RAI-MDS 2.0 ASSESSMENT GUIDE FOR USE BY CANADIAN SQLI NURSING HOMES AND NEWFOUNDLAND AND LABRADOR HOMES HOW TO USE THIS GUIDE: Use this guide alongside the RAI-MDS 2.0 Tracking Tool to track your target residents and their prescriptions for antipsychotic medication and processes related to your AUA approach. Most measures in this tracking tool are based on the Canadian version of the Resident Assessment Instrument - Minimum Data Set (RAI- MDS) 2.0. The tool itself contains helpful information to facilitate data completion. The amplifying information in this guide should facilitate successful use of the tool, as such, should be used as a resource by your designated team member responsible for submission of data on your AUA cohort of target residents. TARGET RESIDENTS: Target residents are persons with antipsychotic medication use indicated on their RAI-MDS 2.0 assessment (O4a > 0), excluding those who: i. Have a diagnosis of schizophrenia (I1ii=1 / checked off), Huntington s chorea (I1x=1 / checked off), or those experiencing hallucinations (J1i=1 / checked off) or delusions (J1e = 1 /checked off); and ii. Those who are end-stage disease (J5c=1 / checked off) or receiving hospice care (P1ao=1 / checked off) MODULE RAI-MDS2.0: Prior to the start of your AUA Approach, you will identify residents who are candidates for your AUA initiative using the above criteria. You may choose to target all residents in your nursing home meeting the above criteria or residents residing in a specific unit of your nursing home. You will enter baseline information for all target residents you identified that is, their information for the quarter prior to the start of your AUA approach. Following the baseline quarter, you will continue to track this cohort of residents for three additional quarters - that is, during the implementation of your home s AUA Approach. Completed quarterly, this tracking tool will help you follow changes in the use of inappropriate antipsychotic medication, behavioural and symptom changes, reductions made, and discontinuations accomplished. These are useful to monitor your quality improvement efforts in AUA, and share with your staff, stakeholders and leadership. 1
SUBMISSION AND USE OF DATA Resident-level data is to be submitted to CFHI quarterly based on the following submission schedule: Quarter Quarter timeframe To be completed by Baseline April-June 2018 August 10, 2018 Quarter 1 July-September 2018 September 30, 2018 Quarter 2 October-December 2018 December 30, 2018 Quarter 3 January-March 2019 March 30, 2019 Any data submitted by teams participating in the AUA Collaborative will not be disclosed. However, data summarized in an aggregate fashion will be shared with other teams in the Collaborative for the purposes of spreading and disseminating knowledge, evidence (results) and lessons learned during each team s improvement journey (this could take place at in-person workshops, the Desktop or by teams themselves through webinar presentations during interim and final reporting). Information sharing is a key component of the AUA Collaborative and provides an opportunity to individual teams to share their value add to healthcare improvement. Aggregate data may also be used or displayed in summaries, reports or in other handout materials that aim to share collective results and lessons learned from the AUA Collaborative that could be made available on CFHI s website for public to view and download. Please contact your AUA Regional Lead or CFHI (AUA-UAA@cfhi-fcass.ca) if you have any questions or would like support in using the tracking sheet and this assessment guide. Thank you for participating in CFHI s AUA Collaborative! CFHI AUA Team 2
Submission Timeframe Measure Definition RAI-MDS 2.0 item Coding About Target Residents Resident Identifier A resident identifier is a unique residentspecific identifier of your choosing. This code must be used consistently in all subsequent quarterly data submissions (i.e., Q1, Q2, and Q3). N/A Record the resident s chosen code or number. Choose a unique code to use as an identifier for each target resident. This new identifier (resident code) assigned to each target resident must clearly differentiate one resident from another and be used consistently throughout quarters starting from baseline to the last reporting quarter. Assessment Reference Date (ARD) Observation end date for items on the RAI- MDS 2.0. The look back period for most RAI- MDS 2.0 items is 7 days. The Assessment Reference Date (ARD) is the last day of a 7- day period for 7-day items. A3 Enter the ARD in the format: YYYY/MM/DD. Q1 Q2 Q3 Alzheimer s Disease A degenerative and progressive dementia that is diagnosed by ruling out other dementias and physiological reasons for the dementia I1r From the dropdown menu, select if the resident has a diagnosis of Alzheimer s disease: Yes if resident has the I1r box checked off No if the I1r box is not checked off 3
Q1 Q2 Q3 Dementia other than Alzheimer s Disease Includes organic brain syndrome or chronic brain syndrome, senility, senile dementia, multi-infarct dementia and dementia related to neurological diseases other than Alzheimer's (for example, Pick's, Creutzfeldt-Jakob, Huntington's disease, etc.) I1v From the dropdown menu, select if the resident has a diagnosis of dementia other than Alzheimer s disease: Yes if resident has the I1v box checked off No if the I1v box is not checked off Q1 Q2 Q3 Prescribed antipsychotic medication prior to admission Was the person admitted to the nursing home with an existing prescription for an antipsychotic medication? N/A From the dropdown menu, select: Yes if the resident was admitted to the nursing home with a prior prescription for antipsychotic medication. No if the resident was originally prescribed antipsychotic medication in the nursing home. Unknown if no documentation exists to show where the antipsychotic medication was initiated. Baseline Resident Status This item is used to identify the status of the resident after the baseline submission. N/A From the dropdown menu, for each listed target resident, select status: 01 Still a target resident in the nursing home 02 Deceased 03 Transferred to another nursing home or unit 04 Discharged to community care (e.g. private home/apartment/rented room, assisted living community, group home) 05 Discharged to another type of institution for inpatient care (e.g. acute hospital, psychiatric hospital, in-patient rehabilitation hospital/unit, continuing care hospital/unit) 4
06 Discharged to a setting for persons with intellectual disability or to a mental health residence 07 Transferred to hospice/palliative care unit 08 Other If the resident is 01 - Still a target resident in the nursing home, please continue with the data submission for this target resident. If the target resident is coded anything other than 01, indicate the resident s status using codes 02 to 08. There is no need to fill out the remainder of the questionnaire for this resident. About Medication Number of prescriptions for antipsychotic medication Antipsychotic medications include those medications that are classified as antipsychotics by the World Health Organization's Anatomical Therapeutic Chemical (ATC) classification system. See Appendix A Select the number of prescriptions for antipsychotic medication that this resident has. Refer to the Home and Continuing Care (HCC) Medication List (2017-2018) for a full list of these drugs or Appendix A of this document. Baseline Status of antipsychotic prescription compared to baseline Records changes in the resident s prescription for antipsychotic medication compared to the baseline quarter. If collected, consult Section U Use the following codes to identify the status of each antipsychotic prescription: No change in medication/dose if the resident s prescription for the antipsychotic medication remains the same as in the baseline quarter. Medication/dose reduced if the dose of the antipsychotic medication the resident is 5
prescribed is lower than that in the baseline quarter. Increased dose if the dose of the antipsychotic medication the resident is prescribed is higher than that in the baseline quarter. Discontinued if the resident has been discontinued from the antipsychotic medication. New/Added medication if the resident has been given a new prescription for an antipsychotic medication. Number of prescriptions for other psychotropic medications Other psychotropic medications include antidepressants, anxiolytics and hypnotics. Refer to the HCC Medication List (2017-2018) for a full list of these drugs or Appendix A of this document. See Appendix A Select the number of prescriptions for psychotropic medication that this resident has. Baseline Status of prescription for other psychotropic medications compared to baseline Records changes in the resident s prescription for other psychotropic medications compared to the baseline quarter. If collected, consult Section U Use the following codes to identify the status of each prescription for other psychotropic medication: No change in medication/dose if the resident s prescription for the other psychotropic medication remains the same as in the baseline quarter. Medication/dose reduced if the dose of the other psychotropic medication the resident is prescribed is lower than that in the baseline quarter. Increased dose if the dose of the other psychotropic medication the resident is prescribed is higher than that in the baseline quarter. 6
Discontinued if the resident has been discontinued from the other psychotropic medication. New/Added medication if the resident has been given a new prescription for another psychotropic medication. About Processes Trunk Restraint Includes any device, equipment or material that the resident cannot easily remove (for example, vest or waist restraint). P4c Chair prevents rising Any type of chair with a locked lap board or a chair that places the resident in a recumbent position that restricts rising or a chair that is soft and low to the floor. Includes comfort cushions (for example, lap buddy). P4e For each device type, enter for the last 7 days if the device was: 0 - Not used 1 - Used, but used less than daily 2 - Used daily Limb Restraint Includes any device or equipment or material that the resident cannot easily remove, that restricts movement of any part of an upper extremity (i.e., hand, arm) or lower extremity (i.e., foot, leg). P4d Clinical Monitoring: Behaviours Verbal Abuse Physical Abuse For example, others were threatened, screamed or cursed at. For example, others were hit, shoved, scratched, or sexually abused. If the E4bA E4cA For each behavioural symptom, enter their frequency in last 7 days: 7
Socially Inappropriate or Disruptive Behaviour resident strikes out, but the intended target moves and is therefore not hit, it still should be considered physical abuse. For example, made disruptive sounds or noises, screamed out, self-abusive acts, sexual behaviour, disrobing in public, smeared or threw food or feces, hoarded, or rummaged through other's belongings. E4dA 0 - Behaviour not exhibited in last 7 days. 1 - Behaviour occurred on 1 to 3 days, in last 7 days. 2 - Behaviour occurred 4 to 6 days, but less than daily. 3 - Behaviour occurred daily Resists care May be verbal or physical. For example, the resident resists taking medications, pushes caregiver while receiving assistance with ADLs or eating. Does not include situations where a resident makes an informed choice not to follow the course of care. E4eA Clinical Monitoring: Falls Falls Any unintentional change in position where the person ends up on the floor, ground, or other lower level; includes falls while being assisted by others J4a Select whether the resident fell in the last 30 days: 0 No 1 Yes 2 Not known Clinical Monitoring: Service Use Hospital stay(s) The resident was formally admitted by a physician as an inpatient with the expectation that the resident will stay overnight. It does not include day surgery, outpatient services, etc. P5 Type in the number of hospital admissions in the last 90 days. Enter 0 if no hospital admissions occurred in the last 90 days. 8
Emergency Room (ER) visit(s) A visit to an emergency room. Exclude prior scheduled visits for physician evaluation, transfusions, chemotherapy, etc. If a person is in the ER overnight, but not actually admitted to the hospital, count as an ER visit even though they stayed overnight. If the person was in ER and then admitted, do not count the ER visit just the hospital admission. P6 Type in the number of ER visits in the last 90 days (or since the last assessment if less than 90 days). Enter 0 if no ER visits occurred. Clinical Monitoring: Outcome Scales Cognitive Performance Scale (CPS) Scores are based on coma, cognitive skills for daily decision-making, making self understood, short-term memory recall and eating self-performance. Calculated score from interrai assessment From the dropdown menu, enter the appropriate CPS score for the resident: 0 - Intact 1 - Borderline intact 2 - Mild impairment 3 - Moderate impairment 4 - Moderate/severe impairment 5 - Severe impairment 6 - Very severe impairment If the score is not available for the resident for the given quarter, choose not available. Depression Rating Scale (DRS) The DRS is based on seven items: negative statements, persistent anger, expressions of unrealistic fears, repetitive health complaints, repetitive anxious complaints, sad, pained or worried facial expression, and tearfulness. Calculated score from interrai assessment From the dropdown menu, enter the appropriate DRS score for the resident. Scores range from 0 to 14. 0 No symptoms of depression 1 to 2 Some symptoms of depression 3 to 5 Possible depression 6+ Possible severe depression 9
If the score is not available for the resident for the given quarter, choose not available. Aggressive Behaviour Scale (ABS) Scores are based on verbal abuse, physical abuse, socially inappropriate/disruptive behaviour and resists care. Calculated score from interrai assessment The ABS Score is a summary scale that provides a measure of aggressive behaviours based on the information entered for the following four behaviour items: physical behaviours directed toward others, verbal behaviours directed toward others, other behavioural symptoms not directed toward others and rejection of care. The final ABS score is calculated by summing the scores on the above four behavior items after they have been allocated a score from 0 to 3. The ABS score for the resident ranges from0 to 12. Higher scores indicate a greater level of aggressive behaviour. If the score is not available for the resident for the given quarter, choose not available. Pain Scale Scores are based on two pain questions: pain frequency and pain intensity. Calculated score from interrai assessment From the dropdown menu, enter the appropriate pain scale score for the resident: 0 - No pain 1 - Less than daily pain 2 - Mild/moderate daily pain 3 - Daily severe pain If the score is not available for the resident for the given quarter, choose not available. Index of Social Engagement (ISE) Scores describe the resident s sense of initiative and social involvement within the facility. The score is based on ease of interacting with others, ease with structured, planned and self-initiated activities, establishes own goals, N/A From the dropdown menu, enter the appropriate ISE score for the resident. The score ranges from 0 to 6. Higher scores indicate a greater level of social engagement. 10
involvement in facility life, and acceptance of invitations to group activities. If the score is not available for the resident for the given quarter, choose not available. ADL Long Form This scale provides a measure of the resident s ability to perform ADLs. The ADL Long Form is more sensitive to clinical changes than the other ADL scales. N/A From the dropdown menu, enter the appropriate ADL Long Form score for the resident. Score ranges from 0 to 28. Higher scores indicate more impairment in self-sufficiency in ADL performance. If the score is not available for the resident for the given quarter, choose not available. 11
APPENDIX A Source: Canadian Institute for Health Information. Home and Continuing Care (HCC) Medication List, 2017-2018. ANTIPSYCHOTIC MEDICATION Classification Chemical Common brand name ANTIPSYCHOTICS/NEUROLEPTICS (ATC Classification: N05A) ARIPIPRAZOLE ASENAPINE CHLORPROMAZINE CLOZAPINE DROPERIDOL FLUPENTIXOL FLUPHENAZINE HALOPERIDOL LEVOMEPROMAZINE (METHOTRIMEPRAZINE) LITHIUM LOXAPINE LURASIDONE OLANZAPINE PALIPERIDONE PERICIAZINE PERPHENAZINE PIMOZIDE PIPOTIAZINE PROCHLORPERAZINE QUETIAPINE RISPERIDONE THIOPROPERAZINE TIOTIXENE (THIOTHIXENE) TRIFLUOPERAZINE ZIPRASIDONE ZUCLOPENTHIXOL ABILIFY SAPHRIS LARGACTIL CLOZARIL DROPERIDOL FLUANXOL MODITEN HALDOL NOZINAN, METHOPRAZINE, NOVO CARBOLITH, LITHANE, DURALITH LOXAPAC LATUDA ZYPREXA INVEGA NEULEPTIL TRILAFON ORAP PIPORTIL STEMETIL SEROQUEL RISPERDAL MAJEPTIL NAVANE TERFLUZINE ZELDOX CLOPIXOL 12
OTHER PSYCHOTROPIC MEDICATION Classification Chemical Common brand name ANTIDEPRESSANTS (ATC classification: N06A, N06C) ANTI-ANXITIES (ATC classification A03C, N05B ) AMITRIPTYLINE BUPROPION CITALOPRAM CLOMIPRAMINE DESIPRAMINE DESVENLAFAXINE DOXEPIN DULOXETINE ESCITALOPRAM FLUOXETINE FLUVOXAMINE IMIPRAMINE LEVOMILNACIPRAN (LEVOMILNACIPRAN HYDROCHLORIDE) MAPROTILINE MIRTAZAPINE MOCLOBEMIDE NORTRIPTYLINE PAROXETINE PHENELZINE SERTRALINE TRANYCLYPROMINE TRAZODONE TRIMIPRAMINE TRYPTOPHAN VENLAFAXINE VORTIOXETINE (VORTIOXETINE HYDROBROMIDE) ALPRAZOLAM BROMAZEPAM BUSPIRONE CHLORDIAZEPOXIDE CLIDINIUM-CHLORDIAZEPOXIDE COMBINATIONS CLONAZEPAM CLORAZEPATE POTASSIUM ELAVIL, LEVATE WELLBUTRIN CELEXA ANAFRANIL NORPRAMIN PRISTIQ DOXEPINE CYMBALTA CIPRALEX PROZAC LUVOX TOFRANIL FETZIMA LUDIOMIL REMERON MANERIX AVENTYL, NORVENTYL PAXIL NARDIL ZOLOFT PARNATE DESYREL SURMONTIL TRYPTAM EFFEXOR TRINTELLIX XANAX LECTOPAM BUSPAR CHLORDIAZEPOXIDE LIBRAX RIVOTRIL APO-CLORAZEPATE, TRANXENE 13
HYPNOTICS (ATC classification: N05C) DIAZEPAM HYDROXYZINE LORAZEPAM OXAZEPAM CHLORAL HYDRATE DEXMEDETOMIDINE FLURAZEPAM MIDAZOLAM NITRAZEPAM TEMAZEPAM TRIAZOLAM ZOLPIDEM ZOPICLONE VALIUM, DIAZEMULS ATARAX ATIVAN OXPAM NOCTEC PRECEDEX DALMANE, SOMNOL MIDAZOLAM INJECTION MOGADON RESTORIL HALCION SUBLINOX IMOVANE, RHOVANE 14