Event Title: C.A.L.M. in the Storm Curtailing Antipsychotic Use in LTC Medicine Event Date: July 12, 2018 Event Time: 11:00am 12:00pm EST

Transcription

1 Event Title: C.A.L.M. in the Storm Curtailing Antipsychotic Use in LTC Medicine Event Date: July 12, 2018 Event Time: 11:00am 12:00pm EST Good morning everyone. My name is Doreen Ostapchuk. I am from the New England QIN-QIO. Thank you for joining us. Our webinar is C.A.L.M. in the Storm: Curtailing Antipsychotic Use in LTC Medicine, hosted by the New England QIN-QIO Quality Care Collaborative. Before we get started, I will quickly review some housekeeping items. This call will be recorded for training purposes. The presentation is available on the webpage, and the link was posted in chat. Phone lines will be on mute for the duration of the presentation. Please do not place us on hold. If you find the presentation is cut off, use your plus or minus icon at the top right of the presentation window. This will adjust your screen accordingly. Our speaker, Dr. Fazeli, will monitor chat throughout the presentation and answer questions in real time. You can also ask questions in chat. Remember to send it to All Participants. At this time, I will mute all lines. I will now pass this over to Margie McLaughlin with the New England QIN-QIO to introduce our speaker, Dr. Jabbar Fazeli. Thank you so much, and I want to thank you for joining us on the call. We are all very concerned about reducing antipsychotic drugs. I'm happy to report that today's speaker is someone who has found some wonderful and innovative approaches to reduce antipsychotic drugs. Not only is he a great champion of nursing home care, but he is also a passionate eldercare specialist and a good friend to the New England QIN-QIO. We are grateful to have with us today, Dr. Jabbar Fazeli. He is passionate about many elderly causes. He works as part of the dementia partnership and is the medical director for many of the Maine nursing homes. We are delighted to have with us Dr. Jabbar Fazeli. Thank you, Dr. Fazeli. Thank you. Welcome, everyone. At the start I will say I included about 100 slides here. Not because I will be discussing all of them, but because I want to have a comprehensive handout if you reference them later. I will take questions during the presentation, but I will leave time at the end to answer any questions as well. Some questions can be answered with the subsequent slides. I will leave enough time at the end once everyone has heard the presentation. The basic presentation is focused on my work after the 2012 CMS initiative to reduce antipsychotic use. It basically created an approach that would try to achieve that objective. We initially had three facilities that we covered if you look at the first slide that shows you the national trend for the first three years from CMS. The subsequent slide is the more up-to-date one. As you can see, the general use of antipsychotics nationally has dropped, but we are still hovering between 15% and 18% or so. The following slide is the national average for facilities that are falling behind. They are late implementers which is the best way to look at the worst performers. You can see over the past five years that some facilities are on the tail end and are still struggling. This slide shows Maine and the national average.

2 Before we started the program, we had facilities on the left side, Durgin Pines, Maine, and Varney Crossing. You can see here that Durgin Pines was the best. It's been consistently sustained since 2013 and 2014 up until now with a one or 2% variation. This is the same slide for Durgin Pines. You can see in the national average that there is a trend of antipsychotic use. If you remember when the CMS initiative started, the goal was 15% reduction. That was a relative reduction, not going to 15%. This was way past the expectation. This second-best performer basically had a reduction, but we never really broke the 5% margin. We broke the 10% and hovered around that. We left that facility in I kept track of the data because it was public knowledge and was on Medicare Compare. This is how it trended. The good news is that once the program was implemented, there was some sustainability. Obviously, there were better benefits, and all the elements were in place. The third was not a full implementation of the program. You can see this as any other quality initiative. We are back to where we were. Ironically, it is now one of the facilities was one of the late implementers. Here is another facility. There is a drop in 2015 which was one of the DON s move there. You can see the drop that where the director of nursing alone was able to achieve roughly around a 10% drop. To go down to 5% and below, you really need the medical director s involvement. Here I can show you that the top performer is one of the new facilities. The best performer, Durgin Pines is on the list. The key lessons on the protocol was that under the best of circumstances once fully implemented, we can achieve 5% or less usage in general. That leaves us with two to four focus cases. We still must treat them as challenging and needing constant revision and monitoring. Those are the cases that basically need specialized attention. Imagine when we are asking people to change everything. Often, we are facing the issue of the practical barriers to having patient-centered care. When you are looking at this from the standpoint you are only doing this for three or four cases, then it becomes less impossible. By the same token you hear from facilities that are small. You complain that this is hard but you can't impact it as much because a few cases result in some of this. The data shows that if you did one case in a very small facility and dropped your use by 20%, you are a facility that is 50 or less. That is a big drop from this alone. Being a small facility doesn't mean you must deal with higher rates. The protocol does not call for zero tolerance. I mentioned that because it's the approach for some providers and facilities to the initiatives. I'm sure if you look at the numbers, you will see the approach doesn't achieve 5% or less. I reviewed the data for some corporate facilities that have their own physicians employed and make it a zero-tolerance policy. Those facilities don't necessarily fall under best performers. Sustainability is a big challenge for everyone. In our case, we looked at it in terms of dealing with new admissions. This and dealing with staff who are not on the same page was a big sustainability issue. One of the issues we dealt with is site referrals. We found when there are more site referrals, they are more into antipsychotic use. One of the last challenges we have is to address the issue of shifting from antipsychotics to others. It wasn't good enough to reduce antipsychotics because we ended up with higher drug use. Looking at quality measures is important. I will skip this slide because we are going fast. It's good to know this data is a few months old. It is reviewed monthly, and you have a way of dealing with sudden

3 spikes. What is C.A.L.M.? The modules are environmental, nursing, and medical provider modules. The plus one is the leadership triangle and the necessity we found for the leadership to be involved at a very high level and to have a collaborative thing between the medical director and the administrator and the director of nurses. It is important to implement all the three modules that we have. Without that it would not work. It's not a zero-tolerance program. We also do not mandate that everyone is reduced. It does not call for automatically signing off on pharmacy regulations for gradual dose reduction. We do not avoid antipsychotic use for FDA indications that are not included in the CMS initiative; for example, bipolar disorder, depression with psychosis, dementia, etc. More importantly if we update days and treat when clinically appropriate. We are still even less than 5%. Maybe culture change is the biggest item when discussing cases that are difficult. At the beginning of the conversation, you start with, we have done everything already. That is usually a nonstarter conversation. That is a prelude to a silver bullet which is often a medication. We've addressed with our staff that everything being done is impossible to achieve. There are opportunities for something to be done. What can be done today can be different tomorrow. If the family and staff expect dementia patients to be cooperative with us and listen to us, it may be an impossible goal to achieve. We do address acceptable dementia behaviors that are not treatable. Then the big piece is addressing new staff education. You can do this and three months later have a 20% turnover to correct. There are some technical barriers like the medical provider. The other thing I can highlight here is real time data collection and real-time feedback. You usually see a review of data at the quality improvement meetings, and then you would have the review of cases in the morning rounds or huddles. What we recognize is that most of this feedback needs to go to the night shift and on-call nurses. Usually they are not present during the morning huddle or the quality improvement meetings. We established review with the medical director within one to two business days of all cases and that either an antipsychotic was started or there was a call after hours to the provider. The director of nursing would have an opportunity to discuss this on the night shift that was involved in the case. This was extremely important because if we are doing education and feedback, it is not going to the right people. I will include a few pictures of QPP in Maine. I will mention the systemic changes we address. You can see the lighting reduction. You can see the picture here. We reduced the lighting to every other light. The facility was looking too bright. That is not conducive to someone trying to calm down and wind down at night. The administrator was involved in discussing light limitations with state surveyors and making sure we were within the boundaries of regulations. I will mention the mealtime change specifically because we addressed the mealtime behaviors or at least the focus cases we have. There were a lot of challenges during mealtime, not only for themselves but also for other residents. You can imagine if your dementia is not as bad as everyone else and you re hearing screaming and howling during mealtime. The quality of life during mealtime drops. You may not enjoy your meal despite the fact that the facility has done everything they can to make the meal enjoyable. Also this addresses other care issues like residents who are incontinent or at low risk for incontinence. When we separated the mealtime focus patients from the rest of the population, it ended up helping those residents as well, because the CNA had more time to spend. You can imagine splitting the time by half an hour and making a big difference. Actually, I want you to think about which group we

4 put first. Did we put the high-need residents first or did we put the self-feeding, low maintenance dementia patients first? The answer is that we put the self-feeding first because they don't need as much care. When the CNA is dealing with the more challenging resident they have more time to spend with them and don't feel rushed. Once we implemented this as the best performance facility, they found it to be very useful and conducive. I am not going to mention the rest; but, as you can imagine, noise reduction and protocol is important. Then there are case-specific environmental changes. Usually it's not very well received when you say change the environment for every resident. It's not practical when you first hear it either. You can imagine that is practical if you are only talking about a few patients. When you do everything right, you end up dealing with only two to five patients. You don't have to think of it as insurmountable. Sometimes all you need is a wheelchair change. If you put any of us in a Geri-Chair, we would be restless eventually because it's not very comfortable. But that is an example of how to help with this. If you have an opportunity to place the resident, we address the flexibility to work around the resident where they are seated for example. If a resident happens often, we found an easy solution is to present that, and that creates a barrier for them to have negative interactions. Part of the environmental change would be diet. If you use sugar at night which is what we have for comfort food such as ice cream, etc., it provides a sugar rush with someone you are trying to encourage to sleep. If you have a high protein snack, that produces a serotonin surge, and we have the experience of eating a meal and feeling sleepy afterwards. We spent a lot of time on environmental changes because it's something that is not often in conversation. I will now discuss the module. At the outset I would say that the services before and after and the education session provide a better idea of the effectiveness of the education as well as focusing attention on key points. One CNA key point is that when I review cases, I find there is a case where you have a CNA who has a great response to the resident and better luck with them. We want to interrogate that CNA and ask probing questions. Are there tricks to the trade? Maybe they are doing things differently that work than the rest of us that work. The key point here is that that information is not systematically passed on to the nurses or necessarily other CNAs. Secreting a habit of passing on that information. Always asking for it. Asking if anyone works better with a certain resident and what the secret is. Another pertinent thing is routine care. We often ask the question, is the routine care necessary? Is it required with the same frequency? Also crowding. It is convenient for us to have two or three people doing the shower which doesn't mean the resident will be positive about that. They can be very sensitive to people around them. Addressing evening showers. I found if you have a focus case, are they getting their showers at night? That is an easy fix. We can move the shower to the morning where they are less resistant and where we have the most staff to help us not to be as rushed. I find that the CNAs actually decide the shower time. They decide that based on the time allocation and the resident patient logs. So the way to fix that is to have a unit manager deal with a focus case and shower time and make sure that the CNAs have those particular patient showers in the morning whenever possible with the scans for diabetics and the daily

5 blood pressure checks and vital sign checks for skilled patients. Keep in mind that skilled patients require daily vital signs and skilled care. You need to have a doctor's order if you are going to review the standard of care. I find that most of our residents are woken up too early. If they haven't slept until 4 a.m., that creates a problem even without ascertaining what time is a normal time to wake up and what time did they got to sleep the night before. There are other items you can see. Moving onto the nursing, one of the main things we address at first is the type of behavior and the proper nomenclature. We can't address the problem if the description of the problem is wrong from the beginning. If someone is described as anxious, in a clinical sense they are having an anxiety or panic disorder and would have to be on a drug. That is not true. If there is confusion related behavior, it needs to be described as such. Some families consider delusions when a dementia resident thinks a daughter is a granddaughter or a son is the husband. That is not delusional that is a confused state but not delusional. There are more obvious cases where a resident says my daughter is putting me in the nursing home to take my money. It is still not considered delusional. It's more of a fill in the gaps or trying to make sense of what happened with a dementia mind. Then the other step is teaching. We first described what the symptoms are and how to describe them. Then we discuss what is treatable and what is not. Dementia behavior is caused by confusion. They are not treatable. Then if we go to the level of delusions and hallucinations, we still have cases where we don't need to have them treated. For example, if someone has a hallucination about puppies, it doesn't necessarily require an antipsychotic to get rid of it because it's not bothering anyone. But seeing people with knives in the room and a constant fear is a big issue and needs to be treated. The staff acceptance of the untreatable behavior. They accept there is no medicine to treat this to tell the resident or make the resident feel at home. The only way they will feel at home is seeing the place as home over time. In some cases they never reach this. One thing to keep in mind is that it's not useful to treat the confused state or the confusion related symptoms because confusion is the reason for those symptoms, When you make the confusion worse, your symptoms potentially get worse. We also addressed the seriousness of the behavior. I will just say one thing here. I had an incident where a patient hit me, and that was something I would never forget. I remember the nurse wanting to go get the Ativan. That was a clear example of a case where I could see how I was the trigger when I moved too fast or I moved someone for a problem and was rushing. I had other cases to see that day and I rushed. I didn't stop or pause long enough or make eye contact. There I was in that person s space. Just because that would be considered severe uncontrolled behavior, it doesn't mean that is every circumstance. This is considered an opportunity to be treated, and you have to see what triggers the behavior. I will mention small talk quickly. If someone is agitated or irritable, those are the residents that are not amiable to small talk. It is really hard to tell the CNAs not to initiate conversation with the resident. It's really what they need. Some residents need to be treated like the boss because they were the boss. Again, what work today may not work tomorrow. We also teach the principles to respond to a repeated question. I see people go through four or five senses to explain things, and this is normal. There is staff

6 burnout. Sometimes with antipsychotics, there is a moment to say I have had enough. I am calling the doctor. This addresses that issue. Be informal. Being formal in sexually inappropriate patients is important, and we teach our nurses that. Nursing communication with the doctor is also a very integral part of a protocol. If you don't remember anything from today's discussion, remember the modified SBAR. In the regular SBAR, nurses communicate the problem, but they have to come up with recommendations. Unfortunately, with dementia care, not only are we making a lot of decisions on the phone, but also the provider becomes rubberstamps to the yes or no answer function to say yes to antipsychotics or no and having to explain why. We identified this, and we said the recommendation must come from the physician or nurse practitioner. The focus should be getting out as much information as possible throughout the case and being ready to respond to questions because obviously the provider is not on site and needs a lot of encouragement in breaking down dementia symptoms and recognizing dementia symptoms that are not treatable, along with recognizing psychotic symptoms and when to treat the psychotic symptoms. Those are some of the principles that the nurses are taught; yet the decision would still fall on the provider. Avoiding night and weekend medication changes is one of the biggest deals. That is why we have the DON review the cases that happen after hours. Family education I will say that some people do this for families. I think that unless we do the in-service every week, it is impractical. Families would know and learn whatever the nurses know and learn. That is their point of contact. If the nurse is on board, then they know what you know. They will communicate that to the family. The other piece is addressing certain principles; for example, medication which causes more confusion. Some medications affect the brain. Anything that is caused by confusion will get worse. Setting expectations is important, too. I will skip over the leadership model, but, basically, it's important to recognize that without the medical director and administrator and DON being on the same page and championing, not just for one month but forever, it will not work. It will always relapse to the prior state. We will go all the way. Did I mention the leadership challenges? Staff turnover and maintaining education is one of the leadership challenges and addressing minority opinions. You will always have one or two people that don't believe in this, and leadership needs to address it. In consistency of communication, you would have one person saying one thing and one saying another until we meet with them setting the right expectations and teaching the modified SBAR to every new person. This is the medical provider model. I will spend about 10 minutes doing this and we can go to questions if any of you have any. Obviously not all medical providers are comfortable with dementia care. Providers need be given an opportunity to learn about dementia. Otherwise, they will pass the buck to someone else. Psychiatry needs to be working with the medical director to reduce antipsychotics. You can imagine that if you reduce the site referrals in your facility, it is not a good incentive for that service to be as involved. We also focus on treatment and diagnosis such as during the medication part if necessary and how to do it. The first question we ask providers is, are we overusing antipsychotics in dementia patients? We have a 20% rate now and a 100-bed facility that is one or five patients. We're not even counting other

7 drugs. If you added all of those it almost ends up being 80%. It's really all chemical restraints if we look at it appropriately. It doesn't mean all dementia patients need to be on it; but when they prescribe it, we teach them to defend that decision. Practical guidelines are again prescribing when it's needed, not just because you are asked. Dementia residents evolve. The dementia gets worse and the confusion changes. Sometimes the behavior changes. Just because someone was on the psych floor two years ago doesn't mean they can't tolerate it now. Also keep in mind that delirium cases which have psychosis with hallucinations and grabbing at things and asking that you put poison in the food etc. must be treated. We teach that to our providers. One of the things we address with the providers is you must address the antipsychotics at the gate. When people come in, we can address if they need some of the medications right there and then. I can give you an example. If a person was never on an antipsychotic and was started in the hospital, that is an easy decision. If it's confusion related behavior, the antipsychotic makes it worse. He would be doing harm. If you want to give them something to sleep for three days, that's another story. If you do it because they are confused, an antipsychotic is the wrong drug. >> Recent new orders have a time limit. We tell our providers to keep the same meds for three days and evaluate during the three days. During that time, you have enough information to base your decision on. The major exception, which is like the opposite of everything we are talking about, is that if someone is coming straight from the psych floor and they had a major breakdown recently and a lot of major antipsychotic use was part of the plan, you can just treat them. However, you cannot just treat them like everyone else and start tapering. You must allow time to pass. You will find that a pharmacy will not take that into account. They will send a gradual dose reduction recommendation. It is imperative to say no until the right time. End of life. If someone is at end of life and they have hallucinations and problems from the pain meds, it's important to treat it. It's not okay to say we are trying to keep our numbers down, we can't treat it. There are two sides to the coin. The treatable. We mentioned that true delirium and psychotic symptoms impede the patient and their quality of life or impact other residents in a severe way. If they resist care, they are confused. If they stay up all night because that is their pattern, that is dementia related. If they are exit seating, they are confused. They are not delusional. The polypharmacy that we teach our providers is to eliminate the causes in the medication list. And then what to do to treat the behavior. Even if it's nonpsychotic behavior, there is room for inhibitors as a trial if they are not already on them. I should say I don't have any conflict of interest with any drug company. If you see me use the names, it is not to promote them. I don't do talks for them. As Seinfeld would say, not that anything is wrong with that, but I don't. The other things we teach the providers is to know the antipsychotics. If you use Risperdal, all you have to know is the duration. It's a drug that is used once or twice a day, not five times a day. If you use this, you should know that it drops your blood pressure and is sedating. If someone is on it at night only and they come from a hospital, that is an easy switch for sleep.

8 This is important, but from the family perspective, we talk to the family and say this antipsychotic is promising but can cause sudden death or early death. They don't seem to mind that too much. We focus on the symptoms that matter, and they happen to be true. Everyone's afraid of strokes, so that's why you have a 100-year-old uncommitted. Everyone can understand antipsychotics cause side effects such as Parkinson's. Parkinson's patients with behavior. Now you can imagine you get a lot of cases with Parkinson's in skilled and long-term care. Especially at the latter stages. Some of the medications were pushed to the limit before they got to the nursing home because they tried to keep them independent. Now that they are at the nursing home they are high-dose. Some of these drugs can cause psychosis. I find that instead of adding a medication to treat those psychotic symptoms, we can just eliminate or reduce the dose. Often, I eliminate the evening dose of Parkinson's medication. That works. Also you can imagine if someone is restless at night and they have Parkinson's and you're giving them something that keeps them active, it defeats the purpose. This slide has one of the new drugs that came out to treat true psychosis associated with Parkinson's. If you can eliminate the one drug that causes the problem, you don't have the need to add another drug, even if it's the right one. Keep in mind, Parkinson's patients have a lot of blood pressure issues, such as drugs that drop your blood pressure even though they are popular with neurologists because they have the least marketed symptoms. They are not friendly to Parkinson's patients who have blood pressure issues. All antipsychotics will give you man-made Parkinson's. That is an extrapyramidal side effect. If you are dealing with a Parkinson s patient and see antipsychotics added, you must question that every time. They cause Parkinson's or symptoms of Parkinson's. If you are trying to help them, you can eliminate that drug and reduce the Parkinson's medication. Lewy Body dementia Is another thing. Akathisia Is when you run around nonstop and are always on the go. Guess what drugs cause that? Antipsychotics. If you see a patient like that, it is contraindicated. I am going to stop here and ask you to send in your question. I will move the conference to Doreen so she can pass on questions to me. We want to thank you for taking the time and sharing a little bit about C.A.L.M. We have questions in the queue, so Doreen can you take that? Sure. One of the approaches to antibiotic stewardship is to monitor provider level data and give feedback to each provider. You are a high performer or you are not a high performer. Is there a role for this type of behavioral nudge with reducing antipsychotics? Yes. Remember we said real-time feedback is part of the C.A.L.M. protocol. We are not only given the data at the end of each month, but we also review the cases that happen from day to day. The provider knows the data. I find this is universally true that no one likes to be an outlier. If you tell a provider your facility is performing below average, it won't sit well. They will try to do better I'm pretty sure. If they know they are doing the best thing for the resident, it is all positive. Can you give examples of readiness to respond?

9 For example, if a nurse calls me and says a person is agitated I will be asking about change. Was there anything different today compared to other days? If they say yes, then they address that particular question. If they say no, we have to go further back and ask more questions if the nurses mentioned that they have to go through the nurses notes and review those before getting back to us. What are the vital signs? From the very basic questions to specific questions. Sometimes they must pause and put you on hold and asked the CNA. They must be ready to respond. What would you recommend for a medical director who does not buy in to the reduction of APM? I have a slide, and if they say they don't believe in this, the only way of doing this is going back to basics. Doctors are scientists. They are taught to be scientists to review data and make sense of it. You review the data with the medical director and expose them to the data and expose them to the conferences and talks where that data is discussed; for example, if they don't know the dementia system versus the psychotic symptoms and don't have that, they see it as one. They think they are advocating for the resident by prescribing. It is important for them to understand the clinical reason. Most doctors, once they get in to that and see the success like they would see the difference when a person is on antipsychotic and what it's not, they start seeing it as a very personal thing. Nurses are the same way. They are great advocates for residents. Once they learn that all the medicines make dementia worse, and so everything that is confusion will get worse, then they must advocate against that medication by necessity, and they do. Is there something a nurse can do when being asked to slide a resident over to another type of drug after they have already eliminated an antipsychotic? Are you talking about shifting to another drug? Yes. That is one of the biggest challenges. It is no good, in my opinion, and most of the time, the other drug is worse. When I was a younger doctor, most of the medication used for dementia was Benzodiazepine. Most of this fear was maybe some doctors reverting to Ativan and Valium because it is less regulated. It's a bigger issue. It treats no symptoms because the anxious state we described is often a secondary symptom not a primary one. They are anxious because you are not letting them walk as much as they want or you are closing the door or you are trying to give them a shower. They are not truly having an anxiety disorder or panic disorder. When those drugs are used, you get the same consequence in terms of worsening dementia and causing falls and increasing incontinence. Imagine if someone had only urinary incontinence and you give them a drug. Now they are more confused so now suddenly they have fecal incontinence. That changes the dynamic of the resident care. That changes the quality of life and it changes the depression. If they are aware of the situation, they would be embarrassed and depressed. All these things are really horrible. They should be avoided. I did want to mention one thing. If a family asks for it, and says, I need it,. I want it, I don't care, you need to treat that the same way you treat a request for a physical restraint. We still have families asking for physical restraint I'm sure. I am not seeing many facilities putting people on physical restraints just because the family asked for it.

10 We have another question. In the buildings in Maine where antipsychotic reduction was successful, did any of those buildings have dedicated dementia special care units with a large population of people with dementia? The answer is no. I will address that in two ways. There are psych units in Maine that have a limited number of them. Keep in mind that almost 80% of your population has dementia. Like I said in the slides, you will end up with 5% minimum of cases that require a lot of attention. To say that our cases are worse than others or your cases are worse is not statistically defensible. Most long-term care facilities have a lot of dementia residents. Now people are waiting so long to get to the nursing home, they do have dementia. I am personally against putting these residents in specialized units mostly because there will never be enough beds to house that many people. The second reason is, you need to learn how to treat these people on site and not put all the bad apples in one place where suddenly you have a horrible unit where the quality of life is very poor, and you have to put 90% of the people on medication. Being spread out through the building, helps you. It is not a hindrance. Is there any data on if the new regulation require a face-to-face clinical evaluation every two weeks and every time antipsychotics have an impact? You must define the measure of success. The impact is your numbers. The latest regulation that came with a time limitation or as needed medication was the latest change. It is in line with everything else. There is not enough data now to show if they had a major impact or not. You would have to wait for the next two or three quarters to see if the national average drops. I find that like everything else with dementia care, this is multifaceted. You don't have one thing that leads to good results. There is no silver bullet in quality measure initiatives, just like there is no silver bullet in the treatment of dementia. If you have everything falling in place and everyone is on the same page, you always have a few cases that are an exception, but you end up with the majority of cases without medications. Keep in mind, if you get good at the tough cases, and you get better at it, you will find it makes every other case easier. You will learn from those experiences. Are you available to provide education to providers in states other than Maine? Yes. How can you identify cases in which chemical restraint is suspected even though the indication on the order does not reflect chemical restraint? That is a unique drug. I have a slide on that. It is for TBA. Basically, it is emotional incontinence for lack of a better word. A person would repeat the same thing or they are laughing uncontrollably or crying uncontrollably without meaning to. You talk to them, and as soon as they are distracted they stop crying. If you ask why they are you crying, there is no clear reason. In that case it is used as a cough medicine. It is not sedating, so it cannot be labeled as a chemical restraint. The only issue is arrhythmia if the dose is high enough. The dose usually is not. The other issue is using it and it doesn't work so you must stop it. Let's go back to the original premise of the question. How do you label something a

11 chemical restraint? It's a provider, and if they cannot defend the use of medicine based on symptoms and/or diagnose then it is a chemical restraint. How could facility Q.A.P.I. committees engage medical directors to be active participants and drivers of quality improvement efforts focusing on antipsychotic medication reduction? That is a loaded question. Think of it this way. If a provider is asked to be part of something on paper and maybe do a few talks it is not that. They must be part of the planning and discussion as you start this. If they understand the problem by number, you show them the number and compare yourself to 20 miles around you and your state. You say this is where he we want to be and this is where we are. We have data that we can share with the providers if they have nurse practitioners and they ask, can you help us understand all the data in as much detail and then be the source of information for our nurses? Can you help us? If they learned it to the point where they can teach it, then they learned it to the point where they can do it. We have time for this last question. Do you know if there's any relationship between residents on antipsychotics and Akathisia. Again, it is a group effect. For example, when we look at proton pump inhibitors, that is a group effect. All antipsychotics cause this. The fact is in an ICD code called drug induced Akathisia. We can't claim one of the new antipsychotics will cause it. We will have to wait years for them to have enough for the dementia and elderly to have data that show it causes it. All these antipsychotic drugs are not in that. They are not having data when they produce them during marketing about the elderly with dementia. We find it after marketing. Basically it is a group effect. All other antipsychotics can cause it. There is no reason to think it. Thank you, Dr. Fazeli for a great discussion. I have a few announcements. Mark your calendars. There is a webinar coming up on August 14. On prevention and management of C. diff and other HAIs. We are now on social media. Please connect with us on Facebook and/or LinkedIn for the latest resources and webinars and other offerings from the New England QIN-QIO. As a reminder, we would like to thank nursing homes participating in the New England Care Collaborative that have been actively engaged in collaborative activities and committed to quality improvement. If you have received your badge, we are asking you to share your commitment to quality by posting a photo of the badge in the front of your building and posted to social media using the hashtag #wecommit. Don't forget to tag the New England QIN-QIO on Facebook, Twitter, and LinkedIn. Later this year, we will announce the winners. The New England QIN-QIO shares best practices throughout nursing homes in New England. We are asking you to share all your successes. I have posted a link in the chat to submit your success stories. We will highlight a success story of the month in the monthly newsletter and will highlight your successes with CMS.

12 Finally, here is the contact information for the New England QIN-QIO if you have any questions. Please contact your state lead. When you close out of the webinar, an evaluation will automatically appear. I will post that link in chat in a moment. We greatly appreciate you completing the evaluation. If you don't have time to do that or you are sharing a computer with someone else, you will receive an containing the link to the evaluation. As we mentioned at the beginning, the PowerPoint presentation is currently posted on our website. Within the next few business days, a recording and transcript will be added. The link for this will be included in tomorrow's . Thank you again for a great presentation, Dr. Fazeli, and to everyone for attending. Have a wonderful day.