Improving Dementia Care in Nursing Homes Through Best Care Practices

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Star Rated by US Govt. Copyright 2012 Morris J. Kaplan.

1 Improving Dementia Care in Nursing Homes Through Best Care Practices Morris J. Kaplan, Esq., NHA President, Kaplan Health Management, LLC Operating Partner, Gwynedd Square Nursing Center 5 Star Rated by US Govt. Copyright 2012 Morris J. Kaplan. All rights reserved. 773 Sumneytown Pike Lansdale, PA

3 Black Box Warning Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. between 1.6 to 1.7 times the risk of death most either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia).

4 American Psychiatric Association Doctors: Anti-psychotic meds overused for dementia, kids * \ *USA TODAY - September 23, 2013 Anti-psychotic medications should not be the first treatments doctors or patients think of when dealing with dementia in an elderly person, behavior problems in a child or insomnia in an adult. (C) Copyright 2013, 2012 by Morris J. Kaplan. All Rights Reserved.

5 American Psychiatric Association & American Medical Directors Association Don t prescribe antipsychotic medications for behavioral and psychological symptoms of dementia (BPSD) in individuals with dementia without an assessment for an underlying cause of the behavior. (C) Copyright 2013, 2012 by Morris J. Kaplan. All Rights Reserved.

6 Report by Office of Inspector General US Department of Health and Human Services 83% (1,197,442) of atypical antipsychotic drug claims were for elderly nursing home residents diagnosed with conditions for which the drugs use was not approved by FDA (i.e., the drugs were used off-label). 88% (1,263,641) were for residents diagnosed with dementia. May 2011 Department of Health and Human Services, Office of Inspector General (C) Copyright 2013, 2012 by Morris J. Kaplan. All Rights Reserved.

Record Penalties (or just a cost of doing business?) January 2009 drug company Eli Lilly & Co. agreed to pay $1.4 billion to resolve allegations of off-label promotion of the anti-psychotic Zyprexa.

7 Record Penalties (or just a cost of doing business?) January 2009 drug company Eli Lilly & Co. agreed to pay $1.4 billion to resolve allegations of off-label promotion of the anti-psychotic Zyprexa. November 2009 Omnicare pays US $98 million settlement to resolve allegations that it received kickbacks to recommend drugs, including Risperdal (an atypical antipsychotic), for use in nursing homes. May 2012 Abbott Laboratories settled for $1.6 billion over its marketing of the anti-seizure drug Depakote July 2012 Glaxo Agrees to Pay $3 Billion in Fraud Settlement improper marketing of drugs July 2012 Johnson and Johnson Ordered to Pay $2.2 Billion in Risperdal Settlement August 2012 Johnson and Johnson subsidiary Janssen Pharmaceuticals, Inc. agrees to $181 Million Settlement of Off-Label Drug Marketing Allegations.

8 Goal: To reduce the use of antipsychotics in residents with dementia It s over 26 years since the Nursing Home Reform Act of 1987! More than a quarter century has passed since the start of the campaign to end physical and chemical restraints in nursing homes. (C) Copyright 2013, 2012 by Morris J. Kaplan. All Rights Reserved.

10 The Wall Street Journal August 26, 2013 by Lucette Lagnado Effort to reduce use of antipsychotic drugs falls short of goal $7.6 billion spent by Medicare Part D on antipsychotics in 2011 In 2011, the Inspector General 88% of the time, the drugs had been prescribed to patients suffering from dementia a situation he later said was "potentially most alarming.

17 Key: To make people feel good and happy about themselves Use individualized, person-centered care practices Make people with dementia feel happy and good about themselves Reduce the incidence of significant behavioral symptoms Reduce the need for antipsychotic, antianxiety and hypnotic drugs Reduce the risk of falls (C) Copyright 2013, 2012 by Morris J. Kaplan. All Rights Reserved.

Pharmacological Approaches to Behavioral Symptoms Antipsychotic medication can be appropriate when using the lowest possible dose of medication, for the shortest possible duration, helps to maintain

18 Pharmacological Approaches to Behavioral Symptoms Antipsychotic medication can be appropriate when using the lowest possible dose of medication, for the shortest possible duration, helps to maintain the resident s highest level of psychosocial & physical well being. Interdisciplinary communication is critical to insure that the resident is functioning at his/her highest level. (C) Copyright 2013, 2012 by Morris J. Kaplan. All Rights Reserved.

19 Basic Prerequisites for Good Care Leadership ownership & management must be active & involved; board, corporate executives, Administrator, DON Quality improvement comes from the top down. Adequate Staffing with consistent assignments ratio of CNAs to residents by shift: 1 st shift 1:8 2 nd shift 1:9 3 rd shift 1:16 Interdisciplinary Communication that includes the resident and/or family representatives (to the extent possible) Adequate Medicaid Rates (also, Medicare) (C) Copyright 2012 by Morris J. Kaplan. All

20 Gwynedd Square Nursing Center, Lansdale, PA 75% Medicaid 181 beds for profit not part of a chain family owned & operated since 1980 (C) Copyright 2013, 2012 by Morris J. Kaplan. All Rights Reserved.

21 Key to managing behavioral symptoms: Helping to guide confused residents through their day by keeping them active, engaged and monitored in level-appropriate activities & dining programs. (And also letting them take naps whenever they want to). (C) Copyright 2013, 2012 by Morris J. Kaplan. All Rights Reserved.

22 Individualized Activity & Dining Programs at Gwynedd Square Offer 5, level-appropriate, activity programs Employ 11 activity staff members for approximately 181 residents (All activity staff are trained to assist residents, as needed, with meals.) Provide 3 different dining programs for lunch & dinner A resident can be kept active, engaged and monitored in levelappropriate activity and dining programs for much of the day. (C) Copyright 2013, 2012 by Morris J. Kaplan. All Rights Reserved.

23 Activity Programs Friendship Club early stage dementia Sunshine Club late stage dementia Rising Stars Program high fall risk, late stage dementia Korean Elders Program includes 41 out of 181 residents Alert & Oriented Group and whole community functions (C) Copyright 2013, 2012 by Morris J. Kaplan. All Rights Reserved.

29 At later stages of life, people with dementia require assistance with eating. Without help eating, these people will lose weight. If you help people with dementia to eat, they are much less likely to lose weight. Key: Eating at the resident s own pace and arranging the staff schedule to fit the pace of the residents. (C) Copyright 2013, 2012 by Morris J. Kaplan. All Rights Reserved.

34 Dining Programs (60-90 minutes) Main Dining Room independent dining -- includes some total assist tables Lunch Bunch & Supper Club early & middle stage dementia -- enabling residents with memory impairment through cueing, directing and assisting Lakeside Dining Program late stage dementia/cva -- total feeding assistance (C) Copyright 2013, 2013 by Morris J. Kaplan. All Rights Reserved.

Lakeside Dining Program total feeding assistance (C)

39 the substitute for seroquel Keeping people active, engaged and monitored throughout the day through activity programming + specialized dining programs. (C) Copyright 2013, 2012 by Morris J. Kaplan. All Rights Reserved.

40 Behavioral symptoms can be observed, anticipated, redirected and minimized, and the use of antipsychotic medication can be reduced or avoided. (C) Copyright 2013, 2012 by Morris J. Kaplan. All Rights Reserved.

41 Best Practices Required for a Successful Program to Reduce Antipsychotic Use: At admission information is obtained from the family on resident s preferences/routine/major life experiences/positive interventions. The information obtained at admission on resident s preferences/routine/positive interventions, etc. is conveyed in person (not simply in writing) on the day of admission by admissions or social service staff to the resident s direct care nurse and CNA(s). CNA to Resident Ratio 1 st shift nd shift rd shift 1-16 Facility has permanent assignments (same CNA to same resident 5 days/week). Administrator & DON regularly attend care plan meetings. Family is strongly encouraged to attend either in person or by speakerphone. Administrator & DON review monthly Facility Quality Measures Report from CMS and use it to identify residents with poor outcomes who need improved or different care interventions. (C) Copyright 2012 by Morris J. Kaplan. All Rights Reserved.

42 Best Practices Required for a Successful Program to Reduce Antipsychotic Use: Administrator & DON review pharmacy consultant s report quarterly (with pharmacy consultant, medical director). Each month, Administrator & DON use Quality Measures report, along with the pharmacy consultant report, to identify residents appropriate for possible reduction/elimination of antipsychotics. Administrator & DON together with family and care plan team are involved in the process to find effective interventions to address behavioral symptoms. The facility provides at least two different level activities programs twice daily (one for higher functioning residents and one for lower functioning residents). Key Performance Indicator: Monthly Facility Quality Measure Report - percentage of residents on antipsychotics & comparison to state and national averages (C) Copyright 2012 by Morris J. Kaplan. All Rights Reserved.

Psychotropic Medication. Including Role of Gradual Dose Reductions

Psychotropic Medication. Including Role of Gradual Dose Reductions Psychotropic Medication Including Role of Gradual Dose Reductions What are they? The phrase psychotropic drugs is a technical term for psychiatric medicines that alter chemical levels in the brain which