Plante Moran Clinical Group

Transcription

1 Handouts Prepared By: Jane Belt, MS, RN, RAC-MT Plante Moran Clinical Group 2 Plante Moran Clinical Group

2 Objectives Delineate the key requirements in F329 Unnecessary Medications Describe the key principles of avoiding unnecessary medications Identify key strategies for collaboration between interdisciplinary team members to provide best care practices for medication use and the role of non-pharmacological interventions Detail the required documentation components of staying in compliance with F329 3 A Bit of Background First CMS in looking for quality improvement started to focus on the use of antipsychotics used to treat NH residents with dementia CMS Administrator at the time (Dr. Donald Berwick) asked stakeholders to provide to CMS their proposals for reducing their use As the discussions continued all realized that there should not be a focus on one class of drugs as that could trigger overuse of other drugs 4 Plante Moran Clinical Group

3 January January Plante Moran Clinical Group

4 National 21.71% 7 Multi-dimensional Approach Includes 3 R s: RETHINK approach to dementia care RECONNECT with residents via person-centered care practices RESTORE good health and quality of life January 2013 July 10, Plante Moran Clinical Group

5 July 10, July 10, Plante Moran Clinical Group

6 Key Requirements in F329: (l) Unnecessary Drugs 1. Each resident s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: (i) In excessive dose (including duplicate therapy); or (ii) For excessive duration; or (iii) Without adequate monitoring; or (iv) Without adequate indications for its use; or (v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (vi) Any combinations of the reasons above 11 Key Requirements in F329: (l) Unnecessary Drugs 2. Antipsychotic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that: (i) Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and (ii) Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. 12 Plante Moran Clinical Group

7 Key Requirements in F329: Intent Each resident s entire drug/medication regimen be managed and monitored to achieve the following goals: Medication regimen helps promote or maintain the resident s highest level of function as identified by the resident/and or representative in collaboration with the attending physician and facility staff; Each resident receives only those medications, in doses for the duration clinically indicated to treat the resident s assessed condition(s); Non-pharmacological interventions (such as behavioral interventions) are considered and used when indicated, instead of, or in addition to medication:. 13 Key Requirements in F329: Intent (continued) Each resident s entire drug/medication regimen be managed and monitored to achieve the following goals: Clinically significant adverse consequences are minimized; and The potential contribution of the medication regimen to an unanticipated decline or newly emerging or worsening symptom is recognized and evaluated, and the regimen is modified when appropriate 14 Plante Moran Clinical Group

8 Key Requirements in F329 In other words - the facility s medication management program supports and promotes selection of medications(s) based on assessing relative benefits and risks to the resident; Evaluation of the resident s signs and symptoms to identify the underlying cause(s), including adverse consequences of medications; Selection and use of medications in doses and for the duration appropriate to each resident s clinical conditions, age, and underlying causes of symptoms;. 15 Key Requirements in F329 Use of non-pharmacological interventions, when applicable, to minimize the need for medications, permit use of the lowest possible dose, or allow medications to be discontinued; Monitoring of medications for efficacy and clinically significant adverse consequences; and Accurate and appropriate documentation, i.e., the resident s clinical record documents and communicates to the entire interdisciplinary team the basic elements of the care process. 16 Plante Moran Clinical Group

9 Key Requirements in F329 The guidance at F329 applies to all categories of medications, including antipsychotic medications. 17 F329 Clarifications per S&C: NH effective May 24, 2013 Restated the goal of the National Partnership is to optimize the quality of life and function by improving approaches to meeting all the needs of residents, especially those with dementia Described common practice to use various types of psychopharmacological medications to address behaviors without first determining the medical, physical, functional, psychological, emotional, psychiatric, social or environmental cause of the behaviors 18 Plante Moran Clinical Group

10 F329 Clarifications per S&C: NH effective May 24, 2013 Reiterated the medications used without clinical indication are likely to cause harm Concern that NHs, hospitals, ambulatory care use medications as a quick fix for behavioral symptoms or as a substitute for a holistic approach (thorough assessment of underlying causes of behaviors and individualized person-centered interventions Antipsychotics often prescribed for residents with dementia who have behavioral or psychological symptoms of dementia (BPSD) 19 Behavioral or Psychological Symptoms of Dementia (BPSD) The term used to describe behavior or other symptoms in individuals with dementia that cannot be attributed to a specific medical or psychiatric cause When drugs used without adequate rationale, little chance they will be effective and often cause complications, such as: Movement disorders, falls, hip fractures, CVAs or TIAs, and increased risk of death 20 Plante Moran Clinical Group

11 As a Result. Food & Drug Administration (FDA) Black Box Warnings Regarding Atypical Antipsychotics in Dementia Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at increased risk of death compared to placebo 21 More from the S&C and Surveyor Training Dementia Care Principles: includes an interdisciplinary approach with focus on the needs of the resident as well as the needs of the other residents in the nursing home: Person-Center Care Quality and Quantity of Staff Thorough Evaluation of New or Worsening Behaviors (BPSD) evaluation by the IDT, including the physician in order to identify and address treatable medical, physical, emotional, psychiatric, psychological, functional, social and environmental factors that may be contributing to behaviors 22 Plante Moran Clinical Group

12 More from the S&C and Surveyor Training Dementia Care Principles (continued) Individualized Approaches to Care Critical Thinking Related to Antipsychotic Drug Use Interviews with Prescribers Engagement of Resident and/or Representative in Decision-Making 23 Additions to F329 5/13 Antipsychotic Medications All classes, e.g., First generation (conventional) agents, e.g., chlorpromazine fluphenazine haloperidol loxapine mesoridazine molindone perphenazine promazine thioridazine thiothixene trifluoperazine triflupromazine Second generation (atypical) agents, e.g., asenapine (Saphris) aripiprazole clozapine iloperidone (Fanapt) lurasidone (Latuda) olanzapine paliperidone (Invega) quetiapine risperidone ziprasidone 24 Plante Moran Clinical Group

13 A Comparison of Antipsychotic Agents Antipsychotic Agent Dosage Forms Sedation (Incidence) Extrapyramidal Side Effects Anticholinergic Side Effects Orthostatic Hypotension Weight Gain Aripiprazole Abilify Solution; tablet; orally disintegrating tab; injection Atypical Antipsychotic Agents Low Low Very low Very low Very low Asenapine Tablet, sublingual Moderate Low Very low Low/ moderate Low Saphris Clozapine Tablet; tablet, orally Clozaril,Fazaclo High Very low High High High disintegrating Iloperidone Fanapt Tablet Low Low Very low Low/ moderate Low/ moderate Lurasidone Tablet Moderate Low/ Moderate Low Low Very Low Latuda Olanzapine Zyprexa Zyprexa Relprew Injection; tablet; orally disintegrating tab Injection, long-acting Moderate/ high Paliperidone Invega Tablet, extended release Low/ Invega Sustenna Injection, long-acting moderate Quetiapine Seroquel, XR Risperidone Risperdal Risperdal Consta Tablet; tablet, extended release Solution; tablet; orally disintegrating tab Injection, long-acting Moderate/ high Low/ moderate Ziprasidone Geodon Capsule; injection, powder Low/ moderate Traditional Antipsychotic Agents Low Moderate Moderate High Low Very low Moderate Low Very low Moderate Moderate Moderate Low Very low Moderate Low/ moderate Low Very low Low/ moderate Low Chlorpromazine Injection; tablet High Moderate Moderate Moderate/ high Fluphenazine Haloperidol Haldol Haldol Decanoate Solution, concentrate; injection; tablet Low High Low Low Injection, long-acting Solution, concentrate; injection; tablet Injection, long-acting Low High Low Low Loxapine Capsule Moderate Moderate Low Low Loxitane Perphenazine Tablet Low Moderate Low Low Pimozide Tablet Moderate High Moderate Low Orap Thioridazine Tablet High Low High Moderate/ high Thiothixene Capsule Low High Low Low/ moderate Navane Trifluoperazine Tablet Low High Low Low Woods SW, "Chlorpromazine Equivalent Doses for the Newer Atypicals," J Clin Psychiatry, 2003, 64(6): Source: Lexicomp Online ( October 2012 Contact us today to learn more about Remedi SeniorCare s pharmacy services and the most accurate, most efficient, most everything med pass ever! Remedi5 ( ) or visit Remedi SeniorCare. All rights reserved.

14 Additions to F329 Indications for Use Antipsychotic Medications Conditions other than dementia: Schizophrenia Schizo-affective disorder Schizophreniform disorder Delusional disorder Mood disorders (e.g., bipolar disorder, severe depression refractory to other therapies and/or with psychotic features Psychosis in the absence of dementia Medical illnesses with psychotic symptoms and/or treatment related psychosis or mania Tourette s Disorder Huntington s Disease Hiccups (not induced by medication) Nausea and vomiting associated with cancer of chemotherapy 25 Additions to F329 Indications for Use Antipsychotic Medications Behavioral or Psychological Symptoms of Dementia (BPSD) Use this guidance in conjunction with guidance at F309 Quality of Care, Review of Care and Services for a Resident with Dementia. Also consider F154 Right to be informed in advance about care and services; F155 Right to refuse treatment; and F280 Right to participate in planning care and treatment. Antipsychotics only appropriate for elderly residents in a small minority of circumstances (unless the antipsychotic is prescribed to treat previously diagnosed mental illness such as schizophrenia or possibly other conditions listed above). FDA warned healthcare professionals that both conventional and atypical antipsychotics are associated with an increased risk of death in elderly patients treated for dementia-related psychosis. 26 Plante Moran Clinical Group

15 F329 Inadequate Indications for Use Antipsychotic Medications Antipsychotic medications in persons with dementia should not be used if the only indication is one or more of the following: wandering poor self-care restlessness impaired memory mild anxiety insomnia fidgeting nervousness inattention or indifference to surroundings sadness or crying alone that is not related to depression or other psychiatric disorders uncooperativeness (e.g., refusal of or difficulty receiving care) One or more of these identified conditions alone does not warrant use unless the following criteria are met: The behavioral symptoms present a danger to the residents or others AND one or both: The symptoms are identified as due to mania or psychosis; OR Behavioral interventions have been attempted and included in the POC, except in emergency 27 F329 Additional Criteria: Acute Situations/Emergency Must meet the above criteria and all of the following additional requirements: 1. The acute treatment period is limited to 7 days or less; 2. A clinician in conjunction with the IDT must evaluate and document the situation within 7 days to identify and address any contributing and underlying causes of the acute condition and verify the continuing need for an antipsychotic medication 3. If the behaviors persist beyond the emergency, pertinent nonpharmacological interventions must be attempted, unless clinically contraindicated, and documented following the resolution of the acute psychiatric event. 28 Plante Moran Clinical Group

16 F329 Additional Criteria: Enduring Conditions Enduring = non-acute, chronic or prolonged Antipsychotic may be used if condition/diagnosis meets criteria in BPSD In addition, target behavior must be clearly and specifically identified and documented Monitoring must ensure that Not due to a medical condition or problem (e.g., pain fluid imbalance, infection, medication side effect) that can be expected to improve as underlying condition is treated or the offending medication is discontinued AND 29 Enduring Conditions (continued) Monitoring must ensure the behavioral symptoms Not due to a medical condition or problem (e.g., pain fluid imbalance, infection, medication side effect) that can be expected to improve as underlying condition is treated or the offending medication is discontinued AND Not due to environmental stressors alone (e.g., alteration in the resident s customary location or daily routine, unfamiliar care provider, hunger or thirst, excessive noise for that individual, inadequate or inappropriate staff response), that can be addressed to improve the symptoms or maintain safety; AND 30 Plante Moran Clinical Group

17 Monitoring Enduring Conditions and Must Not Be Due to (cont.) Not due to psychological stressors alone (e.g., loneliness, taunting, abuse), anxiety or fear stemming from misunderstanding related to his or her cognitive impairment (e.g., the mistaken belief that this is not where he/she lives or inability to find his or her clothes or glasses, unaddressed sensory deficits) that can be expected to improve or resolve as the situation is addressed; AND Persistent. There must be clear documented evidence in the medical record that the situation or condition continues or recurs over time (persists) and that other approaches that have been attempted have failed to adequately address the behavioral/psychological symptoms and that the resident s quality of life is negatively affected by the behaviors/symptoms as described above. 31 F329 Additional Criteria: New Admission Many residents admitted already on an antipsychotic. The facility is responsible for: Preadmission screening for mentally ill and intellectually disabled individuals, and; Obtaining physician s orders for the resident s immediate care Residents not requiring PASRR screening and admitted on an antipsychotic medication use of the antipsychotic medication must be reevaluated at the time of admission and/or within two weeks of admission (initial MDS) to consider whether or not the medication can be reduced or discontinued 32 Plante Moran Clinical Group

18 F329 Additional Criteria: Dosage/Duration Treatment should be at the lowest possible dose to improve the target symptoms being monitored. It is important to note that doses for acute indications (e.g. delirium or acute psychosis) may differ from those used for long-term treatment of various conditions. Table inserted as a general dosage guide Duration - Refers to Guidance Section V Tapering of a Medication Dose/Gradual Dose Reduction (GDR) 33 F329 Additional Criteria: Monitoring Important to not only evaluate ongoing effectiveness and potential adverse consequences, but also to evaluate the use of any other psychopharmacological medications (e.g. mood stabilizers, benzodiazepines) being given to the resident. Specifically, surveyors should review the record to determine whether the facility can explain the rationale for adding, or switching from an antipsychotic to another category (or categories) of psychopharmacological agents; otherwise, both may potentially be unnecessary medications. 34 Plante Moran Clinical Group

19 F329 Additional Criteria: Monitoring Surveyors should investigate further in cases where more than one antipsychotic agent has been prescribed. Surveyors should investigate further in cases where more than one antipsychotic agent has been prescribed, or where an antipsychotic has been discontinued and a medication such as a mood stabilizer has been added. 35 F329 Additional Criteria: Effectiveness After initiating or increasing the dose of an antipsychotic medication, the behavioral symptoms must be reevaluated periodically (at least during quarterly care plan review, but often more frequently, depending on the resident s response to the medication) to determine the effectiveness of the antipsychotic and the potential for reducing or discontinuing the dose based on target symptoms and any adverse effects or functional impairment. 36 Plante Moran Clinical Group

20 F329 Additional Criteria: Potential Adverse Consequences Assuring residents are adequately monitored for adverse consequences such as: General: anticholinergic effects (see Table II), falls, excessive sedation Cardiovascular: cardiac arrhythmias, orthostatic hypotension Metabolic: increase in total cholesterol and triglycerides, unstable or poorly controlled blood sugar, weight gain Neurologic: akathisia, neuroleptic malignant If any identified, facility must act 37 Key Principles of Avoiding Unnecessary Medications Does each medication have a clear indication? Is there documentation of a positive response? Are clinical staff monitoring for adverse effects? Is the drug being used at the lowest effective doe and is the need for continuing the medication being assessed at regular intervals? Are non-pharmacological interventions suggested and tried? Has the resident, family or designated decision-maker been informed of risks and benefits and concurs with treatment? 38 Plante Moran Clinical Group

21 Examples of Non-Pharmacological Interventions Increasing the amount of exercise, intake of liquids and dietary fiber to prevent or reduce constipation and the use of meds (laxatives, stool softeners) Determining causes of distressed behavior such as boredom and pain Sleep hygiene techniques Encouraging reminiscent lifelong work or activity patterns Individualized toileting schedules 39 Examples of Non-Pharmacological Interventions Develop interventions specific to resident s interest, abilities, strengths and needs Using massage, hot/warm compresses to address resident s pain or discomfort Enhancing taste and presentation of food, assisting the resident to eat, addressing food preferences and increasing finger foods and snacks for an individual with dementia, to improve appetite and avoid unnecessary use of medications to stimulate appetite 40 Plante Moran Clinical Group

22 Monitor Your Data Nursing Home Compare Compare facility QMs to state and national averages Use the graph function for a visual aid Remember QM values on NHC are a 3-quarter average and lag by 3 months Use the Five-Star provider preview reports Includes QM values for each quarter 3-quarter average, and the national comparison Generated typically on the 3 rd Thursday of each month 41 Monitor Your Data NHC Calculations: Measure: Percentage of Long-Stay Residents Who are Receiving Antipsychotic Medication Description: The percentage of long-stay residents (>100 cumulative days in the nursing facility) who are receiving antipsychotic medication Exclusions: Any of the following conditions are present on the target assessment (unless otherwise indicated): 2.1. Schizophrenia (I6000 = [1]) Tourette s Syndrome (I5350 = [1]) Tourette s Syndrome (I5350 = [1]) on the prior assessment if this item is not active on the target assessment and if a prior assessment is available Huntington s Disease (I5250 = [1]). Measure: Percentage of Short-Stay Patients Who Have Antipsychotics Started Incidence Description: The percentage of short-stay residents (<=100 cumulative days in the nursing facility) who have antipsychotic medications started after admission Exclusions 2. Any of the following related conditions are present on any assessment in a look-back scan: 2.1. Schizophrenia (I6000 = [1]) Tourette s Syndrome (I5350 = [1]) Huntington s Disease (I5250 = [1]) 42 Plante Moran Clinical Group

23 Surveyor Quality Measures Psychoactive Medication Use in the absence of Psychotic or Related Condition (LS) Exclusions: Schizophrenia Psychotic disorder Manic depression Tourette s Syndrome Huntington s Hallucinations Delusions At some point this QM will be replaced by Short stay Residents Who Newly Received Antipsychotic Medication 43 Survey Process Key elements for severity determination for F329 are as follows: 1. Presence of potential or actual harm/negative outcome(s) due to failure related to unnecessary medications 2. Degree of potential or actual harm/negative outcome(s) due to a failure related to unnecessary medications 3. The immediacy of correction required 44 Plante Moran Clinical Group

24 What Will Surveyors Expect? Will be looking more intensively at persons with dementia who are on antipsychotics Surveyor guidance has been revised with input from several professional associations (AHCA, Leading Age, AMDA, ASCP, NADONA, AAGP, AGS and others), advocates and other stakeholders Surveyors will include residents with dementia who are receiving an antipsychotic in their sample 45 What Will Surveyors Expect? Surveyors will look for the same systematic process that providers and practitioners should be using to determine the underlying causes of behaviors in persons with dementia Surveyors will look to see that care plans include plans for residents with dementia that address behaviors, include input from the resident (to the extent possible) and/or family or representative and that those plans are consistently carried out 46 Plante Moran Clinical Group

25 What Will Surveyors Expect? Surveyors are looking for a systematic process to be evident and for that process to be followed for every resident 47 Systematic Process Get details about the resident's behavioral expressions of distress (nature, frequency, severity, and duration) and the risks of those behaviors, and discuss potential underlying causes with the care team and family Exclude potentially remediable causes of behaviors (such as delirium, infection or medications), and determine if symptoms are severe, distressing or risky enough to adversely affect the safety of residents 48 Plante Moran Clinical Group

26 Systematic Process Try environmental and other approaches that attempt to understand and address behavior as a form of communication in persons with dementia, and modify the environment and daily routines to meet the person s needs Assess the effects of any intervention (pharmacological or non-pharmacological); Identify benefits and complications in a timely fashion; Adjust treatment accordingly 49 Systematic Process For those residents for whom antipsychotic or other medications are warranted, use the lowest effective dose for the shortest possible duration, based on findings in the specific individual Monitor for potential side effects - therapeutic benefit with respect to specific target symptoms/expressions of distress Inadequate documentation: Behavior improved. Less agitated. No longer asking to go home. 50 Plante Moran Clinical Group

27 Systematic Process Include specifics, why they behaviors were harmful/dangerous/distressing and what the person is now able to do (positive) as a result of the intervention Try tapering the medication when symptoms have been stable or adjusting doses to obtain benefits with the lowest possible risk 51 The Survey Process Input from nursing assistants, nurses, social workers, therapists, family and other caregivers working closely with the resident is essential; Input from all three shifts and weekend caregivers is also important in telling the story Surveyors will look at communication between shifts, between nurses and practitioners or prescribers 52 Plante Moran Clinical Group

28 The Survey Process Surveyors will also look at whether medications prescribed by a covering practitioner in an urgent situation are re-evaluated by the primary care team and discontinued when possible Surveyors will look at whether or not other psycho-pharmacologicals are prescribed if/when antipsychotic medications are discontinued or reduced 53 How can we reduce antipsychotic use in persons with dementia? Focus on each individual resident and use a careful, systematic process to evaluate his/her needs; This is what surveyors will be looking for During off-site preparation, surveyors will also review the antipsychotic rate in the nursing home; Surveyors will ask staff about the home s approach to persons with dementia 54 Plante Moran Clinical Group

29 How can we reduce antipsychotic use in persons with dementia? Consider forming a behavioral health committee or team for dementia care practices, or include in existing committee structure; Include the consultant pharmacist, medical director, administrator, director of nursing, recreational and other therapy staff, social worker, direct care partners/staff (CNAs) Include behavioral health specialists/consultants if possible Include resident, family members when policies/practices (not individuals) are being discussed 55 How can we reduce antipsychotic use in persons with dementia? Consider forming a behavioral health committee or team for dementia care practices, or include in existing committee structure; Include the consultant pharmacist, medical director, administrator, director of nursing, recreational and other therapy staff, social worker, direct care partners/staff (CNAs) Include behavioral health specialists/consultants if possible Include resident, family members when policies/practices (not individuals) are being discussed 56 Plante Moran Clinical Group

30 Use Medications Appropriately PROBING QUESTIONS Why is our use of antipsychotics high for individuals with dementia? Has the use of antipsychotics risen over the last three months? Is our use of antipsychotics more than the average for our state? How does our rate compare to the national average? Which groups are affected? a. Residents Are the individuals with dementia long stay or short stay? Are individuals on the same unit? Are residents on scheduled antipsychotics, as needed (PRN) antipsychotics or both? Do we discuss the use of anti-psychotics with residents and/or families and gain their consent for their use? b. Prescribers Do the prescriptions for antipsychotics come from the same prescriber or are there different prescribers? Are antipsychotics started outside of the nursing home (for example - hospital, outside consultant) or are the drugs started after people are in the nursing home? For those whose medications are started in the nursing home is there an assessment done prior to, or shortly after the initiation of an antipsychotic medication? Have there been conversations with the prescribers about reducing or stopping antipsychotics? Have there been any consulting pharmacist recommendations to reduce the antipsychotics and were these recommendations followed? Processes and Resources to Consider What practices do we have in place to minimize the use of antipsychotic medications? Is there an optimum number of staff and do staffing patterns support individualized, personcentered care? Does our staffing pattern provide for flexibility based on the number of persons with dementia, and/or the severity of their illness? Does our staffing pattern provide adequate coverage for crisis management? Is there adequate staff training on dementia and on understanding and responding to behavior as a means of communication? 30 1

31 Does support exist within the nursing home to change the utilization of antipsychotics? Do staff request antipsychotics prior to assessment of a resident? Do staff request antipsychotics prior to systematic attempts to identify and address unmet needs that may be triggering behavioral responses? Are there patterns of use? Are there clear and acceptable clinical rationale for use of medications? Are gradual dose reductions being conducted at our home? Are the medications being monitored by objective measures? If so, are the outcomes positive for the individual? Are the medications causing adverse effects for the resident and/or change in function? 2010 Advancing Excellence in Long Term Care Collaborative Advancing Excellence welcomes the use of any and all of its materials with appropriate attribution. Where such uses would alter 2 the original content or be used for profit, such users must notify Advancing Excellence and request permission to so. 31

32 Use Medications Appropriately LEADERSHIP FACT SHEET Advancing Excellence in America s Nursing Homes is a national campaign that began in September Our goal is to improve the quality of care and life for the 1.5 million people served by nursing homes in the United States. Nursing homes and their staff, along with residents and their families and consumers, can join in this effort by working on the campaign goals that are designed to improve quality. We do this by providing tools and resources to help nursing homes achieve their quality improvement goals. To learn more about the campaign, visit The appropriate use of medications is paramount in insuring the safety and well-being of residents in nursing homes. Almost any medication use could potentially be considered inappropriate if used in the wrong way, such as, being prescribed for too long a period of time, for the wrong reason, or in excessive doses. One class of medications that is frequently misused is antipsychotic medications. CMS has announced an initiative to reduce the inappropriate use of antipsychotic medications in nursing homes with their Partnership to Improve Dementia Care. As part of this initiative CMS has also released the Hand in Hand Training series, which has been free of charge to all nursing homes. This fact sheet will highlight different aspects when evaluating antipsychotic use within your facility. What are antipsychotic medications? Antipsychotic medications are drugs used to treat symptoms of serious mental and emotional disorders such as schizophrenia or bi-polar disorder. Their use affects thinking and behavior by altering chemical substances in the brain. When prescribed properly these medications can help a person to think more clearly and take part in everyday life. Examples of antipsychotic medications include risperidone (Risperidol), quetiapine (Seroquel) and haloperidol (Haldol). Antipsychotic drugs are not approved to treat people with Alzheimer s disease and other dementias, including people who have dementia related psychosis. Why is reducing the inappropriate use of antipsychotic medications important? Nursing home leaders are charged with making sure that their residents receive appropriate care to prevent or minimize the symptoms or behaviors associated with mental illness, or dementia. When antipsychotics are prescribed to quiet a resident or for staff convenience, it could be considered a chemical restraint. The use of chemical restraints is prohibited by federal law. A skilled nursing facility is required to provide services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, in accordance with a written plan of care. (Social Security Act, Section 1819(3)(b)(2)) In addition, antipsychotics have been shown to have possible adverse effects on the residents daily activities and quality of life. They can also contribute to and cause falls, metabolic disturbances, weight gain or loss, confusion as well as the associated increased incidence of heart attack and stroke. There is heightened scrutiny during the annual survey with regards to use of anti-psychotics; consumers looking for a nursing home may also evaluate your home based on the Quality Measures on anti-psychotic use. 32 1

33 Are there times when the use of antipsychotics may be appropriate and beneficial? When the individual poses a serious threat to herself or others, short term use of antipsychotics may be appropriate. Care planning should always include resident centered nonpharmacologic interventions and if antipsychotics are indicated they should be carefully monitored. If used appropriately, with informed consent and individualized care planning, nursing home residents may be better able to participate fully in care, translating into a safer environment. How can nursing home leaders prevent the unnecessary use of antipsychotics? Various leadership techniques can support and promote care that prevents the unnecessary use of antipsychotics. Following are a few suggestions based on successful practices. Increase staff training: Provide educational opportunities for all staff regarding assessment and management of behavior in ways that don t require medications or at least minimize their use; Teach staff to recognize nonverbal signs of pain or unmet need, especially in residents with dementia, as these may be contributing to the behaviors; Teach staff the importance of documenting care, particularly the use of non-pharmacological, person-centered approaches to individuals with dementia. Promote a person-centered culture: Build your systems including staffing adjustments to promote activity and meal schedules based on the preferred schedule of residents; Develop policies that direct the staff to identify resident-specific needs, optimize choices, and promote consistent assignment so that staff knows residents well enough to meet their specific care needs; Recognize staff that excel in assessment and creative management of behavioral problems; Promote communication and teamwork among all levels of staff; for example, include direct care staff who know the resident best in care planning meetings. Quality Assurance: Have the medical director work closely with an interdisciplinary team composed of nursing, social services, therapeutic recreation specialist and a pharmacist to monitor the use of antipsychotics; Use the medical director to communicate between the interdisciplinary team and attending physicians to enhance information transfer, improve attending physician awareness of standards of care and regulatory expectations and monitor compliance. Require and document informed consent when antipsychotics are considered; Use the Advancing Excellence Medication tool when evaluating antipsychotic use. For instance, evaluate the incidences of prescribers failing to provide a relevant rationale for using an antipsychotic; Ensure chart reviews that monitor when an antipsychotic medication is prescribed indefinitely (for months or more) without any attempts to reduce or discontinue it; When the resident is not improving or is experiencing burdensome side effects from antipsychotic medications, it is the responsibility of care leaders to assure alternatives to antipsychotic medications are evaluated and implemented as appropriate for the individual. Where can you get more facts about the appropriate use of antipsychotic? Find information to improve the appropriate use of antipsychotic medications throughout the nursing home at Advancing Excellence in Long Term Care Collaborative 2 Advancing Excellence welcomes the use of any and all of its materials with appropriate attribution. Where such uses would alter the original content or be used for profit, users must notify Advancing Excellence and request permission to do so. 33

34 How can we reduce antipsychotic use in persons with dementia? Begin by looking at each resident with dementia who is on an antipsychotic and considering the case in detail; Look for underlying causes of the behavior; Consider whether a gradual dose reduction may be indicated and communicate with the practitioner; Engage your medical director and consultant pharmacist Tools are on Advancing Excellence website; National experts are available 57 F329 Investigative Protocol Objectives Determine that each resident provided: Only medications clinically indicated in dose and duration to meet assessed needs Non-pharmacological approaches when indicated in an effort to reduce the need for a dose of medication GDR attempts for antipsychotics (unless clinically contraindicated) 58 Plante Moran Clinical Group

35 F329 Investigative Protocol Objectives to determine that facility in collaboration with the prescriber: Identifies parameters for monitoring medications that pose a risk of adverse consequences and monitoring for effectiveness Recognizes and evaluates onset or worsening of signs or symptoms, or a change in condition to determine whether these potentially may be related to the medication regimen; and follows-up as necessary upon identifying adverse consequences 59 F329 Investigative Protocol Objectives to determine if the pharmacist: Performed monthly medication regimen review, and identified any existing irregularities regarding indications for use, dose, duration, and potential for, or the existence of adverse consequences or other irregularities; and Reported any identified irregularities to the attending physician and director of nursing 60 Plante Moran Clinical Group

36 F329 Investigative Protocol Observation and Record Review Interview: Resident and or family/responsible party to determine their participation; and alternative approaches discussed; their evaluation of the results of the drug therapy Medication Regimen Review to determine whether facility and practitioner acted on the report of any irregularity 61 Determination of Compliance For a resident who has been, or is, receiving medication(s), the facility is in compliance if they, in collaboration with the prescriber: Assessed the resident to ascertain, to the extent possible, the causes of the condition or symptoms requiring treatment, including recognizing, evaluating, and determining whether the condition or symptoms may have reflected an adverse medication consequence; 62 Plante Moran Clinical Group

37 Determination of Compliance Based on the assessment, determined that medication therapy was indicated and identified the therapeutic goals for the medication; Utilized only those medications in appropriate doses for the appropriate duration, which are clinically necessary to treat the resident s assessed condition(s); 63 Determination of Compliance Implemented a gradual dose reduction and behavioral interventions for each resident receiving antipsychotic medications unless clinically contraindicated; Monitored the resident for progress towards the therapeutic goal(s) and for the emergence or presence of adverse consequences, as indicated by the resident s condition and the medication(s); and Adjusted or discontinued the dose of a medication in response to adverse consequences, unless clinically contraindicated. If not, cite F Plante Moran Clinical Group

38 Determination of Compliance The update provides additional examples regarding the difference between compliance and non-compliance at severity levels 4, 3, and 2 Survey readiness help also available by reviewing the QIS Critical Elements for Unnecessary Medications _Unnec_Med_CE_ pdf 65 Questions?? Submit questions by dialing #6 to unmute the phone line After asking question, hit *6 to mute the phone line again 66 Plante Moran Clinical Group

39 Ideas for the next series? Evaluation Forms Sign-in Sheet Audio Order Form Preferably TODAY, but no later than 1 week from today For a great 2013 MDS 3.0 Long Distance Learning Series 67 Thank you. Jane Belt Plante Moran Clinical Group jane.belt@ 68 Plante Moran Clinical Group

40 Resources CMS MLN Connects National Provider Calls Education/Outreach/NPC/National-Provider-Calls-and-Events- Items/ Dementia-NPC.html CMS S&C: NH: Advanced Copy: Dementia Care in Nursing Homes Certification/SurveyCertificationGenInfo/Downloads/Surveyand-Cert-Letter pdf Surveyor Training Resources Remedi SeniorCare web site Innovative Solutions 70 Plante Moran Clinical Group

41 71 72 Plante Moran Clinical Group

42 73 Resources Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homes s1n2.pdf 74 Plante Moran Clinical Group