Antipsychotics & beyond: what you need to know

1. Antipsychotics & beyond:what you need to know Originally Presented February 26, 2013 Updated June 19, 2013

2. Antipsychotic Drugs and the Regulatory System Ellen J. Mullins RN Research and Development Director, The Compliance Store

3. Survey and Certification Letters S&C Letter 13-34 Videos S&C Letter 13-35 Clarifications Manual Instruction Advanced Copy Effective Date

4. No Regulation Changes • Interpretive Guidance • Guidance to Surveyors • Interpretation

5. Dementia Care Principles • Person Centered Care • Quality and Quantity of Staff • Evaluation of New and Worsening Symptoms • Individualized Approaches to Care • Critical Thinking re: Antipsychotic Drug Use • Interviews with Prescribers • Engagement of Resident and Family in Decision Making

6. Surveyor Focus • “Process of Care” • Interviews • Observations • Record Reviews

7. Sample Selection Appendix P QM > 75th percentile

8. Be Prepared! List of residents with dementia and orders for antipsychotic medications past 30 days Articulate how individualized care is provided to residents with dementia Policy for use of antipsychotic medications in residents with dementia

9. F-309 – Quality of Care Addresses care areas not specifically covered by other F-tags in this regulatory grouping No investigative protocol Checklist: “Review of Care and Services for a Resident with Dementia”

10. F-329 – Unnecessary Drugs • Four new medications added to the list of antipsychotic medications: • Saphris • Fanapt • Latuda • Invega

11. Antipsychotic Medication • Indications for Use: • Schizophrenia • Schizo-affective disorder • Schizophreniform disorder • Delusional disorder • Mood disorders • Psychosis in the absence of dementia • Mental Illnesses with psychotic symptoms • Tourette’s disorder • Huntington disease • Hiccups • Nausea and vomiting

12. BPSD • Behavioral or Psychological Symptoms of Dementia • “Antipsychotic medications may be considered for elderly residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes have been identified and addressed. Antipsychotic medications must be prescribed at the lowest possible dose for the shortest period of time and are subject to gradual dose reduction and re-review.”

13. Inadequate Indications • Wandering • Poor self-care • Restlessness • Impaired memory • Mild anxiety • Insomnia • Inattention/indifference to surroundings • Sadness or crying unrelated to depression or psychiatric disorders • Fidgeting • Nervousness • Uncooperativeness • Criteria for Antipsychotic Drug Use: • Behavior is a danger to resident or others AND • Symptoms are due to mania or psychosis OR • Interventions attempted and included in the care plan (except in an emergency)

14. Emergency Use of Antipsychotic Medications • Criteria in the prior slide must be met IN ADDITION TO ALL OF THE FOLLOWING… • Acute treatment period is 7 days or less • Clinician evaluation and documentation within 7 days • Underlying causes • Contributing factors • Verification of the need to continue the antipsychotic medication • Persistent behaviors • Nonpharmacological interventions • Attempted – unless contraindicated • Documented

15. Enduring Conditions • Clearly identify and document the target behavior • Monitoring must include: • Assuring the cause is not a medical condition or medication • Environmental stressors • Psychological stressors • Persistence that negatively affects quality of life

16. New Admissions Attempt to identify an indication for use PASRR Physician’s orders Within 2 weeks, re-evaluate the use of the medication to consider reduction or discontinuation

17. Adverse Consequences “The facility MUST act upon this!” The facility AND prescriber MUST document the rationale for the decision and the inclusion of the resident or family in the decision.

18. Documentation • Diagnosis • Expected outcome • Monitoring of resident response • Risk / benefit • Adverse consequences • Re-evaluation of behavioral symptoms • Continued effectiveness • Potential reduction

19. Prioritize Dose Reduction Efforts Avoid initiating antipsychotic drugs for residents not currently taking them Re-evaluate residents recently prescribed antipsychotic drugs for the first time Carefully assess all residents admitted with antipsychotic drugs for reason/benefit/side effects and reduction/elimination Residents with long term antipsychotic use should be carefully evaluated for dose reduction or elimination of antipsychotic drug use

20. F-329 – Antipsychotic Drugs • Based on a comprehensive assessment of a resident, the facility must ensure that – • Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessaryto treat a specificcondition as diagnosed and documented in the clinical record; • Residents who use antipsychotic drugs receive gradualdose reductions, andbehavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

21. How Do We Reduce Our Reliance on Antipsychotics? Cheryl Swann RN-BC, BSN, WCC, LNHAVice President of Content,Relias Learning

22. Getting Started on Reducing Antipsychotics • Form a committee – an interdisciplinary team (IDT) to: • Review residents’ diagnoses and medications • Dementia diagnosis priority • Reason for medication • Last dose reduction • Review behavior tracking log

23. Trends the IDT Will Find • A large number of behaviors in residents with dementia occur during personal care • Bathing • Dressing • Is this behavior inappropriate?

24. A Look at the Behavior Tracking Log • Analyze the behavior tracking logs to determine if there is a particular trigger for the resident’s behaviors • Shift • Staffing

25. Meaning Behind the Behavior • All behavior has meaning • Shift from “How do I stop behaviors?” to “What are these behaviors trying to tell me?” • Rule out medical causes • Pain, constipation, infection, delirium • Look at current medications • Talk to the family • Know the resident

26. Behavioral Triggers • Three types of triggers: • Internal • Environmental • Caregiver • Must evaluate behavioral triggers to determine the most appropriate behavioral intervention

27. Behavioral Interventions • Internal triggers • Eliminate physical factors, such as pain, hunger, or elimination needs • Provide stimulating, interactive exercise or activities • Provide one-to-one care • Redirection

28. Behavioral Interventions • Environmental triggers • Reduce or remove environmental stimuli • Reduce/eliminate overhead paging • Alarms • TV/Radios • Play music/headphones

29. Behavioral Interventions • Caregiver triggers • Consistent assignments • Does the staff working with the resident know them? • What is in the care plan? • What do they like/dislike? • How do they typically communicate needs/react in certain situations? • How is information communicated? • Allow to make simple decisions and choices

30. Behavioral Interventions Understand or explain the rationale for interventions/approaches Monitor the effectiveness of those interventions/approaches Provide ongoing assessment as to whether they are improving or stabilizing the resident’s status or causing adverse consequences

31. Documentation and Proof • New Survey Process • Compliance with care plan • Staff knowledgeable of behaviors • What did you do to try and figure out the cause of the behavior? • What was the resident communicating with his/her behavior? • What was the reason for the resident acting out? • What interventions did you try to reduce the behavior?

32. Care Process for a Resident with Dementia Recognition and assessment Cause identification and diagnosis Development of care plan Individualized approaches and treatment Monitoring, follow-up and oversight Quality assessment and assurance (QAA)

33. Recognition and Assessment Past life experiences Cognitive status Presence of pain, medical conditions, medications Preferences for daily routines, food, music, exercise How do they communicate physical needs? Description of behaviors (specific)

34. Cause Identification and Diagnosis • Meaning behind behavior • Medical/psychiatric conditions • Medications • Look at root cause • Boredom • Changes in routine • Unmet needs • Environmental

35. Develop Care Plan Well-defined problem-statement/outline goals of care Identify staff responsibilities to implement approaches Goals to monitor the effectiveness Collaboration with resident and family

36. Monitoring and Follow Up Staff monitors and documents the effectiveness of interventions to target behaviors Interventions changed as needed Collaborate with physician regarding medications

37. Quality Assessment and Assurance Resident care policies reflect the facility’s approach to care of residents with dementia How the facility ensures that appropriate interventions are used Sufficient staffing Data to monitor pharmacological and non-pharmacological interventions Facility’s response to concerns identified during pharmacy review

38. Quality Assessment and Assurance • Staff training • Understanding the Meaning Behind Behaviors – Actions and Reactions • Psychotropic Medications – Antipsychotics and Beyond

39. Measurement of Psychoactive Medications and Continuous Quality Improvement Theresa Schmidt MA, RAC-CTManager of Education, eHealth Data Solutions

40. Goals • Understand how CMS measures antipsychotic medications in CASPER and Nursing Home Compare • Identify which residents trigger these measures and why • Compare your performance to benchmarks • Assess effectiveness of interventions and progress over time through trend and SPC charts

41. Antipsychotic Quality Measures Short-Stay Measure Long-Stay Measure Percent Long-Stay Residents Who Received AntipsychoticN0410A=[1,2,3,4,5,6,7] Exclusions: Schizophrenia, Tourette’s, Tourette’s on prior assessment, Huntington’s • Percent Short-Stay Residents Who Newly Received Antipsychotic N0410A=[1,2,3,4,5,6,7] • Target MDS must be different from initial MDS • Exclusions: • Antipsychotic use on initial MDS • Schizophrenia, Tourette’s, Huntington’s

42. Long-Stay vs. Short-Stay • Select all residents whose latest episode either ends during the target period or is ongoing at the end of the target period • This latest episode is selected for QM calculation • For each episode that is selected, compute the cumulative days in the facility (CDIF) • If the CDIF is less than or equal to 100 days, the resident is included in the short-stay sample • If the CDIF is greater than or equal to 101 days, the resident is included in the long-stay sample

43. Nursing Home Compare Measures Available to the public at http://medicare.gov/nursinghomecompare Long-stay and short-stay antipsychotic medication measures were added in summer, 2012

44. CASPER – Certification And Survey Provider Enhanced Reports Quality measure reports are available to state surveyors and facility staff through CMS’ CASPER reporting system Psychoactive measures were updated this spring to match Nursing Home Compare Measures Prior to the updates, only a Long Stay Psychoactive measure was present, and more conditions were excluded If you compare your Long Stay measure from a CASPER report generated in February to one today, both your facility and benchmark rates will likely be higher today

47. CASPER Reports vs. Nursing Home Compare

48. Translating QMs to QI • Static Displays of Data • Benchmark: Compares your data for a particular interval of time against national or state norm or against your historical data • Percentile Ranking: (1-100) the percent of other facilities that are better than your facility • Dynamic Displays of Data • Trend Charts: Displays your performance over time • Statistical Process Control Charts: Your performance over time plus control limits that indicate how predictable your process is and expose significant events

49. Statistical Process Control Charts (SPC) • Is variation due to “common cause” or “special cause”? • Need 12-15 periods of data • Review monthly for QI committee. Look for: • 5-7 points in a row increasing or decreasing • 5-7 points in a row climbing higher or lower than your mean • A data point (or points) outside your control limits • Benchmark outside your control limits

50. Trend Charts in Excel