- Email: [email protected]
Reducing Inappropriate Use of Antipsychotics in Long Term Care Residents
B22
Poster Abstracts / JAMDA 15 (2014) B3eB28
these medications. No resident was on all five classes. 8 residents (40%) were on none of these medications. C) Regarding falls: All falls occurred in persons on 2 or more classes of these at-risk medications. Of 5 falls on the unit at the time of the point-prevalence assessment, 3 were on residents receiving 3 classes of these medications; and 2 were in the resident receiving 4 classes of these medications. No falls occurred in persons not on any of these medications, and no falls occurred in recipients of only 1 class of these at-risk medications. D) Association of numbers of classes of at-risk medications and falls: Increased number of classes of medications simultaneously prescribed in recipients was positively associated with falls (p<0.05). E) Impact of Results: As a result of identification of increased medication load burdens on recipients and outcome association (falls), care team created multiple means of interventions to lessen/minimize risk (with goal of attempt to eliminate risk), which included: assessment of goals/benefits/burdens of each at-risk class of medication in recipients, and the total effects of multiple classes of these medications in recipients; non-pharmacologic interventions (e.g. hygiene, exercise, socialization) to less perceived need to prescribe medications in the at-risk classes for behavioral reasons; and team interaction/surveillance as to the abilities to identify behavioral antecedents amenable to non-pharmacologic interventions so as to lessen/minimize (with a goal of eliminating) primary pharmacologic interventions for behaviors not uncommonly found in the long term care environment. Conclusion: Two of the authors (BTN, AD) of this presentation at prior AMDA meeting poster presentations (2010, 2011) have looked at various of these classes of medications separately on nursing home populations, but not yet as a total risk burden on individual recipients. This quality improvement intervention firstly identified at-risk classes of medications in a long term care population; secondly, it identified increased load burden risk of multiple simultaneous at-risk medication classes among recipients; thirdly, it created a basis for a team approach to identifications and interventions to promote interdisciplinary, non-pharmacologic approaches to surveillance and management of behaviors not uncommonly seen in the LTC milieu; and fourth, it advanced and promoted development and progress of a paradigm on this LTC unit of team learning and caring for the behavioral languages of the LTC residents we serve. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
QA Meets PI Presenting Author: Jane C. Pederson, MD, MS, Stratis Health Author: Jane C. Pederson, MD, MS
Background: A modified learning collaborative that included in-person educational sessions, on-site technical assistance and additional webbased learning sessions and training modules. Participants: 17 nursing homes in 4 states participated in the demonstration project. The homes represented a wide range of experience with quality improvement and represented a range of characteristics including: ownership, urban and rural settings, Five Star ratings, and services offered. Objective/Aim: To determine what tools and resources are needed to assist a nursing home in implementing the Five Elements of QAPI. Quality Improvement Methods: The collaborative was described as “modified” because the goal was to identify the needs of the homes as they worked through the QAPI five elements in order to determine what types of tools and resources need to be available when QAPI is rolled out nationally. The collaborative consisted of three in-person, two-day meetings held in three of the four states, individual technical assistance through onsite meetings and telephone support, topic-based teaching modules, and periodic web-based educational sessions focusing on specific topics, tools or resources related to QAPI. Each home was assigned a QAPI liaison who served as their primary contact and was present at each of the on-site meetings. Through the course of the collaborative, over 25 tools were designed to help carry out various QAPI tasks. Qualitative data was collected from the homes throughout the learning collaborative. In addition, a structured evaluation was completed pre and post demonstration to determine the facilities progress toward implementing the key components of each of the five QAPI elements.
Results: All homes took active steps to improve their quality. Nursing homes that used the tools generally performed better. However, success was not solely determined by the use of tools. For many facilities QAPI required a change in mind set. QAPI is intended to be data driven but staff in nursing homes tend to be intuitive. Instead of finding problems and opportunities for improvement by looking at objective data, they instead turn to their experiences and insights. The data-driven nature of QAPI will require many facilities to gain or recruit staff with new skills in data analysis and translation. Conclusion: Implementing QAPI is feasible. The demonstration provided insight into practice and policy alignment questions that need to be answered for successful national rollout of QAPI. Author Disclosures: No additional financial support was provided for this abstract submission other than the funding provided through Jane Pederson’s employment at Stratis Health.
Reducing Inappropriate Use of Antipsychotics in Long Term Care Residents Presenting Author: Sahebi Saiyed, MD, Emory University Author(s): Sahebi Saiyed, MD, Phyllis Tawiah, MD; and Manuel Eskildsen, MD, MPH
Background: High prevalence rates of antipsychotic medications use have been reported in long term care (LTC) residents in several studies, despite an FDA black box warning in 2005 for dementia patients, and extensive data showing both marginal clinical benefits and more serious adverse effects in elderly populations. Studies have also shown that the likelihood of a resident’s receiving an antipsychotic medication is correlated to the facility-level antipsychotic prescribing rate. CMS is making the reduction of off-label use of antipsychotic medications a national priority, as evidenced by two new quality measures related to antipsychotics that are now being posted on CMS’s Nursing Home Compare website. Objective/Aim: Assess the use of antipsychotics at one facility in LTC residents. Minimize the off-label use of antipsychotics with a particular emphasis on BPSD. Reinforce appropriate laboratory and EKG monitoring in residents with appropriate indications. Quality Improvement Methods: Residents at the Budd Terrace Skilled Nursing Facility in Atlanta, GA who were on antipsychotics were selected for an intervention from monthly pharmacy reports. We conducted chart audits for patients on antipsychotics evaluating for appropriate indications and laboratory monitoring. Patients without FDA approved indications were identified and discussed with the primary physician for possible gradual dose reduction (GDR). Post intervention, we reviewed pharmacy reports and monitored patients for any adverse effects of medication withdrawal. Results: We were able to reduce total antipsychotic use from 17/71 LTC residents (24.0%) to 9/69 (13.0%) and off-label use was reduced from 8/71 residents (11.3%) to 1/69 (1.4%) post intervention. 2/10 (20%) residents with FDA-approved indications did not have the appropriate indications on their medication records, giving an impression of inappropriate use which was corrected. 5/6 patients with off-label use underwent GDR to discontinuation of medication without any significant behavioral change during the 4-6 weeks of monitoring. Scheduled lab/EKG monitoring was in place for 8/17 (47%) of the residents pre-intervention and improved to 100% post intervention. Conclusion: Our intervention led to a significant reduction in the proportion of residents in nursing homes taking antipsychotics. Total antipsychotic use was reduced from 23% to 13% beyond the state and national level, which also exceeded the CMS target of 15% reduction. We were successful in eliminating off-label use in patients with dementia without any adverse effects. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
Reducing Medication Use in a Skilled Nursing Facility - A Quality Improvement Project Presenting Author: Claudia Nassaralla, MD, PhD, MS, Duke University
Poster Abstracts / JAMDA 15 (2014) B3eB28
these medications. No resident was on all five classes. 8 residents (40%) were on none of these medications. C) Regarding falls: All falls occurred in persons on 2 or more classes of these at-risk medications. Of 5 falls on the unit at the time of the point-prevalence assessment, 3 were on residents receiving 3 classes of these medications; and 2 were in the resident receiving 4 classes of these medications. No falls occurred in persons not on any of these medications, and no falls occurred in recipients of only 1 class of these at-risk medications. D) Association of numbers of classes of at-risk medications and falls: Increased number of classes of medications simultaneously prescribed in recipients was positively associated with falls (p<0.05). E) Impact of Results: As a result of identification of increased medication load burdens on recipients and outcome association (falls), care team created multiple means of interventions to lessen/minimize risk (with goal of attempt to eliminate risk), which included: assessment of goals/benefits/burdens of each at-risk class of medication in recipients, and the total effects of multiple classes of these medications in recipients; non-pharmacologic interventions (e.g. hygiene, exercise, socialization) to less perceived need to prescribe medications in the at-risk classes for behavioral reasons; and team interaction/surveillance as to the abilities to identify behavioral antecedents amenable to non-pharmacologic interventions so as to lessen/minimize (with a goal of eliminating) primary pharmacologic interventions for behaviors not uncommonly found in the long term care environment. Conclusion: Two of the authors (BTN, AD) of this presentation at prior AMDA meeting poster presentations (2010, 2011) have looked at various of these classes of medications separately on nursing home populations, but not yet as a total risk burden on individual recipients. This quality improvement intervention firstly identified at-risk classes of medications in a long term care population; secondly, it identified increased load burden risk of multiple simultaneous at-risk medication classes among recipients; thirdly, it created a basis for a team approach to identifications and interventions to promote interdisciplinary, non-pharmacologic approaches to surveillance and management of behaviors not uncommonly seen in the LTC milieu; and fourth, it advanced and promoted development and progress of a paradigm on this LTC unit of team learning and caring for the behavioral languages of the LTC residents we serve. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
QA Meets PI Presenting Author: Jane C. Pederson, MD, MS, Stratis Health Author: Jane C. Pederson, MD, MS
Background: A modified learning collaborative that included in-person educational sessions, on-site technical assistance and additional webbased learning sessions and training modules. Participants: 17 nursing homes in 4 states participated in the demonstration project. The homes represented a wide range of experience with quality improvement and represented a range of characteristics including: ownership, urban and rural settings, Five Star ratings, and services offered. Objective/Aim: To determine what tools and resources are needed to assist a nursing home in implementing the Five Elements of QAPI. Quality Improvement Methods: The collaborative was described as “modified” because the goal was to identify the needs of the homes as they worked through the QAPI five elements in order to determine what types of tools and resources need to be available when QAPI is rolled out nationally. The collaborative consisted of three in-person, two-day meetings held in three of the four states, individual technical assistance through onsite meetings and telephone support, topic-based teaching modules, and periodic web-based educational sessions focusing on specific topics, tools or resources related to QAPI. Each home was assigned a QAPI liaison who served as their primary contact and was present at each of the on-site meetings. Through the course of the collaborative, over 25 tools were designed to help carry out various QAPI tasks. Qualitative data was collected from the homes throughout the learning collaborative. In addition, a structured evaluation was completed pre and post demonstration to determine the facilities progress toward implementing the key components of each of the five QAPI elements.
Results: All homes took active steps to improve their quality. Nursing homes that used the tools generally performed better. However, success was not solely determined by the use of tools. For many facilities QAPI required a change in mind set. QAPI is intended to be data driven but staff in nursing homes tend to be intuitive. Instead of finding problems and opportunities for improvement by looking at objective data, they instead turn to their experiences and insights. The data-driven nature of QAPI will require many facilities to gain or recruit staff with new skills in data analysis and translation. Conclusion: Implementing QAPI is feasible. The demonstration provided insight into practice and policy alignment questions that need to be answered for successful national rollout of QAPI. Author Disclosures: No additional financial support was provided for this abstract submission other than the funding provided through Jane Pederson’s employment at Stratis Health.
Reducing Inappropriate Use of Antipsychotics in Long Term Care Residents Presenting Author: Sahebi Saiyed, MD, Emory University Author(s): Sahebi Saiyed, MD, Phyllis Tawiah, MD; and Manuel Eskildsen, MD, MPH
Background: High prevalence rates of antipsychotic medications use have been reported in long term care (LTC) residents in several studies, despite an FDA black box warning in 2005 for dementia patients, and extensive data showing both marginal clinical benefits and more serious adverse effects in elderly populations. Studies have also shown that the likelihood of a resident’s receiving an antipsychotic medication is correlated to the facility-level antipsychotic prescribing rate. CMS is making the reduction of off-label use of antipsychotic medications a national priority, as evidenced by two new quality measures related to antipsychotics that are now being posted on CMS’s Nursing Home Compare website. Objective/Aim: Assess the use of antipsychotics at one facility in LTC residents. Minimize the off-label use of antipsychotics with a particular emphasis on BPSD. Reinforce appropriate laboratory and EKG monitoring in residents with appropriate indications. Quality Improvement Methods: Residents at the Budd Terrace Skilled Nursing Facility in Atlanta, GA who were on antipsychotics were selected for an intervention from monthly pharmacy reports. We conducted chart audits for patients on antipsychotics evaluating for appropriate indications and laboratory monitoring. Patients without FDA approved indications were identified and discussed with the primary physician for possible gradual dose reduction (GDR). Post intervention, we reviewed pharmacy reports and monitored patients for any adverse effects of medication withdrawal. Results: We were able to reduce total antipsychotic use from 17/71 LTC residents (24.0%) to 9/69 (13.0%) and off-label use was reduced from 8/71 residents (11.3%) to 1/69 (1.4%) post intervention. 2/10 (20%) residents with FDA-approved indications did not have the appropriate indications on their medication records, giving an impression of inappropriate use which was corrected. 5/6 patients with off-label use underwent GDR to discontinuation of medication without any significant behavioral change during the 4-6 weeks of monitoring. Scheduled lab/EKG monitoring was in place for 8/17 (47%) of the residents pre-intervention and improved to 100% post intervention. Conclusion: Our intervention led to a significant reduction in the proportion of residents in nursing homes taking antipsychotics. Total antipsychotic use was reduced from 23% to 13% beyond the state and national level, which also exceeded the CMS target of 15% reduction. We were successful in eliminating off-label use in patients with dementia without any adverse effects. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
Reducing Medication Use in a Skilled Nursing Facility - A Quality Improvement Project Presenting Author: Claudia Nassaralla, MD, PhD, MS, Duke University