UPDATE ON F329/309 AND DEMENTIA CARE Lisa Venditti, CEO Long
Term Solutions Inc. 845 208 3328 1
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OBJECTIVES Become familiar with changes in F329 and F309
Discuss how to comply with regulatory changes Discuss non
pharmacological interventions for Addressing Mood and Behavior
2
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March 29, 2012 CMS launched the national partnership with the
goal to reduce unnecessary antipsychotic drug use in nursing homes
AKA The Partnership to Improve Dementia Care in Nursing Homes
NATIONAL PARTNERSHIP
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Optimize the quality of life and function of residents in
nursing homes by improving approaches to meeting the health,
psychosocial and behavioral health needs of all residents,
especially those with dementia. NATIONAL PARTNERSHIP: GOAL
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CHALLENGE OF BEHAVIORS EASY QUICK FIX Psychopharmacological
medications Often ineffective May cause harm HARD CHALLENGE of
assessment WHY IS THERE A BEHAVIOR: MEDICAL PHYSICAL FUNCTIONAL
PSYCHOLOGICAL EMOTIONAL PSYCHIATRIC SOCIAL ENVIRONMENTAL
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IS THERE A BALANCE??
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F 329 UNNECESSARY MEDICATIONS Any drug used -Without
appropriate indication -For excessive duration -In excessive dose
-Without adequate monitoring -In the presence of adverse
effects
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Elderly patients with dementia-related psychosis treated with
atypical antipsychotic drugs are at an increased risk of death
compared to placebo FDA BLACK BOX WARNING
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Schizophrenia Schizo-affective disorder Schizophreniform
disorder Mood disorders: Bipolar/severe depression refractory to
other therapies Psychosis IN THE ABSENCE OF DEMENTIA Medical
illnesses with psychotic symptoms (neoplastic disease) and/or
treatment related psychosis or mania (high dose steroids) Tourettes
Disorder Huntingtons Disease Hiccups Nausea and vomiting associated
with cancer or chemotherapy ANTIPSYCHOTIC MEDICATIONS INDICATIONS
FOR USE
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WHAT IS PSYCHOSIS? PSYCHOSIS A serious mental disorder (as
schizophrenia) characterized by defective or lost contact with
reality often with hallucinations and delusions HALLUCINATION
Hallucinations involve sensing things while awake that appear to be
real, but instead have been created by the mind. DELUSION Delusions
are irrational beliefs, held with a high level of conviction, that
are highly resistant to change even when the delusional person is
exposed to forms of proof that contradict the belief. 10
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ANTIPSYCHOTIC MEDICATION INDICATIONS FOR USE Behavioral or
Psychological Symptoms of Dementia (BPSD) ONLY AFTER MEDICAL,
PHYSICAL, FUNCTIONAL, PSYCHOLOGICAL, EMOTIONAL, PSYCHIATRIC, SOCIAL
AND ENVIRONMENTAL CAUSES HAVE BEEN IDENTIFIED AND ADDRESSED MUST BE
PRESCRIBED AT THE LOWEST POSSIBLE DOSAGE FOR THE SHORTEST PERIOD OF
TIME AND ARE SUBJECT TO GRADUAL DOSE REDUCTION 11
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INADEQUATE INDICATIONS FOR USE Wandering Poor self care
Restlessness Inattention or indifference to surroundings Impaired
memory Fidgeting Nervousness Insomnia Uncooperativeness/refusal of
care or difficult receiving care 12
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DOSE THRESHOLDS Minor updates and revisions (Maximum total dose
of zyprexa is now 5mg instead of 7.5mg) Newer Atypical Agents Added
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CRITERIA FOR USE DIAGNOSIS ALONE DOES NOT WARRANT THE USE OF
ANTIPSYCHOTICS BEHAVIORAL SYMPTOMS MUST PRESENT DANGER TO RESIDENT
OR OTHERS AND SYMPTOMS ARE DUE TO MANIA OR PSYCHOSIS BEHAVIORAL
INTERVENTIONS ATTEMPTED AND INCLUDED IN PLAN OF CARE 14
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Clinical condition/diagnoses meets criteria Prior to initiation
/ titration of an antipsychotic medication for enduring conditions,
the target behavior/s must be clearly and specifically identified
and documented and MEDICAL, PHYSICAL, FUNCTIONAL, PSYCHOLOGICAL,
EMOTIONAL, PSYCHIATRIC, SOCIAL AND ENVIRONMENTAL CAUSES HAVE BEEN
IDENTIFIED AND ADDRESSED ANTIPSYCHOTIC MEDICATIONS: ENDURING,
CHRONIC OR PROLONGED CONDITIONS
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For residents who are admitted on an antipsychotic medication:
Facility must re-evaluate the use/GDR of the antipsychotic
medication at the time of admission, and/or within 2 weeks of
admission NEW ADMISSIONS
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When an antipsychotic medication is being initiated or used to
treat an emergency situation (acute onset or exacerbation of
symptoms or immediate threat to health or safety of resident or
others), additional requirements for use include: 1. The acute
treatment is limited to 7 days 2. A clinician in conjunction with
the interdisciplinary team 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 3. If the behaviors persist, non-pharmacological interventions
must be attempted, unless clinically contraindicated ANTIPSYCHOTIC
MEDICATIONS: ACUTE OR NEWLY INITIATED
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OTHER HIGHLIGHTS SURVEYORS ARE ADVISED TO SPEAK TO PRESCRIBER
AND /OR CONSULTANT PHARMACIST WHEN ANTIPSYCHOTIC IS USED FOR
DEMENTIA FACILITY AND PRESCRIBER MUST DOCUMENT RATIONALE FOR
DECISION TO USE ANTIPSYCHOTIC FAMILY MEMBER/RESIDENT/OR LEGAL
REPRESENTATIVE IS AWARE OF AND INVOLVED IN THE DECISION TO CONTINUE
THE MEDICATION 18
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OTHER HIGHLIGHTS POTENTIAL ADVERSE CONSEQUENCES OF
ANTIPSYCHOTICS: ANTICHOLINERGIC: CONSTIPATION NEUROLOGIC:
AKATHISIA/PARKINSONISM/TIA/STROKE CARDIOVASCULAR: ORTHOSTATIC
HYPOTENSION/CARDIAC ARRYTHMIA METABOLIC: INCREASE IN
CHOLESTEROL/TRIGLYCERIDES/WEIGHT GAIN/ POORLY CONTROLLED BLOOD
SUGARS 19
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OTHER HIGHLIGHTS FOCUS ON RESIDENT IF MORE THAN ONE
ANTIPSYCHOTIC PRESCRIBED ANTIPSYCHOTIC DISCONTINUED AND REPLACED
WITH OTHER PSYCHOPHARMACOLOGIC DRUG 20
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SURVEY READY!
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Use facility QM Report to preselect concerns for any QM that is
flagged at the 75 th or greater national percentile If either of
the QMs for residents on antipsychotic medications are flagged,
include the questions related to dementia care and antipsychotic
medication use during the ENTRANCE CONFERENCE OFF SITE PREP
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SURVEY SAMPLES SAMPLE MUST INCLUDE AT LEAST ONE RESIDENT ON AN
ANTIPSYCHOTIC FOR A COMPREHENSIVE OR FOCUSED RECORD REVIEW REQUEST
A LIST OF RESIDENTS WITH DEMENTIA AND WHO HAVE: RECEIVED AN
ANTIPSYCHOTIC IN THE PAST 30 DAYS ARE CURRENTLY RECEIVING AN
ANTIPSYCHOTIC HAVE OR HAD A PRN ORDER FOR AN ANTIPSYCHOTIC IN THE
LAST 30 DAYS 23
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SURVEY SAMPLES DNS AND ADMINISTRATOR WILL BE ASKED: HOW DOES
FACILITY PROVIDE INDIVIDUALIZED CARE AND SERVICES TO THOSE WITH
DEMENTIA WHAT ARE YOUR POLICIESRELATED TO THE USE OF ANTIPSYCHOTICS
FOR THOSE WITH DEMENTIA. 24
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Each resident must receive and the facility must provide the
necessary 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 This
includes, but is NOT limited to, care such as CARE OF A RESIDENT
WITH DEMENTIA, end-of-life, diabetes, renal disease, fractures,
congestive heart failure, non-pressure related skin ulcers, pain
and fecal impaction F 309: QUALITY OF CARE
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THE CARE PROCESS OVERVIEW A. Recognition and Assessment B.
Cause Identification and Diagnosis C. Development of Care Plan D.
Individualized Approaches and Treatment E. Monitoring, Follow-up
and Oversight F. Quality Assessment and Assurance (QAA) 26
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RECOGNITION AND ASSESSMENT Medical record must include past
life experiences description of behaviors preferences for daily
routines/food/music/exercise oral health presence of pain medical
conditions cognitive status medications 27
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RECOGNITION AND ASSESSMENT CMS expects that the resident and
family/representatives, to the extent possible, are involved in
helping staff to understand the potential underlying causes of
behavioral distress and to participate in the development and
implementation of the residents care plan. 28
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RESIDENT/FAMILY/REPRESENTATIVE INVOLVEMENT How have you
involved them in discussions about: Potential approaches to address
behaviors? Potential risks and benefits of psychopharmacological
medications (including boxed warnings)? Expected duration of use of
a medication? Use of individualized approaches? Plans to evaluate
the effects of treatment? Pertinent alternatives? Necessity of
informed consent (only applicable in some states) All discussion
should be documented in the residents record 29
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CAUSE IDENTIFICATION AND DIAGNOSIS Identification of
co-existing medical or psychiatric conditions and adverse
consequences from medications Establish root cause of behaviors
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DEVELOPMENT OF CARE PLAN For any medications the care plan must
include: Indication/Rationale for use Dosage Monitoring for
efficacy or adverse consequences Specific target behaviors and
expected outcomes Duration Plans for Gradual Dose Reduction 31
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INDIVIDUALIZE APPROACHES AND TREATMENT Identify and document
specific target behaviors, expression of distress and desired
outcomes Implement appropriate, individualized, person centered
interventions and document the results Communicate and implement
plan of care, over time and across all shifts. Mandatory training
on the care of individuals with dementia must occur at hire and
annually thereafter for all nursing assistants. 32
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MONITORING /FOLLOW-UP/OVERSIGHT Review progress towards defined
goals Adjust interventions accordingly Notify prescriber of
concerns regarding effectiveness/adverse consequences Prescriber
must respond timely 33
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QUALITY ASSURANCE AND ASSESSMENT Medical Director and QAA
committee must - oversee resident care policies -monitor compliance
with policies -provide sufficient training to insure that
medications are not used instead of pertinent non pharmacological
interventions. 34
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1. Provide Person-Centered Care 2. Maintain Quality and
Quantity of Staff 3. Thorough Evaluation of New or Worsening
Behaviors 4. Use Individualized Approaches to Care 5. Critical
Thinking Related to Antipsychotic Drug Use 6. Prepare prescriber
and other disciplines for Interviews with Surveyors 7. Engagement
of Resident and/or Representative in Decision- Making ESSENTIAL
ELEMENTS FOR COMPLIANCE
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Find the balance between quality of life and improvement in
outcomes Documentation is critical Communication is key F309 and
F329 are tied together SUMMARY
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INDIVIDUALIZED, PERSON-CENTERED INTERVENTIONS MUST BE
IMPLEMENTED TO ADDRESS BEHAVIORAL EXPRESSIONS OF DISTRESS IN
PERSONS WITH DEMENTIA and USE OF ANTIPSYCHOTICS IS NOT FIRST LINE
TREATMENT FOR BSPD BOTTOM LINE