Event Name: More Music! Less Medication! Event Date: 04/11/2018 Event Time: 11:30am-12:30pm ET Good morning again my name is Doreen Ostapchuk from the New England QIO, and I will be your moderator for today's webinar. More Music, Less Medication. Dementia Care in Nursing Homes. Thank you for joining us for today s webinar hosted by the New England Quality Care Collaborative in partnership with the New England rural health roundtable. A few housekeeping items, this webinar will be recorded for training purposes. I will provide you with details on accessing the recording at the end of the webinar. Phone lines will be on mute for the duration of the presentation. We will take a few questions at the end of the presentation if time allows. I will provide you with instructions on how you can ask questions over the phone at the end of the webinar and through chat. If you have a question during the session you can post it directly in the chat box at the bottom right of your screen. Make sure to send questions to all participants so we can keep up with the incoming messages. I have put a link into the chat box to download today's webinar presentation. At this time I am going to mute all lines. Speakers, press #6 to unmute your line. You will need to wait about 10 or 15 seconds to switch over and speak. At this time I would like to introduce our speakers, Sarah Dereniuk-Dudley, Senior Program Administrator from the New England QIN-QIO who will get us started. Then we will hear from Annette Blanchard, Director of Nursing; Miranda Thayer, Assistant Director of Nursing; and Alita Potts, Staff Development Nurse. The latter three are from the Franklin County Rehab Center in Vermont. I will now pass things over to Sarah to get us started. Sarah? Thank you, Doreen. On today's webinar the team from Franklin County Rehab in Vermont will present their journey to improve dementia care with their residents, helpful tips for successfully implementing a music and memory program, reducing antipsychotic medication use in persons with dementia, along with identifying key challenges, successes in implementing the program, and steps for sustainability. Before I turn it over to the team at Franklin County rehab, we want to provide a brief background on why we are reducing antipsychotic medications that has been a focus in nursing homes and other healthcare settings. Antipsychotic medications both atypical, also referred to as second-generation, and older typical firstgeneration antipsychotics are indicated to treat conditions and diagnoses like schizophrenia and bipolar disorder. This includes atypical antipsychotics like Abilify, Risperdal, Seroquel, and Zyprexa and first-generation antipsychotics like Haldol. While there are no FDA-approved dementia-related psychosis, delusions, and hallucinations, they are frequently prescribed off label to treat the symptoms. Some of the risks of using antipsychotics in persons with dementia include serious side effects such as dizziness, sedation, and delusions. There is an increased risk for hospitalization and a potential for falls and other adverse events
including increased risk for pneumonia, stroke, and death. It is important to know that while clinicians have the option of using these drugs in persons with dementia, antipsychotics come with the black box warning specifically for this population. In 2008, the FDA mandated that antipsychotic drug manufacturers add black box warnings to the labels and prescribing information because of the link found between antipsychotics and an increase mortality risk in elderly dementia patients. With high prevalence rates of antipsychotic medication use in nursing homes in 2012, CMS launched a national quality initiative to reduce antipsychotic medications in nursing homes called the National Partnership to Improve Dementia Care in nursing homes. The partnership mission has been to provide better, person-centered dementia care leading nursing homes to eliminate and prevent the off-label use of antipsychotics in long-stay nursing home residents. The initial goal to reduce the prevalence rate of antipsychotics by 15% nationwide was achieved at the end of 2014, and CMS has since increased this goal to 25% by December 2015, and 30% by the end of 2016. CMS has now set a new goal for additional 15% improvement by the end of 2019 for all nursing homes identified at late adopters. Nursing homes that are unsure if they have been identified as a late adopter should contact their QIN-QIO state nursing home lead. Contact information will be provided at the end of this webinar, and I will also add the list of contacts in chat. Since the launch of the National Partnership to Improve Dementia Care in nursing homes, significant reduction in the prevalence of antipsychotic medication use in long-stay nursing home residents have been documented as you can see here on this slide. We have included improvement rates and current prevalence rates across New England and nursing homes have worked toward enhancing the quality of life for people with dementia implementing innovative person-centered care practices that ultimately reduce antipsychotic indication use including programs like OASIS, therapy hand-in-hand, and music and memory. However, as you can see from this list of where each state ranks in comparison with other states across the country, there is still an opportunity for further improvement. The folks from Franklin County rehab are here to talk more about their music and memory program which has helped significantly reduce the unnecessary use of antipsychotic medications in their facility. Miranda and Alita, I will turn it over to you now. Good morning everyone. I am Annette Blanchard, the Director of Nursing here, and I will have Miranda Thayer introduce herself along with Alita Potts. I am Miranda Thayer. This is my fourth year here, and I will be moving onto Director of Nursing in the next week or so. I have 27 years of long-term care experience. Good morning. My name is Alita Potts. I have 23 years of nursing experience and been here at Franklin County Rehab for 47 years. We are going to do a combination of talking throughout the presentation
We are a 64-bed facility and opened our doors in 2014. We have 20 designated private rehab rooms and 44 long-term care beds. Our average occupancy is about 90-94%. Medicare is about 27% of our census. Self-pay is about 21%. Medicaid is about 50%. We do not have a memory care unit as defined by CMS guidelines, but we do have significant population of in-state dementia residents. Currently we only have two residents on antipsychotics, and one of them is a patient who has been here for rehab and another is long-term care. We have been successful in reducing that rate to have that number of people right now. This program has been significant in achieving that. Quality is important to us. We received the AHCA national quality bronze award in 2016. We are a fivestar rated facility and participate in Advancing Excellence. We input data for people who are receiving antipsychotics. Examples of residents who would not go into the program are the ones who have a corresponding diagnosis that is acceptable. If somebody has schizophrenia or bipolar disorder, they will not go into our numbers of people who are on antipsychotics. It is preferable that they not receive that medication. We participate in ABAQIS and have a QAPI program with meetings every. We measure things that are going to affect our five-star rating and our care to our patients. We go over this type of information such as who is on antipsychotics or whatever the measure is we are trying to pursue. This has been one of the subjects we review consistently to make sure that our numbers are not going up; and if they are that it is for a justifiable reason. We had a deficiency free survey in 2016 and 2017. In 2012, our facility administration committed to participating in the Vermont Healthcare Association training on OASIS and reducing antipsychotics in Vermont. Oasis uses an interdisciplinary approach to care that emphasizes patient-centered care and focuses on strengths, wants, needs, and personal goals in addition to healthcare needs. It addresses challenging behaviors by focusing on understanding and addressing resident s unmet needs. Music and memory is just one aspect of our overall effort. Dan Cohen had a brainstorm idea that came from his own desire to listen to his favorite music from the 60s if he ever was admitted to a nursing home. He had a unique background in social work and technology in education and learned that of the 16,000 nursing homes in the United States, none were using ipods. In 2008 he expanded the program on a larger scale. In 2012 the music and memory program went even further with a video light inside. If you're not one of the 11 million people who have seen this clip of Henry, you should do so after this webinar. It is indescribable. 2008, when he took his test to a larger scale, he released his life inside. In 2013, the Wisconsin Department of Health launched a music and memory initiative. In 2015, 11 states, including Vermont, made public policy statements, and today music and memory has spread throughout the United States, Canada, and Europe and elsewhere in the world. Just a bit about the development of our program. We have a small group formed to work on the development of our program which started in 2013. We sent several people to a workshop in that state regarding OASIS and train the trainer focusing on the reduction of antipsychotics.
We started training our own staff in 2013 and 2014. We did this through in-services on the OASIS modules and the risks and benefits of using antipsychotics in the elderly population. It is best to start small and slow when you are making any changes within your facility. We began planning for music and memory in 2014 with a formal introduction of the music and memory program in the spring of 2015. Challenges and barriers with starting the program. Changes are very hard and staff are very set in their ways and their routine. Staff must buy in before any change will work, and they usually say, why do we have to change? We do not have time to learn about OASIS and music and memory and have no time to leave the unit. We don't have time to get to each resident s unique needs. Those are some issues we encountered along the way. You must change the way of thinking from a facility-centered program to a resident-centered one: Our toileting schedules versus the resident s, our sleep schedules versus the resident s. Education is the key and getting staff to understand that they need to recognize each resident s unique personality, interests, strengths, and challenges. Another challenge that we had was where to incorporate this in the electronic medical record and how to document behaviors, the use of music and memory, and how to describe it if it was effective or not. Staff was initially worried about behaviors, but they were excited about having new tools to work with. We learned that if staff understood the benefits and why we were trying these new things, they had an easier time hanging in. I think once they understand they are making a difference, that helps them to buy into the program. For our training, we mentioned the train-the-trainer on the OASIS module. We use this method to spread the OASIS method to senior LNA enrichment staff and charge nurses. Initially we chose pieces of the module to begin the training. Behaviors are a sign of unmet needs, and we carried that over to the annual training for dementia care. Some areas we have done. We focused on eating with different diets and utensils, a virtual dementia tour, music and memory, and aromatherapy programs and effectiveness. We also covered person-centered care; walk in my shoes; power of labels; and Mr. Jones, not the man in 213. Case studies and training on dementia and OASIS also occurred with orientation and annually looking at specific resident means from an interdisciplinary approach. Why does music and memory work? Our brains connect music with long-term memory. The limbic brain or primitive brain is the major center of emotional stimulus and remains intact even in late stages of dementia. Whenever I hear 80s music, it takes me right back. Other areas remain intact, such as emotional memories, order memories, understanding of facial expressions, tone of voice, rhythm, singing an automatic speech. What is important when you're starting a music and memory program? You must make the music and memory impact the resident by using their own favorite music. It is a connection to the outside world and the elder s history.
>> The choice of music supports the elder s security, and music has meaning as it is tied to the life they have experienced and choices they have made. The benefits of music and memory are happier and more social elders and stronger and deeper relationships between elders, staff, and families with calmer and more supportive environments, decreased behaviors, reduced reliance on antipsychotics and antianxiety medications, and decreased refusals with increased attention to tasks. Other benefits are increased reminiscing skills and verbal output and increased ability to access spontaneous movement. Several of our residents look very anxious during bathing, and care staff learned that if they sing to them during care, that would help to calm them down during bathing. We also had another resident that would cry out frequently during the day, but after music and memory came into play, they would frequently find her humming in the hall with her headphones on. Several residents have improved food intake and appetite if music was played during their meal. To roll out our music and memory program, we purchased our own equipment. I believe some facilities received grants to do this. We purchased about 24 ipod Shuffles with headphones and chargers. We have a laptop specific for loading music onto the Shuffles and used itunes or other music websites to build the music library for each resident. We chose a core team of designated staff to start the program. We had a team leader from our Enrichment Program who was familiar with the ipods and downloading music and took on that role. You also need someone who is a very comfortable and has good communication skills to interview the resident and find out what music they would like. We started very small and chose about four or five residents to focus on who had behaviors, anxieties, social withdrawals, and failure to thrive. We asked people to give us $20 donations for use of the ipod, so we did get some that were used when we started our program. Choosing the music is key to success. You must involve the resident and the family because residents cannot tell you. We asked lots of questions (e.g., what genre of music did they listen to with their parents or their kids, what was their favorite song, artist, or type of music, etc.). You do not want to load all the Billy Joel songs and just listen to Billy Joel. You really want to have a variety. Families were also asked what the resident s favorite music was and if there was music from a song, wedding, anniversary, or birth of a child that stood out for them? Families were asked if the resident listened to music while they were working, if they were a teacher, what they did for work, or if they had favorite hymns or spiritual songs. They were asked if the resident sang in a choir or had a favorite holiday and holiday music. Again, use a variety of music. Really get to know and learn about the person. In April 2015, we had three residents participating in the program. By June we had seven and nine in August. In January 2016, we had 18 residents in the program. We currently have 21 residents who participate in music and memory. How are we maintaining our success with music and memory? Our staff now think of music and memory for all incoming residents, whether they are a rehab resident or a long-term care resident. It is addressed in every care plan meeting for any resident who may benefit, and I find that music is a big part of our enrichment program. We have a weekly exercise program with music, Zumba, a resident
choir for holidays, and weekly ongoing musical guests in the facility from accordion to piano to fingers. We have lots of music in the facility. We try to think outside the box and incorporate music into person-centered care not only through the use of ipods and headphones, but by using music in CD players, movies, musical choices, playing music during care, and before bath and shower days. We encourage them to sing while providing care. Families play an active role in resident care, enabling us to really provide person-centered care. Families are invited and encouraged to participate in care planning, facility programs, and activities and are a true presence in the facility. We start looking at people who are taking antipsychotics those who are admitted on them or prescribed antipsychotics while they are here From a clinical standpoint, one of the first things we do is reveal their medical data and look at the laboratory data. We make sure they do not have an infection or medication interactions going on. Obviously in long-term care, we have people with complex medical problems and on possible medications where we try to reduce polypharmacy as much as we can. That is one of the first steps. We want to make sure they are not in pain or that they are not ill or that they have something new going on. Ideally, we would like to get a psychiatric consultation done if we can get somebody to come in and do that. Sometimes we take them out of the building for that. These are first steps in looking at how we might reduce the antipsychotic rate. We are going to address the first, the unmet needs, and a different way of thinking. We are not trying to curb the behavior but trying to figure out what it is the patient might need so we are not chemically restraining a resident. Interventions must address the individual needs. Music and memory is one of those interventions. Some of the other ones include a restorative nursing program where our LNAs who have been trained by our therapy team help the resident with mobility or assist with other forms of exercise if the person cannot move. We also have walking programs. If we have behavior issues, we will do time studies and see when those behaviors occur such as around the time the resident needs to use the bathroom. If the resident is awake at night, our night staff will try to engage them in ways that are relevant to them rather than try to keep them in bed. Our therapist who does evaluations for us comes up with care plans that include meaningful and resident-specific activities for that individual. For example, we have one resident who throws items across her room, hits staff, shouts out frequently, and threatens to put herself on the floor and does it. She will refuse meals and care. You cannot reason with her. Our activity and therapy department staff get involved. This lady had been a teacher and loved art and music. With the implementation of the music and memory program and the activities department sometimes just doing one-on-one activities with her, she would end up doing art in her room with activities. Sometimes she would join the many art programs they were doing with the group and she would sit by the fish tank. We had a counselor coming from NTFS, and even if she did not monitor at all,
the counselor would sit there with her and engage in conversation that was meaningful to her. She would talk about her teaching and the kinds of things she could remember. Sometimes the resident needs time to adjust to their stay before you can even consider decreasing antipsychotics. If we have people coming in on our rehabilitation unit on antipsychotics, the first thing we do is not try to reduce something that they probably have been on for quite some time. They will not to like the idea of reducing it. But eventually, if they are here long enough, we are trying to do a gradual dose reduction taking into consideration their doctor's recommendations and diagnosis. We help them be successful with that. A lot of the patients have emotional triggers, and they experience a lot of losses such as independence, loss of family and friends, and loss of mobility if they have a CVA. Change can be an emotional trigger for them. On music and memory and the other interventions I mentioned, we try and address all of it and really get a big picture of the resident to be successful in reduce antipsychotic use. Reducing antipsychotic medication involves the entire interdisciplinary team. It is part of the team that meets every Tuesday, part of our QAPI program including nursing, part of our physical therapy and activities departments, part of administration, part of social services, and part of dietary. Our psychiatric services get an accurate diagnosis and treatment which is sometimes hard when you have people with dementia who can barely speak but are still very useful. I mentioned before that counselors are often effective even with dementia patients who do not speak but when they do they speak about subjects that remain relevant to them. Staff does eventually buy in as they witness the success of the program. We do consults to Deer Oaks Counseling Services and listen to the RNA, the staff on the floo,r and the people who interact with them the most who have a lot of insight into what these residents might need. In gradual dose reduction, you must involve and educate the resident, the resident s family members, and sometimes the physician who might have prescribed the medication and may have been the primary care physician at the time. Often, we consult with neurology or another specialist and discuss dose reduction with them as well. We work closely with the pharmacy to reduce doses carefully and slowly. We involve the staff prior to reduction, and we pay attention to how residents react. Then we monitor the target behavior. We provide reminders about individual triggers and approaches. For example, bathing without a bottle is a program that we have had some of the nursing and LNA staff watch because a lot of residents are triggered when you try to undress and bathe them. Another part of reducing medicine is making sure that documentation is being done correctly and addressing the behaviors that are in the electronic medical record. We found that hospitals are now less likely to use the antipsychotic during an acute stay if they are considering rehabilitation transfer from the hospital. As far as pharmacist involvement, I think most of the facilities probably have pharmacist consultants. We have a pharmacist that we work specifically with that provides her meds to us and have been very helpful. An example of something you might expect from a pharmacist is if you have a resident with a biological disorder where the way they express their emotions is with sudden and involuntary expressions that are disruptive to them and can go from crying to laughing within one
minute and you could tell the woman was very anxious and upset. We ended up talking to a pharmacist who said there is a medication called you Dexter that could treat this kind of medical diagnoses, but it is new and very expensive and insurance will not cover it. It ended up with the pharmacist saying there are two ingredients in that medication which is a cough syrup and codeine; and we ended up giving the resident these ingredients with the pharmacist recommending the dose, speaking with the physician, and speaking with the nursing, and it eventually helped this patient. That is an example of how you can get your consultant pharmacist involved. In 2012, we had about 20 patients in one quarter who were using antipsychotic medication and about 25 in another quarter, described in this graph. If you read down the graph, you will see the numbers continue to gradually reduce. Right now, we have one long-term care resident using an antipsychotic and one rehab patient using an antipsychotic, and that is it. If a person is admitted with a diagnosis of schizophrenia bipolar, that diagnosis would justify the use of antipsychotics. Those are not the people we are doing gradual dose reductions on but, rather, those who have been prescribed those meds for behaviors such as anxiety and depression not necessarily related to the diagnosis which justifies use according to CMS. Successes of antipsychotic medication reduction. We certainly use them as a last resort when all other interventions have been exhausted and only with the approval of the administrator and medical director. We discuss this at an interdisciplinary team meeting and care plan before we consider using these. Staff has seen changes in resident status with dose reduction. We did try dose reductions on one of our residents and noticed increased behavior and continued back on the previous dose. We did do a trial. We have experienced more participation in social interactions and more aware and happy residents who have gained some functional status as well. They do become empowered knowing they are making a difference. So now we are beginning to think of other interventions before utilizing any antipsychotic or psychoactive medications. The challenges in sustaining the program is staff turnover. Long-term care is a moving target, and, yes, you may have just done education on dementia and OASIS and antipsychotics six months ago; but now you have 15 new staff members and you must do it again. You must repeat, repeat, and repeat the education. Of course, the ever-changing regulation impact is how you can sustain the program. You divert your energy to working on the regulations and making staff understand them and making sure you are meeting them and that takes away from continuing your work with the other program. Healthcare delivery system and the increased acuity. We are getting more and more people coming to us with higher needs, and that also impacts how we can continue to sustain the program.
Technology updates are always happening. Just when you get staff trained on the electronic medical record, there is an update on how they document changes. that is time-consuming, and you have to do education all over again. >> Documentation and complacency with it can sometimes be a challenge. We have very good documentation process for our music and memory program. We have choices of what they used the music and memory for and if it was effective and how effective it was. We see that step just documents that they used it and does not answer the rest of those questions. Maybe because the staff are new and do not know the pieces of all the documentation or maybe they are just too busy or don t want to do that documentation. That can sometimes be a challenge. Thank you for letting us share our story and are here to answer any questions. I am going to turn it back to Doreen. Thank you for great presentation. At this time, we will take some questions. If you would like to ask the question over the phone please press #6 to unmute your line to speak. You can also post your question in the chat box. Remember to send your post to All Participants. Doreen, we do not have any questions in chat now. We did get a few questions earlier about getting the slides and I am resending the link. The slides are now up on the website if those folks want to click on the link. I will put it in chat right now; and if you click on the link, scroll down, and you will find how to download the presentation. We do have a question, how does your activity step document resident participation in the music and memory program? We use American Health Tech for our electronic medical record. Our LNA has access to the computer for their documentation. It is really a point and click system. We have music and memory built into all our residents care plans, but certain ones are on the program. If they use music and memory during a bath for Mrs. Jones, they click on music and memory and will be asked if music and memory was used. The person answers, yes. They click on why they used it and answer, to calm residents during care. They click on, was it effective and answer yes or no. We can have a report produced and can print out who is using it, what they re using it for, and if it s effective. We have another question. How do you track the ipods so they do not disappear? That is a very good question. Our Enrichment Department created these little bags that have all the supplies for music and memory in them. We train the LNA to place the bag in one location inside the closet in the resident s room, and there is a little charger that goes with the ipod. I am not going to say that some of them have not been found in other places, but it is re-educating staff that they go in one place. We have another question from Laura. Have you ever had a consult with a board-certified therapist? I do not believe we have, no.
From Dena, we have a question of what grant did you use to obtain monies for the program? We did not submit for any grants, but I do believe there are some available. We thought it was an important program and purchased the ipod equipment ourselves. Do we have any other questions? Thank you all for a great discussion. I have a few announcements before we end today's call. On this slide, are the local contacts for your state. Please make sure to reach out if you have any additional questions or need support. As you close out of this webinar, the evaluation will automatically appear on your computer. If you could fill it out, we would greatly appreciate it. If you do not have the time to fill it out or are sharing a computer with someone else, you will receive an email tomorrow with the link to the evaluation. Also in the email tomorrow you will receive a link to the event page on our website. The PowerPoint presentation is currently posted on the website; and within the next few business days, a recording and transcript of this webinar will also be added. Thank you again for attending, and have a wonderful day.