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Bringing It All Together: The Starring Role of Activities in Dementia Care,
Antipsychotic Reduction, and QAPI
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HQIHQI
CCME
KHCKFMC
Health Quality Innovation Network
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Discuss Activity Professional role in:
• QAPI• Dementia Care• Antipsychotic Reduction• Care Planning
Objectives
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Do you ever feel like this?
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Regulatory Timeline: Quality Assurance Performance Improvement (QAPI)
Phase 1• QAA Committee• Effective November 2016
Phase 2• QAPI Plan• Effective November 2017
Phase 3• Implementation of QAPI• Effective November 2019
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QAPI DefinedReactive: An internal review process that audits the quality of care delivered and implements corrective actions to remedy any deficiencies identified.
Proactive: Focuses on systems rather than individual performance and seeks to improve quality rather than correcting errors when thresholds are crossed
Quality
Assurance
Performance
Improvement
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QAPI Five Elements
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Element 1: Design and Scope• Address all systems of care and
management practices• Include clinical care, quality of life,
and resident choice• Aim for safety and high quality with
all clinical interventions while emphasizing resident autonomy/choice
• Utilize the best available evidence to define and measure goals
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Element 2: Governance and Leadership
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Element 2: Governance and Leadership• Promote a fair and open culture where staff are
comfortable identifying quality problems and opportunities
• Create a culture that embraces the principles of QAPI
• Promote engagement, and commitment of staff, residents and families in QAPI
• Involve residents and families
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Element 3: Feedback, Data Systems, and Monitoring Use and make data meaningful
• Identify what you need to monitor• Collect, track, and monitor
measures/indicators• Set goals, benchmarks, thresholds• Identify gaps and opportunities• Prioritize what you will work on to
improve• Use data to drive decisions
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Suggested Data SourcesFeedback Systems
• Resident/Family Satisfaction Surveys
• Staff Satisfaction Surveys• Resident/Family Council
Meetings• Community Partnerships• Regulatory Surveys• Grievance/Compliment Logs
Clinical Data • Quality Measures• Medication Errors• Vaccination Compliance• Nutrition• Unplanned Hospitalizations• Unexpected Deaths• Abuse/Neglect• Decline in Functional Status
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Element 4: Performance Improvement Projects (PIPs)
• Focus on topics that are meaningful and address the needs of residents and staff
• Support staff in being effective PIP team members.
• Plan implement, measure, monitor, and document changes, using a structured PI approach
• Enhance QAPI communications
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What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Act
Plan
Study
Do
Model for Improvement
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Element 5: Systemic Analysis and Action
Understand and focus on organizational processes and systems
• Model and promote systems thinking
• Practice RCA - get to the root of problems
• Take action at the systems level
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Effecting and Sustaining ChangeKeys to Success
• Teamwork• Systems thinking• Be proactive rather than reactive• Identify risk factors and anticipate
problems before they occur
Dementia Care Regulations
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• F-607 Develop/Implement Abuse/Neglect, Policies
• F-745 Provision of Medically Related Social Services
• F-679 Activities Meet Interest/Needs of Each Resident
• F-725 Competent Nursing Staff• F-740/F-741 Behavioral Health Services• F-550 Resident Rights/Exercise of Rights• F-758 Free From Unnecessary Psychotropic
Meds/PRN Use• F-744 Treatment/Service for Dementia
• F-490/ F-835 Administration• F-943 Abuse, Neglect, and Exploitation
Training• F-838 Facility Assessment• F-947 Required In-Service Training for
Nurse Aides• F-600 Free from Abuse and Neglect• F-677 ADL Care Provided for Dependent
Residents• F-690 Bowel and Bladder incontinence• F-693 TF Management/Restore Eating Skills• F-700 Bed Rails
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F744 Treatment/Service for DementiaA resident who displays or is diagnosed with dementia receives the appropriate treatment and services to attain or maintain his/her highest practicable physical/mental/psychosocial wellbeing.
A facility must have “qualified staff that demonstrate the competencies and skills to support residents through the implementation of individualized approaches to care (including direct care and activities) that are directed toward understanding, prevention, relieving and/or accommodating a residentʼs distress or loss of abilities.”
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F744 Treatment/Service for DementiaThe facility must provide dementia treatment and services which may include, but are not limited to the following:
• Ensuring adequate medical care and supports based on diagnosis;
• Ensuring that the necessary care and services are person-centered and reflect the residentʼs goals;
• Utilizing individualized, non-pharmacological approaches to care
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F740 Behavioral Health ServicesEach resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
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F740 Behavioral Health ServicesThe facility must provide behavioral health care and services which include:
• Person-centered and reflect the residentʼs goals for care• Direct care staff interact and communicate in a manner
that promotes mental and psychosocial well-being• Providing meaningful activities• Providing an environment and atmosphere that is
conducive to mental and psychosocial well-being
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F679 ActivitiesThe facility must provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both in dependence and interaction in the community.
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Activity Approaches for Residents with Dementia
All residents have a need for engagement in meaningful activities. For residents with dementia, the lack of engaging activities can cause boredom, loneliness and frustration, resulting in distress and agitation. Activities must be individualized and customized based on the residentʼs previous lifestyle (occupation, family, hobbies), preferences and comforts.
https://www.caringkindnyc.org/_pdf/CaringKind-PalliativeCareGuidelines.pdf
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F758 Unnecessary Psychotropic DrugsWhat is a Psychotropic Drug?
Any drug that affects brain activities associated with mental processes and behavior. These include, but are not limited to, drugs in the following categories:
• Antipsychotic• Antidepressant• Antianxiety• Hypnotic
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F758 Unnecessary Psychotropic Drugs
Facility must ensure that:
• Residents who have not used psychotropics are not given these drugs unless absolutely necessary
• Residents who use psychotropics drugs receive gradual dose reductions, and behavioral interventions
• Residents do not receive PRN psychotropic drugs unless absolutely necessary
• PRN orders for antipsychotic drugs are limited to 14 days
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What is the problem? BPSD (Behavioral and Psychological Symptoms of Dementia)
Behavioral Symptoms• Physical aggression• Screaming• Restlessness• Agitation• Wandering• Culturally inappropriate behaviors• Sexual disinhibition• Hoarding• Cursing• Shadowing
Psychological Symptoms• Anxiety• Depressive mood• Hallucinations• Delusions
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Course of BPSD• Increases as the disease progresses
• May tend to occur during different periods of the disorder
• Wandering and agitation seem to be the most enduring
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Impact of BPSD• Premature institutional care• Staff turnover and burnout (consistent assignment?)• Worse prognosis and more rapid decline in function• Adds to direct and indirect costs of care• Hospitalizations and emergency room transfers
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Approach to Residents with BPSD• Recognition of BPSD• Assessment for cause(s) of the symptoms including
scope and severity of the symptoms• Treatment
• Nonpharmacologic interventions• Pharmacologic interventions (acute vs. chronic)
• Monitoring• Response to therapies• Adjust care plan/management
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Medication Unresponsive Symptoms• Wandering• Annoying repetitive activities,
including “exit seeking” • Disrobing • Persistent disruptive
vocalization (swearing, offensive comments, yelling/screaming)
• Restlessness/ repeated attempts to unsafely arise from chair or climb out of bed
• Hiding/hoarding • Eating inedibles • Climbing into bed with other
residents • Sleep disturbance, diurnal
reversal• Pushing wheelchair-bound
residents* may be related to pain or discomfort
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Medication Responsive Symptoms
• Persistent and distressing delusions or hallucinations • Manic-like symptoms • Anxiety • Depressive symptoms • Persistent physical aggression • Sleep disturbance, insomnia
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Nonpharmacological Interventions
Goals for Agitation/Aggression
• Prevent the symptoms• Treat episodes
• Lessen severity• Lessen duration
• Lessen caregiver burden/stress
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Resident who constantly walks
• Providing a space and environmental cues that encourages physical exercise, decreases exit behavior and reduces extraneous stimulation;
• Providing aroma(s)/aromatherapy;
• Validating the residentʼs feelings and words;
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Resident who is verbally and physically abusive, sexually inappropriate, or compulsive
• Calm, non-rushed environment, with structured, familiar activities;
• One-to-one or small group activities that comfort the resident;
• Eating a favorite snack;• Looking at familiar pictures• Exercise and movement activities• Exchange self-stimulatory activity
for a more socially appropriate activity that uses the hands
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Resident who disrupts group activities• Offer activities in which the
resident can succeed• Involve in familiar
occupation-related activities• Involve in physical activities
or projects requiring strategy, planning, and concentration or physically resistive activities
• Slow exercises
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Resident who goes through othersʼ belongings• Offer normalizing or
sorting activities• Involve in organizing
activities• Provide rummage areas in
plain sight• Use non-entry cues
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Resident who has withdrawn from previous interests/routines and isolates self in room
• Offer activities just before or after mealtime and where the meal is being served;
• Offer in-room volunteer visits, music, or videos of choice;
• Encourage volunteer-type work that begins in room and needs to be completed outside of the room;
• If resident agrees, offer small group activity in the residentʼs room;
• Invite to special events with a trusted peer or family/friend;
• Invite resident to participate on facility committees
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Resident who excessively seeks attention
• Include in social programs
• Include in small group activities
• Include in service projects
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Resident who lacks awareness of personal safety• Observing closely during
activities, taking precautions with materials;
• Involve in smaller groups or one-to-one activities that use the hands;
• Focus attention on activities that are emotionally soothing;
• Focus attention on physical activities
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Resident who has delusional and hallucinatory behavior
• Focus on activities that decrease stress and increase awareness of actual surroundings;
• Offer verbal reassurance• Acknowledge that the
residentʼs experience is real to her/him
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COVID-19 Dementia Care Approaches
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Proactive Strategies• Provide a consistent routine
• Try to keep staff consistent
• Stay positive. Create a feeling that all is well.
• Consider every interaction or task as an opportunity for engagement
• Share person-centered information across the IDT
• Remind and assist with hand hygiene, social distancing, and use of cloth face coverings
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Exercise• Maximize the use of open-air spaces through social distancing
• If outdoor space is limited, set scheduled times so everyone can get some fresh air
• If exercise equipment is shared disinfection time should be allotted between residents
• Blow up a balloon and enjoy a simple one-on-one balloon toss
• Ask the resident to mimic your dance moves to fun music
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Dining and Nutrition• Hold theme nights and creative menus
• Provide reminders or prompts to drink and eat
• Be familiar with residentʼs eating and drinking patterns and abilities
• Use verbal, visual, or tactile cues and model behavior
• Sit and talk with the resident during mealtimes
• Provide a favorite treat
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Communication and Connection• Use an old-school type of telephone to plug into the tablet so
the resident can hold the phone while looking at the tablet.
• Introduce new residents and long stay residents using tablet to tablet connections from across the hall and throughout the facility
• Tell a funny story or joke
• Ask an opinion
• Evoke a happy memory from a personʼs life story
• Do some brain aerobics with simple word associations
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Testing/Vaccinations• Spend additional time as needed with residents either before,
during, or after vaccination or testing
• Consider the time of day for discussing and administering vaccines or tests for residents with dementia
• Use a comforting or familiar space for vaccination and testing
• Consider having a family member present
• Simple things like the tone of voice, body posture, quick movements, noise, disrupted routines and environments can induce challenging behaviors
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Care Planning• F-655 Baseline Care Plan
• F-656 Develop/Implement Comprehensive Care Plan
• F-657 Care Plan Timing & Revision
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Baseline Care PlanThe facility must develop and implement a baseline care plan for each resident that include the instructions needed to provide effective and person-centered care of the resident.
MUST:• Be developed within 48 hours of a
residentʼs admission• Provide the resident and their
representative with a summary of the baseline care plan
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Comprehensive Care PlanThe facility must develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a residentʼs medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.
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Person Centered• Goals for admission and desired outcomes• Ethnicity• Cultural values• Lifelong interests• Spirituality• Life roles• Support systems• Resident/representative choice or preference• Advanced directive decisions
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Care Plan Development and RevisionComprehensive care plan must be:
• Developed within 7 days after completion of the comprehensive assessment
• Prepared by an interdisciplinary team
• Reviewed and revised by the interdisciplinary team after each assessment
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Interdisciplinary Team• Attending physician or designee• Registered Nurse• Certified Nursing Assistant• Nutrition Services• Resident or Representative• Other appropriate staff in
disciplines as determined by the residentʼs needs or as requested by the resident
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Resident/Representative ParticipationThe facility must:
• Provide advance notice of care planning conference
• Facilitate the participation in the care planning process
• If inclusion is not practicable, documentation of the reasons, including the steps the facility took, must be included in the medical record
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Care Plan Building Blocks
• MDS/CAAs
• Departmental Assessments
• Observation
• Resident/Family Interviews
• Discharge Plan
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Care Plan Process
Monitor
Select Intervention
Identify Goals
Diagnosis/Cause and Effect Analysis
Identify Problem/Risk
Assessment
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Identify Risks/Opportunities• Medical Conditions• MDS/CAA
• Section C. Cognitive Patterns
• Section D. Mood• Section E. Behavior• Section F. Activities• Section Q. Return to
Community• PASARR• Department Assessments• Risk Assessments
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Setting Goals• Use SMART framework
• Address what you hope to accomplish
• Improvement• Decline• Remain the same
• Realistic for both resident and IDT
• Reflect residentʼs goals
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Finding BalanceFacility
• Facility Practice• Clinical Standards
Resident• Choice • Beliefs• Preferences
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Interventions• Enable the resident to meet his/her goals
• Address the opportunity/risk
• Realistic
• Person centered
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Monitoring of ProgressReview
• After MDS completed• When residentʼs preferences or
goals change• When residentʼs condition
changes• When a risk becomes a reality• When a resident/representative
decline services or treatments
Modify• To address response to new
condition or treatment• Decide if the IDT is going to:
• Continue Plan• Modify Plan• Eliminate Plan
• Identify care or service being declined and IDT efforts to educate and provide alternatives
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Use the Same Form as the Surveyors
See LTC Survey Pathways Updated 08-03-2018 ZIP File:Activitieshttps://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html
Review the specific questionnaire/observational checklist used by surveyors
FOR MORE INFORMATIONCall 877.731.4746 or visit www.hqin.org
Allison Spangler, RN, BSN, RAC-CT, QCPQuality Improvement Advisor
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CONNECT WITH USCall 877.731.4746 or visit www.hqin.org
@HQINetworkHealth Quality Innovation Network
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