It’s the responsibility of the nursing home to ensure that the medications are provided; if for some reason the patient’s pharmacy costs aren’t covered by insurance and he can’t afford to pay out of pocket, the nursing home is required to make arrangements for the medications to continue.

Most nursing homes don’t have in-house pharmacies – they usually contract with commercial pharmacies to deliver medications twice a day. The nursing home faxes the doctor’s orders to the pharmacy and they’re included in the next medication run. This can be a problem because the nursing home must fax the orders at least an hour before the driver leaves the pharmacy; otherwise the patient might not receive his medications for over 12 hours. For the patient who has been newly admitted, this means that he might remain in pain or distress overnight while he waits for his medications to be delivered. Some nursing homes will make special arrangements for the patients to receive their medications, such as sending a worker to pick up the medications or asking the pharmacy to make a special delivery. This doesn’t always happen, though – and the nurses can’t do anything about it.

There are ways to ensure that your family member doesn’t encounter this problem: ask that he be sent to the nursing home before noon so that there is sufficient time for the medications to arrive (and make sure that they give him all of those medications that are due before he leaves the hospital). If the patient’s transfer time can’t be better coordinated, bring his medications from home in the original bottles to the nursing home and insist that they be administered to the patient. The medications must be listed on the Admission Orders that the doctor has signed – if the patient was taking a certain medication at home that isn’t listed on the orders, it won’t be given to the patient even if it’s in the original prescription bottle.

If you do bring medications to the nursing home, make sure that you only bring enough to last a couple of days. It’s common for nursing homes to destroy medications that the family members bring, which can mean hundreds of dollars in unnecessary replacement costs. If the patient will be returning home, those medications will come in handy.

The doctor doesn’t always order the same medications that the patient was taking at home; after the patient has been in the nursing home for a few days, ask the nurse to compare the list of home medications against the ones they’re prescribed in the nursing home. If there are differences, ask to speak with the doctor. If you feel that the nursing home staff doesn’t respect your ability to ask questions, feel free to discuss the issue with the nursing home administrator or call the Ombudsman. You have the right to ensure there’s continuity of care for your family member.

It does make a difference as to whether the patient is staying in a facility for short-term care or long-term care as to how the nursing home will obtain the medications:

Short-Term Rehabilitation under Medicare Part A

When a senior is admitted to a nursing home from the hospital under the Medicare Part A benefit, the nursing home is required to pay for all of his medications regardless of the cost. It’s common for a nursing home to accept a senior with a full awareness of his medication regimen, and then ask the doctor to change his medications to something less expensive. While the nursing home has the right to ask for a less expensive equivalent, it might not always be in the patient’s best interest to change to a different medication altogether. This is a gray area, ethically speaking. If asked, the nursing home will deny responsibility, saying that the doctor changed the medications when in fact it’s the nursing home that requested the change. The nursing home should not dictate the care that the senior is receiving, but this happens more often than one would imagine.

An example of cost-saving measures is chemotherapy drugs used to treat cancer. Most nursing facilities won’t accept patients receiving these expensive medications, which can cost over $1,000 per day. As soon as the patient is admitted, the nursing home administrator or another staff member will ask the physician to change the medication to something cheaper, or delay the treatment until the patient is discharged home. If the patient receives care for the 100 day maximum, such a delay in treatment could hasten the patient’s death. Patients and family members have the right to refuse changes in medications – and the nursing home will be obligated to pay for the medications the doctor originally ordered. 

The same rules apply to radiation, which are another type of treatment for cancer. Most nursing homes won’t admit patients who require radiation because they’re required to pay for the treatment – and it’s expensive. Those nursing homes that do provide radiation use a contracted provider – this is okay as long as the patient receives the care he needs. However, it’s possible that the nursing home will attempt to decrease the number of treatments to save money. Just as with chemotherapy, patients and their families have the right to refuse changes in the treatment plan.

Because these treatments are so expensive, the nursing home might try to force the senior to participate in the maximum amount of therapy no matter how poorly he feels in order for Medicare to pay the nursing home at the highest rate. If the nursing home is able to pull this off, they won’t lose money on the chemotherapy and radiation. However, if the patient doesn’t feel like participating in as much therapy as the nursing home prefers, it’s unethical for the nursing home to threaten him with a discharge if he won’t work harder. A quick call to the nursing home Ombudsman or state regulatory agency can help to resolve these issues.

Long-Term Care

Those patients who are in the nursing home for long-term care will obtain their medications via the Part D benefit in the same manner as if they were at home. Instead of the nursing home paying for the patient’s medications, the pharmacy bills the patient’s insurance (usually Medicare Part D). Patients whose room & board are paid by Medicaid don’t have a co-payment, while patients who pay privately will have co-payments and deductibles.

If a senior didn’t have coverage for medications at home, is sent to a nursing home and doesn’t qualify for Medicaid, he’ll have to pay out-of-pocket for his medications. However, as mentioned above, if he doesn’t have the ability to pay, the nursing home will have to make arrangements for the pharmacy to continue providing the medications.

If the patient’s Part D drug plan doesn’t contract with the commercial pharmacy, the nursing home is required to make arrangements to obtain the medications from a contracted pharmacy until the patient is able to change plans during the next open enrollment period. Private-pay patients whose Medicare Part D plan isn’t accepted by the pharmacy can usually request that a 90-day supply be ordered from the mail order pharmacy with which the drug plan works. Once the nursing home receives the medications, they’re often sent to the commercial pharmacy to be bubble-packed so that an accurate count of the medications can be kept. The cost of bubble-packing is generally less than $5.00 per card (30 pills per card).

Veterans who are eligible for the Veteran’s Administration to pay for the medications will receive them in bottles from the VA mail order pharmacy; these also can be bubble-packed by the commercial pharmacy when they arrive.

Patients whose room & board is paid via the Medicaid benefit are able to change Part D drug plans as often as necessary to keep costs down; if one of the prescribed medications is no longer covered under the patient’s drug plan he can change immediately rather than to have to wait for open enrollment at the end of the year.