Vanderbilt & Qsource Webinar Series
Vanderbilt Medical Center Vanderbilt University Center for Quality Aging Qsource
Session #1: Introduction to Dementia Care & QAPI Session #2: Dementia & Behavioral Disturbances Session #3: Psychopharmacology in the Nursing Home Session #4: Principles of Non-pharmacologic Management & the Formulation of Behavioral Care Plans Session #5: The Implementation of Behavioral Strategies & the Management of Pharmacologic Interventions Session #6: Addressing Barriers to Change: the Perspective of Psychiatry, Nursing, and Medical Directors
Chat Monitor: Britt Kuertz, RDN Brittany.t.kuertz@vanderbilt.edu 615-936-1499 Moderator: Emily Hollingsworth, MSW Emily.k.hollingsworth@vanderbilt.edu 615-936-2718
How many people are in the room with you to view this webinar? (Please answer in the chat pane, and be sure to include your full facility name)
How would you describe your facility s current efforts to reduce antipsychotic medication use? A. We just recently started focusing on this topic and are trying to learn more. B. We ve been actively trying to reduce antipsychotic medications but have experienced challenges and need further guidance. C. We have successfully reduced antipsychotic medications but there is still room for more improvement.
Presenters: Beth Hercher, CPHQ, Qsource Carrie Plummer, PhD, ANP-BC, Vanderbilt School of Nursing James Powers, MD, Vanderbilt University Medical Center
James Powers, MD Carrie Plummer, PhD, ANP-BC Beth Hercher, CPHQ
1. To provide an overview of dementia and problem behaviors in nursing homes. 2. To describe the potential adverse effects of antipsychotic medications for managing problem behaviors. 3. To provide an introduction to QAPI and its application to reduce antipsychotic medications.
Of Medicare beneficiaries residing in Nursing Homes, 64% have Alzheimer s Disease (AD) or other dementias. 78% of nursing home residents with dementia exhibit behavioral and psychological symptoms of dementia (BPSD). 41% of residents with BPSD exhibit symptoms of psychosis. https://www.alz.org/downloads/facts_figures_2014.pdf
Caring for a person with dementia requires an average of 197 more care hours per year than caring for someone without dementia. This number increases as the severity of cognitive impairment increases.
Wandering Sleep Disturbances Sexual Inappropriateness Verbal Agitation: Abnormal/Repetitive Vocalizations Physical Agitation: Repetitive Motor Activity Verbal and/ or Physical Aggression Crying Psychosis (delusions and/or hallucinations)
Centers for Medicare and Medicaid Services (CMS) Initiative released in April 2012. Office of Inspector General (OIG) reportoveruse of antipsychotics in nursing homes. Antipsychotic use factors into CMS- issued Star Rating.
CMS has developed a national partnership to improve the quality of care provided to individuals with dementia living in nursing homes This partnership is focused on delivering health care that is person-centered, comprehensive, and interdisciplinary. Reduce use of unnecessary antipsychotic medications
The average percentage of long-stay residents on antipsychotics: 18.7% in reporting nursing homes in the Unites States (CMS, 2015 Q1) 21.6% in Tennessee (CMS, 2015 Q1) CMS goal is to reduce antipsychotic use to 15% nationally (or 17% for Tennessee)
Associated Adverse Effects: Sedation Confusion/ Cognitive Worsening Worsening Psychotic Symptoms Restlessness/ Movement Disorders Slowness of Gait Increased Fall Risk Weight Gain Increased Blood Sugar
When antipsychotics are necessary how do we appropriately document this necessity? CMS guidelines: Must present a danger to the person with dementia or others, or cause the person with dementia to experience one of the following: Inconsolable or persistent distress, A significant decline in function, or Substantial difficulty receiving needed care.
How do we institute improvements at our facility?
The Model for Improvement What are we trying to accomplish? Aim How will we know that a change is an improvement? Measure What changes can we make that will result in improvement? Change
Specific Measurable Attainable Relevant Time-bound Example Aim: To reduce the percentage of residents receiving routine antipsychotics to manage problem behaviors by 10% in the next six months.
Determine which data to monitor routinely Set targets for performance in the areas you are monitoring Identify benchmarks for performance Develop a data collection plan, including: who will collect which data? who will review it? how frequently will it be collected and reported? Download resource at http://www.qsource.org/12-action-steps-qapi/
Provide a Baseline Identify areas needing further investigations Identify areas needing improvement Evaluate impact of new changes or programs Effectiveness of quality improvement program Balancing measures (unexpected changes of program) Determine which changes resulted in improvements
How do you know the changes will produce the desired outcomes? Root Cause Analysis (RCA) Plan, do, study, act (PDSA) cycles
Helps identify the primary cause(s) of a problem to determine what happened determine why it happened determine what to do to reduce the likelihood of it happening again Tools: RCA Five Whys Worksheet Fishbone Diagram
Identify event to be investigated and what questions to ask Establish leadership team to review Describe what happened Identified the contributing factors Identify root causes http://www.cms.gov/medicare/provider-enrollment-and- Certification/QAPI/downloads/qapifiveelements.pdf
What are we trying to accomplish? In the next six months, our facility will reduce the number of residents with dementia who are receiving routine antipsychotics to manage problem behaviors. Think SMART: S Specific M Measurable A Attainable R Relevant T Time-bound
How will we know that a change is an improvement? We will track the incidence of antipsychotic use among high-risk residents by conducting weekly behavioral assessments
What changes can we make that will lead to improvement? We will document and implement nonpharmacological interventions for residents with behavioral disturbance
Monitor and modify effectiveness Changes that result in improvement Learning Hunches, theories, ideas e.g., action plans or interventions
QAPI is a new regulatory requirement facilities must adopt to avoid penalties A. True B. False
Full video available on project website: www.vanderbiltantipsychoticreduction.org
Retired army colonel with dementia Hospitalized with UTI Structured geriatric ward Family meeting on goals of care
Medications for agitation should be a last resort after failing non-pharmacologic management Low-dose medications with continued efforts to reduce and eliminate psychotropics Avoid p.r.n. s
Patient-centered goals of care should be developed with the resident and family Medications for agitation should be a last resort Non-pharmacologic management techniques include Normalize day and night schedules Re-orient, re-direct Anticipate resident needs
Antipsychotic medication should be used only after non-pharmacological treatment has been attempted. A. True B. False
Antipsychotic medications are commonly used to manage problem behaviors (21.6% in TN) There are numerous potential adverse effects of these medications (e.g., sedation, confusion, falls) The QAPI framework can be used to safely and appropriately reduce the use of these medications There will be a second presentation of Session #1 on Tuesday, October 27 th at 1pm CST/ 2pm EST
Two options for attending Session 2: November 3rd (Tuesday) 1pm CST/ 2pm EST November 18th (Wednesday) 10am CST/ 11am EST
Emily Hollingsworth Emily.K.Hollingsworth@vanderbilt.edu Britt Kuertz Brittany.T.Kuertz@vanderbilt.edu Project Website: www.vanderbiltantipsychoticreduction.org Vanderbilt Center for Quality Aging 615-936-1499 www.vanderbiltcqa.org for other resources