Achieving Success in Reducing Inappropriate Use of Antipsychotic Medication in Patients with Dementia Amy J. Osborn, NHA, PMP Executive Director, Health Services Advisory Group (HSAG) Rick Foley, PharmD, CPh, CGP, FASCP, BCPP Clinical Professor of Geriatrics, University of Florida College of Pharmacy President, Florida Chapter - American Society of Consultant Pharmacists Maureen Brown, MSN, MBA, HCM Administrator, Miami Shores Nursing and Rehab Center August 10, 2016 OBJECTIVES Examine the potentially inappropriate use of antipsychotic medication in patients with dementia Integrate interventions to reduce the inappropriate use of antipsychotic drugs in patients with dementia Learn the key elements to include in an antipsychotic medication reduction QAPI plan 2 NATIONAL PARTNERSHIP TO IMPROVE DEMENTIA CARE Amy Osborn NHA, PMP Executive Director, Health Services Advisory Group (HSAG) https://www.cms.gov/medicare/provider Enrollment and Certification/SurveyCertificationGenInfo/National Partnership to Improve Dementia Care in Nursing Homes.html 3 1
GOAL FOR 2016: 30% OR GREATER REDUCTION What is your current rate? What percentage reduction has your center achieved? 4 Let s Compare! Partnership Results Florida Q4 2011 Q4 2015 Florida 24.5 16.9 Reduction of 31.1% Nation 23.9 17.0 Reduction of 28.8% Florida National Rank 35 of 51 26 of 51 5 IMPROVING CARE AND QUALITY OF LIFE FOR PATIENTS WITH DEMENTIA IN LONG- TERM CARE Rick Foley, PharmD, CPh, CGP, FASCP, BCPP Consultant Pharmacist Omnicare Clinical Professor of Geriatrics UF College of Pharmacy President Florida Chapter American Society of Consultant Pharm 6 2
The Pharmacist s Perspective First do no harm The regulations Trends in the field Recognizing prescribing patterns that lead to antipsychotic (AP) use 7 First Do No Harm EPS 1 in 10 patients taking olanzapine, 1 in 20 with risperidone CVA 1 in 34 patients taking risperidone During 10 12 week trials, 1 out of every 100 patients taking an atypical AP died www.cms.gov accessed October 2015 24 Conventional and atypical antipsychotics appear to increase the risk of hospitalization for femur fracture in a population of institutionalized elderly patients. These medications should be used with caution, especially among patients with a high risk of falls Journal of Clinical Psychiatry 2007, 68 (6): 929 34 Atypical antipsychotic drugs may be associated with a small increased risk for death compared with placebo JAMA: 2005 October 19, 294 (15): 1934 43 increase the risk of hospitalization The studies have also shown, however, a greater risk of mortality and adverse cerebrovascular events with several of these agents than with placebo in individuals with dementia Harv Rev Psychiatry. 2005 Nov Dec;13(6):340 51. increased risk for death Our findings suggest that many older people with Alzheimer's dementia and NPS can be withdrawn from chronic antipsychotic medication without detrimental effects on their behaviour Neuropsychopharmacology. 2008 April ; 33(5): 957 970. doi:10.1038/sj.npp.1301492. Among patients continuing phase 1 treatment at greater 12 weeks, risk there of mortality were no significant differences between antipsychotics and placebo on cognition, functioning, care needs, or quality of life American Journal of Psychiatry 2008, 165 (7): 844 54 3
F329 Unnecessary Drugs New concept May 2013 Individualized, person centered approaches that may help reduce potentially distressing or harmful behaviors and promote improved functional abilities and quality of life for residents Bottom line APs can only be used after ALL other causes of behavior have been ruled out 10 F329 - continued Requirements when using APs Diagnosis Target behaviors quantitative documentation each shift; specific guidance on TBs Dose limitations, unless documented rationale is present Daily monitoring of side effects Assessment of movement side effects at least every 6 months GDR twice within first year, in two separate quarters and separated by at least 1 month Contraindication requires significant rationale 11 Quarter 4-2015 CMS National Partnership for the Treatment of Dementia Initial antipsychotic use reduction set at 15% for 2012 National average reduction 15.1% New goal set to reduce by 25% by the end of 2015 and 30% by the end of 2016 Florida 31.1% (Q4 2015) Reinforces the concept of non pharmacologic approaches ALL regions achieved goal As of Q4 2015, Florida ranks 26th of 50 states + District of Columbia; Mississippi 51st at 20.5% Hawaii ranked #1 at 7.6% with a 39.3% reduction www.cms.gov 28 4
Trends In The Field Microdosing of Quetiapine Potent binding and antagonism of H 1 and α 1 receptors Sedation, orthostasis, weight gain Side effects may be enhanced at low doses 25mg QHS for dementia sleep? 25mg QHS and my patient is falling! Blanket contraindication statements Preprinted progress notes Staff pushback on GDR despite documentation 13 Other Patterns Justifying admission orders Newly diagnosed schizophrenia at age 95? Benadryl from home? Must be itching, at HS Disregard of the geriatric demographic Ignoring ongoing prescribing cascades 14 Prescribing Cascades and Aps: A Real World Example New resident w/ dementia agitated MD called Behaviors become constant, patient moved to locked unit Resident is now disinhibited and falls Given 3x PRN Xanax New order for risperidone for BPSD Pt develops tremor PD diagnosed Sinemet ordered Midodrine ordered TID 3 weeks of behaviors Resident naps due to sedation Postural HA Sxs worsen Psychiatry consulted GDR clinically CI Risperdal increased 15 5
Prescribing Cascades Common Issues Limited information for practitioners Assuming disease manifestation Broad strokes with blank check orders Underestimation of drugs side effect potential and severity anticholinergic load Overestimation of efficacy of behavior meds prescribed Lack of zero budgeting drug regimen evaluation A method of prescribing in which medications must be justified for each new period. Zero based budgeting starts from a zero base and every treatment, goal of therapy, and expected and realistic patientfocused outcome, is analyzed for its appropriateness and risk benefit profile 16 Non Pharmacologic Approaches To Behaviors Avoid confrontation Remove environmental triggers Create calm, quiet environment (offer gentle help) Structure daily routine Address pain, discomfort Use aromatherapy Use scheduled or prompted toileting AMDA Multidisciplinary Medication Management Manual, American Medical Directors Association, March 2011 17 Antipsychotic Reduction Miami Shores Nursing and Rehabilitation Center Maureen Brown, RN, MSN, MBA Administrator 6
An Administrator s Approach Why should you take on this effort? Identify strategies that made our efforts successful What specific Interventions were implemented and integration with QAPI program Discuss the time it took accomplish our success Discuss some barriers faced and how we overcame them What are the actual facility wide results of the reduction Discuss the impact on the quality of life of our residents 2012 Facility Long-Term Quality Measure Rate 94% for antipsychotic medication utilization making the facility #1 in Florida. 20 Strategies that Made Our Efforts Successful Utilizing a Interdisciplinary Team Care Meetings Communication Champions of Care/Peer Coaches Support and Resources from FHCA & HSAG Involvement of Pharmacy 7
Integration Of Interventions In QAPI Program Tools used in QAPI program Plan Do Study Act Model Root Cause Analysis Assessments MDS data Consistent Assignment Person Centered Individualized Care Staff Education and Cross Training Music Therapy and Variety of Activities Examples Of Tools Used Examples of Tools Used (continued) 8
Examples of Tools Used (continued) How can we keep it going? Should we try a new plan? Did it work? What is our data? Act Plan PDSA Study Do What are we doing now? Is it a big problem? What can we try? Let s try our plan. Barriers Faced Physician cooperation and education Family cooperation and education Staff motivation/staff burn out Dealing with admissions and readmissions Alternatives options Staff turnover/staffing for individualized care Solutions That Worked To Maintain Reduced Antipsychotic Rates Must have designated gatekeeper addressing admissions (pre admission interviews with family) Your direct care staff needs assistance at the point of care so peer coaching is a great idea. Staffing has to be flexible based on care needs Take and interdisciplinary approach cannot be done by the nursing department only. Must educate all providers especially the physicians Person Centered Individualized Care 27 9
Long-term Care (LTC) Residents taking Antipsychotic Medications/Off-Label Use 30 25 Percentage 20 15 10 5 0 Q1 Q4 2011 Q4 2013 Q3 2015 Florida 26.5 21.2 17.6 Nation 23.8 20.3 17.4 Source: CMS Minimum Data Set (MDS) Data LTC Residents taking Antipsychotic Medications/Off-Label Use: Miami Shores 100 90 80 70 Percentage 60 50 40 30 20 10 0 Q1 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q4 2013 2013 2013 2013 2014 2014 2014 2014 2014 2015 2015 2015 2016 2011 Miami Shores 94.8 7.7 8.8 7.6 3 2.8 1.3 0 1.4 0 0 0 1.5 0 Source: CMS Minimum Data Set (MDS) Data Impact On Quality of Life For Our Residents Resulted in a culture change in our facility that affected residents, family members, and staff in a positive way Drastic reduction in falls and accidents rates in our facility Facility saw improved outcomes in all our other quality measures indicators More engaged staff and improved resident/staff relationships Improved resident, family, and staff satisfaction Better Survey outcomes 10
Contact Information Maureen Brown MBrown@doshealthcare.com Rick Foley Rick.Foley@omnicare.com Amy Osborn AOsborn@hsag.com 31 11