1. BEHAVIOR DRUG MONITORING A GUIDE TO MONITORING FOR PSYCHOPHARMACOLOGICAL BEHAVIORAL DRUG DOCUMENTATION

2. Objectives  The Participants will:  Identify a portion of the regulations that are related to Psychopharmacological drug monitoring (also known as behavior drug monitoring).  Identify the regulations and the monitoring tool to evaluate the documentation supporting the use of the psychoactive medication.

3. Objectives -2  The Participants will:  Review a monitoring tool and the instructions for completion of documentation to support the use of the Psychopharmacological drugs (aka, psychotherapeutic, behavior drugs, psychoactive drugs, antipsychotics, antidepressants, anti-anxiety).  Complete a documentation monitoring process using the attached monitoring tool.

4. Quality Monitoring  The following slides outlines in a brief way the requirements for documentation and clinical considerations for assessing, evaluating and monitoring use of psychopharmacological drugs for behavioral conditions.  Utilize the monitoring tool attached to collect data for the IDT review and follow up.

5. Quality Monitoring -2  The monitoring of documentation and identification of documentation items that are in compliance and items that need to be re-assessed are included in the monitoring tool. After the health record is reviewed, tabulate the findings and measure the areas of compliance vs. those where action is needed.

6. Quality Monitoring -3  Refer the findings to the IDT and to the Quality Assurance and Improvement Committee for review and action for documentation items in compliance and those where improvement may be needed.  When possible present the findings using a graphic format.

7. Overview of the Regulations  The following slides outline some key areas from the CMS regulations that are applicable to psychopharmacological documentation.

8. Psychopharmacological Medication  Defined as any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders.

9. Resident’s Clinical Record  Documents/Communicates to the entire team the basic elements of the care process, including:  The assessment  Indication for use  Planning care  Evaluation and monitoring of progress of the resident’s indication for use of the medication (behavioral manifestation/s)

10. Resident’s Clinical Record -2  Documents/Communicates (cont.)  Resident Assessment Protocols (RAPs), an integral part of the comprehensive resident assessment, help identify some possible categories of causes of various symptoms including: behavioral symptoms of distress, delirium, and changes in functional status.  Evaluation of the Resident’s Psychiatric disorders or distressed behavior – As with all symptoms, it is important to seek the underlying cause of distressed behavior, either before or while treating the symptom.

11. Gradual Dose Reduction  Most recent attempt at a GDR within the facility; and  The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident’s function or increase distressed behavior.As applicable…psychiatric disorder this may not be applicable.

12. Documentation Monitoring  Monitoring of the documentation looks at:  Entire drug/medication regimen monitored to achieve the following goals:  Promote or maintain the resident’s highest practicable mental, physical, and psychosocial well-being.  Promote or maintain the resident’s highest practicable mental, physical, and psychosocial well-being.  Evaluate those medications, in doses and for the duration clinically indicated to treat the resident’s assessed condition(s)

13. Drug Monitoring & Non Pharmaceutical Approaches  Monitoring to determine if there is documentation that indicates the  Non-pharmacological interventions (such as behavioral interventions) are considered and used when indicated, instead of, or in addition to, medication;

14. Drug Monitoring & Non Pharmaceutical Approaches -2  Monitor to assist the clinical team to evaluate and determine if  Clinically significant adverse consequences are minimized;  Assessment “indications for use of the Psychotherapeutic/behavioral medications and used after other interventions used/considered and treatment chosen is the most efficacious method of treatment

15. Monitoring for Dose Reduction  Gradual Dose Reduction (GDR)” is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.  Refer to the monitoring tool attached to review the instruction.

16. Medication Management  Medication management includes recognition or identification of the problem/need, assessment, diagnosis/cause identification, medication management/treatment, monitoring, and revising interventions, as warranted.  One of the uses of the monitoring of the documentation is to assist the staff in the review of the documentation findings.

17. Physician Monitoring  The attending physician plays a key leadership role in medication management by developing, monitoring, and modifying the medication regimen in conjunction with residents and/or representative(s) and other professionals and direct care staff (the interdisciplinary team).

18. IDT – Planning Care  Part of the uses of the monitoring of psychoactive medications is to also look at the documentation related to the non- pharmacological interventions. Many of the facility Interdisciplinary team members participate in the care process via “drug review, IDT Care Planning, etc. and they can use the information from the documentation monitor to identify, assess, address, advocate for, monitor, and communicate the resident’s needs and changes in condition.

19. Monitoring Care & Clinical Data Collection  “Monitoring” is the ongoing collection and analysis of information (such as observations and diagnostic test results) and comparison to baseline data in order to support decisions about modifying, discontinuing, or continuing any interventions.  Documentation monitoring also assists the IDT to carry out this task and improve the quality of care.

20. Non-Pharmacological Approaches  All medication management, (including antipsychotics), is important for the interdisciplinary team to consider non- pharmacological approaches.  All medication management, (including antipsychotics), is important for the interdisciplinary team to consider non- pharmacological approaches.  Quality Monitoring of documentation and the use by the IDT of the results will assist them to look at the non- pharmacological approaches.

21. EXAMPLES of Non- Pharmacological Approaches  Increasing the resident ’ s exercise, intake of liquids and dietary fiber in conjunction with an individualized bowel regimen to prevent or reduce constipation and the use of medications (e.g. laxatives and stool softeners);  Increasing the resident ’ s exercise, intake of liquids and dietary fiber in conjunction with an individualized bowel regimen to prevent or reduce constipation and the use of medications (e.g. laxatives and stool softeners);  Identifying, addressing, and eliminating or reducing underlying causes of distressed behavior such as boredom and pain  Identifying, addressing, and eliminating or reducing underlying causes of distressed behavior such as boredom and pain

22. EXAMPLES of Non- Pharmacological Approaches -2  Using sleep hygiene techniques and individualized sleep routines;  Accommodating the resident’s behavior and needs by supporting and encouraging activities reminiscent of lifelong work or activity patterns, such as providing early morning activity for a farmer used to awakening early;

23. EXAMPLES of Non- Pharmacological Approaches -3  Individualizing toileting schedules to prevent incontinence and avoid the use of incontinence medications that may have significant adverse consequences (e.g., anticholinergic effects);  Individualizing toileting schedules to prevent incontinence and avoid the use of incontinence medications that may have significant adverse consequences (e.g., anticholinergic effects);  Developing interventions that are specific to resident ’ s interests, abilities, strengths and needs, such as simplifying or segmenting tasks for a resident who has trouble following complex directions;  Developing interventions that are specific to resident ’ s interests, abilities, strengths and needs, such as simplifying or segmenting tasks for a resident who has trouble following complex directions;

24. EXAMPLES of Non- Pharmacological Approaches -4  Using massage, hot/warm or cold compresses to address a resident ’ s pain or discomfort; or  Enhancing the taste and presentation of food, assisting the resident to eat, addressing food preferences, and increasing finger foods and snacks for an individual with dementia, to improve appetite and avoid the unnecessary use of medications intended to stimulate appetite.

25. EXAMPLES of Non- Pharmacological Approaches -5  The resident’s clinical record documents and communicates to the entire team the basic elements of the care process.

26. Consents  Resident Choice –right to be informed about the resident’s condition; treatment options, relative risks and benefits of treatment, required monitoring, expected outcomes of the treatment; and has the right to refuse care and treatment be informed of risks related to the refusal, and discuss appropriate alternatives such as offering the medication at another time or in another dosage form, or offer an alternative medication or non-pharmacological approach, if available.

27. Documentation Monitors and Advantages  Looking at the documentation to support,  Indications for use of medication (including initiation or continued use of antipsychotic medication)  Monitoring for efficacy and adverse consequences  Dose (including duplicate therapy)  Duration

28. Documentation Monitors and Advantages -2  Looking at the documentation as part of the evaluation, gathering and analyzing information  Helps define clinical indications  Provide baseline data for subsequent monitoring,  Consider tapering of a medication dose/gradual dose reduction for antipsychotic medications,  Prevention, identification, and response to adverse consequences

29. Monitoring Tool  Refer to the Monitoring Tools attached, one blank for your use and the other with instructions.

30. Thank you!