Understanding the Role of the Hospice PBM

Hospice is about keeping patients comfortable by managing pain and other symptoms of terminal conditions. With drug therapy so central to that mission, it’s no surprise pharmacists play a big role in patient care. So, too, does the hospice pharmacy benefit manager, or PBM.

In the larger healthcare space, the main role of a PBM is to process claims and reimburse pharmacies for the dispensing of medication. They also help manage drug costs through formulary management and by negotiating pricing with drug companies.

Because hospices have unique needs, they tend to rely on PBMs and other pharmacy providers that specialize in hospice. Enclara Pharmacia’s roots go back to some of the first pharmacies and PBM providers to cater exclusively to the hospice sector. Today, it serves about 450 hospices representing over 90,000 daily patients.

What Does a Hospice PBM Do?

Each hospice PBM offers a unique blend of services. They fall into a few major categories:

  • Medication access
  • Utilization management
  • Pharmacological guidance
  • Regulatory compliance
  • Workflow optimization

Medication Access

Hospice patients are typically treated at home but often rely on powerful pain management drugs you won’t find in the average corner pharmacy. Their conditions can also change from hour to hour. Ensuring symptom relief may require new medications, dosages, or formulations at a moment’s notice.

Hospice PBMs provide medication access in various ways. Some hospice PBMs operate or contract with several “closed door” non-retail pharmacies throughout the country to dispense medications. However, maintaining adequate coverage can be a challenge in some areas. Enclara offers several models based on use of retail pharmacies and, often, Enclara’s own mail order pharmacy which can support next-day needs.

Enclara ensures local access to hospice-critical medications with its Neighborhood ConnectionsTM program. It includes an actively-managed network of over 7,000 pharmacy locations among the larger network of over 65,000. These pharmacies agree to stock hospice-critical medications and meet other service standards. The Neighborhood Connections team works with hospices to build relationships with pharmacies in their service area. Through this model, Enclara can also handle billing for ancillary services such as courier delivery.

Utilization Management

Drug costs are often a hospice’s largest expense after labor and facilities. Hospice PBMs can help clients develop tools and best practices to improve quality and manage costs. Enclara’s clinical pharmacists use a variety of tools, including:

  • Custom formularies
  • Evidence-based treatment algorithms
  • Deprescribing protocols
  • Education on clinically appropriate, lower-cost alternatives

Another important tool for utilization management is reporting. Enclara’s proprietary business intelligence platform, EnclarityTM, provides real-time trending data and visualization. Users can drill down to various levels (e.g. site and team) to identify opportunities to improve care and manage costs. Custom alerts can flag potential cost spikes in real time.

Pharmacological Guidance



The goals of hospice care are different from curative health care and so is the pharmacology. There is often limited data on the effectiveness of certain drugs for terminally ill patients. The dying process presents complex challenges around how medications are metabolized. Patients may also need alternate routes of administration as their conditions decline.

Hospice PMBs should provide expert clinical services specific to hospice and palliative care, along with immediate access to drug information and education. That includes offering evidence-based options around the ways a medication can be administered, either in response to availability concerns or to better meet patient needs.

Enclara’s clinical support program includes strategic utilization management and educational opportunities as well as pharmacists available 24/7 to assist with the management of medication therapies, enhancing the interdisciplinary team. They support nurses and prescribers with many challenges, including:

  • Complex cases
  • Dose conversion
  • Drug substitutions
  • Precautions
  • Deprescribing

Regulatory Compliance

Hospices are highly regulated, including around medication use. For instance, Medicare’s Conditions of Participation require drug utilization reviews upon admission and on an ongoing basis. These cover all a patient’s prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. Enclara clinical pharmacists use this as an opportunity to look critically at the medication list to identify treatments for which risks may exceed benefits. They can be especially helpful in reviewing over-the-counter medications and supplements with potential for adverse effects or interactions.

Over the last several years, concerns around opioids have led to increased regulation of controlled substances. Enclara helps hospices strengthen compliance with existing and emerging state and federal regulations through appropriate policies, practices, and workflows. Enclara can also review overall utilization to identify areas of potential risk.

Workflow Optimization

Hospice nurses foster deep relationships with patients and their caregivers to build trust and support the highest quality care. Complicated or outdated medication management workflows can take them away from that important work. Nurses may spend hours ordering medications, tracking down faxes and reentering information in multiple systems. This not only interrupts patient care, it also negatively affects staff morale and retention.

Enclara has invested in technology and best practices that let nurses be nurses. The E3 platform includes mobile and desktop medication management applications to support both mail order and, in partnership with an e-prescribing provider, local pharmacy utilization. Integrations with a growing list of the leading electronic medical record (EMR) systems for hospices eliminate double-entry. These are complemented by a structured and collaborative implementation process to ensure digital tools translate into efficient workflows.

Learn More About Enclara Pharmacia’s Custom Hospice PBM Options

Just as drug therapy is central to hospice care, the PBM is central to hospice operations. Enclara Pharmacia understands that every hospice is different and tailors its solutions to each client’s needs, challenges, and values. To learn more about this subject and Enclara’s solutions, please refer to the following resources: