Optimizing Outcomes and Ensuring Quality Care Clinical and Management Issues

1. Optimizing Outcomes and Ensuring Quality CareClinical and Management Issues Leo J. Borrell, MD Medical Director of Senior PsychCare in affiliation with Senior Psychological Care Houston and San Antonio AMDA 29th Annual Symposium

2. Faculty Disclosures: Dr. Leo J. Borrell Forest Laboratories: Speakers Bureau Bristol-Myers: Honoraria Janssen Laboratories: Honoraria Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

3. Quality Care Is In The Eye Of The BeholderClinical Issues Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

4. Patient Quality Chain Value Value Chain Problems Get to and From Hospital -Location -Language -Financial Situation Deal With Stress -May not have Support at Home -Few “in-hospital” support systems Find Out Patient Status -Difficult to Talk to Attending Physician -Conflicting Statements from Multiple Sources -Unfamiliar Vocabulary & Concepts Pay Bills -Bills are Difficult to Understand -Insurance is Difficult to Understand -Insufficient Resources Give Post Discharge Care -Loss of Income While Visiting -Little Help Available -Unfamiliar, Complex Activities -Costs

5. Physician Nursing Lab Value Pharmacy Diagnostic Imaging Physical Therapy General Quality Chain Value Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

6. Assess -Shortage of nurses -Documentation is time-consuming -Time-consuming -Not used as a communication tool -Supplemented with oral Care Plans -Not enough equipment -Not enough time and nurses -Nurses do non-nursing tasks -Manual documentation takes time Provide Care Discharge Prep -High acuity makes coordination difficult -All Manual -Increasing requirements from JCAHO -Everything must be documented Document Nursing Quality Chain Value Value Chain Problems

7. Physician Quality Chain Value Value Chain Problems -Privileges not clarified -Get the wrong room -Bed unavailability -No coverage or restricted coverage Locate patient Make diagnosis -Delays in obtaining medical records -Delays in getting consultants Orders & results -Delays in waiting for test to be performed -Results not delivered on time Treat patient -Scheduling conflicts for treatment rooms -Medications not given on time -Must go to hospital for dictation -Paperwork required for JCAHO, legal dept., HCFA -Reimbursement and coverage paperwork Document in chart

8. Quality From Medicare’s Perspective Documentation Guidelines • 15501 B • Medical necessity a must • Documentation must support level of service given • 15509.1 • Will pay for visits necessary for Medicare required assessments • For psychiatric visits, patient must be able to benefit, must NOT be suffering from a severe enough cognitive impairment to prevent effectiveness of service

9. Documentation - Timing of Visits • Medicare will only pay for necessary andreasonable preventive/routine care. • Necessary and reasonable defined as what is needed, according to the attending physician, to professionally “assess, plan, manage and monitor the health care of a resident or patient in the facility” within accepted principles of medical practice. Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

10. General Principles of Documentation Medical Records Criteria • Complete and legible • Include date of service, a plan for care • Include past and present diagnoses • Include progress, response to treatment, and compliance • Written plan with treatment, frequency of visits, and medications & dosage • Support level of evaluation performed MUST DOCUMENT NECESSITY OF SERVICE Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

11. Quality from a Surveyor Perspective Quality Indicators of Validity • Prevalence of Indwelling Catheter • Bladder/Bowel Incontinence • UTIs • Infections • Inadequate Pain Management • Pressure Ulcers • Late-loss ADL Worsening • ADL Worsening • Locomotion Worsening • Improvement in Walking • Worsening Bladder Incontinence Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

12. Quality Mental Health Care From A Medical Director Perspective • Understanding Implications of F Tags for The Mental Health Team • Qualifications of Mental Health Care Professionals • Responsibilities for Documentation • Understanding The Biosocial Approach: Communication, Collaboration, Evaluation, Education (Psychotherapy Requires MMSE >10) • Quality Is in The Eye of The Beholder Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

13. Quality from A Medical Director and Primary Care Physician PerspectiveF329, F429 TagsWhat It Means for Psychiatrists and Mental Health Practitioners Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

14. Frequent Fluctuation of Symptoms of Alzheimer Disease Progression Requires Weekly Monitoring and Medication Adjustment 90 80 70 60 50 40 30 20 10 0 Agitation Diurnal Rhythm Depression Wandering Aggression Peak of Occurrence (% Patients) Social Withdrawal Hallucinations Anxiety Socially Unacceptable Paranoia Suicidal Ideation 1 2 3 4 5 6 7 8 PROGRESSION OF SYMPTOMS BY YEARS Jost BC, et al. Journal of American Geriatric Soc. 1996;44:1078-1081.

15. Necessary Drug Protocol-F329 • Eliminate Unnecessary Drugs – Potential for Severe Adverse Reactions (F329) • Review Drug Regimens – Potential for Less Severe Adverse Reactions (F429) • No Excessive Doses • Must Use Only As Long As Necessary to Achieve Outcome • MUST BE MONITORED AND DOCUMENTED Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

16. Necessary Drug Protocol (cont.) • Must Have Indications for Use • No Long-Acting Benzodiazepines • Short Acting Agents Must Be Attempted First • Exception: Use Retains Functional Status No Use of Hypnotics • Must Limit Dose of Antipsychotics Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

17. Necessary Drug Protocol-F429 • Pharmacist MUST review each resident’s drug regimen once a month • Pharmacist must report irregularities to physician and DON • Reports require notification of MD and acknowledgement, but not action, agreement, or provision of rationale from MD Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

18. Cardiac Safety with Psychotropic Antipsychotics • Prolong QT Syndrome (Mellaril) • Thioridiazine 35.8 m.sec • Geodon 20.6 m.sec • Seroquel 14.5 m.sec • Least Effect Haldol 4.7sec (Haloperidol) • Electrocardiograph • Approximately 25% of patients Taking Pherothiazine have ABNORMALITIES. Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

19. Controlling Risk of Diabetes with Atypical Antipsychotics • Screen all patients for history of diabetes. • Those with DM or impaired fasting glucose must have antipsychotics chosen carefully • Monitor patients on atypical antipsychotics for any symptoms of diabetes. • Educate those at risk and run a baseline fasting glucose, repeating it quarterly. • Any abnormalities should be referred to PCP. • Only consider changing meds after consulting patient and other caregivers. Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

20. Survey Process-Quality Indicators Psychotropic Drug use • Frequency of antipsychotic drug use • Frequency of antianxiety or hypnotic drug use • Hypnotics used more than 2 times in previous week,then regular and psychotherapy Quality of Life • Use of daily physical restraints • Little or no activity for resident Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

21. Quality Mental Health Care A Nursing Home PerspectiveFocus Areas Culture of Care Quality of Care Environment Dementia Special Care Quality of Life Managing Behavior Therapeutic Activities Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

22. Goal of Quality Mental Health CareA Psychiatrist’s PerspectiveGlobal States of Well-being Sense of Worth Sense of Agency Social Confidence Hope Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

23. Quality - A Patient PerspectiveEnhancing Quality of Life Dignity Meaning And Purpose Identity Sense Of Security Psycho- Social Needs Sense Of Control Intimacy And Love Self- Esteem Belonging And Inclusion Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

24. Benefits of Quality Well-being Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

25. Facilitating Well-being • Recognize each person as unique • Give residents choices • Stress “working together”, not “doing for” • Interact and express self spontaneously • Stimulate the senses • Celebrate task accomplishment • Allow resident to give reciprocally to staff Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

26. Factors Contributing to Poor Compliance Illness-Related • Paranoid ideation • Negative symptoms/reduced motivation • Depression • Demoralization • Lack of insight • Cognitive impairment • Substance abuse • Grandiosity Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

27. Factors Contributing to Poor Compliance Treatment-Related • Inadequate therapeutic alliance • Side effects • Inconvenient regimen • Multiple drugs • Cost • Lack of psychoeducation • Misperception of therapeutic effect • Ineffective treatment Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

28. Factors Contributing to Poor Compliance Environment-Related • Lack of psychocosial support • Isolation • Stress • Stigma Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

29. Quality From an Administrator Perspective Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

30. Annual Cost of Therapy Depakote ER 500 mg QD $ 588 Depakote 500 mg + 250 mg $ 912 Depakote ER 500 mg – 2 tabs $1174 Risperdal 2 mg QD $1596 Risperdal 0.5 or 1.0 mg QD $ 960 *Risperdal 0.5 or 1.0 mg BID $1920 Zyprexa 5mg QD$2052 Zyprexa 10 mg QD$3120 *50% Risperdal RXs BID AWP 12 Months RX Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

31. Quality Care for Dementia Makes Dollars and Sense Annual Costs of Caring for Residents with and without AD • 26.4% had documented dementia • Average additional 229 hours of care per year • Average additional $4700 per patient with dementia per year • Problem behaviors add costs to LTC • Cholinesterase inhibitors may reduce this cost • Residents with this medication, $49.60 a day • Residents who discontinued it, $55.16 a day Patients who continued donepezil incurred $6.90 less per day, cost savings of over $2500 per year! Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

32. Total Cost Savings From Quality Care Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

33. F501 Tag What It Means for Psychiatrists and Mental Health Practitioners Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

34. Short Term Goal:Establish Responsibilities • Provide appropriate resident care • Make periodic visits to the facility • Provide medical orders • Provide coverage • Provide support for transfers • Provide documentation • Collaborate with other members of Treatment Team defining Treatment Goals Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

35. Short Term Goals to Comply with 501Core Areas to Establish with Policy and Procedures • Develop criteria/policies relating to care • Set standards for appropriate physician and mental health professional services • Review credentials of all professionals & CME • Review performance providing feedback • Liaison between mental health providers and facility staff and managers • Mental health and psychiatrist participate in quality assurance Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

36. Long Term Goal: Establishing A Performance Improvement Committee • Medical Director and QM Director Lead • Identify Staff to Be at Quarterly Meetings • Define Expected Practice Standards • Identify Process for Morbidity/Mortality Reviews • Develop Standardized Forms • Utilize Available Resources: Involve Everyone in PI Process Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

37. Long Term Goals Goals to Comply with 501 Through the Performance Improvement Committee • Develop criteria/policies relating to care • Set standards for appropriate physician and mental health professional services • Review credentials of all professionals & CME • Review performance providing feedback • Liaison between mental health providers and facility staff and managers • Participate in quality assurance Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

38. Implications of 501 Guidelines According to the CMS Guidelines on coordination of medical care, the Medical Director should: • provide information • identify educational needs • assist in obtaining services • evaluate services • get feedback from physicians. Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

39. Implications of 501 Guidelines • Medical Director is connected to the staff and should share mutual respect, communication, cooperation, accountability, feedback, and care. • Collective leadership implies coordinating care with attending physicians. Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

40. Implications of 501 Guidelines • Change needed in medical director/staff interfacing. • Medical Director should be included in: quality assurance, staff education, and facility organizational issues. • Include Medical Director as integral part of leadership team. Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

41. Implications of 501 Guidelines Surveyors are not our enemies. We must work towards a collaborative, positive relationship in which the Medical Director can provide information on: • Physician issues • Practices • Resident issues Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

42. Change in the Role of Medical DirectorProcess Rather Than Context • Medical directors must embrace dual mental models (values) • Medical model focuses on clinical expertise, medical care, individualized thinking. • Organizational leadership model focuses on physicians as leaders working in collaboration to achieve quality care goals in 3 areas: individual, team/group, and organization Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

43. Medical DirectorF-Tag 501 Implications for Mental Health New Responsibilities: • Collaboration rather than only compliance. • Involvement of psychiatrist and mental health in the quality assurance process identifying staff educational meetings. • Asking and clarifying expectations regarding mental health services. • Coordination of service with nursing staff, families, and primary care physician. Reference: Collaboration is Key to Success with F-Tag 501, Caring for the Ages, Dee Dixon, February, 2006, 8-9 Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

44. F-Tag 501 Has Major Implications for Mental Health • The CME Interpretive Guidelines emphasizes: • Coordinating of medical care • Providing information and medical director identifying educational needs of staff • Obtaining adequate services with qualified professionals • Evaluating the quality of mental health services delivered • Obtaining feedback from mental health providers and patients and family Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

45. Reasons to Avoid Quality Standards for Psychiatrists and Mental Health Practitioners • Don’t Know Enough About Patient Care to Dictate Clinical Practice • Mental Health Practitioners Have A Right to Practice As They See Fit Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

46. The Different Type of Quality Psychiatric and Psychotherapy Care Model • Consultation Acceptable • Individual Provider Good • Team Approach Better • Integrated Comprehensive Best and Mental Health Care Recommended by the President’s Commission on Aging Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

47. Quality and Best Practices in Geriatric Psychiatric Services (President’s Commission on Aging) 1. A multidisciplinary team approach 2. Specific geriatric expertise and competence 3. Individualized assessment and treatment planning with routine follow-up, ideally using standardized outcome measures 4. Collaborative treatment planning between the consultant and the nursing home staff 5. A strong educational component Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

48. Quality Required Quantity Future Visits Determined By Complexity of Decision

49. Quality Care From A Physician’s Perspective Senior PsychCare in affiliation with Senior Psychological Care “A Better Quality of Life Through Integrated Mental Health Care”

50. Non-Compliance Psychological Social Factors Compliance Effective Valued Valued but not effective Effective but not valued Bio-Medical Factors Complex Decisions That Appear Simple: Interaction of BioPsychosocial