behavior drug monitoring a guide to monitoring for psychopharmacological behavioral drug...

BEHAVIOR BEHAVIOR DRUG DRUG

MONITORINGMONITORING

A GUIDE TO MONITORING FOR A GUIDE TO MONITORING FOR PSYCHOPHARMACOLOGICALPSYCHOPHARMACOLOGICAL

BEHAVIORAL DRUG BEHAVIORAL DRUG DOCUMENTATIONDOCUMENTATION

ObjectivesObjectives

The Participants will:The Participants will: Identify a portion of the regulations that are Identify a portion of the regulations that are

related to related to PsychopharmacologicalPsychopharmacological drug drug monitoring (also known as behavior drug monitoring (also known as behavior drug monitoring).monitoring).

Identify the regulations and the monitoring tool Identify the regulations and the monitoring tool to evaluate the documentation supporting the to evaluate the documentation supporting the use of the psychoactive medication.use of the psychoactive medication.

Objectives Objectives -2-2

The Participants will:The Participants will: Review a Review a monitoring tool and the monitoring tool and the

instructionsinstructions for completion of documentation to for completion of documentation to support the use of the support the use of the PsychopharmacologicalPsychopharmacological drugs (aka, psychotherapeutic, behavior drugs, drugs (aka, psychotherapeutic, behavior drugs, psychoactive drugs, antipsychotics, psychoactive drugs, antipsychotics, antidepressants, anti-anxiety).antidepressants, anti-anxiety).

Complete a documentation monitoring process Complete a documentation monitoring process using the attached monitoring tool.using the attached monitoring tool.

Quality MonitoringQuality Monitoring

The following slides outlines in a brief way The following slides outlines in a brief way the requirements for documentation and the requirements for documentation and clinical considerations for assessing, clinical considerations for assessing, evaluating and monitoring use of evaluating and monitoring use of psychopharmacological drugs for behavioral psychopharmacological drugs for behavioral conditions.conditions.

Utilize the monitoring tool Utilize the monitoring tool attached to collect data for attached to collect data for the IDT review and follow up.the IDT review and follow up.

Quality Monitoring Quality Monitoring -2-2

The monitoring of documentation and The monitoring of documentation and identification of documentation items that identification of documentation items that are in compliance and items that need to be are in compliance and items that need to be re-assessed are included in the monitoring re-assessed are included in the monitoring

tool. After the health record is tool. After the health record is reviewed, tabulate the findings and reviewed, tabulate the findings and measure the areas of compliance measure the areas of compliance vs. those where action is needed.vs. those where action is needed.

Quality Monitoring Quality Monitoring -3-3

Refer the findings to the IDT and to the Refer the findings to the IDT and to the Quality Assurance and Improvement Quality Assurance and Improvement Committee for review and action for Committee for review and action for documentation items in compliance and documentation items in compliance and those where improvement may be needed.those where improvement may be needed.

When possible present the findings using a When possible present the findings using a graphic format.graphic format.

Overview of the RegulationsOverview of the Regulations

The following slides outline some key areas The following slides outline some key areas from the CMS regulations that are from the CMS regulations that are applicable to psychopharmacological applicable to psychopharmacological documentation.documentation.

Psychopharmacological Psychopharmacological MedicationMedication

Defined as Defined as any medication used for any medication used for managing behavior, stabilizing mood, or managing behavior, stabilizing mood, or treating psychiatric disorders.treating psychiatric disorders.

Resident’s Clinical RecordResident’s Clinical Record

Documents/Communicates to the entire Documents/Communicates to the entire team the basic elements of the care team the basic elements of the care process, including:process, including: The assessmentThe assessment Indication for useIndication for use Planning carePlanning care Evaluation and monitoring of progress of the Evaluation and monitoring of progress of the

resident’s indication for use of the medication resident’s indication for use of the medication (behavioral manifestation/s)(behavioral manifestation/s)

Resident’s Clinical Record Resident’s Clinical Record -2-2

Documents/CommunicatesDocuments/Communicates (cont.)(cont.) Resident Assessment Protocols (RAPs), an Resident Assessment Protocols (RAPs), an

integral part of the comprehensive resident integral part of the comprehensive resident assessment, help identify some possible assessment, help identify some possible categories of causes of various symptoms categories of causes of various symptoms including: behavioral symptoms of distress, including: behavioral symptoms of distress, delirium, and changes in functional status. delirium, and changes in functional status.

Evaluation of the Resident’s Evaluation of the Resident’s Psychiatric Psychiatric disorders or distressed behaviordisorders or distressed behavior – As with – As with all symptoms, it is important to seek the all symptoms, it is important to seek the underlying cause of distressed behavior, either underlying cause of distressed behavior, either before or while treating the symptom.before or while treating the symptom.

Gradual Dose ReductionGradual Dose Reduction

Most recent attempt at a GDR within the Most recent attempt at a GDR within the facility; andfacility; and

The physician has documented the clinical The physician has documented the clinical rationale for why any additional attempted rationale for why any additional attempted dose reduction at that time would be likely dose reduction at that time would be likely to impair the resident’s function or increase to impair the resident’s function or increase distressed behavior.As applicable…distressed behavior.As applicable…psychiatric disorder this may not be psychiatric disorder this may not be applicable.applicable.

Documentation MonitoringDocumentation Monitoring

Monitoring of the documentation looks at:Monitoring of the documentation looks at: Entire drug/medication regimen monitored to Entire drug/medication regimen monitored to

achieve the following goals:achieve the following goals: Promote or maintain the resident’s highest practicable Promote or maintain the resident’s highest practicable

mental, physical, and psychosocial well-being. mental, physical, and psychosocial well-being. Evaluate those medications, in doses and for the Evaluate those medications, in doses and for the

duration clinically indicated to treat the resident’s duration clinically indicated to treat the resident’s assessed condition(s)assessed condition(s)

Drug Monitoring & Non Drug Monitoring & Non Pharmaceutical ApproachesPharmaceutical Approaches

Monitoring to determine if there is Monitoring to determine if there is documentation that indicates thedocumentation that indicates the Non-pharmacological interventions (such as Non-pharmacological interventions (such as

behavioral interventions) are considered and behavioral interventions) are considered and used when indicated, instead of, or in addition used when indicated, instead of, or in addition to, medication;to, medication;

Drug Monitoring & Non Drug Monitoring & Non Pharmaceutical Approaches Pharmaceutical Approaches -2-2

Monitor to assist the clinical team to Monitor to assist the clinical team to evaluate and determine ifevaluate and determine if Clinically significant adverse consequences are Clinically significant adverse consequences are

minimized;minimized; Assessment “indications for use of the Assessment “indications for use of the

Psychotherapeutic/behavioral medicationsPsychotherapeutic/behavioral medications and and used after other interventions used/considered used after other interventions used/considered and treatment chosen is the most efficacious and treatment chosen is the most efficacious method of treatmentmethod of treatment

Monitoring for Dose Monitoring for Dose ReductionReduction

Gradual Dose Reduction (GDR)” is the Gradual Dose Reduction (GDR)” is the stepwise tapering of a dose to determine if stepwise tapering of a dose to determine if symptoms, conditions, or risks can be symptoms, conditions, or risks can be managed by a lower dose or if the dose or managed by a lower dose or if the dose or medication can be discontinued.medication can be discontinued.

Refer to the monitoring tool attached to Refer to the monitoring tool attached to review the instruction.review the instruction.

Medication ManagementMedication Management

Medication management includes Medication management includes recognition or identification of the recognition or identification of the problem/need, assessment, problem/need, assessment, diagnosis/cause identification, medication diagnosis/cause identification, medication management/treatment, monitoring, and management/treatment, monitoring, and revising interventions, as warranted. revising interventions, as warranted.

One of the uses of the monitoring of the One of the uses of the monitoring of the documentation is to assist the staff in the documentation is to assist the staff in the review of the documentation findings.review of the documentation findings.

Physician MonitoringPhysician Monitoring

The attending physician plays a The attending physician plays a key leadership role in medication key leadership role in medication management by developing, management by developing, monitoring, and modifying the monitoring, and modifying the medication regimen in medication regimen in conjunction with residents and/or conjunction with residents and/or representative(s) and other representative(s) and other professionals and direct care staff professionals and direct care staff (the interdisciplinary team). (the interdisciplinary team).

IDT – Planning CareIDT – Planning Care

Part of the uses of the monitoring of Part of the uses of the monitoring of psychoactive medications is to also look at the psychoactive medications is to also look at the documentation related to the non-documentation related to the non-pharmacological interventions. Many of the pharmacological interventions. Many of the facility Interdisciplinary team members facility Interdisciplinary team members participate in the care process via “drug review, participate in the care process via “drug review, IDT Care Planning, etc. and they can use the IDT Care Planning, etc. and they can use the information from the documentation monitor to information from the documentation monitor to identify, assess, address, advocate for, identify, assess, address, advocate for, monitor, and communicate the resident’s needs monitor, and communicate the resident’s needs and changes in condition.and changes in condition.

Monitoring Care & Clinical Monitoring Care & Clinical Data CollectionData Collection

““Monitoring” is the ongoing collection and Monitoring” is the ongoing collection and analysis of information (such as analysis of information (such as observations and diagnostic test results) observations and diagnostic test results) and comparison to baseline data in order to and comparison to baseline data in order to support decisions about modifying, support decisions about modifying, discontinuing, or continuing any discontinuing, or continuing any interventions.interventions.

Documentation monitoring also Documentation monitoring also assists the IDT to carry out this assists the IDT to carry out this task and improve the quality of care.task and improve the quality of care.

Non-Pharmacological Non-Pharmacological ApproachesApproaches

All medication management, All medication management, (including antipsychotics), is (including antipsychotics), is important for the interdisciplinary important for the interdisciplinary team to consider non-team to consider non-pharmacological approaches. pharmacological approaches.

Quality Monitoring of Quality Monitoring of documentation and the use by documentation and the use by the IDT of the results will assist the IDT of the results will assist them to look at the non-them to look at the non-pharmacological approaches.pharmacological approaches.

EXAMPLES of Non-EXAMPLES of Non-Pharmacological Pharmacological ApproachesApproaches

Increasing the resident’s exercise, intake of Increasing the resident’s exercise, intake of liquids and dietary fiber in conjunction with liquids and dietary fiber in conjunction with an individualized bowel regimen to prevent an individualized bowel regimen to prevent or reduce constipation and the use of or reduce constipation and the use of medications (e.g. laxatives and stool medications (e.g. laxatives and stool softeners); softeners);

Identifying, addressing, and eliminating or Identifying, addressing, and eliminating or reducing underlying causes of distressed reducing underlying causes of distressed behavior such as boredom and pain behavior such as boredom and pain

EXAMPLES of Non-EXAMPLES of Non-Pharmacological Approaches Pharmacological Approaches -2-2

Using sleep hygiene techniques and Using sleep hygiene techniques and individualized sleep routines; individualized sleep routines;

Accommodating the resident’s behavior and Accommodating the resident’s behavior and needs by supporting and encouraging needs by supporting and encouraging activities reminiscent of lifelong work or activities reminiscent of lifelong work or activity patterns, such as providing early activity patterns, such as providing early morning activity for a farmer used to morning activity for a farmer used to awakening early;awakening early;


Individualizing toileting schedules to prevent Individualizing toileting schedules to prevent incontinence and avoid the use of incontinence incontinence and avoid the use of incontinence medications that may have significant adverse medications that may have significant adverse consequences (e.g., anticholinergic effects); consequences (e.g., anticholinergic effects);

Developing interventions that are specific to Developing interventions that are specific to resident’s interests, abilities, strengths and resident’s interests, abilities, strengths and needs, such as simplifying or segmenting needs, such as simplifying or segmenting tasks for a resident who has trouble following tasks for a resident who has trouble following complex directions; complex directions;


Using massage, hot/warm or cold compresses Using massage, hot/warm or cold compresses to address a resident’s pain or discomfort; orto address a resident’s pain or discomfort; or

Enhancing the taste and presentation of food, Enhancing the taste and presentation of food, assisting the resident to eat, addressing food assisting the resident to eat, addressing food preferences, and increasing finger foods and preferences, and increasing finger foods and snacks for an individual with dementia, to snacks for an individual with dementia, to improve appetite and avoid the unnecessary improve appetite and avoid the unnecessary use of medications intended to stimulate use of medications intended to stimulate appetite.appetite.


The resident’s clinical record documents The resident’s clinical record documents and communicates to the entire team the and communicates to the entire team the basic elements of the care process. basic elements of the care process.

ConsentsConsents

Resident ChoiceResident Choice –right to be informed about –right to be informed about the resident’s condition; treatment options, the resident’s condition; treatment options, relative risks and benefits of treatment, relative risks and benefits of treatment, required monitoring, expected outcomes of the required monitoring, expected outcomes of the treatment; and has the right to refuse care and treatment; and has the right to refuse care and treatment be informed of risks related to the treatment be informed of risks related to the refusal, and discuss appropriate alternatives refusal, and discuss appropriate alternatives such as offering the medication at another time such as offering the medication at another time or in another dosage form, or offer an or in another dosage form, or offer an alternative medication or non-pharmacological alternative medication or non-pharmacological approach, if available. approach, if available.

Documentation Monitors Documentation Monitors and Advantagesand Advantages

Looking at the documentation to support, Looking at the documentation to support, Indications for use of medication (including Indications for use of medication (including

initiation or continued use of antipsychotic initiation or continued use of antipsychotic medication)medication)

Monitoring for efficacy and adverse Monitoring for efficacy and adverse consequencesconsequences

Dose (including duplicate therapy)Dose (including duplicate therapy) DurationDuration

Documentation Monitors Documentation Monitors and Advantages and Advantages -2-2

Looking at the documentation as part of the Looking at the documentation as part of the evaluation, gathering and analyzing evaluation, gathering and analyzing information information Helps define clinical indicationsHelps define clinical indications Provide baseline data for subsequent monitoring, Provide baseline data for subsequent monitoring, Consider tapering of a medication dose/gradual Consider tapering of a medication dose/gradual

dose reduction for antipsychotic medications,dose reduction for antipsychotic medications, Prevention, identification, and response to Prevention, identification, and response to

adverse consequencesadverse consequences

Monitoring ToolMonitoring Tool

Refer to the Monitoring Tools attached, one Refer to the Monitoring Tools attached, one blank for your use and the other with blank for your use and the other with instructions.instructions.

Thank you!Thank you!