1. Reducing inappropriate prescribing of antipsychotics for residents with dementia Making it Happen Mountains Nursing Home Brecon and The Rhallt Care Home, Welshpool 26 th March 2013, Llandudno

2. Mountains Care Home 2

3. Some facts  EMI Nursing Home, Libanus, Brecon  Since 2004, part of Milkwood Care Limited  Number of beds: 47  Manager: Stephanie Myles  Deputy manager: Jane Saunders 3

4. Count us in! 4

5. Staffing levels  RGNs: 7  RMNs: 3 (including manager and deputy manager)  Health Care Assistants: 38  Activities officer: 1 (with extra support)  Kitchen staff, Domestic staff and handyman 5

6. 1000 Lives+ Pilot Project  Initiated August 2011  Multidisciplinary team: Mountains Care Home GP – Brecon Medical Practice OPCMHT – Consultants Powys tHB – Medicines Management Pharmacist 6

7. Aim of the Pilot Scheme  Reduce unnecessary drug treatment  Develop a multidisciplinary team approach  Support carers in alternative approaches to managing challenging behaviour  Improve communication and transfer of information between healthcare settings 7

8. Recognised strengths  Enthusiasm and commitment of all those involved. Weekly visits from same GP.  Already started reductions. Open to new ideas  Good working environment – staff feel valued, low staff turn-over rate  Good in-house staff training  Active activities officer working within the care home  Good interaction and communication with families

9. Issues identified  Discharge from hospital wards to care homes: information delay, poor quality info, and level of antipsychotic prescribing  Lack of regular and formal engagement with CMHT  Three monthly review: responsibility - CMHT/GP role?  Education: GP & Care home staff (perceptions and attitude)  In-house staff communication  Need for non-pharmacological treatments/holistic care approach/person-centred activities  Need for multi-agency approach and improved communication

10. Improvement methods/ Interventions  Staff awareness raising and training sessions  Improved in-house communication  Introduction of new care home tool: Antipsychotic Monitoring pack for individual residents; including behavioural monitoring chart  Patient/carer leaflet introduced  Defined review procedures and responsibilities  Guidelines and Education for GPs  Staff information posters – care homes, hospital wards, CMHTs, GP practices

11. Improvement methods/ Interventions (cont)  Improved formalised links between OPCMHT and hospital wards. Improved communication Secondary care antipsychotic initiation and review form introduced Secondary Care Discharge Summary template for EMI ward Care home HCA visits to wards and Pre-assessment process additions. 11

12. Data collection and Outcome measures  Data collected every 3/12 Number of patients who have a diagnosis of dementia %age patients who are receiving an antipsychotic % residents reviewed in past 3 months % of patients with dementia who have been receiving antipsychotic medication for more than 9 months

13. Process  Regular meetings with care homes to assess outcome of interventions (PDSA cycles)  On-going dialogue with lead GP and lead Consultant  Baseline audit and 4 further audits  Spreading the initiative in to other Powys care homes  Sharing experiences with other care homes, nationally

14. 14 Baseline Audit 1—August 2011 30 residents with a primary diagnosis of dementia 16 prescribed an antipsychotic 40% reviewed in last 3 months 85% taking antipsychotic medication for more than 9 months

15. 15 Audit 2—November 2011 Intervention Outcomes 7 residents: medication stopped 1 resident: dose reduced 1 resident: dose maintained 70% reviewed in past 3 months 75% taking antipsychotics for over 9 months

16. 16 Audit 3—February 2012 4 residents: dose reduced 50% reviewed in past 3 months 62.5% taking antipsychotics for over 9 months

17. 17 Audit 4—May 2012 Intervention Outcomes 2 residents: medication stopped 4 residents: dose reduced 1 resident: dose maintained 77% reviewed in past 3 months 55% taking antipsychotics for over 9 months

18. 18 Data after initial audit demonstrates 70% reduction in patients on antipsychotics 100% reviewed in last 3 months 50% receiving antipsychotic medication for more than 9 months Overall Outcomes

19. 19 Residents less sedated and more active Residents better able to interact, communicate and participate in activities Staff more confident to deal with challenging behaviour through person-centred care and non-pharmacological approaches Increased job satisfaction for staff Improved Quality of Life

20. Sharing the learning: The Rhallt Care Home

21. Spread: Rolling out the improvement methods/ interventions  The Rhallt Care Home, Welshpool  Manager: Nick Oulton  Deputy manager: Pauline O’Connor  Part of Barchester Healthcare  Nursing Home, max 91 residents  40-bed Memory Lane Unit  Head of Care: Cristina Poama

22. Staffing levels on Unit  RGNs: 2 (including Head of Care)  RMNs: 4  Health Care Assistants:18  Activities Coordinators: 3, peripatetic throughout the Home)  Kitchen and domestic staff

23. 1000 Lives + Follow up project: June 2012  Multidisciplinary team: Memory Lane Unit staff GP – Welshpool Medical Practice OPCMHT – Consultant and CPN Powys tHB – Practice pharmacy technician North Powys Psychologist

24. Strengths and Weaknesses: Improvement methods and interventions  Similar situation to Mountains Added Strengths:  Explanatory letter sent to all families  Environmental changes made  Additional Nurse training in use of medicines  Psychology input Additional staff training Regular meetings and discussions with psychologist around individual patient care Added weakness  Lack of dedicated activities officer for the Unit

25. 25 Baseline Audit 1—August 2012 40 residents living on Memory Lane Unit; majority with a primary diagnosis of dementia 9 residents on MLU prescribed an antipsychotic for dementia 0% reviewed in last 3 months 100% taking antipsychotic medication for more than 9 months

26. 26 Audit 2—December 2012 Intervention Outcomes 3 residents: medication stopped 1 resident: medication stopped and then restarted 1 resident: dose reduced 4 residents: dose maintained 78% reviewed in past 3 months 100% taking antipsychotics for over 9 months

27. 27 Audit 3—March 2013 Further 2 residents: medication reduced (by consultant) Further 1 resident medication stopped (by GP) 100% reviewed in past 3 months 100% taking antipsychotics for over 9 months

28.  Thank you for listening!  Do you have any questions or comments?  Do you have anything you would like to share? 28