is antipsychotic medication reduction making you crazy?

Is Antipsychotic Medication Reduction Making You

Crazy?

HARMONY UNIVERSITYThe Provider Unit of

Harmony Healthcare International, Inc. (HHI) Presented by:

Kim Steele RN, WCC, RAC-CT, CHHRPRegional Consultant and Trainer

Speaker Bio

Regional Consultant and Trainer for Harmony Healthcare International, Inc.Over 28 years experience in Long-term Care and Cardiac CCU

Shift SupervisorMDS and Care Plan Coordinator for 5 yearsDirector of Nursing for 18 yearsTrained staff in IV-Certification, MDS 2.0, MDS 3.0, PPS, ADLs and Regulatory Compliance, Infection Control and OSHA

Specialty in Wound Care and Survey Compliance for both Standard and QIS SurveysProvides education in all aspects of Therapy and Nursing Medicare Documentation Requirements, completing CAAs and Care Plan Development, Wound Assessment and DocumentationExpert in NY State Medicaid/CMI Reimbursement and Documentation and training for Successfully Preparing for the NY State OMIG Audit

Copyright © 2013 All Rights Reserved 2Harmony Healthcare International, Inc.

Is Antipsychotic Medication reduction Making You Crazy?

Disclosures: The planners and presenters of this educational activity have no relationship with commercial entities or conflicts of interest to disclosePlanners:

Elisa Bovee, MS, OTR/LDiane Buckley, BSN, RN, RAC-CTBeckie Dow, RN, RAC-MTKeri Hart, MS CCC, SLP, RAC-CTKristen Mastrangelo, OTR/L, MBA, NHAChristine Twombly, RNC, RAC-MT, LHRM

Presenter:

Kim Steele, RN, WCC, RAC-CT, CHHRP


Is Antipsychotic Medication reduction Making You Crazy?Disclosure

Speaker: Kim Steele, RN, WCC, RAC-CT, CHHRP Regional Consultant and Trainer

The speaker has no relevant financial relationships to disclose

The speaker has no relevant nonfinancial relationships to disclose


Program Objectives

The learner will be able to discuss the content of S&C Memo 13-35-NHThe learner will be able to articulate the impact of F309 and F329 on resident health and well-beingThe learner will be able to list three risks of antipsychotic use for the elderlyThe learner will be able to identify the seven Dementia Care Principles The learner will be able to list three non-pharmacological interventions for behavior management


Is Antipsychotic Medication Reduction Making You Crazy?


S&C Memo 13-35-NH

Released May 24, 2013Conveys clarification to Appendices P and PP related to nursing home residents and F309 (Quality of Care) and F329 (Unnecessary Drugs)Announces mandatory surveyor trainings, which are available online at http://surveyortraining.cms.hhs.gov


http://surveyortraining.cms.hhs.gov/


F309-Quality of Care (§483.25)

Each resident must receive and the facility must provide the

necessary care and services to attain or maintain the highest practicable physical, mental,

and psychosocial well-being, in accordance with the

comprehensive assessment and plan of care


F309-Quality of Care (§483.25)

Intent:

The facility must ensure that the resident obtains optimal improvement or does not

deteriorate within the limits of a resident’s right to refuse treatment, and within the

limits of recognized pathology and the normal aging process


F329-Unnecessary Drugs (§483.25)

Antipsychotic Drugs—Based on a comprehensive assessment of the 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 medical record; and



Antipsychotic drugs, (continued)(ii)Residents who use antipsychotic

drugs receive gradual dose reductions, and behavioral

interventions, unless clinically contraindicated, in an effort to

discontinue these drugs



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

The medication regimen helps promote or maintain the resident’s highest practicable mental, physical, and psychosocial well-being, as identified by the resident and/or representative(s) in collaboration with the attending physician and facility staff;Copyright © 2013 All Rights Reserved 12Harmony Healthcare International, Inc.


Intent (Continued)Each resident receives only those medications, in doses and 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;



Intent (Continued)Clinically significant adverse consequences are minimized; andThe 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


Partnership to Improve Dementia Care in Nursing Homes

Launched March 29, 2012 (formerly known as National Partnership to Improve Dementia Care and Reduce Unnecessary Antipsychotic Drug Use in Nursing Homes)The goal of this partnership is to “optimize the quality of life and function of residents in America’s nursing homes by improving approaches to meet the health, psychosocial and behavioral health needs of all residents, especially those with dementia”



Per CMS, “Individualized, person-centered approaches may help reduce potentially distressing or harmful behaviors and promote improved functional abilities and quality of life for residents”



The CMS has joined with various stakeholders to improve care in nursing homesActions:

Surveyor training videosUpdated Appendix PUpdated Appendix PP



Three Surveyor Training Videos:http://surveyortraining.cms.hhs.govOverview of dementia care and potential approaches to addressing behavioral distressWalks surveyors thorough portions of an annual survey and focuses on the evaluation of a patient with dementiaRevised interpretive guidance for F309 and F329 and how to determine severity for non-compliance related to care of a patient with dementia (still under development)




Updates to Appendix P:Changes to the resident sampling process for the traditional surveyChanges to QIS were included in the recent 10.1.3 releaseThis change is intended to ensure that the survey sample includes an adequate number or residents with dementia who are receiving antipsychotic medication



Updates to Appendix PP:A new section of interpretive guidance at F309 related to the review of care and services for a resident with dementiaRevisions to the antipsychotic medication section of Table 1 at F329New severity example at he end of the interpretive guidance at F329



A checklist was created for surveyor useThis checklist can be used in either traditional or QIS surveyThe checklist is not part of the SOM, but was included in 13-35-NH for providers review


The Concern…

In the past, psychopharmacological medications have been used without first determining whether there is a medical, physical, functional, psychological, emotional, psychiatric, social or environmental cause of the behaviorsMedication may be effective when they are used appropriately to address significant, specific underlying medical of psychiatric causes, or new or worsening behavioral symptomsCopyright © 2013 All Rights Reserved 22Harmony Healthcare International, Inc.

The Concern…

Medications may be ineffective and are likely to cause harm if given without a clinical indicationAll interventions, including medications, need to be monitored for efficacy, risks, benefits and harmCMS states that its concern is that NHs may use medication as a “quick fix” for behavioral health issues and concerns


The Risk…

Antipsychotic medication is frequently prescribed for residents who have behavioral or psychological symptoms of dementia (BPSD)The term BPSD is used to describe behavior or other symptoms in individuals with dementia that cannot be attributed to a specific medical or psychiatric cause


The Risk…

When antipsychotic medications are used without an adequate rationale, or for the purpose of limiting or controlling behavior of an unidentified cause, there is little change that they will be effectiveThese medications commonly cause complications such as movement disorders, falls, hip fractures, CVAs, TIAs, and increased risk of death


The Risk…

The Food & Drug Administration (FDA) Black Box Warning Regarding Atypical Antipsychotics in Dementia reads: “Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk for death compared to placebo”


Resident’s Rights…

Informed Decision-Making: Residents have the right to be informed about the risks and benefits of any medicationRight to Refuse: Residents have the right to refuse any medicationFreedom from Chemical Restraints: It is against the law to give medications that do not benefit the resident, such as for convenience of staff


Dementia Care Principles

Fundamental principles of care for a resident with dementia include an interdisciplinary approach that focuses on the needs of the resident as well as the needs of other residents in the nursing homeThe revised CMS guidance and surveyor training highlight and re-emphasize these principles



1. Person-Centered Care CMS requires nursing homes to

provide a supportive environment that promotes comfort and recognizes individual needs and preferences



2. Quality and Quantity of Staff The nursing home must provide

staff, both in terms of quantity (direct care as well as supervisory staff) and quality to meet the needs of the residents as determined by resident assessments and individual plans of care



3. Thorough Evaluation of New or Worsening Behaviors

Residents who exhibit new or worsening symptoms should have an evaluation by the interdisciplinary team, 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



4. Individualized Approaches to CareUtilizing a consistent process that focuses on a resident’s individual needs and tries to understand behavior as a form of communication may help to reduce behavioral expressions of distress in some residentsIndividualized approaches are the first line intervention for BPSD in the US, UK, and Canada



5. Critical Thinking Related to Antipsychotic Drug UseSome residents will benefit from the use of antipsychotic medicationThe resident should only be given the medication if clinically indicated and as necessary to treat a specific condition and target symptoms as diagnosed and documented in the medical record



5. Critical Thinking Related to Antipsychotic Drug UseResidents who use antipsychotic drugs must receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugsSurveyors are instructed to review F222 (Right to be Free from Chemical Restraints)



6. Interviews with PrescribersSurveyors are instructed to evaluate the process of care, not evaluate the practice of medicineSurveyors interview the attending physician or other primary care provider (NP, PA), behavioral health specialist, pharmacist, and other team members to better understand the reasons for using a psychopharmacological agent or any other intervention for a specific resident



7. Engagement of Resident and/or Representative in Decision-MakingResidents (to the extent possible) and/or family or resident representatives must be involved in the discussion of potential approaches to address behavioral symptomsThese discussions with the resident and/or family or representative should be documented in the medical record


Antipsychotic Meds and Quality Measures


Antipsychotic Meds and Quality Measures

Antipsychotic med use affects two Quality MeasuresOne long-stay and one-short stay

Percent of Residents Who Newly Received an Antipsychotic Medication (short)Percent of Residents Who Received an Antipsychotic Medication (long)


Purpose of the Quality Measures

According to the CMS, Quality Measures (QMs) have four purposes for consumers:

To give you information about the quality of care at nursing homes in order to help you choose a nursing home for yourself or others;To give you information about the care at nursing homes where you or your family members already live;


Purpose of the Quality Measures

According to the CMS, Quality Measures (QMs) have four purposes for consumers (Continued):

To give you information to facilitate your discussions with the nursing home staff regarding the quality of care; andTo give data to the nursing home to help them in their quality improvement effortsCopyright © 2013 All Rights Reserved 40Harmony Healthcare International, Inc.

Quality Measures: The Basic Calculation

QMs begin as a simple fraction (or ratio):

Numerator: all residents that triggerDenominator: all residents of the facility minus exclusions

Risk adjustment then refines raw QM scores to better reflect the status of residents in the facilityMost measures use at least one exclusionThe prevalence of an outcome after exclusions is the facility-level observed score


Percent of Residents Who Newly Received an Antipsychotic Medication (Short-Stay)

Numerator: Short-stay residents for whom one or more assessments in a look-back scan indicates antipsychotic medication was receivedDenominator: All short-stay residents who do not have exclusions and who meet all of the following conditions:

Has a target assessmentHas a initial assessmentTarget and initial assessment are not the same assessment



Exclusions:Incomplete / missing dataDiagnosis coded on the MDS:

SchizophreniaTourette’s SyndromeHuntington’s Disease



Clinical Considerations:Non-pharmacological approaches to behavior management and appropriate GDRsAntipsychotic medications carry a number of risks for use in the elderlyIndividualized behavior plansPharmacy reviews and Psych evaluationsAssess cognition and “play up” strengthsCopyright © 2013 All Rights Reserved 44Harmony Healthcare International, Inc.

Percent of Residents Who Received an Antipsychotic Medication (Long-Stay)

Numerator: Long-stay residents with a target assessment that indicates an antipsychotic medication was receivedDenominator: All long-stay residents who do not have exclusions



Exclusions:Incomplete / missing dataAny of the following diagnoses coded on the MDS:

SchizophreniaTourette’s SyndromeHuntington’s Disease



Clinical Considerations:Non-pharmacological approaches to behavior management and appropriate GDRsAntipsychotic medications carry a number of risks for use in the elderlyIndividualized behavior plansPharmacy reviews and Psych evaluationsAssess cognition and “play up” strengthsCopyright © 2013 All Rights Reserved 47Harmony Healthcare International, Inc.


Clinical ConsiderationsUse of antipsychotics should be at t he recommendation of the Interdisciplinary Team, a Mental Health Professional or MDAll patients who receive an antipsychotic should have routine screening for extra pyramidal effects. This screen should be initiated within 72 hours of starting edication to establish a baseline.



Clinical ConsiderationsNotify the appropriate medical personnel of any changesWhen the Interdisciplinary Team feels it would be inappropriate from a clinical standpoint to attempt a GDR, consider completing a risk vs. benefit analysis that the team, MD and patient or family reviews and signs


Documentation Requirements

Determine appropriateness of a Gradual Dose Reduction (GDR) and document that decision in detail.

Current regulation requires ongoing monitoring for adverse consequence and GDR when clinically appropriate.Patients receiving any psychoactive medication must have the positive effect and/or potential adverse consequence monitored routinely by the Interdisciplinary Team


Documentation Requirements

This monitoring should be documented and reviewed by the attending MD on a regular basis who will then make a decision regarding the clinical appropriateness of a GDR and document that decision in detailEnsure that the Pharmacy Consultant is involved in this process and makes recommendations as indicatedCopyright © 2013 All Rights Reserved 51Harmony Healthcare International, Inc.

Monitoring

Clinically appropriateTime framesAll disciplines responsibleExpected by DOH

Rationale for monitoringBest way to track adverse consequenceAssists with clinical support for attempting or not attempting GDRAssist with care planning


Monitoring

Multiple tools availableAIMS

Facial and oral movementsExtremity movementGlobal judgmentDental Status

EPSE –Extra Pyramidal Side Effect Tool


Monitoring

Facility specific tool – things to consider

TremorsBlink rateWeight fluctuationChange in sleep patternChange in behaviors


Developing the Plan of Care

Develop non-medication interventions from all disciplines Be creative in developing new interventions if some don’t work Some conditions will require immediate medication intervention When the Team determines it is clinically appropriate to do so, medication therapy will be initiated


Developing the Plan of Care

KEY POINT: The use of any psychoactive medication will require the Care Plan Team to develop a detailed and patient specific care plan addressing the behavioral symptom that the medication is being given for


Developing the Care Plan

Some patients will continue to have behaviors that are not relieved with non-pharmacological interventions

Once the decision to use antipsychotic medication is made it is critical to address the use of the antipsychotic medication in the existing care plan Include how the patient will be monitored for both positive effects and adverse consequences


12 Questions to Consider During Interdisciplinary

Team Review


Question 1

If the behavioral symptoms represent a change or worsening, was a medical work-up performed to rule out underlying medical or physical causes of the behaviors, if appropriate?


Question 2

Were current medications considered as potential causes of the behaviors (i.e., those with significant anticholinergic or other side effects?)


Question 3

If a medical cause (e.g., UTI) was identified, was treatment (if indicated) initiated in a timely manner?


Question 4

If medical causes were ruled out, did the staff attempt to establish the root causes of the behaviors, using a careful and systematic process and individualized knowledge about the resident when possible? Were family caregivers or others who knew the resident prior to his/her dementia consulted about prior life patterns, responses to stress, etc?


Question 5

Was the clinical indication for the medication valid?


Question 6

Were non-pharmacologic, person-centered intervention tried before medications (other than emergency)? Were the results documented?


Question 7

Were specific target behaviors identified and desired outcomes related to those behaviors documented? Were caregivers aware of the target behaviors and desired results of the medication?


Question 8

Was the resident or appropriate legal representative consulted about the decision to use an antipsychotic medication and was that discussion documented?


Question 9

If the drug is continued for more than a few weeks, is the original clinical indication still valid (are the behaviors still present)?


Question 10

Is appropriate monitoring in place and is the team aware of the potential side effects?


Question 11

If new symptoms or changes in condition occurred after an antipsychotic medication was started, was medication use considered as a potential cause of a change or symptom?


Question 12

If on a medication, did the pharmacist perform a medication regimen review and identify related signs and symptoms, or did the staff inform the pharmacist if symptoms occurred after the last pharmacist visit?


Provider Self-Assessment Tool

Appropriate dementia care includes more than managing individuals with dementia-related behaviorFacilities must manage various factors while also optimizing function in medically complex patientsFacility systems are key in antipsychotic medication management



See handouts:Partnership to Improve Dementia Care in Nursing Homes State Coalition Provider Question Worksheet (Self-Assessment Tool)Partnership to Improve Dementia Care in Nursing Homes Provider Implementation Flow Diagram



Explore staff’s reaction to behavioral responses by persons with dementia in your facilityDetermine if residents and families given information about care options for persons with dementia, including those that do or do not use medications



How will your facility measure success in improving dementia care and reducing or optimizing antipsychotic drug use?Involve medical director, pharmacistStaff education about behavior management and facility policy and procedure for behavior managementCopyright © 2013 All Rights Reserved 75Harmony Healthcare International, Inc.

Section S (State Specific)

Section S is an optional section of the MDS 3.0 assessmentEach state can choose if they wish to include Section SEach state can also determine what items they wish to include in Section SMassachusetts recently added antipsychotic reduction questions


Section S (state specific)

Massachusetts Section S:Determines if the resident has received and antipsychoticDetermines if a dose reduction was doneDetermines if the dose reduction was maintainedDetermines if non-pharmacological resident centered care techniques were utilized


Final Thoughts

Unnecessary use of antipsychotic medications can have serious side effects for the elderly populationIndividualized, person-centered approach to manage behavioral symptoms is keyHolistic, interdisciplinary approach to behavioral symptom management


References

Survey & Certification Memo 13-35-NH http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-13-35.html

Quality Measures Users Manual http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures.html


http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-13-35.html




http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures.html



References

Advancing Excellence in America’s Nursing Homes http://www.nhqualitycampaign.org/star_index.aspx?controls=dementiaCare

Circular letter DHCQ 13-9-597 (state of Massachusetts)


http://www.nhqualitycampaign.org/star_index.aspx?controls=dementiaCare

http://www.nhqualitycampaign.org/star_index.aspx?controls=dementiaCare

Questions/Answers

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