12/17/2012. Unnecessary Drugs

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1 Nursing Home Social Work Webinar Series December 19, 2012 Dr. Robin P. Bonifas, PhD, MSW Arizona State University School of Social Work Importance of familiarity with psychotropic medication regulations. Review of key federal regulations and interpretive guidelines associated with psychotropic medications: F tag 329: Unnecessary drugs F tag 330: Antipsychotic drugs, specific conditions F tag 331: Antipsychotic drugs, dose reductions Care planning guidelines for psychotropic medications Questions and discussion 1 2 Psychotropic medications are a common adjunct to behavioral interventions in skilled nursing facilities (SNFs). The use of such medications in SNFs is highly regulated. When social services personnel are aware of these regulations, they can play key roles in enabling facilities to maintain regulatory compliance in conjunction with advocating for quality resident care. Your administrator or director of nursing should have a copy you can reference. If not, order from the American Health Care Association Unnecessary Drugs Each resident s drug regimen must be free from unnecessary drugs. An unnecessary drugs is any drug when used: In excessive dose (including duplicated therapy); or For excessive duration; or Without adequate monitoring; or Without adequate indications for its use; or In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or Any combinations of the reasons above

2 The goals of these regulations and guidelines are to: Stimulate appropriate differential diagnosis of behavioral symptoms so the underlying cause of the symptoms is recognized and treated appropriately. Prevent the use of psychopharmacological drugs when the behavioral symptom is cause by conditions such as: Environmental stressors Psychosocial stressors Treatable medical conditions Types of psychotropic medications to be familiar with: Benzodiazepines Anxiolytics/Sedatives Hyponotics Antipsychotics See the handout for example listings of these medications. 7 8 Should not be used unless a shorter acting benzodiazepine has failed. After a shorter acting benzodiazepine has failed, longer acting benzodiazepine should not be used unless 9 Evidence exists that other possible reasons for the resident s distress have been considered and ruled out. Its use results in maintenance or improvement in the resident s functional status. Daily use is less than four continuous months unless an attempt at gradual dose reduction is unsuccessful; and Its use is less than or equal to the total daily dose listed in The Long Term Care Survey unless contraindicated. 10 Use for purposes other than sleep induction should only occur when: Evidence exists than other possible reasons for the resident s distress have been considered and ruled out. Use results in a maintenance or improvement in the resident s functional status. Daily use is less than four continuous months unless an attempt at gradual dose reduction is unsuccessful (Twice within one year). 11 Use is for one of the following indications: Generalized anxiety disorder Delirium, dementia, and amnesic and other cognitive disorders with associated agitated behaviors, which Are quantitatively and objectively documented, Are persistent and not due to preventable reasons, Constitute sources of distress or dysfunction to other residents, or Represent a danger to the resident or others. Panic disorder Symptomatic anxiety that occurs in residents with another diagnosed psychiatric disorder.e is equal to or less than doses listed in Guidance to Surveyors, (see pp 316) unless contraindicated. 12 2

3 Drugs for sleep induction (hypnotics) should only be used if: Evidence exists that other possible reasons for insomnia have been ruled out. The use of a drug to induce sleep results in the maintenance or improvement of the resident s functional status. Daily use of the drug is less than ten continuous days unless an attempt at gradual dose reduction is unsuccessful (3 times within 6 months). is equal to or less than doses listed in Guidance to Surveyors, (see pp 318) unless contraindicated. Dosage limitations exist for use in delirium, dementia, and amnesic and other cognitive disorders unless contraindicated; see The Long Term Care Survey. Monitoring required for the following adverse effects: Tardive dyskinesia Postural hypotension Cognitive/behavioral impairment Akathisia; Parkinsonism Examples of documentation supporting use outside of guidelines when it is in the resident s best interest: Physician s note documenting why dose and duration is clinically appropriate. Medical or psychiatric consultation that supports physician s judgment. Documentation that resident is being monitored for adverse consequence. Documentation that previous dose reduction attempts have been unsuccessful. Documentation showing resident s improvement or maintenance of function while taking the medication. Antipsychotic Medications, Specific Conditions 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. Should not be used unless the clinical record documents that the resident has one or more of the following specific conditions : Schizophrenia Schizoaffective disorder Delusion disorder Psychotic mood disorder Acute psychotic episodes Brief reactive psychosis Schizophreniform disorder Atypical psychosis Tourette s disorder Huntington s disease

4 Antipsychotic drugs should not be used unless the clinical record documents that the resident has one or more of the following specific conditions : Delirium, dementia, amnesic and other cognitive disorders with associated psychotic and/or agitated behaviors Which have been quantitatively and objectively documented Which are persistent Which are not caused by preventable reasons Which are causing the resident to: Present a danger to himself/herself or to others, or Continuously scream, yell, pace if these specific behaviors cause impairment in functional capacity, or Experience psychotic symptoms which cause the resident distress or impairment Antipsychotic drugs should not be used if one or more of the following is/are the only indication: Wandering Poor self care Restlessness Impaired memory Anxiety Depression (without psychotic features) Insomnia Unsociability Indifference to surroundings Fidgeting Nervousness Uncooperativeness Agitated behaviors which do not represent danger to the resident or others Antipsychotic Drugs, Dose Reductions 21 Residents who take antipsychotic drugs must receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Dose reductions are clinically contraindicated when: Resident has specific condition (slide 18) with a history of recurring symptoms. Resident has organic mental syndrome (i.e. dementia) and a gradual dose reduction has been attempted twice in one year resulting in return of symptoms. The physician provides justification for continued use of the drug 22 Physician s justification must include: Diagnosis with description of symptoms Discussion of the differential psychiatric and medical diagnosis (i.e. why behavioral symptoms are thought to be related to dementia rather than underlying physical pain or some other stressor). Description of the justification for the choice of a particular treatment Discussion why the present dose is necessary to manage the resident s symptoms. Information can be located throughout the resident s medical record, not necessarily in just one progress note (see slide #15)

5 Problem Statement (See handouts) Statement of general problem or concern In relationship to diagnosis List specific symptoms the resident is experiencing Note complicating factors conditions or issues that exacerbate the primary problem Measurable goals Approaches and interventions Requires stating problems and goals clearly. What is wrong with the following problem and goal? Alteration in behavior due to agitation GOAL Episodes of agitation will decrease A better example Alteration in behavior related to agitation as evidenced by continuous yelling Help me!, wringing hands, and distressed facial expression with inability to express specific needs. GOALS 1. Episodes of continuously yelling Help me! will not occur during meals. 2. Will not have episodes of wringing hands for 30 minutes following 1 on 1 supportive visit. 3. Will display relaxed facial expressions for 30 minutes following 1 on 1 supportive visit. How effective is the following problem and goal statement? Alteration in mood as evidenced by daily episodes of anxiety during care and treatment. GOAL Episodes of anxiety will decrease to one time a week or less Define anxiety. Define daily. What is care and treatment? A more specific and measurable example: GOAL 29 Alteration in mood with anxiety as evidenced by crying, fearful statements, repetitive questions, and trembling during care and treatment associated with genital area. Episodes of anxiety (as defined in problem statement) will decrease to one time a week or less within one month. 30 5

6 Specify what the entire team is doing to address the problem and achieve the goal(s). Include interventions for: Licensed Staff, i.e. Rule out pain when resident is calling out CNAs, i.e. Approach from the left, resident has low vision in right eye Social Services Activities Mental Health All Staff Include the psychotropic medication as one of the interventions, but list it last; include monitoring side effects and link the medication to specific care plan goals (see example care plan). Individualized approaches that address specific interventions that are effective for the particular resident. Consider information obtained from the following sources: Social history/ assessment Family interview CNA input Mental Health/ Social Services recommendations Example: A resident who enjoyed cooking might be redirected by looking at cookbooks or recipe cards Utilize the MDS to help identify the basic problem and build from there by specifying exact symptoms for the resident: Example: for being short tempered and easily annoyed on section D0500 J (Mood the PSQ 9), specify what the resident does and in what context:...as evidenced by ongoing critical comments toward peers during meals and activities, such as Can t you do anything right? Utilize the social history/ assessment, activity preferences, daily preferences, and customary routine (MDS section F) to enhance individuality of the care plan. Integrate monitoring and quantifying of behavioral symptoms as required per psychotropic drug regulations via: Listing goals that reflect the target behaviors the psychotropic medication is intended to treat. To limit the number of goals, select the most problematic symptoms and address those. Then, monitor episodes of target behaviors listed in the goals (See example care plan) Example A resident is receiving zyprexa 5.0 mg qhs for treatment of dementia with psychosis AEB visual hallucinations of bugs on the floor and in the bed. Goal: Episodes of visual hallucinations of bugs on the floor or in the bed will decrease to zero by 3 months. Monitor: Document number of episodes resident has visual hallucinations of bugs on the floor or in the bed. Example care plan Behavioral monitoring tools

7 Partner with your multidisciplinary team to: Update your residents care plans to align with psychotropic medication regulations. Review your residents medical records to ensure compliance with psychotropic medication regulations. Keep the following in mind 37 Mastering the content of the psychotropic regulations can be overwhelming! Don t attempt to master all of this content at once. Don t try to assure that all of your residents care plans are completely in compliance in all areas simultaneously. Start with one aspect and review and revise charts as the quarterly MDS becomes due. I would suggest beginning with antipsychotics since CMS is currently focused on reducing usage of these medications. 38 Questions and 39 7

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