The Top Five Challenges of Hospice Inpatient Medication Management and How a PBM Can Help

Ealia Washington, PharmD, BCACP, BCGP, Director of IPU Operations

In March 2021, Enclara recorded a session for the 2021 NHPCO Leadership and Advocacy Conference, entitled Minimizing GIP Costs: Being Medication Payment and Distribution Savvy, outlining challenges faced in General Inpatient (GIP) management and how to assess medication payment and distribution models with the intent to minimize costs. Christine Simmers, PharmD, VP Clinical Logistics & Resource Utilization at Seasons Healthcare Management, Inc., shared a provider’s perspective on managing medication costs alongside a hospice pharmacy benefit manager (PBM) perspective from Enclara Pharmacia’s Director of IPU Operations Ealia Washington, PharmD, BCACP, BCGP. The following article is based on their presentation.


The GIP level of hospice care is defined by Medicare as being for “pain control or acute or chronic symptom management which cannot be managed in other settings.” It is delivered in a hospice inpatient unit (IPU), which can be a standalone facility or located within a hospital or long-term care facility. GIP is an essential level of care and one that Medicare recently recognized as historically harder for hospices to support due to low reimbursement rates. Even with recent payment increases for GIP, staffing and facility requirements can make for tight operating margins. Controlling medication costs is one area where the right model can make the difference between an operating surplus and deficit. Strong relationships with pharmacy partners are essential for both quality of care and cost containment.

Understanding and managing the unique challenges of GIP medication management is an important way to ensure positive clinical and financial outcomes. These fall into five broad categories:

  • High Acuity Patients
  • Short Length of Stay
  • Different Levels of Care in Unit
  • Medication Availability
  • Model Variability

High Acuity Patients

Patients often arrive in the IPU with uncontrolled symptoms that led to their placement. Every minute counts when it comes to selecting and obtaining medications, which can be especially challenging when serving patients with complex needs.
“In the IPU we are caring for the sickest of patients with uncontrolled symptoms, which means we often have exhausted our standard medications,” Simmers said. “Higher patient acuity also means there may not be time or the opportunity to vet the most cost-effective medication options.”

The pharmacist is an essential partner when it comes to identifying treatments to meet each patient’s unique needs. “Evaluate and leverage the best route of administration to utilize for effective symptom control,” Washington said. “Let’s think. Can the medication be administered rectally or is there a commercially available product for rectal use? Oftentimes, pain management medications can be administered sublingually if the patient is unable to swallow solid dosage forms.”

The PBM also plays the role in establishing efficient medication workflows. No matter which medication access model an IPU employs, workflow optimization can help clinicians avoid delays rewriting or refaxing orders, manually logging medications, obtaining authorizations, or awaiting delivery from local pharmacy.

Short Length of Stay

The general inpatient level of care is often associated with a short length of stay, measured in days rather than weeks. Patient needs may change quickly, or the patient may pass, creating potential for medication waste for hospices utilizing a patient-specific dispensing model. Short stays can also make it difficult to eliminate drugs which are no longer effective or for which the risks outweigh the benefits.

When it comes to medication waste, a hospice PBM like Enclara can help with optimizing supply through business analytics and clinical best practices. It can also help with clinical guidance around which drugs may be discontinued and why, also known as deprescribing. Deprescribing has the potential to lower costs for hospices while improving patient care, but it typically requires buy-in from patients and family members. “In the inpatient setting sometimes, we have limited time to establish relationships and build trust with patients’ family and caregivers, and that trust is so critical when it comes to making medication changes,” Simmers said.

Different Levels of Care in Unit

Most patients in a hospice IPU are receiving the Medicare-defined GIP level of care, but hospices may also provide temporary Respite Care and Routine Home Care in an IPU. These services have different requirements and reimbursement rates. Additionally, IPUs typically provide services under other payment models, such as private insurance and state Medicaid programs.

“This can be challenging from a financial standpoint, since your IPU pharmacy contract, your staffing, formulary, etc., are all likely based on the GIP level of care and reimbursement, not on the routine or respite rates,” Simmers said. “Routine and respite patients may also be taking more or different medications than a GIP patient and may even want to bring medications to the IPU from home, which can cause a variety of safety, storage, and compliance concerns.”

Enclara’s EnclarityTM business intelligence platform can be an essential tool to track how hospice pharmacy costs vary by model of care and the Enclara Clinical Pharmacy Manager can help develop interventions to manage those costs.

Medication Availability

High acuity and short stay both mean time is of the essence when it comes to getting medications to the patient. There are three basic medication access models used in the IPU:

  • Patient-specific dispensing
  • Stock dispensing
  • Automated dispensing

Patient-Specific Dispensing

With patient-specific dispensing, a local pharmacy fills a supply of each drug a patient is prescribed. An emergency kit or “e-kit” is kept on site with first doses of selected medications to treat new or worsening symptoms until the local pharmacy can dispense and deliver the patient-specific supply. This model has the lowest upfront costs and overhead, but a number of downsides, including delays in symptom management while awaiting delivery and a high risk of waste due to leftover medication. Courier and STAT delivery charges can also add up.

Stock Dispensing

Many of the medication access problems with patient-specific dispensing are eliminated with the stock dispensing model, as inventory of some medications is kept on site and accessed as needed for each patient. However, stock dispensing requires significant manual documentation, reconciliation and “pill counting” at the end of each shift to keep track of medication and prevent diversion. For hospices using this model, Simmers recommends stocking unit-dosed medications such as blister packs wherever possible. “It’s more compliant and safer, versus a bulk stock bottle type of model, which can be more time consuming,” she said.

Automated Dispensing

The “gold standard” for IPU medication access is automated dispensing, in which the hospice PBM manages access to medications which are stored in a machine. Hospice inpatient nurses consult with prescribers to obtain orders, request medications from the pharmacy and, upon drug utilization review by the PBM pharmacist, the drug is released. There is no waste, since doses are withdrawn as they are administered to patients, and automation takes care of documentation and pill counts. Automated dispensing also reduces the risk of medication errors since only the correct drug and dosage is dispensed.

Enclara’s automated dispensing program supports two of the largest dispensing machine vendors, BD Pyxis™ and Omnicell®, includes 24/7 medication access and support, and helps set appropriate stock levels and reordering thresholds to minimize overhead while ensuring prompt access to medication. Although the machines themselves are a significant investment, savings in staff time and reduced waste make automation a net positive for many hospices.

Unfortunately, the ability to leverage the use of automated dispensing in the hospice inpatient setting varies by state. In some states, only first doses of pain management drugs may be dispensed through this model, necessitating some patient-specific dispensing. In others the model is simply not feasible for most hospices unless they are part of a larger facility with an on-site pharmacy.

Model Variability

Hospices that operate multiple IPUs are faced with the challenge of managing multiple medication access models. This is primarily an issue for hospices operating in multiple states, but variation may exist within a state due to factors such as facility size, urban vs. rural location, or local partnerships. A hospice PBM can help design a solution that accounts for variability while still taking advantage of opportunities for coordination.

“When an organization operates multiple locations and multiple states, one dispensing model may not be ideal to support all locations,” Washington said. “To minimize variability, we recommend one base model and evaluate an alternative model or models. Payment model and formulary can remain consistent for the organization while dispensing model may vary.”


GIP care often requires a level of symptom management that’s not feasible in other settings. However, the cost to provide this service is significant. Medications account for a large percentage of operational costs, but there are ample opportunities to proactively manage those costs. The hospice PBM has an important role to play in both helping the hospice select appropriate payment and distribution models, as well as ongoing clinical and operational support.

Further Reading