CALTCM: A Collaborative Partner

1. CALTCM: A Collaborative Partner Debra Bakerjian, PhD, MSN, FNP, FAANP John Fullerton, MD, AGSF, FACP, CMD

2. CALTCM – Who We Are • California State Chapter of AMDA with 400 + members • Interprofessional membership • Focus on interprofessional collaboration • Effective collaboration with stakeholders (CDPH, CAHF, CCCC, POLST, CHCF) • Interdisciplinary membership (leaders within SNFs) with academic and clinical expertise with QI focus the past 6 years

3. Collaboration of the Future • Value of CMD, MD/NP teams is proven • Improved quality with CMDs and MD/NP teams – BUT it is not enough • Need NHAs, DONs, DSDs, CAHNR, others • Need pharmacists, hospitalists, social workers, discharge planners • Proponents of action oriented behavioral interventions • Need organizational change to adopt QAPI • Need support at the organizational and consumer levels

4. CALTCM Perspective • We agree that antipsychotic medications are often overused in patients with dementia, and are dangerous in this population • Efforts to reduce use have had limited success • We support the CMS and CDPH measurable goals of 15% or more reduction • We believe a QAPI approach is needed to achieve this goal • We are a significant part of the CA team that addresses this issue!

5. What Does CALTCM Bring to the Table? • CALTCM offers significant medical and QI leadership for this initiative • We are an interprofessional and collaborative organization • We have proven systems and processes that can be shared and adapted to this effort

6. History of QI Technical Expertise CALTCM is a national leader in SNF quality improvement •         INTERACT-II-III project •         Depression CQI project •         POLST statewide leadership in collaboration with other state organizations •         Teaching and academic leadership •         Nationally renowned leaders/clinicians

7. The Problem • Antipsychotic medication prescribing is driven by multiple factors that must be addressed before outcomes can be expected to change • Resident conditions, diagnoses, behaviors • Organizational factors (staffing, policies and procedures, knowledge of staff, organizational culture) • Leadership • Experience with QAPI • “Every system is perfectly designed to produce exactly the results it achieves.”

8. Why are antipsychotics used in patients with dementia? • They do work in some patients for acute behavior problems and patients with dementia—NOT ALL USE IS INAPPROPRIATE • Behavioral interventions and programmatic interventions are anecdotal – little evidence that they are helpful • Comfort (resident/family/staff) may override function or longevity as primary goal for many patients with advanced dementia and other advanced illnesses • Prescribing physicians are often distant from the site of care and have limited information • The need for a short term solution - the culture of the US (SNFs in particular) is to provide immediate response to problems leading to more prescriptions • Patients come to SNFs from hospitals and home while on antipsychotics; with no good reason and these medications are never discontinued • SNF nurses need help to manage patients who have behavioral problems that are out of control

9. CALTCM Proposal:Drive Performance Improvement with QAPI • Training • Educate the prescriber community widely • Include training for frontline staff – charge nurses, CNAs, others • Work with acute care hospitals to improve discharge planning • Include consumers (families) in the education • Train SNFs in alternatives to antipsychotics and link that to outcomes to determine what works • Provide greater incentives for behavior change; • Continued combination of sanctions and documentation requirements • Rewards for excellent outcomes

10. CALTCM Proposal:Drive Performance Improvement with QAPI • QAPI Interventions – develop QAPI process based on the 5 principles • Design and scope • Governance and leadership • Feedback, data systems, and monitoring • Performance improvement projects • Systematic analysis and systemic action • Application to reducing antipsychotics • Rapid and more frequent antipsychotic medication taper trials • IDT review of every patient on antipsychotic medication without FDA indication • Include attending primary care prescriber, medical director and pharmacist when possible • Determine when they are available to maximize participation • Improve monitoring of behaviors prior to initiation of antipsychotics when feasible • Be precise about non-pharmacological interventions – what actually works? • Enhanced activities programs

11. Change the Process and Monitor Outcomes • Use a “readiness for change” approach; establish leadership group of SNFs who will commit to change and are ready to follow through • Partnership of all groups working together-CAHF, HSAG, CDPH, CCCC, others • Must have dedicated leadership (DON, administrator, DSD, Pharmacist, prescribers) • Include other medical organizations including American College of  Physicians, Society of Hospital Medicine, American Academy of Geriatric Psychiatry, GAPNA • SNF leadership (QAPI) team should meet frequently • Training programs in the SNF should include CNAs and other front-line staff • Reward those who achieve 25% reduction or have antipsychotic rates at more than 25% below the mean • Possibly quality certification of some kind from CDPH and CMS?

12. Essential Goals for Success • Establish strong collaborative partnerships that leverages each organization’s expertise • Work in true collaboration • Keep activities person-centered and evidence base • Follow QAPI process and use AE and other evidence based tools and resources • Follow principles of interprofessional collaborative practice