1. 1 Reducing the Inappropriate Use of Antipsychotics Barbara Anthony, RN, LNC La. Dementia Partnership Project Coordinator Baranthony51@gmail.com 225-235-7411

2. 2 Louisiana Dementia Partnership Workgroup Update on Workgroup Activities

3. 3 Partnership to Improve Dementia Care New Orleans Pilot by B&F Consulting Developed and tested a method for reducing the use of antipsychotics for residents with a dementia-only diagnosis. Worked with five homes in the New Orleans area identified as having the highest # of residents receiving antipsychotics with dementia-only diagnosis. Provided on-site visits to assist pilot homes, once a month for four visits, with customized assistance to figure out the step by step process.

4. 4 Common Areas of Concern in Collaborative Homes The following common areas of concern were identified during the Collaborative visits to 5 nursing homes. The following common areas of concern were identified during the Collaborative visits to 5 nursing homes. –Need to communicate with consultant pharmacist so that the Drug Regimen Review process supports eliminating off-label use of AP’s –MDS coding errors –Not using the Casper report to track and trend inappropriate use

5. 5 Common Areas of Concern in Collaborative Homes (cont) Care plans were not individualized for residents with distressed behaviors Care plans were not individualized for residents with distressed behaviors Need to update policies/procedures to reflect new survey guidance Need to update policies/procedures to reflect new survey guidance

6. 6 Objectives 1. 1. Utilize the MDS data as a tool in the reduction in use of antipsychotic (AP) medications. 2. 2. Utilize the Consultant Pharmacist, MDS, and Casper Reports to identify residents receiving AP medications without an appropriate diagnosis based on CMS exclusions.

7. 7 Step 1 - Establish a leadership team for the effort The team that coordinates the effort needs to include decision-makers, both clinical leaders and leaders who have direct responsibilities for daily care. This includes the DON and unit-based nurse managers, MDS coordinator, social work and activities staff. Choose a team leader who has a clinical role, is able to use the MDS CASPER data, is knowledgeable about dementia care, and is a creative, engaging implementer with the authority to carry out interventions.

8. 8 Step 3 – Analyze the MDS CASPER Resident Level Quality Measure Report to Determine Your Target Population In order to review your Casper report, we will need to discuss the MDS and how it is completed regarding the use of AP’s.

9. 9 MDS Data Source of data CMS uses to compile reports that are available to the public. Source of data CMS uses to compile reports that are available to the public. –Therefore, it is imperative the MDS nurse and ID team complete the assessment accurately. Accurate data entry on the MDS could affect if and how a resident's disorder is treated. Accurate data entry on the MDS could affect if and how a resident's disorder is treated.

10. 10 MDS Data Below are the areas of the MDS we will be discussing regarding the use of antipsychotic medications: – –Section N: Medications – –Section I: Active Diagnosis – –Section I: Neurological – –Section I: Mood and Psychiatric Disorder – –Section E: Behavior

11. 11 Section N: Medications This area captures whether the resident has received an antipsychotic within the last 7 days This area captures whether the resident has received an antipsychotic within the last 7 days If N0410 A. is marked, this will trigger further review of the MDS. If N0410 A. is marked, this will trigger further review of the MDS.

12. 12 Section I - Active Diagnosis Marking that the resident received an antipsychotic requires a review of Section I - Active Diagnosis. Marking that the resident received an antipsychotic requires a review of Section I - Active Diagnosis. The MDS nurse should ensure there is a correlating ICD 9 code/diagnosis on the medical record to explain the use. The MDS nurse should ensure there is a correlating ICD 9 code/diagnosis on the medical record to explain the use. In some instances, the resident may be receiving the medication but this section is not properly coded, therefore, making it appear on the MDS that the resident is receiving the medication without a supporting diagnosis. In some instances, the resident may be receiving the medication but this section is not properly coded, therefore, making it appear on the MDS that the resident is receiving the medication without a supporting diagnosis.

13. 13 Section I: Neurological Section When completing the Neurological section, you should not mark both Alzheimer’s and Non- Alzheimer’s on an MDS assessment. This will result in the resident being captured twice in the data base and skews the percentage of use. When completing the Neurological section, you should not mark both Alzheimer’s and Non- Alzheimer’s on an MDS assessment. This will result in the resident being captured twice in the data base and skews the percentage of use. If the only diagnosis marked on the MDS to support the use of the AP is 4200 or 4800 for any resident, this would indicate dementia is the only reason they are receiving an AP and this resident will require further review. If the only diagnosis marked on the MDS to support the use of the AP is 4200 or 4800 for any resident, this would indicate dementia is the only reason they are receiving an AP and this resident will require further review.

14. 14 Section I: Psychiatric/Mood Disorder One of the categories in this section should be marked only if there is a supporting diagnosis/ICD 9 code in the medical record that supports the use of the AP the resident is receiving. One of the categories in this section should be marked only if there is a supporting diagnosis/ICD 9 code in the medical record that supports the use of the AP the resident is receiving.

15. 15 Section I: Psychiatric/Mood Disorder When assessing any resident receiving an antipsychotic, you can use the forms in the QIO Antipsychotic Management Toolkit to assist you with this process (2 Handouts). When assessing any resident receiving an antipsychotic, you can use the forms in the QIO Antipsychotic Management Toolkit to assist you with this process (2 Handouts).

16. 16 Section I - Active Diagnosis The diagnoses marked in these sections of the MDS should match what the consulting pharmacist report has as a supporting diagnosis for the AP. The diagnoses marked in these sections of the MDS should match what the consulting pharmacist report has as a supporting diagnosis for the AP. Matching these 2 documents is the first step in reviewing the use of an AP. Matching these 2 documents is the first step in reviewing the use of an AP.

17. 17 Group Exercise Compare the Consultant Pharmacist report of residents on an AP and their supporting diagnosis with the MDS list of residents on an AP and the supporting diagnosis listed on the MDS in Section I - Active Diagnosis. Compare the Consultant Pharmacist report of residents on an AP and their supporting diagnosis with the MDS list of residents on an AP and the supporting diagnosis listed on the MDS in Section I - Active Diagnosis. Highlight any differences. Highlight any differences.

18. 18 Casper Report

19. 19 Step 3 – Analyze the MDS CASPER Resident Level Quality Measure Report to Determine Your Target Population This report lists every active resident and 18 Quality Measures. The left hand column lists names of all active residents. Find the column marked “Antipsych Meds (L)” for long-term residents on your Casper Report. Remember, there will be an “X” if a person is receiving antipsychotics but doesn't have Schizophrenia, Huntington’s or Tourette’s.

20. 20 Casper Report Exercise Look at the sample Casper Report in your exercise handout. Look at the sample Casper Report in your exercise handout. On the sample Casper Report above the resident names, you will see 5 MDS codes/diagnoses written in. These represent diagnoses that could support the use of an AP if the appropriate guidelines are followed. On the sample Casper Report above the resident names, you will see 5 MDS codes/diagnoses written in. These represent diagnoses that could support the use of an AP if the appropriate guidelines are followed.

21. 21

22. 22 Casper Report Exercise 4200 – Alzheimer’s 4800 – Non-Alzheimer’s Dementia Psychotic Disorders 5900 – Manic Depression 5950 – Psychotic Disorder 5100 – Post Traumatic Stress Disorder

23. 23 Casper Report Exercise As you review each resident with an X on your Casper report, place the MDS code marked on the list you have next to the resident’s name (see sample). As you review each resident with an X on your Casper report, place the MDS code marked on the list you have next to the resident’s name (see sample). If you don’t have a code marked on the MDS for a resident, place an * next to that resident’s name. They will require further review. If you don’t have a code marked on the MDS for a resident, place an * next to that resident’s name. They will require further review.

24. 24 Casper Report Exercise Does anyone with an X actually have a serious mental illness that is not correctly documented? On the first visit to one of the pilot homes, all but one of the residents who were listed as dementia-only actually had a psychiatric diagnosis but because they had not been coded correctly, the residents showed up as dementia only. Once the coding errors were corrected, the home had no further need for assistance

25. 25 Casper Report Exercise After you have finished marking all of the residents, count the number of residents that were marked for each diagnosis code you used. After you have finished marking all of the residents, count the number of residents that were marked for each diagnosis code you used. Using this information, you will be able to track and trend the diagnoses being used by your facility to support residents receiving an antipsychotic. Using this information, you will be able to track and trend the diagnoses being used by your facility to support residents receiving an antipsychotic. A review of data for our state identified that “Psychotic Disorder” was the most commonly used psychiatric disorder marked on the MDS.

26. 26 Review of DRR report with Casper Report If this process is performed on a monthly basis when the consultant pharmacist report is received, you can identify possible errors and make corrections in a timely manner. If this process is performed on a monthly basis when the consultant pharmacist report is received, you can identify possible errors and make corrections in a timely manner. This process can be a QAPI PIP project. This process can be a QAPI PIP project.

27. 27 Triage: Review Why Each Resident is Receiving Antipsychotics and Take Care of Easy-to-Act-On Situations Make a plan for how you are going to review residents who get an AP. Using your final list of residents who are receiving an AP, you can look at “Section E: Behaviors” to determine if the reason for the use of the AP may be attributed to specific behaviors identified on the MDS. Using your final list of residents who are receiving an AP, you can look at “Section E: Behaviors” to determine if the reason for the use of the AP may be attributed to specific behaviors identified on the MDS.

28. 28 Section E: Behavior If a resident has been identified as exhibiting behaviors, the medical record must support what is marked in this section, whether it is in progress notes or some type of behavior monitoring form. If a resident has been identified as exhibiting behaviors, the medical record must support what is marked in this section, whether it is in progress notes or some type of behavior monitoring form. The documented information, if in more than one location, must match, i.e. The nurses notes reflect that the resident has been exhibiting behaviors but the Behavior Monitoring form has "0"s for every day/every shift. The documented information, if in more than one location, must match, i.e. The nurses notes reflect that the resident has been exhibiting behaviors but the Behavior Monitoring form has "0"s for every day/every shift.

29. 29 Section E: Behavior Behaviors marked on the MDS in E 0200 are what you would expect to see identified in the resident’s care plan as the problem to be addressed, not a diagnosis. You can also look at Section E0800 to determine if behaviors could be a direct result of ADL care being given.

30. 30 Section E: Behavior The MDS may not reflect any behaviors being exhibited. However, the care plan must still reflect the actual reason the resident is receiving the AP. Having a diagnosis marked on the MDS is not sufficient to justify the use of an AP.

31. 31 Step 4 – Triage: Review Why Each Resident is Receiving Antipsychotics and Take Care of Easy-to-Act-On Situations If residents do not have a mental illness and are only receiving an AP because they have dementia as a diagnosis (Alzheimer’s or Non-Alzheimer’s), they are going to be your targets for discontinuation of an AP. This afternoon Margie will be discussing residents with dementia receiving an AP.

32. 32 Step 4 – Triage: Review Why Each Resident is Receiving Antipsychotics and Take Care of Easy-to-Act-On Situations If a diagnosis of Mood Disorder or PTSD were marked on the MDS, these diagnoses are deemed appropriate for the use of an AP. If a “Psychotic Disorder” diagnosis was marked on the MDS, because this is a very broad category, you must be able to determine why the resident was given this diagnosis.

33. 33 Step 4 – Triage: Review Why Each Resident is Receiving Antipsychotics and Take Care of Easy-to-Act-On Situations Determine why the AP’s are being given and when they were started Some AP’s may have originated while they were living at home or during a hospital stay. What were the circumstances? Was the AP started after a psych consult or a geri- psych hospitalizations? Was it initiated during an off-hours shift? Was it because of behaviors related to receiving other medications and not a mental illness diagnosis, i.e. delirium. This will be discussed in the afternoon.

34. 34 Step 4 – Triage: Review Why Each Resident is Receiving Antipsychotics and Take Care of Easy-to-Act-On Situations Go Slow – At first, not more than one resident per unit/neighborhood Start with the easiest person, not the hardest

35. 35 Triage: Review Why Each Resident is Receiving Antipsychotics and Take Care of Easy-to-Act-On Situations If the resident has a diagnosis of “Psychotic Disorder” and you have been unable to determine why the resident was given that diagnosis, implementing GDR as Margie spoke about earlier should assist you in making that determination. As the medication is being reduced, your care plan should reflect closer observations of that resident as the effects of the medication wear off. If the use of the medication was attributed to specific behaviors, those behaviors should begin to manifest themselves.

36. 36 Triage: Review Why Each Resident is Receiving Antipsychotics and Take Care of Easy-to-Act-On Situations As soon as the resident begins to manifest behaviors, you must attempt to use non- pharmacological interventions to alter the resident’s behavior unless the behavior is causing a danger to the resident or others. If it is determined that these interventions are not altering the resident’s behavior, the medication dosage can be adjusted. The care plan must reflect all of the attempts and whether they are successful or not.

37. 37 Triage: Review Why Each Resident is Receiving Antipsychotics and Take Care of Easy-to-Act-On Situations If behaviors begin to appear and the use of non-pharmacological interventions are successful in controlling or eliminating those behaviors, you should be able to recommend to the MD to discontinue the AP.

38. 38 Triage: Review Why Each Resident is Receiving Antipsychotics and Take Care of Easy-to-Act-On Situations When looking at why the resident is receiving an AP, consider the age of the resident or the resident’s current ADL status to determine if the AP is still needed or could be continued.

39. 39 MDS Tracking We will continue to track the national CMS data as we get it. We will also continue to track DHH data on a quarterly basis to monitor what diagnoses are being used in our state to support the use of AP’s for residents in nursing homes.

40. 40 To Be Continued The following will be discussed after lunch: The following will be discussed after lunch: –Care plans were not individualized for residents with distressed behaviors –Need to update policies/procedures to reflect new survey guidance.