handouts prepared by: jane belt, ms, rn, rac-mt plante moran 2017. 8. 23.¢  training...

Download Handouts Prepared By: Jane Belt, MS, RN, RAC-MT Plante Moran 2017. 8. 23.¢  Training Dementia Care

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  • ©Plante Moran Clinical Group 2013 614-222-9020

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    Handouts Prepared By: Jane Belt, MS, RN, RAC-MT

    Plante Moran Clinical Group jane.belt@plantemoran.com

    614-222-9020

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    Objectives

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     Delineate the key requirements in F329 – Unnecessary Medications

     Describe the key principles of “avoiding unnecessary medications”

     Identify key strategies for collaboration between interdisciplinary team members to provide best care practices for medication use and the role of non-pharmacological interventions

     Detail the required documentation components of staying in compliance with F329

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    A Bit of Background First  CMS in looking for quality improvement started to

    focus on the use of antipsychotics used to treat NH residents with dementia

     CMS Administrator at the time (Dr. Donald Berwick) asked stakeholders to provide to CMS their proposals for reducing their use

     As the discussions continued – all realized that there should not be a focus on one class of drugs as that could trigger overuse of other drugs

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    January 2013

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    January 2013

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    National 21.71%

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    Multi-dimensional Approach Includes 3 R’s: RETHINK – approach to dementia care RECONNECT – with residents via person-centered

    care practices RESTORE – good health and quality of life

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    January 2013 July 10, 2013

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    Key Requirements in F329: §483.25(l) Unnecessary Drugs 1. Each resident’s drug regimen must be free from unnecessary

    drugs. An unnecessary drug is any drug when used:

    (i) In excessive dose (including duplicate therapy); or

    (ii) For excessive duration; or

    (iii) Without adequate monitoring; or

    (iv) Without adequate indications for its use; or

    (v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

    (vi) Any combinations of the reasons above 11

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    Key Requirements in F329: §483.25(l) Unnecessary Drugs 2. Antipsychotic Drugs. Based on a comprehensive assessment

    of a resident, the facility must ensure that:

    (i) Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and

    (ii) Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

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    Key Requirements in F329: Intent  Each resident’s entire drug/medication regimen be managed

    and monitored to achieve the following goals:  Medication regimen helps promote or maintain the resident’s highest

    level of function as identified by the resident/and or representative in collaboration with the attending physician and facility staff;

     Each resident receives only those medications, in doses for the duration clinically indicated to treat the resident’s assessed condition(s);

     Non-pharmacological interventions (such as behavioral interventions) are considered and used when indicated, instead of, or in addition to medication:

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    Key Requirements in F329: Intent (continued)

     Each resident’s entire drug/medication regimen be managed and monitored to achieve the following goals:

     Clinically significant adverse consequences are minimized; and

     The potential contribution of the medication regimen to an unanticipated decline or newly emerging or worsening symptom is recognized and evaluated, and the regimen is modified when appropriate

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    Key Requirements in F329  In other words - the facility’s medication management program

    supports and promotes selection of medications(s) based on assessing relative benefits and risks to the resident;

     Evaluation of the resident’s signs and symptoms to identify the underlying cause(s), including adverse consequences of medications;

     Selection and use of medications in doses and for the duration appropriate to each resident’s clinical conditions, age, and underlying causes of symptoms;

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    Key Requirements in F329  Use of non-pharmacological interventions, when

    applicable, to minimize the need for medications, permit use of the lowest possible dose, or allow medications to be discontinued;

     Monitoring of medications for efficacy and clinically significant adverse consequences; and

     Accurate and appropriate documentation, i.e., “the resident’s clinical record documents and communicates to the entire interdisciplinary team the basic elements of the care process.”

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    Key Requirements in F329

    The guidance at F329 applies to all categories of medications, including antipsychotic medications.

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    F329 Clarifications per S&C: 13-35- NH – effective May 24, 2013  Restated the goal of the National Partnership is to

    optimize the quality of life and function by improving approaches to meeting all the needs of residents, especially those with dementia

     Described common practice to use various types of psychopharmacological medications to address behaviors without first determining the medical, physical, functional, psychological, emotional, psychiatric, social or environmental cause of the behaviors

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    F329 Clarifications per S&C: 13-35- NH – effective May 24, 2013  Reiterated the medications used without clinical indication

    are likely to cause harm  Concern that NHs, hospitals, ambulatory care use

    medications as a “quick fix” for behavioral symptoms or as a substitute for a holistic approach (thorough assessment of underlying causes of behaviors and individualized person-centered interventions

     Antipsychotics often prescribed for residents with dementia who have behavioral or psychological symptoms of dementia (BPSD)

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    Behavioral or Psychological Symptoms of Dementia (BPSD)  The term used to describe behavior or other

    symptoms in individuals with dementia that cannot be attributed to a specific medical or psychiatric cause

     When drugs used without adequate rationale, little chance they will be effective and often cause complications, such as:  Movement disorders, falls, hip fractures, CVAs or

    TIAs, and increased risk of death 20

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    As a Result….  Food & Drug Administration (FDA) Black Box

    Warnings Regarding Atypical Antipsychotics in Dementia

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    Elderly patients with dementia-related psychosis treated with atypical

    antipsychotic drugs are at increased risk of death compared to placebo

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    More from the S&C and Surveyor Training Dementia Care Principles: includes an interdisciplinary

    approach with focus on the needs of the resident as well as the needs of the other residents in the nursing home: Person-Center Care Quality and Quantity of Staff Thorough Evaluation of New or Worsening Behaviors

    (BPSD) – evaluation by the IDT, including the physician in order to identify and address treatable medical, physical, emotional, psychiatric, psychological, functional, social and environmental factors that may be contributing to behaviors

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    More from the S&C and Surveyor Training Dementia Care Principles (continued) Individualized Approaches to Care Critical Thinking Related to Antipsychotic Drug Use Interviews with Prescribers Engagement of Resident and/or Representative in

    Decision-Making

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    Additions to F329 – 5/13 – Antipsychotic Medications

    All classes, e.g., First generation (conventional) agents, e.g., • chlorpromazine • fluphenazine • haloperidol • loxapine • mesoridazine • molindone • perphenazine • promazine • thioridazine • thiothixene • trifluoperazine • triflupromazine

    Second generation (atypical) agents, e.g., • asenapine (Saphris) • aripiprazole • clozapine • iloperidone (Fanap

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