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Page 1: Handouts Prepared By: Jane Belt, MS, RN, RAC-MT Plante Moran … · 2017. 8. 23. · Training Dementia Care ... Source: Lexicomp Online () October 2012 . Contact us today to learn

©Plante Moran Clinical Group 2013 614-222-9020

plantemoran.complantemoran.com

Handouts Prepared By:Jane Belt, MS, RN, RAC-MT

Plante Moran Clinical [email protected]

614-222-9020

2

1

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Objectives

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Delineate the key requirements in F329 – Unnecessary Medications

Describe the key principles of “avoiding unnecessary medications”

Identify key strategies for collaboration between interdisciplinary team members to provide best care practices for medication use and the role of non-pharmacological interventions

Detail the required documentation components of staying in compliance with F329

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A Bit of Background First CMS in looking for quality improvement started to

focus on the use of antipsychotics used to treat NH residents with dementia

CMS Administrator at the time (Dr. Donald Berwick) asked stakeholders to provide to CMS their proposals for reducing their use

As the discussions continued – all realized that there should not be a focus on one class of drugs as that could trigger overuse of other drugs

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January 2013

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January 2013

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National

21.71%

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Multi-dimensional Approach Includes 3 R’s:RETHINK – approach to dementia care

RECONNECT – with residents via person-centered care practices

RESTORE – good health and quality of life

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January 2013 July 10, 2013

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plantemoran.com 9July 10, 2013

plantemoran.com 10July 10, 2013

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Key Requirements in F329:§483.25(l) Unnecessary Drugs 1. Each resident’s drug regimen must be free from unnecessary

drugs. An unnecessary drug is any drug when used:

(i) In excessive dose (including duplicate therapy); or

(ii) For excessive duration; or

(iii) Without adequate monitoring; or

(iv) Without adequate indications for its use; or

(v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

(vi) Any combinations of the reasons above11

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Key Requirements in F329:§483.25(l) Unnecessary Drugs 2. Antipsychotic Drugs. Based on a comprehensive assessment

of a resident, the facility must ensure that:

(i) Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and

(ii) Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

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Key Requirements in F329:Intent Each resident’s entire drug/medication regimen be managed

and monitored to achieve the following goals:

Medication regimen helps promote or maintain the resident’s highest level of function as identified by the resident/and or representative in collaboration with the attending physician and facility staff;

Each resident receives only those medications, in doses for the duration clinically indicated to treat the resident’s assessed condition(s);

Non-pharmacological interventions (such as behavioral interventions) are considered and used when indicated, instead of, or in addition to medication:

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Key Requirements in F329:Intent (continued)

Each resident’s entire drug/medication regimen be managed and monitored to achieve the following goals:

Clinically significant adverse consequences are minimized; and

The potential contribution of the medication regimen to an unanticipated decline or newly emerging or worsening symptom is recognized and evaluated, and the regimen is modified when appropriate

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Key Requirements in F329 In other words - the facility’s medication management program

supports and promotes selection of medications(s) based on assessing relative benefits and risks to the resident;

Evaluation of the resident’s signs and symptoms to identify the underlying cause(s), including adverse consequences of medications;

Selection and use of medications in doses and for the duration appropriate to each resident’s clinical conditions, age, and underlying causes of symptoms;

. 15

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Key Requirements in F329 Use of non-pharmacological interventions, when

applicable, to minimize the need for medications, permit use of the lowest possible dose, or allow medications to be discontinued;

Monitoring of medications for efficacy and clinically significant adverse consequences; and

Accurate and appropriate documentation, i.e., “the resident’s clinical record documents and communicates to the entire interdisciplinary team the basic elements of the care process.”

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Key Requirements in F329

The guidance at F329 applies to all categories of medications, including antipsychotic medications.

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F329 Clarifications per S&C: 13-35-NH – effective May 24, 2013 Restated the goal of the National Partnership is to

optimize the quality of life and function by improving approaches to meeting all the needs of residents, especially those with dementia

Described common practice to use various types of psychopharmacological medications to address behaviors without first determining the medical, physical, functional, psychological, emotional, psychiatric, social or environmental cause of the behaviors

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F329 Clarifications per S&C: 13-35-NH – effective May 24, 2013 Reiterated the medications used without clinical indication

are likely to cause harm

Concern that NHs, hospitals, ambulatory care use medications as a “quick fix” for behavioral symptoms or as a substitute for a holistic approach (thorough assessment of underlying causes of behaviors and individualized person-centered interventions

Antipsychotics often prescribed for residents with dementia who have behavioral or psychological symptoms of dementia (BPSD)

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Behavioral or Psychological Symptoms of Dementia (BPSD) The term used to describe behavior or other

symptoms in individuals with dementia that cannot be attributed to a specific medical or psychiatric cause

When drugs used without adequate rationale, little chance they will be effective and often cause complications, such as:

Movement disorders, falls, hip fractures, CVAs or TIAs, and increased risk of death

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As a Result…. Food & Drug Administration (FDA) Black Box

Warnings Regarding Atypical Antipsychotics in Dementia

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Elderly patients with dementia-related psychosis treated with atypical

antipsychotic drugs are at increased risk of death compared to placebo

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More from the S&C and Surveyor TrainingDementia Care Principles: includes an interdisciplinary

approach with focus on the needs of the resident as well as the needs of the other residents in the nursing home:

Person-Center Care

Quality and Quantity of Staff

Thorough Evaluation of New or Worsening Behaviors (BPSD) – evaluation by the IDT, including the physician in order to identify and address treatable medical, physical, emotional, psychiatric, psychological, functional, social and environmental factors that may be contributing to behaviors

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More from the S&C and Surveyor TrainingDementia Care Principles (continued)

Individualized Approaches to Care

Critical Thinking Related to Antipsychotic Drug Use

Interviews with Prescribers

Engagement of Resident and/or Representative in Decision-Making

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Additions to F329 – 5/13 –Antipsychotic Medications

All classes, e.g., First generation (conventional) agents, e.g., • chlorpromazine • fluphenazine • haloperidol • loxapine • mesoridazine • molindone • perphenazine • promazine • thioridazine • thiothixene • trifluoperazine • triflupromazine

Second generation (atypical) agents, e.g., • asenapine (Saphris)• aripiprazole • clozapine • iloperidone (Fanapt)• lurasidone (Latuda)• olanzapine • paliperidone (Invega)• quetiapine • risperidone • ziprasidone

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© 2012 Remedi SeniorCare. All rights reserved.

A Comparison of Antipsychotic Agents

Antipsychotic Agent Dosage Forms Sedation

(Incidence) Extrapyramidal

Side Effects Anticholinergic

Side Effects Orthostatic Hypotension

Weight Gain

Atypical Antipsychotic Agents

Aripiprazole Abilify®

Solution; tablet; orally disintegrating tab; injection

Low Low Very low Very low Very low

Asenapine Saphris®

Tablet, sublingual Moderate Low Very low Low/ moderate Low

Clozapine Clozaril®,Fazaclo®

Tablet; tablet, orally disintegrating

High Very low High High High

Iloperidone Fanapt™

Tablet Low Low Very low Low/ moderate Low/

moderate

Lurasidone Latuda®

Tablet Moderate Low/ Moderate Low Low Very Low

Olanzapine Zyprexa®

Injection; tablet; orally disintegrating tab Moderate/

high Low Moderate Moderate High

Zyprexa® Relprew™ Injection, long-acting

Paliperidone Invega®

Tablet, extended release Low/ moderate

Low Very low Moderate Low

Invega® Sustenna® Injection, long-acting

Quetiapine Seroquel®, XR®

Tablet; tablet, extended release

Moderate/ high

Very low Moderate Moderate Moderate

Risperidone Risperdal®

Solution; tablet; orally disintegrating tab Low/

moderate Low Very low Moderate

Low/ moderate

Risperdal® Consta® Injection, long-acting

Ziprasidone Geodon®

Capsule; injection, powder Low/

moderate Low Very low Low/ moderate Low

Traditional Antipsychotic Agents

Chlorpromazine Injection; tablet High Moderate Moderate Moderate/ high

Fluphenazine Solution, concentrate; injection; tablet Low High Low Low

Injection, long-acting

Haloperidol Haldol®

Solution, concentrate; injection; tablet Low High Low Low

Haldol® Decanoate Injection, long-acting

Loxapine Loxitane®

Capsule Moderate Moderate Low Low

Perphenazine Tablet Low Moderate Low Low

Pimozide Orap®

Tablet Moderate High Moderate Low

Thioridazine Tablet High Low High Moderate/ high

Thiothixene Navane®

Capsule Low High Low Low/ moderate

Trifluoperazine Tablet Low High Low Low

Woods SW, "Chlorpromazine Equivalent Doses for the Newer Atypicals," J Clin Psychiatry, 2003, 64(6):663-7. Source: Lexicomp Online (www.lexi.com) October 2012

Contact us today to learn more about Remedi SeniorCare’s pharmacy services

and the most accurate, most efficient, most everything med pass ever!

1-855-Remedi5 (1-855-736-3345) or visit www.BeginWithPaxit.com

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Additions to F329 Indications for Use Antipsychotic MedicationsConditions other than dementia: Schizophrenia Schizo-affective disorder Schizophreniform disorder Delusional disorder Mood disorders (e.g., bipolar disorder, severe depression refractory

to other therapies and/or with psychotic features Psychosis in the absence of dementia Medical illnesses with psychotic symptoms and/or treatment related

psychosis or mania Tourette’s Disorder Huntington’s Disease Hiccups (not induced by medication) Nausea and vomiting associated with cancer of chemotherapy 25

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Additions to F329 Indications for Use Antipsychotic Medications Behavioral or Psychological Symptoms of Dementia (BPSD) Use this guidance in conjunction with guidance at F309 Quality

of Care, Review of Care and Services for a Resident with Dementia. Also consider F154 Right to be informed in advance about care and services; F155 Right to refuse treatment; and F280 Right to participate in planning care and treatment.Antipsychotics only appropriate for elderly residents in a small minority of circumstances (unless the antipsychotic is prescribed to treat previously diagnosed mental illness such as schizophrenia or possibly other conditions listed above). FDA warned healthcare professionals that both conventional and atypical antipsychotics are associated with an increased risk of death in elderly patients treated for dementia-related psychosis.

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F329 Inadequate Indications for Use Antipsychotic Medications Antipsychotic medications in persons with dementia should not

be used if the only indication is one or more of the following: wandering poor self-care restlessness impaired memory mild anxiety insomnia fidgeting nervousness inattention or indifference to surroundings sadness or crying alone that is not related to depression or other

psychiatric disorders uncooperativeness (e.g., refusal of or difficulty receiving care)

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One or more of these identified conditions alone does not warrant use unless the following criteria are met:• The behavioral symptoms present a danger to the

residents or others AND one or both:• The symptoms are identified as due to mania or

psychosis; OR• Behavioral interventions have been attempted

and included in the POC, except in emergency

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F329 – Additional Criteria:Acute Situations/Emergency

Must meet the above criteria and all of the following additional requirements: 1. The acute treatment period is limited to 7 days or less;

2. A clinician in conjunction with the IDT must evaluate and document the situation within 7 days to identify and address any contributing and underlying causes of the acute condition and verify the continuing need for an antipsychotic medication

3. If the behaviors persist beyond the emergency, pertinent non-pharmacological interventions must be attempted, unless clinically contraindicated, and documented following the resolution of the acute psychiatric event.

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F329 – Additional Criteria:Enduring Conditions Enduring = non-acute, chronic or prolonged Antipsychotic may be used if condition/diagnosis meets criteria

in BPSD In addition, target behavior must be clearly and specifically

identified and documented Monitoring must ensure that

Not due to a medical condition or problem (e.g., pain fluid imbalance, infection, medication side effect) that can be expected to improve as underlying condition is treated or the offending medication is discontinued

AND29

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Enduring Conditions (continued) Monitoring must ensure the behavioral symptoms

Not due to a medical condition or problem (e.g., pain fluid imbalance, infection, medication side effect) that can be expected to improve as underlying condition is treated or the offending medication is discontinued

AND

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Not due to environmental stressors alone (e.g., alteration in the resident’s customary location or daily routine, unfamiliar care provider, hunger or thirst, excessive noise for that individual, inadequate or inappropriate staff response), that can be addressed to improve the symptoms or maintain safety;

AND

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Monitoring Enduring Conditions and Must Not Be Due to (cont.)

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Not due to psychological stressors alone (e.g., loneliness, taunting, abuse), anxiety or fear stemming from misunderstanding related to his or her cognitive impairment (e.g., the mistaken belief that this is not where he/she lives or inability to find his or her clothes or glasses, unaddressed sensory deficits) that can be expected to improve or resolve as the situation is addressed; AND

Persistent. There must be clear documented evidence in the medical record that the situation or condition continues or recurs over time (persists) and that other approaches that have been attempted have failed to adequately address the behavioral/psychological symptoms and that the resident’s quality of life is negatively affected by the behaviors/symptoms as described above.

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Many residents admitted already on an antipsychotic. The facility is responsible for: Preadmission screening for mentally ill and intellectually

disabled individuals, and; Obtaining physician’s orders for the resident’s immediate care

Residents not requiring PASRR screening and admitted on an antipsychotic medication – use of the antipsychotic medication must be reevaluated at the time of admission and/or within two weeks of admission (initial MDS) to consider whether or not the medication can be reduced or discontinued

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F329 – Additional Criteria:New Admission

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Treatment should be at the lowest possible dose to improve the target symptoms being monitored. It is important to note that doses for acute indications (e.g. delirium or acute psychosis) may differ from those used for long-term treatment of various conditions. Table inserted as a general dosage guide

Duration - Refers to Guidance Section V – Tapering of a Medication Dose/Gradual Dose Reduction (GDR)

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F329 – Additional Criteria:Dosage/Duration

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Important to not only evaluate ongoing effectiveness and potential adverse consequences, but also to evaluate the use of any other psychopharmacological medications (e.g. mood stabilizers, benzodiazepines) being given to the resident. Specifically, surveyors should review the record to determine whether the facility can explain the rationale for adding, or switching from an antipsychotic to another category (or categories) of psychopharmacological agents; otherwise, both may potentially be unnecessary medications.

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F329 – Additional Criteria:Monitoring

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Surveyors should investigate further in cases where more than one antipsychotic agent has been prescribed.

Surveyors should investigate further in cases where more than one antipsychotic agent has been prescribed, or where an antipsychotic has been discontinued and a medication such as a mood stabilizer has been added.

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F329 – Additional Criteria:Monitoring

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After initiating or increasing the dose of an antipsychotic medication, the behavioral symptoms must be reevaluated periodically (at least during quarterly care plan review, but often more frequently, depending on the resident’s response to the medication) to determine the effectiveness of the antipsychotic and the potential for reducing or discontinuing the dose based on target symptoms and any adverse effects or functional impairment.

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F329 – Additional Criteria:Effectiveness

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Assuring residents are adequately monitored for adverse consequences such as:

General: anticholinergic effects (see Table II), falls, excessive sedation

Cardiovascular: cardiac arrhythmias, orthostatic hypotension

Metabolic: increase in total cholesterol and triglycerides, unstable or poorly controlled blood sugar, weight gain

Neurologic: akathisia, neuroleptic malignant 37

F329 – Additional Criteria:Potential Adverse Consequences

If any identified,

facility must act

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Key Principles of “Avoiding Unnecessary Medications” Does each medication have a clear indication?

Is there documentation of a positive response?

Are clinical staff monitoring for adverse effects?

Is the drug being used at the lowest effective doe and is the need for continuing the medication being assessed at regular intervals?

Are non-pharmacological interventions suggested and tried?

Has the resident, family or designated decision-maker been informed of risks and benefits and concurs with treatment?

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Increasing the amount of exercise, intake of liquids and dietary fiber to prevent or reduce constipation and the use of meds (laxatives, stool softeners)

Determining causes of distressed behavior such as boredom and pain

Sleep hygiene techniques Encouraging reminiscent lifelong work or activity

patterns Individualized toileting schedules

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Examples of Non-Pharmacological Interventions

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Develop interventions specific to resident’s interest, abilities, strengths and needs

Using massage, hot/warm compresses to address resident’s pain or discomfort

Enhancing taste and presentation of food, assisting the resident to eat, addressing food preferences and increasing finger foods and snacks for an individual with dementia, to improve appetite and avoid unnecessary use of medications to stimulate appetite

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Examples of Non-Pharmacological Interventions

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Monitor Your Data Nursing Home Compare

Compare facility QMs to state and national averages

Use the graph function for a visual aid

Remember QM values on NHC are a 3-quarter average and lag by 3 months

Use the Five-Star provider preview reports

Includes QM values for each quarter

3-quarter average, and the national comparison

Generated typically on the 3rd Thursday of each month41

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Monitor Your Data NHC Calculations:

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Measure: Percentage of Long-Stay Residents Who are Receiving Antipsychotic Medication

Measure: Percentage of Short-Stay Patients Who Have Antipsychotics Started – Incidence

Description: The percentage of long-stay residents (>100 cumulative days in the nursing facility) who are receiving antipsychotic medication

Description: The percentage of short-stay residents (<=100 cumulative days in the nursing facility) who have antipsychotic medications started after admission

Exclusions: Any of the following conditions are present on the target assessment (unless otherwise indicated): 2.1. Schizophrenia (I6000 = [1]). 2.2. Tourette’s Syndrome (I5350 = [1]). 2.3. Tourette’s Syndrome (I5350 = [1]) on the prior assessment if this item is not active on the target assessment and if a prior assessment is available. 2.4. Huntington’s Disease (I5250 = [1]).

Exclusions 2. Any of the following related conditions are present on any assessment in a look-back scan: 2.1. Schizophrenia (I6000 = [1]). 2.2. Tourette’s Syndrome (I5350 = [1]). 2.3. Huntington’s Disease (I5250 = [1])

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Surveyor Quality Measures

Psychoactive Medication Use in the absence of Psychotic or Related Condition (LS) Exclusions:

Schizophrenia Psychotic disorder Manic depression Tourette’s Syndrome Huntington’s Hallucinations Delusions

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At some point this QM will be replaced by Short stay Residents Who Newly Received Antipsychotic Medication

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Survey Process Key elements for severity determination for F329

are as follows:1. Presence of potential or actual harm/negative outcome(s) due

to failure related to unnecessary medications

2. Degree of potential or actual harm/negative outcome(s) due to a failure related to unnecessary medications

3. The immediacy of correction required

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What Will Surveyors Expect? Will be looking more intensively at persons with

dementia who are on antipsychotics

Surveyor guidance has been revised with input from several professional associations (AHCA, Leading Age, AMDA, ASCP, NADONA, AAGP, AGS and others), advocates and other stakeholders

Surveyors will include residents with dementia who are receiving an antipsychotic in their sample

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What Will Surveyors Expect? Surveyors will look for the same systematic

process that providers and practitioners should be using to determine the underlying causes of behaviors in persons with dementia

Surveyors will look to see that care plans include plans for residents with dementia that address behaviors, include input from the resident (to the extent possible) and/or family or representative and that those plans are consistently carried out

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What Will Surveyors Expect?

Surveyors are looking for a systematic process to be evident and for that process to be followed for every resident

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Systematic Process Get details about the resident's behavioral

expressions of distress (nature, frequency, severity, and duration) and the risks of those behaviors, and discuss potential underlying causes with the care team and family

Exclude potentially remediable causes of behaviors (such as delirium, infection or medications), and determine if symptoms are severe, distressing or risky enough to adversely affect the safety of residents

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Systematic Process Try environmental and other approaches that attempt

to understand and address behavior as a form of communication in persons with dementia, and modify the environment and daily routines to meet the person’s needs

Assess the effects of any intervention (pharmacological or non-pharmacological); Identify benefits and complications in a timely fashion; Adjust treatment accordingly

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For those residents for whom antipsychotic or other medications are warranted, use the lowest effective dose for the shortest possible duration, based on findings in the specific individual

Monitor for potential side effects - therapeutic benefit with respect to specific target symptoms/expressions of distress Inadequate documentation: “Behavior improved.” “Less agitated.” “No longer asking to go home.”

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Systematic Process

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Include specifics, why they behaviors were harmful/dangerous/distressing and what the person is now able to do (positive) as a result of the intervention

Try tapering the medication when symptoms have been stable or adjusting doses to obtain benefits with the lowest possible risk

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Systematic Process

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The Survey Process

Input from nursing assistants, nurses, social workers, therapists, family and other caregivers working closely with the resident is essential; Input from all three shifts and weekend caregivers is also important in “telling the story”

Surveyors will look at communication between shifts, between nurses and practitioners or prescribers

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Surveyors will also look at whether medications prescribed by a covering practitioner in an urgent situation are re-evaluated by the primary care team and discontinued when possible

Surveyors will look at whether or not other psycho-pharmacologicals are prescribed if/when antipsychotic medications are discontinued or reduced

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The Survey Process

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“How can we reduce antipsychotic use in persons with dementia?”

Focus on each individual resident and use a careful, systematic process to evaluate his/her needs; This is what surveyors will be looking for

During off-site preparation, surveyors will also review the antipsychotic rate in the nursing home; Surveyors will ask staff about the home’s approach to persons with dementia

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“How can we reduce antipsychotic use in persons with dementia?” Consider forming a behavioral health committee or team for dementia care practices, or include in existing committee structure; Include the consultant pharmacist, medical director, administrator, director of nursing, recreational and other therapy staff, social worker, direct care partners/staff (CNAs) Include behavioral health specialists/consultants if possible

Include resident, family members when policies/practices (not individuals) are being discussed 55

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“How can we reduce antipsychotic use in persons with dementia?” Consider forming a behavioral health committee or team for

dementia care practices, or include in existing committee structure; Include the consultant pharmacist, medical director, administrator, director of nursing, recreational and other therapy staff, social worker, direct care partners/staff (CNAs)

Include behavioral health specialists/consultants if possible

Include resident, family members when policies/practices (not individuals) are being discussed

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Use Medications Appropriately PROBING QUESTIONS

Why is our use of antipsychotics high for individuals with dementia?

Has the use of antipsychotics risen over the last three months? Is our use of antipsychotics more than the average for our state? How does our rate compare to the national average?

Which groups are affected? a. Residents Are the individuals with dementia long stay or short stay? Are individuals on the same unit? Are residents on scheduled antipsychotics, as needed (PRN) antipsychotics or both? Do we discuss the use of anti-psychotics with residents and/or families and gain their consent

for their use?

b. Prescribers Do the prescriptions for antipsychotics come from the same prescriber or are there different

prescribers? Are antipsychotics started outside of the nursing home (for example - hospital, outside

consultant) or are the drugs started after people are in the nursing home? For those whose medications are started in the nursing home is there an assessment done prior

to, or shortly after the initiation of an antipsychotic medication? Have there been conversations with the prescribers about reducing or stopping antipsychotics? Have there been any consulting pharmacist recommendations to reduce the antipsychotics and

were these recommendations followed?

Processes and Resources to Consider

What practices do we have in place to minimize the use of antipsychotic medications?

Is there an optimum number of staff and do staffing patterns support individualized, person-centered care?

Does our staffing pattern provide for flexibility based on the number of persons with dementia, and/or the severity of their illness?

Does our staffing pattern provide adequate coverage for crisis management? Is there adequate staff training on dementia and on understanding and responding to behavior

as a means of communication?

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©2010 Advancing Excellence in Long Term Care Collaborative Advancing Excellence welcomes the use of any and all of its materials with appropriate attribution. Where such uses would alter 2 the original content or be used for profit, such users must notify Advancing Excellence and request permission to so.

Does support exist within the nursing home to change the utilization of antipsychotics? Do staff request antipsychotics prior to assessment of a resident? Do staff request antipsychotics prior to systematic attempts to identify and address unmet needs

that may be triggering behavioral responses?

Are there patterns of use?

Are there clear and acceptable clinical rationale for use of medications? Are gradual dose reductions being conducted at our home? Are the medications being monitored by objective measures? If so, are the outcomes positive for the individual? Are the medications causing adverse effects for the resident and/or change in function?

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Use Medications Appropriately LEADERSHIP FACT SHEET

Advancing Excellence in America’s Nursing Homes is a national campaign that began in September 2006. Our goal is to improve the quality of care and life for the 1.5 million people served by nursing homes in the United States. Nursing homes and their staff, along with residents and their families and consumers, can join in this effort by working on the campaign goals that are designed to improve quality. We do this by providing tools and resources to help nursing homes achieve their quality improvement goals. To learn more about the campaign, visit www.nhqualitycampaign.org. The appropriate use of medications is paramount in insuring the safety and well-being of residents in nursing homes. Almost any medication use could potentially be considered inappropriate if used in the wrong way, such as, being prescribed for too long a period of time, for the wrong reason, or in excessive doses. One class of medications that is frequently misused is antipsychotic medications. CMS has announced an initiative to reduce the inappropriate use of antipsychotic medications in nursing homes with their Partnership to Improve Dementia Care. As part of this initiative CMS has also released the Hand in Hand Training series, which has been free of charge to all nursing homes. This fact sheet will highlight different aspects when evaluating antipsychotic use within your facility. What are antipsychotic medications?

Antipsychotic medications are drugs used to treat symptoms of serious mental and emotional disorders such as schizophrenia or bi-polar disorder. Their use affects thinking and behavior by altering chemical substances in the brain. When prescribed properly these medications can help a person to think more clearly and take part in everyday life. Examples of antipsychotic medications include risperidone (Risperidol), quetiapine (Seroquel) and haloperidol (Haldol).

Antipsychotic drugs are not approved to treat people with Alzheimer’s disease and other dementias, including people who have dementia related psychosis.

Why is reducing the inappropriate use of antipsychotic medications important?

Nursing home leaders are charged with making sure that their residents receive appropriate care to prevent or minimize the symptoms or behaviors associated with mental illness, or dementia. When antipsychotics are prescribed to “quiet” a resident or for staff convenience, it could be considered a chemical restraint.

The use of chemical restraints is prohibited by federal law. A skilled nursing facility is required to “provide services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, in accordance with a written plan of care.” (Social Security Act, Section 1819(3)(b)(2))

In addition, antipsychotics have been shown to have possible adverse effects on the residents’ daily activities and quality of life. They can also contribute to and cause falls, metabolic disturbances, weight gain or loss, confusion as well as the associated increased incidence of heart attack and stroke.

There is heightened scrutiny during the annual survey with regards to use of anti-psychotics; consumers looking for a nursing home may also evaluate your home based on the Quality Measures on anti-psychotic use.

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2 ©2012 Advancing Excellence in Long Term Care Collaborative

Advancing Excellence welcomes the use of any and all of its materials with appropriate attribution. Where such uses would alter the original content or be used for profit, users must notify Advancing Excellence and request permission to do so.

Are there times when the use of antipsychotics may be appropriate and beneficial? • When the individual poses a serious threat to herself or others, short term use of antipsychotics

may be appropriate. • Care planning should always include resident centered nonpharmacologic interventions and if

antipsychotics are indicated they should be carefully monitored. • If used appropriately, with informed consent and individualized care planning, nursing home

residents may be better able to participate fully in care, translating into a safer environment. How can nursing home leaders prevent the unnecessary use of antipsychotics? Various leadership techniques can support and promote care that prevents the unnecessary use of antipsychotics. Following are a few suggestions based on successful practices. Increase staff training:

Provide educational opportunities for all staff regarding assessment and management of behavior in ways that don’t require medications or at least minimize their use;

Teach staff to recognize nonverbal signs of pain or unmet need, especially in residents with dementia, as these may be contributing to the behaviors;

Teach staff the importance of documenting care, particularly the use of non-pharmacological, person-centered approaches to individuals with dementia.

Promote a person-centered culture: Build your systems including staffing adjustments to promote activity and meal schedules based

on the preferred schedule of residents; Develop policies that direct the staff to identify resident-specific needs, optimize choices, and

promote consistent assignment so that staff knows residents well enough to meet their specific care needs;

Recognize staff that excel in assessment and creative management of behavioral problems; Promote communication and teamwork among all levels of staff; for example, include direct care

staff who know the resident best in care planning meetings. Quality Assurance:

Have the medical director work closely with an interdisciplinary team composed of nursing, social services, therapeutic recreation specialist and a pharmacist to monitor the use of antipsychotics;

Use the medical director to communicate between the interdisciplinary team and attending physicians to enhance information transfer, improve attending physician awareness of standards of care and regulatory expectations and monitor compliance.

Require and document informed consent when antipsychotics are considered; Use the Advancing Excellence Medication tool when evaluating antipsychotic use. For instance,

evaluate the incidences of prescribers failing to provide a relevant rationale for using an antipsychotic;

Ensure chart reviews that monitor when an antipsychotic medication is prescribed indefinitely (for months or more) without any attempts to reduce or discontinue it;

When the resident is not improving or is experiencing burdensome side effects from antipsychotic medications, it is the responsibility of care leaders to assure alternatives to antipsychotic medications are evaluated and implemented as appropriate for the individual.

Where can you get more facts about the appropriate use of antipsychotic? Find information to improve the appropriate use of antipsychotic medications throughout the nursing home at http://www.nhqualitycampaign.org

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“How can we reduce antipsychotic use in persons with dementia?”

Begin by looking at each resident with dementia who is on an antipsychotic and considering the case in detail; Look for underlying causes of the behavior;

Consider whether a gradual dose reduction may be indicated and communicate with the practitioner;

Engage your medical director and consultant pharmacist

Tools are on Advancing Excellence website; National experts are available

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F329 Investigative Protocol Objectives

Determine that each resident provided:

Only medications clinically indicated in dose and duration to meet assessed needs

Non-pharmacological approaches when indicated in an effort to reduce the need for a dose of medication

GDR attempts for antipsychotics (unless clinically contraindicated)

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F329 Investigative Protocol Objectives to determine that facility in collaboration

with the prescriber:

Identifies parameters for monitoring medications that pose a risk of adverse consequences and monitoring for effectiveness

Recognizes and evaluates onset or worsening of signs or symptoms, or a change in condition to determine whether these potentially may be related to the medication regimen; and follows-up as necessary upon identifying adverse consequences

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F329 Investigative Protocol

Objectives to determine if the pharmacist:

Performed monthly medication regimen review, and identified any existing irregularities regarding indications for use, dose, duration , and potential for, or the existence of adverse consequences or other irregularities; and

Reported any identified irregularities to the attending physician and director of nursing

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F329 Investigative Protocol Observation and Record Review

Interview:

Resident and or family/responsible party to determine their participation; and alternative approaches discussed; their evaluation of the results of the drug therapy

Medication Regimen Review to determine whether facility and practitioner acted on the report of any irregularity

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Determination of Compliance

For a resident who has been, or is, receiving medication(s), the facility is in compliance if they, in collaboration with the prescriber:

Assessed the resident to ascertain, to the extent possible, the causes of the condition or symptoms requiring treatment, including recognizing, evaluating, and determining whether the condition or symptoms may have reflected an adverse medication consequence;

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Based on the assessment, determined that medication therapy was indicated and identified the therapeutic goals for the medication;

Utilized only those medications in appropriate doses for the appropriate duration, which are clinically necessary to treat the resident’s assessed condition(s);

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Determination of Compliance

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Implemented a gradual dose reduction and behavioral interventions for each resident receiving antipsychotic medications unless clinically contraindicated;

Monitored the resident for progress towards the therapeutic goal(s) and for the emergence or presence of adverse consequences, as indicated by the resident’s condition and the medication(s); and

Adjusted or discontinued the dose of a medication in response to adverse consequences, unless clinically

contraindicated. If not, cite F329. 64

Determination of Compliance

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The update provides additional examples regarding the difference between compliance and non-compliance at severity levels 4, 3, and 2

Survey readiness help also available by reviewing the QIS Critical Elements for Unnecessary Medications

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Determination of Compliance

https://www.qtso.com/download/qis/forms/CMS-20082_Unnec_Med_CE_7112012.pdf

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Questions??

Submit questions by dialing #6 to unmute the phone line

After asking question, hit *6 to mute the phone line again

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Evaluation Forms Sign-in SheetAudio Order Form

Preferably TODAY, but no later than 1 week from today

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Ideas for the next series?

For a great 2013 MDS 3.0 Long Distance Learning Series

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Thank you.Jane BeltPlante Moran Clinical [email protected]

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Resources CMS MLN Connects National Provider Calls

http://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2013-07-10-Dementia-NPC.html

CMS S&C: 13-35-NH: Advanced Copy: Dementia Care in Nursing Homeshttp://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-35.pdf

Surveyor Traininghttp://surveyortraining.cms.hhs.gov/

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Resources

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Remedi SeniorCare web site – Innovative Solutions http://www.remedirx.com/resources-innovation/blog/2013/comparison-guide-of-antipsychotic-agents.aspx

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Resources

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• Dementia Care Practice Recommendations for Assisted Living Residences and Nursing Homeshttp://www.alz.org/national/documents/brochure_dcprphases1n2.pdf

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