Part 1: Overview of AHCA/NCAL Clinical Considerations of Antipsychotic Management Toolkit Dr. Cathy Lipton, MD Dr. Anna Fisher, PhD Holly Harmon, RN, MBA, LNHA Introduction Holly Harmon 1
Objectives Summarize recent regulatory changes and national efforts to reduce antipsychotic use. Understand the key components of the Clinical Considerations of Antipsychotic Management Toolkit and how to encourage use of tools to yield optimal outcomes. Identify a systematic approach for using processes and documents in the Antipsychotic Management Toolkit to manage and/or reduce antipsychotic medication use. Background American Health Care Association (AHCA) & National Center for Assisted Living (NCAL) mission: Improving Lives by Delivering Solutions for Quality Care Clinical Practice Committee Goal: Reduce the use of off-label antipsychotic medications through the promotion and dissemination of existing resources Subcommittee: Antipsychotic Reduction 2
Today s Webinar First of a two-part webinar series focused on Antipsychotic Management and Reduction First webinar will include an overview of the issues from a regulatory perspective and an introduction to the AHCA/NCAL clinical toolkit Second webinar will include practical strategies and application of the toolkit to safely reduce antipsychotic use in a resident-centered approach Antipsychotic Use & Initiatives Cathy Lipton 3
Off-Label Antipsychotic Use Antipsychotics and other psychotropic medications being used in increasing numbers for behavioral problems in nursing home residents with dementia; limited efficacy and many side effects FDA approved diagnoses for antipsychotic use: Schizophrenia, Huntington s Disease, and Tourette s Syndrome Centers for Medicare and Medicaid Services (CMS) launched a national initiative aimed at improving behavioral health and minimizing the use off-label antipsychotics in nursing homes Adverse Outcomes in Dementia Patients on Antipsychotics Moderate adverse outcomes: tardive dyskinesia, increase in respiratory and urinary tract infections, EPS, delirium Serious adverse outcomes: stroke and related cerebrovascular events Deaths, due to pneumonia, thrombo-embolic events, and sudden cardiac arrhythmias Meta-analysis by FDA showed 1.5-1.7 fold increase in mortality risk for dementia patients on antipsychotics vs. placebo; risk is elevated and persistent with long term usage 4
National Partnership to Improve Dementia Care in Nursing Homes On May 30, 2012, Centers for Medicare and Medicaid (CMS) announced the Partnership to Improve Dementia Care, an initiative to ensure appropriate care and use of antipsychotic medications for nursing home residents This partnership consists of federal and state entities, nursing homes and other providers, advocacy groups, and caregivers The initiative was spurred by research showing that one quarter of Medicare beneficiaries in nursing homes are prescribed antipsychotic medications and that the use of these medications may be beneficial but may also be associated with increased risk of death National Partnership to Improve Dementia Care in Nursing Homes Coalition includes: The Centers for Medicare and Medicaid Services Leading Age American Health Quality Association American Health Care Association AMDA The Society for Post-Acute and Long-term Care Medicine 5
Partnership to Improve Dementia Care in Nursing Homes Initial goal was a 15% reduction in off-label antipsychotic use in skilled nursing centers between late 2011 and late 2013; this goal was met, with the average reduction just over 17% nationally New goal: additional 10% reduction by the end of 2015 and an additional 5% reduction by the end of 2016, or a total reduction of off-label antipsychotic use of 30% over five years Enhance the use of non-pharmacologic approaches, person-and family-centered dementia care practices, and team-based approaches to dementia care Federal Guidance According to federal guidance, antipsychotics should not be used if the only indication for drug use is one or more of the following issues: Wandering, poor self care, restlessness, impaired memory, anxiety, depression (without psychotic features) Insomnia, unsociability, indifference to surroundings, fidgeting, nervousness, uncooperativeness, or agitated behaviors that do not represent a danger to the resident or others CMS requires attempted gradual dose reductions of the antipsychotic and the use of behavioral interventions (unless clinically contraindicated) 6
AHCA/NCAL Quality Initiative Safely Reduce Off-label Use of Antipsychotics For individuals with dementia, and as illness progresses, behavior often becomes a key form of communication. This can be challenging for families and staff, and too often, antipsychotic medication is used in an attempt to modify behavior. The useof antipsychotic medication to treat behavior associated with dementia is not supported clinically and is considered offlabel by the FDA, which issued a black box warning for the elderly with dementia. AHCA/NCAL Quality Initiative Safely Reduce Off-label Use of Antipsychotics Antipsychotic medications are expensive, costing hundreds of millions of Medicare dollars. They also increase the risk of death, falls with fractures, hospitalizations, and other complications resulting in poor health and high costs. The intent of the AHCA/NCAL Quality Initiative goal to safely reduce the off-label use of antipsychotics is to encourage alternative strategies for responding to challenging behavioral expressions in persons living with dementia before considering medications and to ensure that antipsychotic medications, when used, are as appropriate and safe as possible. 7
Choosing Wisely Initiative of the American Board of Internal Medicine (ABIM) Five Things Physicians and Patients Should Question American Geriatrics Society: 2 of the 5 Things included antipsychotics and benzodiazepines American Psychiatric Association: ALL 5 of the 5 Things included antipsychotic prescribing www.choosingwisely.org American Psychiatric Association s Choosing Wisely Five Things Don t prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring. Don t routinely prescribe two or more antipsychotic medications concurrently. Don t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia. Don t routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults Don t routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders. 8
AHCA/NCAL Toolkit: Clinical Considerations of Antipsychotic Management Anna Fisher Toolkit: Clinical Considerations of Antipsychotic Management Clinically-focused resource with steps, objectives, tools, and expected outcomes Model used is the Nursing, or Care Delivery, Process Multidisciplinary approach Requires center administration investment and leadership Requires input from staff, residents, families, practitioners Seven critical steps needed to ensure quality outcomes that are successful and continuous 9
Toolkit Framework: 7 Steps Leadership Recognition/Assessment Diagnosis/Clinical Judgment Outcomes Planning Implementation Evaluation Staff Education Step 1- Leadership Set center direction and goal to better manage antipsychotic drug use and individuals with dementia Ensure staff and others understand what needs to be done and how to accomplish the goal Provide staff education needed to achieve results 10
Step 1 - Leadership Hold staff accountable for following care process steps Make regular employee rounds to address questions about the goal Ensure all staff are trained on how to identify unmet needs and nurses are trained on recognizing common antipsychotics Recognize departments and staff doing well in implementing process and using tools Step 2 Recognition/Assessment Timely identification of antipsychotic drug use and behavior, mood, cognition, and function changes Be able to recognize antipsychotic drugs commonly used in the long-term care setting and the issues surrounding the use of these medications Observe resident behaviors Describe behavior/symptom details like onset, intensity, duration, severity to self and/or others 11
Step 2 Recognition/Assessment Identify change in level of consciousness (e.g. alert, drowsy, stuporous, comatose) Determine the necessity to control or limit behavior Assess mood, thinking, function, and behavior within 24 hours of admission if an individual is taking an antipsychotic or identified as having a behavior problem For individuals taking antipsychotics, identify where and why treatment started and how effective/problematic the treatment has been Step 3 Diagnosis/Clinical Judgment Use existing medical information and assessment data to form an opinion about probable cause(s) of behavior/symptom Evaluate the current medical regimen as the potential source of behavior/symptom 12
Step 4 Outcomes Planning Collect pertinent information as the basis for having identified a specific cause or causes of the problematic behavior/symptom Gather clinical information and diagnoses Include all medications currently taken by the individual Step 4 Outcomes Planning Gather information about drug considered for GDR Current dose, time(s) of drug administration, and method of administration (tablets, capsules, liquid, injectable, IV). How long has the individual been taking this drug? Is the current drug dose at the lowest available dose? If so, does the dose provide the individual optimal quality of life and ADL functioning? Identify the non-pharmacological approaches used to help address challenging behavioral responses. Did these approaches work? Note assessment findings in the medical record. 13
Step 5 - Implementation Organize and prepare assessment findings and information to be discussed with the physician Identify specific goals for managing the behavior/symptom After consultation with the physician, document the basis for having identified the problem/symptom(s) and basis for the cause of behavior/symptom Step 6 - Evaluation Monitor responses to interventions for each individual and adjust them accordingly Identify and address complications related to interventions Monitor center frequency of antipsychotic drug use and the effectiveness of strategies 14
Step 6 - Evaluation Assess the individual s response to medication discontinuance or tapering. After one month, determine if the individual is at optimal ADL functioning and has an improved quality of life. Repeat any clinical tests and labs ordered by the physician, and evaluate for improvement. Evaluate the effectiveness of non-pharmaceutical approaches to challenging behavioral responses that have been employed, document and change if needed. Step 6 - Evaluation Continue to evaluate and note medication reduction responses in the medical record. Notify the physician about further tapering or drug maintenance as necessary. Monitor for care plan effectiveness. Review each resident s medication regimen for high risk medications and the appropriateness of continued use of any antipsychotic or other psychopharmacological medications. Form a Behavior Management Team to identify unmet needs and monitor and document the effectiveness of interventions. 15
Step 7 Staff Education Ensure that staff have the knowledge and skills needed to appropriately provide care to individuals with behavior/symptom(s) Step 7 Staff Education Instruct clinical staff on how to recognize and identify antipsychotic drugs commonly used in the LTC setting Instruct clinical staff on how to apply a systematic approach to collecting, analyzing, documenting, and reporting medical information and clinical findings for potential cause for behavior/symptom Educate all staff in identifying unmet needs 16
Key Tools in the Toolkit Physician Guidelines for Gradual Dose Reduction Sample Facility Policy for Use of Antipsychotic Medications Considering Cause of Behavior Algorithm Antipsychotic Medication Tapering Checklist SBAR: Situation, Background, Assessment/Appearance, Request More Key Tools in the Toolkit CHAT: Communicating Health Assessments by Telephone Antipsychotic Medications QA Review Tool Assessment of Residents receiving Psychotropic Medications Tool Common Terms and Definitions Case Studies 17
Antipsychotic Prescription Log Antipsychotic Prescription Log Facility Name: Date: Resident Room # Antipsychotic Medication Date antipsychotic medication was started. What setting was the medication started in? Primary mental health diagnosis? Does the resident have dementia? Primary behavioral problems? Does the resident Has GDR have symptoms of been possible drug side attempted? effects? Explain. Date of most recent GDR attempt Outcome of GDR Moving Forward Cathy Lipton 18
JAMDA review October 2014 Interventions to Reduce Inappropriate Prescribing of Antipsychotic Medications in People With Dementia Resident in Care Homes: A Systematic Review. JAMDA 15 (2014) 706-718 Review of 23 articles Education programs, in reach services, medication review, multicomponent interventions Antipsychotic reduction between 12-20% Little information about sustainability and long term reduction Culture and nature of care setting and availability and feasibility of non-drug alternatives Moving Forward CMS is actively seeking input from measurement experts and others on additional measures of person-centered care and dementia care practices in an effort to consider balancing measures, beyond current metrics that quantify antipsychotic medication use. 19
Moving Forward CMS and its partners will continue to look at a variety of efforts and interventions to help meet goals, such as: Focused dementia health and safety care surveys Review of surveyor feedback on guidance and trends in enforcement Additional opportunities to measure and publicly report on improved dementia care Continuation of our national education sessions on nonpharmacological, person-centered care Ongoing work of grassroots state coalitions in all 50 states; and Provision of technical assistance through Quality Improvement Organizations (QIOs) or other quality improvement partners Moving Forward CMS will also continue to monitor potential consequences such as: Prescribing shifts from antipsychotic medications to anxiolytics or sedative/hypnotics Changes in functional or cognitive status of nursing home residents that may result from a shift to approaches that do not rely on medication to treat dementia. 20
Moving Forward CMS and its partners will continue to promote: Research on improving systems of care in nursing homes Use of individualized, person-centered approaches to care of people with dementia Innovative programs such as telepsychiatry for rural nursing homes The effectiveness of this and other national initiatives to reduce unnecessary antipsychotic medication use in nursing homes Closing Holly Harmon 21
Words of Wisdom I did then what I knew how to do. Now that I know better, I do better. Maya Angelou Thank you for improving lives every day! Cathy Lipton: cathy.lipton@optum.com Anna Fisher: fisheranna@email.phoenix.edu Holly Harmon: hharmon@ahca.org 22
www.ahcancal.org ahcancal ahcancal Resources Clinical Considerations of Antipsychotic Management Toolkit AHCA/NCAL Toolkit: Members Only Content (login required) This resource uses a process framework, based on the Nursing Process, to identify care objectives and expectations. It identifies tools and resources to help providers successfully manage antipsychotic medication use at the resident and facility level. The guide focuses on seven (7) critical steps needed to ensure quality outcomes that are successful and continuous. http://www.ahcancal.org/quality_improvement/qualityinitiative/documents/ Antipsychotic%20Management%20Toolkit.pdf 23
Resources The Nursing Process Approach This systematic and evidence-based approach to caring details the steps nurses need to take before contacting the physician to discuss possible gradual dose reduction/tapering for antipsychotics used off-label. The process outlines the information nurses need to collect and analyze in order to make critical decisions about next steps. http://www.ahcancal.org/quality_improvement/qualityinitiative/documents/a%20nursing%20process%2 0Approach%20for%20Antipsychotic%20Drug%20Gradual%20Dose%20Reduction.pdf The Antipsychotic Medication SBAR This is a tool for nurses to gather and organize the information needed in preparation for physician discussion about potential medication side effects, adverse reactions, and drug tapering. Completed SBARs offer a method to document nurse/physician communication and care plan recommendations and are a component of the individual s medical record. Resources Long Term Care Trend Tracker The LTC Trend Tracker tool, an AHCA member benefit, allows organizations to track and compare their performance on the CMS quality measures, including both long-stay prevalence and short-stay incidence in the offlabel use of antipsychotics. 24
Resources The Clinical Considerations of Antipsychotic Management The webinar helps clinicians navigate the toolkit to better manage the clinical factors that contribute to quality care and antipsychotic medication use. Resources A Guide to Reducing Antipsychotic Drugs While Enhancing Care for Persons with Dementia: A Competency-Based Approach This competency-based approach is a guide, filled with resources to increase knowledge, skill, and attitude to address antipsychotic use in your community. CARES Online Training & essentialz Certification AHCA/NCAL offer the CARES Online Dementia Care Training and the Alzheimer s Association essentialz certification program for individuals. 25
Resources Reducing the Off-Label Use of Antipsychotics In this webinar, presenters describe a stepwise approach to behavioral management, which can be guided by use of a toolkit developed through a grant funded by the Agency for Healthcare Research and Quality. Advancing Excellence Antipsychotic Resources Advancing Excellence's seven steps to success. Resources AHCA 6-Part Webinar Series: Be Prepared. Don't Let New Surveyor Guidance for F309 Catch You Off-Guard! (member-only content, log-in required) CMS released new surveyor guidance to assess compliance with F309 and F329 as they relate to residents with dementia and use of antipsychotic drugs. AHCA offers a series of six, brief but content-rich webinars to help your community be prepared for these changes. Improving Antipsychotic Appropriateness in Dementia Patients Developed with the support of the Agency for Healthcare Research and Quality, the IA- ADAPT website helps clinicians, providers, and consumers better understand, assess, and address challenging behaviors in people with dementia using evidence-based approaches. It includes user-friendly resources for care providers, as well as information for families or patients on the risks and benefits of antipsychotics for those living with dementia. 26