1. Steps to Success Eliminating Off-Label Use of Antipsychotics Regulatory Aspects F309- Review of Care and Services for a Resident with Dementia F329 – Unnecessary Meds Margie Huguet, RN, MCS DHH Health Standards Section Long Term Care Supervisor

2. Objectives: 1. Discuss the requirements for appropriate use of antipsychotics in dementia only residents (F309 – Quality of Care & F329 – Unnecessary Meds).

3. CMS S&C: 13-35-NH Interpretive Guideline Revisions F309 Quality of Care Review of Care and Services for a Resident with Dementia F309- Review of Care and Services for a Resident with Dementia

4. F309 – Quality of Care Care and Services for a Resident with Dementia  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. Refer to handout for F309 F309- Review of Care and Services for a Resident with Dementia

5. Person-Centered Care  Care that is individualized by being tailored to all relevant considerations for that individual…  …tailored to an individual’s  risk factors,  current conditions,  past history, and  details of present symptoms. F309- Review of Care and Services for a Resident with Dementia

6. Behavioral Interventions  individualized approaches (including direct care and activities)  provided as part of a supportive physical and psychosocial environment  directed toward understanding, preventing, relieving,  accommodating a resident’s distress or loss of abilities. F309- Review of Care and Services for a Resident with Dementia

7. Behavioral or Psychological Symptoms of Dementia (BPSD)  Behavior or other symptoms in individuals with dementia that cannot be attributed to a specific medical or psychiatric cause.  Specific Guidance for Antipsychotic Use and residents with BPSD. 7 F309- Review of Care and Services for a Resident with Dementia

8. Dementia & Behavioral Health  A person’s attempt toCOMMUNICATE  an unmet need,  discomfort or  thoughts they can no longer articulate. 8 F309- Review of Care and Services for a Resident with Dementia

9. Care Process for a Resident with Dementia 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 F309- Review of Care and Services for a Resident with Dementia

10. A. Recognition and Assessment  Collecting detailed information  Past life experiences  Description of behaviors  Preferences  Oral health  Presence of pain  Medical conditions  Cognitive status  Medications 10 F309- Review of Care and Services for a Resident with Dementia

11. Knowing the Whole Person  How communicates physical needs such as  pain,  discomfort,  hunger or thirst, as well as  emotional and psychological needs such as frustration or boredom; or a desire to do or express something that he/she cannot articulate;  Usual and current cognitive patterns, mood and behavior, and whether these present a risk to the resident or others;  How displays personal distress such as anxiety or fatigue. 11 F309- Review of Care and Services for a Resident with Dementia

12. Knowing the Whole Behavior Conducting a Behavior Assessment  Specific description of behavior  Potential underlying cause  Duration  Intensity  Precipitating events  Environmental triggers, etc…  Related factors such as appearance & alertness 12 F309- Review of Care and Services for a Resident with Dementia

13. B. Cause Identification and Diagnosis  Use the information collected to identify potential causes  Looking to see if a REVERSIBLE CAUSE  Physical  Functional  Psychosocial  Environmental  Interactions with others  Etc… 13 F309- Review of Care and Services for a Resident with Dementia

14. Steps to Eliminate Off-Label Antipsychotic Use Step 6 QI Closest to the Resident Track and Trend and Care Plan Refer to Handout for Process ©B&F Consulting 2015 www.BandFConsultingInc.com

16. 16 ©B&F Consulting 2015 www.BandFConsultingInc.com

17. 17 Track and Trend ©B&F Consulting 2015 www.BandFConsultingInc.com

18. Step 2 – C. Development of Care Plan The care plan should reflect  Baseline and ongoing details of common behavioral expressions and expected response to interventions;  Specific goals for and monitoring of all interventions for effectiveness in responding to target behaviors/expressions of distress; F309- Review of Care and Services for a Resident with Dementia

19. C. Development of Care Plan For any medications  indication/rationale for use,  specific target behaviors and expected outcomes,  dosage, duration,  monitoring for efficacy and/or adverse consequences and  plans for GDR if an antipsychotic medication is used. F309- Review of Care and Services for a Resident with Dementia

20. Changing the Culture of Care Planning TRADITIONALPERSON CENTERED Staff know you by ‘diagnosis’ Staff have personal relationship with resident & family Staff write the care plan based on what they think is best for your diagnosis Resident, family, and staff develop a care plan that reflects what the resident desires for him/herself Interventions are based on standards of practice per diagnosis. Unique interventions which meet the need of that resident. Care Plan is written in the third person. Care plan is written in the first person “I” format.

21. Changing the Culture of Care Planning TRADITIONALPERSON CENTERED Care plan attempts to fit the resident into the facility routine. Care plan identifies the resident’s lifelong routine and how to continue in the nursing home. Nursing Assistants are not part of ID Team. Nursing Assistants are a very valuable part of IDT and present at each care plan conference. The Care Plan is scheduled to fit facility convenience. The Care conference is scheduled at resident and family convenience.

22. Traditional Care Plan “Innovations in Quality of Life – Pioneer Network” ProblemGoalInterventions Resident wanders due to Dementia. Resident will not wander into other resident rooms through the next care planning meeting.  Redirect resident to appropriate areas of facility.  Teach resident not to enter rooms with sashes across door.  Encourage resident to sit in lounge and other common areas.  Praise for cooperation.

23. Person Centered Care Plan “Innovations in Quality of Life – Pioneer Network” ProblemGoalInterventions I need to walk. I will continue to walk freely throughout my home.  After I eat breakfast and get dressed, I want to walk with staff.  I will accompany you anywhere.  I like to help while we are together.  I can fold linen and put things away with you.  I do not like to nap.  If weather permits, please walk outside with me.  I like to keep walking in the evening until I go to bed.  I sit when I am tired; don’t fuss over asking me to sit.

24. D. Individualized Approaches/Treatment Implementing Care Plan Staffing & Staff Training  Quantity of Staff & Quality of Staff  Familiarity with the residents (consistent staffing)  Staff competency in the skills and techniques  Staff Training in the care of individuals with dementia and related behaviors  Involvement of the Medical Team  Monitoring and follow-up to ensure effectiveness of care plan interventions  Revisions to care plan as needed. F309- Review of Care and Services for a Resident with Dementia

25. NON-PHARMACOLOGICAL APPROACHES TO REDUCING THE USE OF ANTIPSYCHOTICS Presented by Wanda Raby Spurlock, DNS, RN-BC, CNE, FNGNA Professor, Southern University and A&M College School of Nursing

26. Non-pharmacological approaches  Think about the PERSON  Think about the PROBLEM behavior  Select a type of intervention  PERSONALIZE the intervention 26 Revised by M. Smith (2005) from M. Smith & K.C. Buckwalter (1993), “Acting Up and Acting Out: Assessment and Management of Aggressive and Acting Out Behaviors,” The Geriatric Mental Health Training Series, for the Hartford Center of Geriatric Nursing Excellence, College of Nursing, University of Iowa.

27. Non-pharmacological approaches  Algorithm for Treating BPSD (handout) Interventions fall into 3 major categories: 1. Adjust care giver approaches 2. Change the environment 3. Use evidence-based interventions 27 Revised by M. Smith (2005) from M. Smith & K.C. Buckwalter (1993), “Acting Up and Acting Out: Assessment and Management of Aggressive and Acting Out Behaviors,” The Geriatric Mental Health Training Series, for the Hartford Center of Geriatric Nursing Excellence, College of Nursing, University of Iowa.

28. https://www.youtube.com/wa tch?v=vk4wcLK9nTc

29. CMS S&C: 13-35-NH Interpretive Guideline Revisions F329 – Unnecessary Medications Antipsychotic Medications F329- Unnecessary Medications Antipsychotic Medications

30. Is the antipsychotic medications being used as a: OR A SUBSTITUTE FOR A HOLISTIC APPROACH (F309)? F329- Unnecessary Medications Antipsychotic Medications

31. §483.25(l) Unnecessary Drugs - F329 Part 1. General (all classifications of meds)  Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:  (i) In excessive dose (including duplicate therapy); or  (ii) For excessive duration ; or  (iii) Without adequate monitoring ; or  (iv) Without adequate indications for its use; or  (v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or  (vi) Any combinations of the reasons above. F329- Unnecessary Medications Antipsychotic Medications

32. §483.25(l) Unnecessary Drugs - F329 “Part 2. 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 ; and  (ii) Residents who use antipsychotic drugs receive gradual dose reductions, and BEHAVIORAL INTERVENTIONS, unless clinically contraindicated, in an effort to discontinue these drugs. F329- Unnecessary Medications Antipsychotic Medications

33. F329- Unnecessary Medications Antipsychotic Medications

34. Psychosis in the Absence of Dementia  What was CMS thinking?  prevent diagnosis of psychosis NOS used to justify antipsychotic medication…  could psychosis be related to symptoms of dementia and non-pharmacolgical approaches if tried been effective…

35. B. Behavioral or Psychological Symptoms of Dementia  Antipsychotic medications:  are only appropriate for elderly residents in a small minority of circumstances  Carry a FDA Black Box Warning  ↑ risk of death in elderly patients treated for dementia-related psychosis 35 F329- Unnecessary Medications Antipsychotic Medications

36. BPSD - Indications for Use - Elderly residents with Dementia  Considered and Prescribed only after :  Medical, physical, functional, psychological, emotional, psychiatric, social and environmental causes have been identified and addressed.  Prescribed at:  the lowest possible dosage  for the shortest period of time  Subjected to:  gradual dose reduction and re-review F329- Unnecessary Medications Antipsychotic Medications

37. §483.25(l) Unnecessary Drugs - F329 BPSD - “Inadequate Indications for Use”  wandering  poor self-care  restlessness  impaired memory  mild anxiety  insomnia  inattention or indifference to surroundings  sadness or crying alone that is not related to depression or other psychiatric disorders  fidgeting  nervousness  uncooperativeness (e.g. refusal of or difficulty receiving care). Antipsychotic medications in persons with DEMENTIA should not be used if the only indication is one or more of the following: F329- Unnecessary Medications Antipsychotic Medications

38. BPSD - Indications for Use - Elderly residents with Dementia  The behavioral symptoms present a danger to the resident or others  AND one or both of the following: 1. The symptoms are identified as being due to mania or psychosis (such as: auditory, visual, or other hallucinations; delusions, paranoia or grandiosity);  OR 2. Behavioral interventions have been attempted and included in the plan of care, except in an emergency. 38 F329- Unnecessary Medications Antipsychotic Medications

39. BPSD - Indications for Use Elderly residents with Dementia  A diagnosis alone without substantiating information in the record is not necessarily justification for the use of a medication.  For example:  Adding a diagnosis of schizophrenia next to an order for an antipsychotic when there is no supporting documentation that substantiates the diagnosis, does not meet the regulatory requirement regarding indication for use. F329- Unnecessary Medications Antipsychotic Medications

40. BPSD Acute Situations/Emergency 1. The acute period is limited to 7 days or less;  AND 2. A clinician with IDT must evaluate/document situation within 7 days to identify /address contributing and underlying causes of the acute conditions and verify the continuing need 3. If behaviors persist, pertinent non-pharmacological interventions must be attempted, unless clinically contraindicated, and documented following the resolution of the acute psychiatric event.

41. BPSD Enduring Conditions  Antipsychotic medications may be used to treat an enduring (i.e., non-acute; chronic or prolonged) condition, if the clinical condition/diagnosis meets the criteria discussed earlier.  Target behaviors must be clearly and specifically identified and documented.

42. BPSD - Enduring Conditions Before initiating or increasing M onitor behavior symptoms to ensure the behavioral symptoms are n ot due to:  Medical condition or problem…; and  Environmental stressors alone…; and  Psychological stressors alone…; and  Persistent…

43. BPSD - New Admissions did  If resident newly admitted/readmitted on an antipsychotic medication and the resident did require a PASRR screen,  the facility is responsible for:  Preadmission screening, and  Obtaining physician’s orders for the resident’s immediate care This PASRR screening (F285) should provide pertinent information including appropriate clinical indications for the use of an antipsychotic.

44. BPSD - New Admissions did not  If resident newly admitted/readmitted on an antipsychotic medication and the resident did not require a PASRR screen,  the facility must re-evaluate the use of the antipsychotic medication at the time of admission and/or within 2 weeks of admission and  consider whether or not the medication can be reduced (tapered) or discontinued.

45. BPSD - Antipsychotic Dosage  Treatment should begin at the lowest possible dose to improve the target symptoms being monitored.  Start low – go slow…

46. Steps to Eliminate Off-Label Antipsychotic Use Step 5 Train Staff on Why and How to Reduce Antipsychotics ©B&F Consulting 2015 www.BandFConsultingInc.com

47. State Licensing Requirement

48.  The initial dementia- specific training required within 90 day of employment must have curriculum approval.  The annual dementia training does not require the department’s approval.

49. 49 F309- Review of Care and Services for a Resident with Dementia

50. 50 Joanne Rader F309- Review of Care and Services for a Resident with Dementia

51. https://www.youtube.com/watch?v=PUZFqERMeE8

52. 10 Steps to Eliminate Off-Label Antipsychotic Use 1. Establish A Leadership Team 2. Review CMS Survey Guidance to Understand Why and How 3. Analyze MDS CASPER Resident Level Quality Measure Report to Identify Target Population and Coding Errors 4. Triage: Review Why Each Resident is Receiving Antipsychotics and Take Care of Easy-to-Act-On Situations 5. Train Staff on Why and How to Reduce Antipsychotics 6. QI Closest to the Resident – Track and Trend and Care Plan 7. Engage Physicians, Prescribers, Consultant Pharmacist 8. Engage Families 9. Update your policies, procedures and forms 10. Sustain and Spread ©B&F Consulting 2015 www.BandFConsultingInc.com

53. Available Toolkits - FREE  Eliminating Off-Label Use of Antipsychotic – A 10 Step Guide for Nursing Homes  Developed by B&F Consulting for the LA Dementia Partnership Workgroup Project & Funded by CMS CMP funds (handout)  A Toolkit for Improving Dementia Care in Nursing Homes - Clinical Consideration of Antipsychotic Management  Developed by AHCA/NCAL Quality Initiative – Antipsychotic Management Toolkit  Archived Webinar (June 24) training on how to use this Toolkit presented by eQHealth Solutions  Promoting Positive Behavioral Health: A Non- pharmacological Toolkit for Senior Living Communities  http://www.nursinghometoolkit.com http://www.nursinghometoolkit.com

54. You Can Do It!