ANTIPSYCHOTICS & BEYOND:WHAT YOU NEED TO KNOW

Originally Presented February 26, 2013

Updated June 19, 2013

Ellen J. Mullins RN Research and Development Director, The Compliance Store

Antipsychotic Drugs and the Regulatory System

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Survey and Certification Letters

• S&C Letter 13-34 Videos• S&C Letter 13-35 Clarifications• Manual Instruction• Advanced Copy• Effective Date

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No Regulation Changes

• Interpretive Guidance>Guidance to Surveyors> Interpretation

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Dementia Care Principles

• Person Centered Care• Quality and Quantity of Staff• Evaluation of New and Worsening Symptoms• Individualized Approaches to Care• Critical Thinking re: Antipsychotic Drug Use• Interviews with Prescribers• Engagement of Resident and Family in Decision

Making

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Surveyor Focus

• “Process of Care”> Interviews>Observations> Record Reviews

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Sample Selection

• Appendix P• QM > 75th percentile

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Be Prepared!

• List of residents with dementia and orders for antipsychotic medications past 30 days• Articulate how individualized care is provided to

residents with dementia• Policy for use of antipsychotic medications in

residents with dementia

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F-309 – Quality of Care

• Addresses care areas not specifically covered by other F-tags in this regulatory grouping• No investigative protocol• Checklist: “Review of Care and Services for a Resident

with Dementia”

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F-329 – Unnecessary Drugs

• Four new medications added to the list of antipsychotic medications:> Saphris> Fanapt> Latuda> Invega

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Antipsychotic Medication

• Indications for Use:> Schizophrenia> Schizo-affective disorder> Schizophreniform disorder> Delusional disorder>Mood disorders> Psychosis in the absence of dementia>Mental Illnesses with psychotic symptoms> Tourette’s disorder> Huntington disease> Hiccups >Nausea and vomiting

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BPSD

• Behavioral or Psychological Symptoms of Dementia

> “Antipsychotic medications may be considered for elderly residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes have been identified and addressed. Antipsychotic medications must be prescribed at the lowest possible dose for the shortest period of time and are subject to gradual dose reduction and re-review.”

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Inadequate Indications

• Wandering• Poor self-care• Restlessness• Impaired memory• Mild anxiety• Insomnia• Inattention/indifference to surroundings• Sadness or crying unrelated to depression or psychiatric disorders• Fidgeting• Nervousness• Uncooperativeness

> Criteria for Antipsychotic Drug Use:• Behavior is a danger to resident or others AND• Symptoms are due to mania or psychosis OR• Interventions attempted and included in the care plan

(except in an emergency)

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Emergency Use of Antipsychotic Medications

• Criteria in the prior slide must be met IN ADDITION TO ALL OF THE FOLLOWING…

1. Acute treatment period is 7 days or less2. Clinician evaluation and documentation within 7 days

• Underlying causes• Contributing factors• Verification of the need to continue the antipsychotic medication

3. Persistent behaviors• Nonpharmacological interventions

– Attempted – unless contraindicated– Documented

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Enduring Conditions

• Clearly identify and document the target behavior• Monitoring must include:

> Assuring the cause is not a medical condition or medication

> Environmental stressors> Psychological stressors> Persistence that negatively affects quality of life

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New Admissions

• Attempt to identify an indication for use• PASRR• Physician’s orders• Within 2 weeks, re-evaluate the use of the medication

to consider reduction or discontinuation

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Adverse Consequences

“The facility MUST act upon this!”

• The facility AND prescriber MUST document the rationale for the decision and the inclusion of the resident or family in the decision.

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Documentation

• Diagnosis• Expected outcome• Monitoring of resident response

> Risk / benefit> Adverse consequences

• Re-evaluation of behavioral symptoms> Continued effectiveness> Potential reduction

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Prioritize Dose Reduction Efforts

• Avoid initiating antipsychotic drugs for residents not currently taking them• Re-evaluate residents recently prescribed

antipsychotic drugs for the first time• Carefully assess all residents admitted with

antipsychotic drugs for reason/benefit/side effects and reduction/elimination• Residents with long term antipsychotic use should be

carefully evaluated for dose reduction or elimination of antipsychotic drug use

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F-329 – 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;

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

Cheryl Swann RN-BC, BSN, WCC, LNHAVice President of Content,Relias Learning

How Do We Reduce Our Reliance on Antipsychotics?

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Getting Started on Reducing Antipsychotics

• Form a committee – an interdisciplinary team (IDT) to: > Review residents’ diagnoses and medications>Dementia diagnosis priority> Reason for medication> Last dose reduction> Review behavior tracking log

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Trends the IDT Will Find

• A large number of behaviors in residents with dementia occur during personal care > Bathing>Dressing

• Is this behavior inappropriate?

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A Look at the Behavior Tracking Log

• Analyze the behavior tracking logs to determine if there is a particular trigger for the resident’s behaviors> Shift> Staffing

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Meaning Behind the Behavior

• All behavior has meaning• Shift from “How do I stop behaviors?” to “What are

these behaviors trying to tell me?”• Rule out medical causes

> Pain, constipation, infection, delirium> Look at current medications

• Talk to the family• Know the resident

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Behavioral Triggers

• Three types of triggers:> Internal> Environmental> Caregiver

• Must evaluate behavioral triggers to determine the most appropriate behavioral intervention

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Behavioral Interventions

• Internal triggers> Eliminate physical factors, such as pain, hunger, or

elimination needs > Provide stimulating, interactive exercise or activities > Provide one-to-one care> Redirection

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Behavioral Interventions

• Environmental triggers> Reduce or remove environmental stimuli> Reduce/eliminate overhead paging> Alarms> TV/Radios> Play music/headphones

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Behavioral Interventions

• Caregiver triggers> Consistent assignments>Does the staff working with the resident know them?

• What is in the care plan?• What do they like/dislike?• How do they typically communicate needs/react in certain

situations?>How is information communicated?

• Allow to make simple decisions and choices

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Behavioral Interventions

• Understand or explain the rationale for interventions/approaches• Monitor the effectiveness of those

interventions/approaches• Provide ongoing assessment as to whether they are

improving or stabilizing the resident’s status or causing adverse consequences

Documentation and Proof

• New Survey Process> Compliance with care plan> Staff knowledgeable of behaviors

• What did you do to try and figure out the cause of the behavior?• What was the resident communicating with his/her behavior?• What was the reason for the resident acting out?• What interventions did you try to reduce the behavior?

Care Process for a Resident with Dementia

• Recognition and assessment• Cause identification and diagnosis• Development of care plan• Individualized approaches and treatment• Monitoring, follow-up and oversight• Quality assessment and assurance (QAA)

Recognition and Assessment

• Past life experiences• Cognitive status• Presence of pain, medical conditions, medications• Preferences for daily routines, food, music, exercise• How do they communicate physical needs?• Description of behaviors (specific)

Cause Identification and Diagnosis

• Meaning behind behavior• Medical/psychiatric conditions• Medications• Look at root cause

> Boredom> Changes in routine> Unmet needs> Environmental

Develop Care Plan

• Well-defined problem-statement/outline goals of care• Identify staff responsibilities to implement approaches• Goals to monitor the effectiveness• Collaboration with resident and family

Monitoring and Follow Up

• Staff monitors and documents the effectiveness of interventions to target behaviors• Interventions changed as needed• Collaborate with physician regarding medications

Quality Assessment and Assurance

• Resident care policies reflect the facility’s approach to care of residents with dementia• How the facility ensures that appropriate interventions are

used• Sufficient staffing• Data to monitor pharmacological and non-pharmacological

interventions• Facility’s response to concerns identified during pharmacy

review

Quality Assessment and Assurance

• Staff training> Understanding the Meaning Behind Behaviors – Actions and Reactions> Psychotropic Medications – Antipsychotics and Beyond

Theresa Schmidt MA, RAC-CTManager of Education, eHealth Data Solutions

Measurement of Psychoactive Medications and Continuous Quality Improvement

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Goals

• Understand how CMS measures antipsychotic medications in CASPER and Nursing Home Compare• Identify which residents trigger these measures

and why• Compare your performance to benchmarks• Assess effectiveness of interventions and progress

over time through trend and SPC charts

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Antipsychotic Quality Measures

SHORT-STAY MEASURE• Percent Short-Stay Residents

Who Newly Received Antipsychotic N0410A=[1,2,3,4,5,6,7] • Target MDS must be different

from initial MDS• Exclusions: > Antipsychotic use on initial MDS> Schizophrenia, Tourette’s,

Huntington’s

LONG-STAY MEASURE• Percent Long-Stay Residents

Who Received AntipsychoticN0410A=[1,2,3,4,5,6,7] • Exclusions: > Schizophrenia, Tourette’s,

Tourette’s on prior assessment, Huntington’s

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Long-Stay vs. Short-Stay

• Select all residents whose latest episode either ends during the target period or is ongoing at the end of the target period • This latest episode is selected for QM calculation• For each episode that is selected, compute the

cumulative days in the facility (CDIF) > If the CDIF is less than or equal to 100 days, the resident is

included in the short-stay sample > If the CDIF is greater than or equal to 101 days, the

resident is included in the long-stay sample

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Nursing Home Compare Measures

• Available to the public at http://medicare.gov/nursinghomecompare • Long-stay and short-stay

antipsychotic medication measures were added in summer, 2012

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CASPER – Certification And Survey Provider Enhanced Reports

• Quality measure reports are available to state surveyors and facility staff through CMS’ CASPER reporting system• Psychoactive measures were updated this spring to match

Nursing Home Compare Measures• Prior to the updates, only a Long Stay Psychoactive

measure was present, and more conditions were excluded• If you compare your Long Stay measure from a CASPER

report generated in February to one today, both your facility and benchmark rates will likely be higher today

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CASPER Reports vs. Nursing Home Compare

Nursing Home Compare CASPER

Time Run once a quarter Updated frequently

Report Periods Uses most recent 3 months for LS and most recent 6 months for SS

Customized by user

Average Across Quarters Average across several calendar quarters

For only one single report period

Risk Adjusted (related to timing) Calculations performed at different times based on national average

Calculations performed at different times based on national average

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Translating QMs to QI

• Static Displays of Data> BENCHMARK: Compares your data for a particular interval of

time against national or state norm or against your historical data

> PERCENTILE RANKING: (1-100) the percent of other facilities that are better than your facility

• Dynamic Displays of Data> TREND CHARTS: Displays your performance over time> STATISTICAL PROCESS CONTROL CHARTS: Your performance

over time plus control limits that indicate how predictable your process is and expose significant events

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Statistical Process Control Charts (SPC)

• Is variation due to “common cause” or “special cause”?• Need 12-15 periods of data• Review monthly for QI committee. Look for:

> 5-7 points in a row increasing or decreasing> 5-7 points in a row climbing higher or lower than your mean> A data point (or points) outside your control limits> Benchmark outside your control limits

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Trend Charts in Excel

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Six Steps to Process Improvement

1. Ensure data are complete and accurate2. Identify opportunities for improvement3. Look for root cause of the current state (and

determine if the process is stable)4. Set measurable goals5. Develop an action plan6. Follow-up to evaluate the effectiveness of your

action plan

QUESTIONS?

THANK YOU

Contact Us!

• Ellen J. Mullins RN, Research and Development Director, The Compliance Store> www.thecompliancestore.com> Ellen.Mullins@pmcoteam.com> (334) 394-2310 ext. 2503

• Cheryl Swann RN-BC, BSN, WCC, LNHA, VP of Content, Relias Learning> www. reliaslearning.com> cswann@reliaslearning.com> (866) 763-4500 ext. 2004

• Theresa Schmidt MA, RAC-CT, Manager of Education, eHealth Data Solutions> www.ehds.biz> tschmidt@ehds.biz> (740) 814-0417

Full Quality Measure Calculations

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NH Compare Calculation: Short-Stay

Percent of Short-Stay Residents Who Newly Received Antipsychotic Medication NUMERATOR • Short-stay residents for whom one or more

assessments in a lookback scan (not including the initial assessment) indicates that antipsychotic medication was received:

• For assessments with target dates on or before 03/31/2012: N0400A = [1].

• For assessments with target dates on or after 04/01/2012: N0410A = [1,2,3,4,5,6,7].

DENOMINATOR • All short-stay residents who do not have

exclusions and who meet all of the following conditions: > The resident has a target assessment, and > The resident has an initial assessment, and > The target assessment is not the same as the

initial assessment.

EXCLUSIONS 1. The following is true for all assessments in the

lookback scan (excluding the initial assessment): 1.1 For assessments with target dates on or before

03/31/2012: N0400A = [-]. 1.2 For assessments with target dates on or after

04/01/2012: N0410A = [-].

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

3. The resident’s initial assessment indicates antipsychotic medication use or antipsychotic medication use is unknown: 3.1 For initial assessments with target dates on or before

03/31/2012: N0400A = [1,-]. 3.2 For initial assessments with target dates on or after

04/01/2012: N0410A = [1,2,3,4,5,6,7,-].

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CASPER and NH Compare Calculation: Long-Stay

Percent of Long-Stay Residents Who Received Antipsychotic Medication NUMERATOR • Long-stay residents with a selected target

assessment where the following condition is true: antipsychotic medications received. This condition is defined as follows:

• For assessments with target dates on or before 03/31/2012: N0400A = [1].

• For assessments with target dates on or after 04/01/2012: N0410A = [1,2,3,4,5,6,7].

DENOMINATOR • All long-stay residents with a selected

target assessment, except those with exclusions.

EXCLUSIONS 1. The resident did not qualify for the

numerator and any of the following is true: 1.1. For assessments with target dates on or

before 03/31/2012: N0400A = [-]. 1.2. For assessments with target dates on or

after 04/01/2012: N0410A = [-].

2. Any of the following related 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]).