COUNTRY VILLA – HEALTH INFORMATION / RECORD WORKSHOP JULY 16, 2012

1. COUNTRY VILLA – HEALTH INFORMATION / RECORD WORKSHOPJULY 16, 2012 Rhonda L. Anderson, RHIA, AHIS, Inc.

2. PRESENTED BY Rhonda Anderson, RHIA Anderson Health Information Systems, Inc. 940 W. 17th Street, Suite B Santa Ana, CA 92706 Email: office@ahis.net Telephone: 714 -558 - 3887

3. ANTIPSYCHOTIC MEDICATION • FOCUS OF NATIONAL AND STATE QUALITY OF CARE INITIATIVES • THE INFORMATION IS TAKEN DIRECTLY FROM CAHF WORKSHOP PRESENTED BY: • La Mer Integrative & Behavioral Medical Group (Jerry G. Bruns MD & Debbie Herrera NP) • CAHF (Mary Jann & Jocelyn Montgomery, RN)

4. ANTIPSYCHOTIC USE IN THE HEADLINES • May 27, 2008 – JAMA and Archives Journals “Short-term Use of Antipsychotics In Older Adults With Dementia Linked to Seniors Adverse Events.” http://jama.ama-assn.org/content/300/4/379.short?citedby=yes&legid=jama;300/4/379

5. ANTIPSYCHOTIC USE IN THE HEADLINES -2 • 2009 – American Journal of Geriatric Pharmacotherapeutics – “There is a statistically significant increase in antipsychotic drug prescriptions form 16.4% in 1996 to 25.9% in 2006. Higher utilization rates were found in nursing homes that were for-profit, had lower Medicare reimbursement rates, and had lower levels of competition.” http://www.medscape.com/medline/abstract/19616182

6. ANTIPSYCHOTIC USE IN THE HEADLINES -3 • January 2010 – Archives of Internal Medicine • University of Massachusetts Medical School of Study (Y. Chen, MD) • More than 1/3 of nursing home residents were prescribed an antipsychotic without clinical indication • Residents in NHs with the highest prescribing rates were 1.37 times more likely to receive antipsychotic medication http://archinte.amaassn.org/cgi/content/short/170/1/89

7. ANTIPSYCHOTIC USE IN THE HEADLINES -4 • 2011- Health and Human Services OIG Report- • 14% of all nursing home residents with Medicare had claims for antipsychotics • 88% of the atypical antipsychotics prescribed off-label were for dementia. http://oig.hhs.gov/oei/reports/oei-07-08-00150.pdf

8. ANTIPSYCHOTIC USE IN THE HEADLINES -5 • OIG Findings • 22% of the atypical antipsychotic drugs claimed were not administered in accordance with CMS standards • 44% did not comply with CMS standards for more than one reason • August 1, 2011 – Senators Grassley and Kohl urge CMS to further examine the use of antipsychotic use in NHs

9. MEANWHILE IN CA…SB 303 VETO MESSAGE • …My Administration is concerned about the inappropriate use of psychotherapeutic medications, especially antipsychotic, in skilled nursing facilities. One recent study concluded that over half of the residents receiving antipsychotic therapy were being treated outside the current Center for Medicare and Medicaid Service guidelines.

10. MEANWHILE IN CA…SB 303 VETO MESSAGE -2 • … “I have instructed my Department of Public Health to identify provider that may be inappropriately prescribing these medications and thereby posting a threat to the health and safety of residents in skilled nursing facilities. If the department’s analysis indicates that such inappropriate prescribing behavior is occurring and recommends statutory changes in this area, I ask the Legislature to immediately seek changes to correct it.”

11. “CDPH/DHCS ANTIPSYCHOTIC COLLABORATIVE” IS BORN • CDPH and DHCS mine data to identify Medi-Cal residents who receive one or more antipsychotic medications • CDPH invests consultant pharmacist resources to conduct “complaint” visits at targeted facilities in these District Office Areas: • Chico, Daly City, East Bay, Fresno (Modesto only), Sacramento, San Diego, San Jose, Santa Rosa/Redwood Coast

12. COLLABORATIVE “TARGET” CRITERIA • Residents currently prescribed either: • Two antipsychotic medications concurrently OR • One (or more) antipsychotic medication(s) with a primary diagnosis of Alzheimer’s dementia with or without a co-existing diagnosis of SMI

13. INVESTIGATIONAL FINDINGS • Data Summary (May 2010 thru June 2011) • Facilities cited for inappropriate antipsychotic drug use: 20 of 31 • Facilities cited for the consultant pharmacist’s failure to identify inappropriate antipsychotic drug use: 20 of 31

14. DEFINITION - PSYCHOTROPIC • Exerting an effect on the mind, capable of modifying mental activity; said especially of drugs. (Dorland’s) • Having an altering effect on perception or behavior. Used especially of a drug. (The American Heritage Medical Dictionary)

15. DEFINITION - PSYCHOTHERAPEUTIC • Drugs that are prescribed for their effects in relieving symptoms of anxiety, depression, or other mental disorders. (Mosby’s Medical Dictionary)

16. WHAT ARE PSYCHO-THERAPEUTIC MEDICATIONS? • Antipsychotics – typical and atypical • Haldol, Seroquel, Risperdal, etc… • Anticonvulsants • Tegretol, Depakote, etc… • Antidepressants • Celexa, Lexapro, etc… • Sedative‐Hypnotic • Ativan, Xanax, etc… • Others • Beta‐blockers, alpha 1‐2, Provera, etc…

17. THE PROPER INDICATIONS FOR USE • Antipsychotics • Psychotic behavior: Auditory or Visual Hallucinations, delusional thinking • Anticonvulsants • Poor impulse control: Aggressive behavior or mood disorder • Antidepressants • Depression or mood disorder • Sedatives‐Hypnotics‐Benzodiazepines • Insomnia or Anxiety • Others • Sexually aggressive, temper outburst, impulsive behavior

18. DHCS WEIGHTS IN… • August 2011 – The Department of Health Care Services (DHCS) adds a “Code I Restriction” for all antipsychotic medications available on the Contract Drug List (CDL) for Fee-For-Service Medi-Cal beneficiaries.

19. DHCS WEIGHTS IN…-2 • After October 1, 2011, all antipsychotic medications listed on the CDL will include the following restriction: “Restricted to…Federal Drug Administration (FD) – approved indications for those beneficiaries residing in Skilled Nursing Facilities only.”

20. DPH FOCUSES ON INFORMED CONSENT • DPH Informed Consent All Facilities Letter (AFL) issuances: • January 7, 2011 – Obtaining informed consent for preexisting orders • April 12, 2011 – Q&A Document • Key is educational acute hospital re: need for informed consent verification • Facility documentation verifying that informed consent has been obtained by the MD http://www.cdph.ca.gov/certlic/facilities/Pages/LnCAFL.aspx

21. REGULATIONS OF INTEREST • Frequency Cited in 2011 • F Tag 329 – Unnecessary Drugs (28%) • F Tag 425 – Pharmacy Procedure (25%) • F Tag 431 – Labeling of Drugs (32%) • F Tag 481 – Professional Standards of Quality (24%)

22. WHAT SURVEYORS EVALUATE? • Medication used are routinely monitored (therapeutic effects, ADR, side effects) according to manufacturer’s specifications or standards of practice; • Necessary labs, weights, VS are taken and recorded; • Doses are appropriation titrated up or down for an elderly person, including planned dose reduction;

23. WHAT SURVEYORS EVALUATE? -2 • Resident with renal/hepatic impairment has appropriate dose of adjustment and; • Whether there is an association between Rx and recently identified symptoms/condition change such as fall/recurrent falls, decline in ADLs or decreased sensorium/increased somnolence.

24. WHEN THE SURVEYOR IDENTIFIES CONCERNS? • Sufficient Nursing Staff… • Medications administered timely • Evaluate resident response to RX • Implement non-pharmacologic interventions when appropriate, and • Identify and respond to resident change in conditions • Physician Supervision- Did the MD supervise the resident’s medical treatment, assess the resident’s need for RX and develop a treatment plan?

25. WHEN THE SURVEYOR IDENTIFIES CONCERNS? -2 • Did the physician/designee: • Review the resident’s total care plan? • Write relevant progress notes? • Establish a treatment regimen that considers non-pharmacological interventions? • Review Rx regimen for potential unnecessary medications-effectiveness-potential complications?

26. CAN WE USE THEM SAFELY? • Rule out all other causes for change in behavior • If there is a proper indication for use, MONITOR side effects, i.e, FALLS, INFECTION • Risk of death – cardiac or pulmonary • Benefits outweigh the risks? • Is the medication used going to: • Improve the quality of their life? • Alleviate undue stress to the resident?

27. REDUCING THE NEED FOR ANTIPSYCHOTIC MEDICATIONS • For people with dementia: • Most approaches are “Culture change” • Vision and leadership and the “will” to do it differently are key • Consistent assignments are imperative • Assessing and accommodating prior routines, likes, dislikes are critical • Tasks and staff must be organized to support individualized care • Building empathy, and rewarding doing it right are a must

28. DEFINITION OF UNNECESSARY DRUG USE • Each resident’s drug regimen must be free from unnecessary drugs, which is any drug used: • In excessive dose (including duplicate drug therapy); • When a resident receives duplicate drug therapy, an evaluation should be completed for accumulation of the adverse effects. • For excessive duration; • Without adequate monitoring; • Without adequate indications for its use; • In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or • Any combination of the above reasons.

29. JUSTIFICATION FOR DRUG USE OUTSIDE GUIDELINES • Medical Provider’s progress note indicating that the dosage, duration, indication & monitoring are clinically appropriate and why they are clinically appropriate; • Carefully considered the RISK/BENEFIT to the resident; • A medical or psychiatric consultation and ongoing evaluation;

30. JUSTIFICATION FOR DRUG USE OUTSIDE GUIDELINES -2 • Evaluations (e.g., Geriatric Depression Scale) confirming the medical provider’s judgment that use of a drug outside the guidelines is in the best interest of the resident; • Documentation of medical provider, nursing, or other health professional indicating that the resident is being monitored for adverse consequences or complications of the drug therapy;

31. JUSTIFICATION FOR DRUG USE OUTSIDE GUIDELINES -3 • Documentation of GDR attempts and outcomes; • Documentation showing why the resident's age, weight, or other factors would require a unique drug dose or drug duration, indication, or monitoring;

32. JUSTIFICATION FOR DRUG USE OUTSIDE GUIDELINES -4 • Documentation showing that the resident's decline or deterioration has been evaluated by the interdisciplinary team to determine whether a particular drug, a particular dose, or duration of therapy may be the cause; • Documentation showing why the resident's age, weight, or other factors would require a unique drug dose or drug duration, indication, or monitoring.

33. GUIDELINES FOR USE OF ANTIPSYCHOTIC DRUGS • Long‐term care centers must ensure, based on a comprehensive assessment of the resident, the following: • When an antipsychotic drug has not been used in the past, it is not given unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record. Antipsychotic drugs should not be used unless the clinical record documents that the resident has one or more of the specific conditions (see next slide).

34. DSM‐IV DIAGNOSIS • Schizophrenia • Schizo‐affective disorder • Delusional disorder • Psychotic mood disorders (including mania and depression with psychotic features) • Acute psychotic episodes • Brief reactive psychosis • Atypical psychosis • Tourette's disorder • Huntington's disease

35. ORGANIC MENTAL SYNDROMES • Delirium, dementia & amnesic & other cognitive disorders w/associated psychotic and/or agitated behaviors that have been quantitatively & objectively documented. This documentation is necessary to assist in: • Assessing whether the resident's behavioral symptom requires some form of intervention. • Determining whether the behavioral symptomis transitory or permanent.

36. ORGANIC MENTAL SYNDROMES -2 • Delirium, dementia & amnesic & other(cont.): • Relating the behavioral symptom to other events in the resident's life to learn about potential causes (e.g., death in the family, adhering to the resident's customary daily routine). • Ruling out environmental causes (e.g., excessive heat, noise, overcrowding). • Ruling out medical causes (e.g., pain, constipation, fever, infection).

37. DEMENTIA WITH BEHAVIOR DISTURBANCE • According to the AHCA • 1st line treatment for residents who do not present immediate danger to themselves or others should be non-pharmacologic. • While no drugs are approved by the FDA for the treatment of behavioral symptoms in older adults with dementia, if pharmacotherapy is deemed appropriate use the most appropriate agent and the lowest effective dose, for the shortest amount of time. • Response to therapy should be monitored and documented frequently and evaluated for gradual dose reduction, tapering or discontinuation.

38. BE PROACTIVE IN YOUR FACILITY • What can you do? • Open transparent communication with patients and their family/responsible parties (RP) • Education (patient/family/RP/staff) • Use your local resources (ALZ association) • Therapeutic communication with medical providers • Ask “is this going to improve the quality of the residents life?” • Interdisciplinary team meetings (IDT)

39. EVALUATE YOUR DOCUMENTATION • Run reports from the P.O. re: psychotrophic and psychotherapeutic drugs • Look at diagnoses • Look at documentation • Look at psychiatric evaluation • Conduct comprehensive audit and follow up (see AHIS HIM #7050 – Behavior Drugs Monitor)

40. QUALITY IMPROVEMENT APPROACH TARGET • By December 31, 2012 at 12:00 p.m. – Reduce the off-label use of antipsychotics by 15 percent.

41. QUESTIONS & ANSWERS Rhonda Anderson, RHIA President, AHIS, Inc. 714-558-3887 office@ahis.net Thank You!