Can nursing homes change a patient's medications?

less fear amongst the vunerable

Not just that, so many elderly are used to a particular GP and it helps as they know their patient's history.

I like that idea, frankly. Changing doctors at the nursing home stage can be tough on patients and caregivers.
Thanks for the input!
Carol

In Britain, most care homes let the residents have their own GP. It makes it easier for families to intervene.

I don't know how long your Mom has been on her medication, but you really should consult the written pamphlet that comes with her psychotropic medication, (or have the Dr. look at it, they rarely really read them!). Did you know the manufacturer many times only recommends being on their medication for 2 years! After that it may become ineffective or worse. I'm just speaking from personal experience with my Mom. Her "new" psychotropic drug is helping her much more than the one she was on for 2 years over the recommended limit.

One thing to think about concerning the reimbursement issue. There are two likely issues at play: 1) The medication is not covered by your insurance. There is little likelihood that the doctor will do anything about this. 2) The insurance company requires prior authorization to get the drug or has the drug on preferred drug list. This means the doctor has to do extra work to get his prescription reimbursed and filled. The requirements and lists are intentionally created to discourage doctors from prescribing expensive medications. In this case, you have a pretty good chance of convincing your doctor to get the authorization.

But please remember this in talking to the doctor. First, he or she might think that the less expensive medication is as good or better than the more expensive one. In this case, he is ethically required to save the money. Or, second, he or she might have been trying to save some work. Stand up for yourself but, at the same time, try to empathize with your doctor. They work mind-bending hours. I know doctors who start and 6 AM and don't get home until after dinner-- 6 days a week. And, on top of that, they're making difficult decisions in exhausting situations all day long. A doctor who sought prior authorization every time it offered a moderate advantage to the patient would burn out. Your gripe is with the insurance company. Stand up for what you or your family member needs. But understand that your doctor is only human.

If they wouldn't write the script at the NH & you are POA the way they over-stepped was by not calling you & informing you the MD wouldn't prescribe. Now again on NH medicaid the MD is only to see a patient once a month. I don't know when the MD saw her but he also may be having trouble prescribing a psyche med when only an assistant saw her or he had already seen her. Psyche meds are thought of differently & I don't know the state rules on them.

In Texas & again it is different in each state & probably even different in different NHs as to what their corporate rules are, but in Texas you can take your loved one out to any doctor that is not on contract with the NH for a check up, labs, anything except the NH is not under any obligation to follow any of that MDs orders (even a specialist) because the physician is not on contract with the facility. Since you mention the state when speaking of payment of the med I am assuming she/he is in the NH on NH medicaid (not medicare). In TX & on dad's Part D, only medicaid would pay for a psychotrope while Part D would pay for non-psychotropes. Don't know about narcotics. When they say that the state won't pay for it I am assuming that they mean since their contract MDs did not order or prescribe it then no insurance is going to cover the cost of it. No NH I have known would be able to fill a prescription written by an outside MD (even a specialist). Now what I have seen done is in the interest of Aricept (non-psych) the resident MD did go ahead & order the prescription because my outside Neurologist had ordered it & I brought the orders from the Neurologist appt. & usually from what I have seen the resident MD wants to follow a specialist's orders because it is a step above theirs. Usually they won't write a script for an outside md if it is a GP like them even though it has been a more thorough office visit. Who in Michigan pays for psyche meds I don't know but I do not think the NH is over-stepping their bounds since they wouldn't get covered unless of staff one wrote the script. I am surprised to hear that any NH anywhere sided against a psyche med. Most jump at the chance to have them on one. I know it is a tough situation because they are truly impossible to meet or speak with. If your NH has more than one doctor to choose from, speak with the DON & ask to switch doctors. Every patient (POA) has the right to choose their own MD. Only problem there is if the other doc doesn't want to take a patient from the current doc then you can end up w/o a doc & the NH cannot keep the patient living there. I would tread lightly on that one & try first to ask for a phone call for the current doc with your phone number rather than trying to meet them. When he calls the number will be blocked. If he doesn't call, call each day & speak to DON. Finally say, I have to request a new doc since this one won't call. You will hear from current doc pretty quick. When he calls just ask why he didn't want to prescribe it. Maybe he thinks the side effects are too dangerous & she is behaving okay. The only times I have consented to a psyche med was when I had to to keep them from throwing my parent out. I don't care for them. I had one MD that simply would not prescribe them for anyone in a NH because of dangerous side effects. Loved her.

To everyone who would like to assume the best intention of the NH doctor, I lived this and I can tell you it is not always the case. I did exactly as I suggested and got control back over my mother's medications, but only after he had pulled her off Warfarin and she had a stroke.

Sure, have a nice talk first, but make sure they understand you mean business and you're watching closely.

Starting 1/1/14 insurance formularies even dropped Xanax! That doesn't mean you can't get it, it means you pay out of pocket for it. If it's not too expensive, keep the meds your MD ordered.
Can they change meds? If you are only a POA, yes they can. If you are a Guardian, no they can't. A Neurologist's order should trump the opinion of the MD at the NH. Make that clear to them any way you can.

The nursing home ( rehab) where my Dad was for 2 weeks gave him the wrong medications. We didn't find out until I filed a complaint against them and in investigating discovered it! I was irate!

The nursing home physician can change the medication. I'd check with the Department of Health Services for Michigan regarding coverage of the medication. However, as he POA for health care they are supposed to be keeping you informed of the decision. If you don't agree with it you can start by filing a complaint against the nursing home with Department of Health Services.

Interesting. Is it up to each state who writes the orders? At the SNF where my mom is, her doctor's office writes all orders, not the medical director at the facility. Now that she's in the ALZ unit, there's a geri psychiatrist that does a consult on each patient but the changes she made had only to do with my mom being on hospice protocol. So any life-sustaining drug was pulled, but her doctor's office was still consulted before it was done.

I had a patient on Seroquel whose insurance stopped paying for it. Through a series of phone calls and a whole lot of stress she was able to get the generic of Seroquel which is Quetiapine. This wasn't a case of her Dr. taking her off of it but a matter of her being able to pay for it.

Dr.'s in nursing home are elusive creatures. You never see them. They don't evaluate the patients in person, you can't catch up to them if you're there while they're there and if you'd like the Dr. in the facility to know someone you have to tell the nurse (not an aide but the nurse) and then follow up to make sure a notation was actually made in the chart. Dr.s in nursing homes are like smoke....or unicorns. No one can ever really get their hands on one.

But I agree, it's the Dr. that you have to talk to. And if the state is discontinuing psychotropics that's going to be one lively facility.

I am in MIchigan. Can't believe Seroquel is not covered. I had patients taking it and never had that problem. On the other hand, you might sign up your mom to palliative care while she is in the NH. Palliative care picks up cost of comfort meds and Seroquel is one of them. Again, you can interview that company who provides such a service to make sure they will cover it. Every hospice/palliative care company have different policies on what they cover and what they do not pay for.

Sarah - please please re-read the subtle advice of MikeB26 & flstrider.

Your mom is in a NH, correct? If so, a NH is a "skilled nursing facility" and the medical director (an MD) of the NH is considered your mom's attending (or primary physician) and as such makes the determination of what medications, PT, OT and other daily health care needs, activities, dietary, etc. are to be done @ NH.

Now that doesn't mean that an outside MD specialist (like an retina specialist or geriatric psychiatrist) cannot be involved in her care, but it has to be co-ordinated with medical & nursing staff @ the NH & within what the facility can provide. So the first ? is - has the Seroquel prescribing MD spoken with the MD of the NH?

For NH/SNF's state regulations on medications are pretty exacting as to how medications are presented into the system of the NH/SNF. You don't say how your mom is paying for her NH, but if she is on Medicaid, then your state Medicaid program will work within Medicare's prescription list to determine the "formulary" for your mom so that all her medications will be covered 100% between what Medicare pays & what Medicaid pays. Seroquel (like other expensive first generation Rx's which don't have generic equivalents) probably isn't on the formulary. (Is Seroquel in your mom's Medicare Part D plan?) So the NH has other med's that they prescribe & they have to stick to what is on that list to be paid. You mention paying for the Seroquel privately, now this is all nice but I bet the issue with outside med's that is since this is a NH/SNF any & all medications MUST come from a secure source. Med's cannot just be something that family drops off @ the nursing station. The NH simply cannot have family bringing in vitamins, Motrin, Theraflu, herbal remedy to dispense.

Now if you mom is private pay NH, then your options are probably more flexible as the NH can order the Seroquel (assuming NH medical director is OK with this) and bill you for the costs of the med & maybe a smallish administrative fee. You probably will have to do a "escrow" like account for 6 mos of prescription $$.

As an aside, my mom is in a TX NH and her med's are in 90 day blister packs, generic with 1 exemption & med's are kept in a hanging bag on a rolling frame with her name on the bag and a check in list attached. All residents med's are like this and all go into a locked room with a glass door when not on the floor being given. When I moved my mom from her NH #1 to NH #2, they (new NH) really stressed that I HAD TO GET MOM'S MED's as Medicare & Medicaid will only pay for Rx's once so if they had to re-order anything it would have to be private pay by me for the Rx's from the local compounding pharmacy they use. Very $$$.

Please, please try to work with the NH as much as possible. If you push her taking Seroquel or other psycotropics & the MD of the NH feels she doesn't need it, then you may find yourself getting a "although we have enjoyed having Jane Smith as a resident, we cannot provide the level of care and oversight required & this is your notice that she needs to move within 30 days". It will be a beast of a challenge to find a psychiatric geriatric facility too. Good luck.

Sometimes when someone is admitted to a nursing home, they ask for you to sign a paper turning their care over to the facility's resident physician. Some places require them to be the only one prescribing for them, so first you should see if that is their policy or not. Some facilities will let you use either their facility doctor, or continue with your own, and some will let you use their facility for common needs, but still allow you to use outside specialists. Most facilities will allow you to purchase a medication on your own that you want continued, if it's ordered by one of the doctors that she is allowed to see. They don't like doing that because it's extra work for them to remember to call you every time it needs refilled, but they will allow it. So, I think that the first place to start is talking with the administrator or DON at her nursing home to find out just what they allow and what they don't allow, and discuss the best way to solve this problem. They often will work with you on what you want because they don't want families bad mouthing them to give them a bad reputation. If they refuse to work with you, you might consider a different facility. If it's OK with them to take orders from the neurologist, and it's just a matter of the cost of the med, I think there are 5 things to consider. 1-Is it available in a cheaper generic? 2-If not, does the neurologist know of a similar med that would do the same thing, but be cheaper? 3-Some doctors' offices can apply to the drug company itself to get the med much cheaper if she can't afford it on her own. 4-Will the nursing home allow you to pay for it yourself? 5-Sometimes, whoever is paying for the meds (Medicare Part D, etc) will let the ordering doctor call the insurance co. himself (must be a personal call from him usually) to explain to them why he is so adamant that she be on this med specifically (often they will require proof that you've tried a few other things that didn't work as well). As mentioned above, sometimes this call needs to be made more than once, but is worth the effort when they finally allow an exception to be made to their policy about that med.

Yes, sadly everything runs on being reimbursed. Yes, the nursing home can deny her that brand name drug, but if you want to pay for it yourself, I'm sure you can work out the details with the nursing home. As POA, you are responsible for making decisions, however, if she is on Medicaid, the nursing home will make decisions based on being paid. I would also ask the neurologist to suggest another psychotropic generic drug, and if he/she will not change the drug, you are free to seek another opinion from another doctor.

In Arizona, the resident physician has total control of the patient and a private specialist would lose their involvement, unless the family wanted to arrange the resident to be taken to the private neurologist on their own. My Dad has both a geri psychiatrist and staff AND a residential medical internist on his case, but his historic private MD and Neurologist cannot be involved, because I live out of town, and my 88 yr old mother is unable to transport him to appointments. I do have it written in his care plan that meds cannot be changed without consulting me, because I am a retired RN, and other family members still see the same neurologist, so I can ASK, informally, what his thoughts are about planned med changes and relay his thoughts to the geri psych Nurse Practitioner...but all orders for meds come from the docs who are affiliated with the facility.

Here I know that they can't do any changes to meds unless authorized by a Dr. I would think that the specialist would have override on the primary care Dr. You need to have the two Dr.'s share notes on the care of your mother and find out the reasoning behind this. If the insurance don't cover them then you should be able to pay out of pocket for them, but really why is it they were covered up until now? Something don't add up here, I would definitely want to talk with the Dr. not the DOC.

Listen to MikeB26. Time for a meeting with the nursing home's doctor, as that is your mother's primary care physician now.

I am an RN. While I recognize that Stargazer is sincerely offering advice in a difficult situation, I don't agree with using intimidating statements about "specialists" or threatening with lawyers unless a situation genuinely calls for litigation.

The doctors I've worked with have been some of the most ethical people I ever met. And yes, billing issues do play a part in medical decision-making-- maybe not the best thing about American medical care, but it is our current situation.

Assume your MD is doing his or her best. First, ask why a change was made. If you still disagree, respectfully seek another opinion or ask the internist to speak with the specialist.

There's nothing wrong with getting a second opinion. In fact, I periodically encouraged patients to get a second opinion (or sought one myself) on my own decisions. And you know what? It wasn't unusual for the second opinion to disagree with me, the patient would agree, and we would all go in that direction.

My point is, if you disagree with a doctor thats fine, or even great in that it means you care and are diligent. But, when you address the issue, assume that the doctor is sincerely trying to do his or bes.

On the "outside" it is unusual for a physician to change in medication without a call to the prescribing physician. However, in the ALF, the house Dr. becomes the attending physician and is responsible for the patient within those quarters. I once had a similar situation with my mother but in that case I was glad that the attending had changed her meds. She was becoming agitated at night on her old meds so the doctor modified some things.

In this case, you are right. It sounds like it is just about the money. Seroquel has not been covered by Medicare unless it is for treatment of a bipolar disorder. It is specifically contraindicated for treatment of insomnia.

Assuming it is within your means, I would write a letter to the facility and the attending physician(s) stating that unless it is an emergency, you do not want any of her medications changed without prior authorization from you. You may wish to state that if the item is not covered by Medicare, you will pay for it as long as you are giving reasonable notice of the situation and the cost.

Pharmacy laws are done by state. Depending on where you live, it might be possible to provide the medication to the ALF for them to dispense. In Maryland, this is not possible as the laws specifically require medication to be dispensed in a blister pack under controlled circumstances.

Some Medicare part D plans have covered Sarah quell. However, there is now a movement from the Obama administration to limit the use of several medications citing improper use and high cost. There was an article in the New York Times on February 21, 2014 about the subject.

I agree with Stargazer. The resident doctor of the nursing home would likely be the person who took her off the meds. If this is just an insurance issue, he or she should be able to push it through the insurance (or the neurologist could). Sometimes it takes several tries.

Try to have a talk with the resident doctor and let him or her know why the neurologist prescribed this medication. See if you can get some cooperation between doctors. I know this shouldn't be your problem, but sometimes this happens. Good luck,
Carol

It seems that the NH is overstepping. I can't even leave a tylenol in Mom's room without getting scolded by the AL. The AL in my state MUST follow orders from the Dr., but they can make suggestions for us to present to the Dr. who can change his/her orders.

Their resident doctor must have pulled her off it. Try tracking him/her down and having a personal talk. Let that doctor know you want her on the med and that her SPECIALIST wants her on it. Say something like, "I don't think either of us wants to get lawyers involved in this." Make it clear that you want to be involved in ANY changes of medication and you want to have final approval.

The nursing home is responsible for paying for her meds. As such, the doctor for the nursing home may try to pull crap. As soon as they know you're watching, they change their tune.

It's Medicare who is picking up the tab, correct? If state funds are involved, try contacting the person in Michigan who oversees the nursing homes and get the real story.

Been here : ( Be strong. Be a fearless advocate! You'll be surprised how people back down when they know you're up for a fight ; )

I can't imagine that they can legally do that. i would call the prescribing doctor and inform him. At my MIL's assisted living, the staff wouldn't even let her take 1 Tylenol, instead of 2 (as prescribed.)