By Andrew Yeung, Pharm.D.
June 09, 2015

Antipsychotics and Dementia Focused Surveys 12 Wasy To Prepare

Antipsychotics and Dementia Focused Surveys: 12 Ways to Prepare

Caralyn Davis, Staff Writer

by Caralyn Davis, Staff Writer | Jun 09, 2015

The national rollout of the Focused Dementia Care Survey has begun. As expected, the implementation of these standalone surveys began in Texas, but additional states are expected to jump on the bandwagon during the current fiscal year (i.e., prior to Oct. 1, 2015), according to survey-and-certification memo 15-31-NH.

Further, although CMS hasn’t announced this nationally, the Texas rollout could indicate that much more widespread use of the Focused Dementia Care Survey is pending. In a May 13 Provider Bulletin, the Texas Department of Aging and Disability Services noted that, in the next fiscal year, it will incorporate these focused survey methods into the ongoing annual survey process.

In conjunction with the MDS 3.0 Focused Survey and the National Partnership to Improve Dementia Care in Nursing Homes, this means that there is a sharper focus than ever on the use of antipsychotic medications. Almost two years ago, Metron Integrated Health in Grand Rapids, Mich., began looking at how its interdisciplinary teams (IDTs) identified and managed patients who are on antipsychotics.

“We owned our problem and used QAPI [quality assurance and performance improvement] to implement systemic change. We formulated a process, which we’ve continued to evolve, based on the question, ‘Is it really necessary for the resident to have that drug?’” says Amy Franklin, RN, RAC-MT, AHIMA ICD-10 trainer and corporate compliance director of reimbursement. “We focused on behavior programs, and we got everyone involved: the nurse aides and nurses on the floor, the unit managers, the directors of nursing, the social workers, and the MDS nurses, along with behavioral health professionals.”

As a result, Metron is 55 percent under the national average, corporation-wide,  on antipsychotic drug use for both the long-stay and short-stay quality measures (QMs) — and well on its way toward being prepared for a Focused Dementia Care Survey. This work also has reaped additional benefits. “We’ve seen fewer employee incident reports of injury, fewer resident-to-resident problems, and less catastrophic staff burnout,” says Franklin. “Those problems haven’t disappeared, but we’ve been on a downward trend since implementing the program.”

Here are some lessons learned at Metron:

Review the psychotropic drug policy

“Providers should ask themselves, ‘Is our psychotropic drug policy and procedure current, and when was the last time the IDT reviewed it?” suggests Franklin. “During a Focused Dementia Care Survey, surveyors will ask, ‘What is your process?’ Team members need to be able to show that they know the facility’s policy and procedure, and that they put it into practice with residents. At a minimum, that requires reviewing the policy and procedure, as well as providing education to the team where there are process gaps.”

Establish a ‘police officer’

“When we first looked at our process, we found that we were meeting the basic regulatory requirements for antipsychotic drugs use. For example, we didn’t have any problems getting an acknowledgement form about potential adverse reactions signed timely by the family and the physician,” says Franklin. “However, we didn’t have a police officer per se focusing attention on the fact that antipsychotics — like anticoagulants — are dangerous drugs, and building on that sense of urgency with the IDT.”

At Metron, social workers took on that role, notes Franklin. “They’ve learned how the QMs work, and they immediately target new residents who come in on an antipsychotic, ensuring they have a psychiatric evaluation and asking the IDT: (A) Is this drug appropriate? and (B) Why is it appropriate? If it’s not appropriate, we have to get rid of the drug, as well as look at why we received the patient. For example, is there something that we didn’t know about the patient upon admission that we should have?”

Keep nurse managers in the loop

While social work ensures that all of the components are in place, the DONs, MDS nurses, and unit managers also play key roles in the process, says Franklin. “They are responsible for the clinical assessment and evaluation, as well as following up on tasks that are required for drugs of this nature, such as getting staff to prioritize labs.”

In addition, all nurse managers work to fill knowledge deficits on the floor, says Franklin. “If an MDS nurse, DON, or unit manager has to look up a medication to learn its classification, then you can guarantee that the floor nurses don't know what the drug is either. Nurse managers must be willing to check their ego, go out on the floor, and say,’ I just read about this drug. Did you know it was an antipsychotic?’ They have to share what they’ve learned and alert the rest of the team to the potential pitfalls of that particular drug for high-risk elderly patients, as well as the assessment and monitoring that will be required.”

Discuss antipsychotics daily

“Whether a facility’s daily meeting is called a standup meeting, a morning meeting, or a department head meeting, antipsychotic medication use should be a major part of the conversation,” says Franklin. “Issues for discussion include, for example, antipsychotic medication dose changes and failed or failing dose reduction residents who need to go back on an antipsychotic. There should be changes within the care planning process, as well as with the Level II PASRR [preadmission screening and resident review] screenings, that merit discussion.”

In addition, these daily meetings should identify new admissions who are on an antipsychotic, says Franklin. “This should not only trigger a discussion of whether that drug is appropriate for the patient, but also assess, if it is appropriate, does the patient have an appropriate diagnosis as well?”

Hold a weekly behavior meeting

At Metron, the entire IDT must participate in a weekly behavior meeting for all patients on antipsychotics, says Franklin. “The first few meetings took a long time to get through. They lasted about four hours. Now they are down to between 30 and 45 minutes.”

This meeting ensures that the IDT is “doing the due diligence of documenting on the patient, assessing the ongoing treatment plan, and determining whether the medication should be continued,” she says. “The hardest part is doing the prep work for the meeting. For example, you have to read the nurses notes, and you have to interview the nurse aides if they can't come to the meeting. So facilities have to decide who will interview the nurse aides: the MDS nurse, the unit manager, or the social worker?”

Since nurse aides document daily and per shift, interviewing them may seem repetitive. “However, a five- or 10-minute interview using a questionnaire enables you to obtain significantly more information,” says Franklin. “We ask five clear, concise questions taken from of Section E of the MDS, and the interviewer isn’t allowed to change the questions.”

Rolling the nurse aides into the QAPI process was critical to this step. “We learned how they needed questions to be asked,” she explains. “For example, we initially asked them, ‘Has the patient had any untoward behaviors?’ But we found out they didn’t understand what ‘untoward’ means, and really why should they? QAPI helped us get down to the nit and the grit, focusing the questionnaire on simple behaviors, such as: Did you get hit, slapped, kicked, or bitten? Is the resident cursing? Is the resident seeing things that aren’t there?”

Don’t threaten the IDT over documentation

“Due to the regulatory component, historically the go-to management style in some facilities has been to threaten nurse aides, ‘If you don’t document behaviors, we’re going to take away the antipsychotic medication,’” says Franklin.

“However, that approach makes it punitive,” she notes. “The goal is to get the aides more involved in the team. The nurse aides need to be empowered — to feel safe — to come up to management and say, ‘The patient is resistant to showering. I’m not showering him until you help figure out how I can get him into the shower room and get him clean.’ Or ‘Every time I lay her down to do peri-care, the patient becomes rigid.’ Having that type of conversation is huge when you’re trying to reduce antipsychotic medication use, and it requires working with the staff members as equals.”

Teach staff about medication impact

“While we found that some antipsychotic drug use was related to pain, some of it was related to patients and nurse aides not being able to communicate,” says Franklin. “So we started sensitizing staff to the fact that these drugs make anyone who takes them numb. The patients are slow to respond because the drugs lower their ability to either verbalize outwardly or communicate effectively with their body other than by striking out. Teaching the direct patient care team — the nurse aides and the floor nurses — basic information about how antipsychotic drugs affect patients, as well as the potential dangers of these drugs, empowers the staff.”

Consider a required clinical review of orders

To avoid institutional inertia, providers have to be willing to develop new strategies. For example, Metron recently implemented a required clinical review for all high-risk psychotropic medications, including antipsychotics and antidepressants, says Franklin. “This means that a unit manager, DON, or MDS nurse must verify the medication order, including dosage changes, prior to it even being sent to the pharmacy. Our software allows us to automatically send a psychotropic drug for clinical review when the order is typed into our electronic health record.”

The responsible nurse then has to determine whether the drug is appropriate or whether the IDT needs to have a conversation with the ordering physician. “The nurse does the due diligence, looking at: Is this considered a restraint? Is it required for the patient’s health condition? Is the diagnosis appropriate?” she explains. “The goal isn’t to question the physician. The goal is to question, ‘Is this drug appropriate for our resident?’ Our medical director has helped create physician buy-in.”

To smooth implementation, Metron created a group e-mail for facility DONs to discuss potential issues, such as how to handle weekend admissions, notes Franklin.

Prioritize Level II PASRR

“Referrals for Level II PASRR screenings can quickly become outdated when facilities are changing or starting antipsychotic medications,” says Franklin. Here’s an example of a common scenario: A facility admits a patient with Huntington’s disease who is on olanzapine (Zyprexa). The facility submits a notification/referral for Level II PASRR screening using this information, and the state determines specialized services are needed. Observing the patient, the IDT notes that the patient is suffering and works with the physician to switch the patient to haloperidol (Haldol).

“You now have an inaccurate PASRR,” she points out. “You need to update the Level II referral form used by your state and notify your state’s PASRR team so that they can decide whether they want to come in and redo the Level II PASRR. In addition, you need to be sure that you get a note back from the state if they decide, ‘No, we’re OK without a new Level II evaluation,’ so that you have that for the medical record.”

Note: The RAI Manual on pages 2-26 – 2-27 discusses how to determine whether a Level II PASRR screening referral is needed in conjunction with a significant change in the resident’s status. The instructions note that referral is indicated for a patient previously identified as Level II when his or her “condition or treatment is or will be significantly different than described in the resident’s most recent PASRR Level II evaluation and determination. (Note that a referral for a possible new Level II PASRR evaluation is required whenever such a disparity is discovered, whether or not associated with a SCSA [significant change in status assessment].)”

“Surveyors will look at PASRR compliance as part of the citation process just like they look at the facility’s policy and procedure for attempting and managing dose reductions and the resident’s plan of care,” says Franklin. “You have to have all of these bones in place to ensure that it’s safe for that patient to receive an antipsychotic medication.”

Build social work’s relationship with state PASRR

“There needs to be rapport between the facility’s social work staff and the state’s Level II PASRR team,” says Franklin. “Having that solid relationship is crucial — particularly in buildings whose antipsychotic medication QMs are flagging high — because those are the people who help push through your recommendations when getting patients off of these drugs.”

Resolve common short-stay vs. long-stay issues

With short-stay residents, sometimes IDTs fail to find out why a patient is on an antipsychotic medication, points out Franklin. “If asked, the IDT might explain, for example, ‘We talked to the physician, and the patient’s been on the antipsychotic medication for a long time. The patient was only here for 14 days for a knee replacement. Since she was returning home, we didn’t address it. We decided to allow community health to manage the medication.’”

The problem with this scenario is, often there’s no evidence in the medical record of either a supporting diagnosis or the reason why the IDT didn’t approach the use of the drug, says Franklin. “Without documentation of a supporting diagnosis, the patient will show up in the short-stay QM, and without a note explaining the team’s assessment and decision-making, a surveyor might question why the patient wasn’t appropriate for gradual dose reduction.”

A common issue with long-stay residents is trying gradual dose reduction once and only once, says Franklin. “For example, the IDT attempted a gradual dose reduction for a patient, Frank, three years ago, and he became very violent. Since then, Frank has been on the same dose of the same medication. Everyone remembers the violence, but no one thinks about the fact that as Frank has aged, his body chemistry has changed. Consequently, he still warrants that review to see if he’s appropriate for reduction.”

Use the MDS as a cross-check

If assessors are coding Section N (medications) and Section I (active diagnoses) of the MDS 3.0 per the RAI Manual, the next step is to use the MDS coding as a consistency edit to double-check that no patient has slipped through the cracks, suggests Franklin. “If N04010A (antipsychotic) is coded as ‘1’ or greater — meaning the resident received an antipsychotic at least one day during the seven-day look-back period — then Section I should be reviewed to ensure that there is a diagnosis to support the use of the drug,” she explains.

“If there’s not, has the IDT assessed whether the patient needs to get off of the drug? Is there documentation within the medical record of why it’s reasonable for this patient to be on this medication?” she asks. “The MDS coordinator should alert the IDT to any inconsistencies between Section N and Section I. Using an audit tool is an easy way to do that.” (For details on the exact role that diagnoses play in the QMs, see the Quality Measures User’s Manualhere.)

Author Description

Andrew Yeung, Pharm.D.

Andrew is a Lead Consultant Pharmacist at SCRx. He has experience at Sharp as a Systems Consultant Pharmacist and was Director of Pharmacy at Palomar Pomerado, Pomerado, Charter and Vista Hill Hospital. Andrew has Doctor of Pharmacy and a Fellowship in Geriatric Pharmacy from USC. He also has a Fellowship in Consultant Pharmacist from ASCP.

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