Achieving Success in Reducing Inappropriate Use of Antipsychotic Medication in Patients with Dementia Deborah Afasano , BSN, RNC, CDONA, HCRM Vice President of Clinical Services, Avante Group Rick Foley , PharmD, CPh, CGP , FASCP , BCPP Clinical Professor of Geriatrics, University of Florida College of Pharmacy President, Florida Chapter - American Society of Consultant Pharmacists Amy J. Osborn , NHA, PMP Executive Director, Health Services Advisory Group, HSAG Polly Weaver , BS Assistant Deputy Secretary of Health Quality Assurance, Agency for Health Care Administration, AHCA March 22, 2016
OBJECTIVES • Examine the potentially inappropriate use of antipsychotic medication in patients with dementia • Analyze de-identified cases of inappropriate use of antipsychotic medication in patients with dementia through root cause analysis • Integrate interventions to reduce the inappropriate use of antipsychotic drugs in patients with dementia 2
NA NATIO IONA NAL L PARTNERSH NERSHIP IP TO IM O IMPR PROVE VE DEME MENT NTIA IA CARE E Amy Osborn NHA, PMP; Executive Director, Health Services Advisory Group, HSAG https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/National- Partnership-to-Improve-Dementia-Care-in-Nursing-Homes.html 3
GOAL FOR AL FOR 20 2016 16: 30% : 30% OR OR GR GREA EATE TER R REDUCTION UCTION What is your current rate? What percentage reduction has your center achieved? 4
Let’s Compare! Partnership Results − Florida • Q4 2011 – Florida 24.5 • Q3 2015 – Florida 17.59 Reduction of 28.2% • Q4 2011 – Nation 23.9 • Q3 2015 – Nation 17.43 Reduction of 27.0% • Florida Ranks – 35 of 51 • Florida Ranks – 35 of 51 5
ACH CHIEV IEVING ING SU SUCCESS CCESS IN IN RE REDUCI DUCING NG IN INAPPROP ROPRIA RIATE TE USE SE OF ANTIP IPSY SYCHO CHOTIC TIC MEDI DICA CATIONS TIONS IN IN P PATIENT IENTS S WI WITH H DEMEN ENTIA TIA – SU SURVEY VEY PERSPECTI SPECTIVE VE Polly Weaver, Assistant Deputy Secretary, Health Quality Assurance Agency for Health Care Administration 6
F309 §483.25 Quality of Care 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. Surveyors use this guidance for a resident with dementia. If the resident is receiving one or more psychopharmacological agents, also review the guidance at F329, Unnecessary Drugs . 7
F309 §483.25 Quality of Care − continued • If a concern is identified during a survey that an antipsychotic medication may potentially be administered for discipline, convenience and/or is not being used to treat a medical symptom, consider reviewing F222 - 483.3(a) Restraints, for the right to be free from any chemical restraints. 8
F309 §483.25 Quality of Care − continued • Facilities should be able to identify how they have involved residents/families in discussions about potential approaches to address behaviors. • Potential risks and benefits of a psychopharmacological medication (e.g., FDA black box warnings). 9
F309 §483.25 Quality of Care − continued • It is expected that the resident’s record reflects the implementation of a systematic care processes: • Recognition and Assessment (MDS) • Cause Identification and Diagnosis; • Development of Care Plan; • Individualized Approaches and Treatment; • Monitoring, Follow-up and Oversight; and • Quality Assessment and Assurance (QAA). 10
F329 §483.25(l) Unnecessary Drugs • Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: – In excessive dose (including duplicate therapy); or – For excessive duration; or – Without adequate monitoring; or – Without adequate indications for its use; or – In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or – Any combinations of the reasons above. 11
F329 §483.25(l) Unnecessary Drugs − continued • Antipsychotic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that: • 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 • Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. 12
F329 §483.25(l) Unnecessary Drugs − continued • The intent of this requirement is that each resident’s entire drug/medication regimen be managed and monitored to achieve the following goals: – Promote or maintain the resident’s highest practicable mental, physical, and psychosocial well-being, as identified by the resident and/or representative(s) in collaboration with the attending physician and facility staff; – Each resident receives only those medications, in doses and for the duration clinically indicated to treat the resident’s assessed condition(s); 13
F329 Unnecessary drugs − continued Goals continued – Non-pharmacological interventions (such as behavioral interventions) are considered and used when indicated, instead of, or in addition to, medication; – Clinically significant adverse consequences are minimized; and – The potential contribution of the medication regimen to an unanticipated decline or newly emerging or worsening symptom is recognized and evaluated, and the regimen is modified when appropriate. 14
F329 Unnecessary drugs − continued The surveyor’s review of medication use is not intended to constitute the practice of medicine. However, surveyors are expected to investigate the basis for decisions and interventions affecting residents . NOTE: This guidance applies to all categories of medications including antipsychotic medications. 15
Unnecessary Medications Investigative Protocol Surveyors use this protocol during every initial and standard survey. In addition, this protocol may be used on revisits or abbreviated survey (complaint investigation) as necessary. 16
F329 Investigative Protocol Not intended to direct medication therapy. However, surveyors are expected to review factors related to the implementation, use, and monitoring of medications. Was there a failure in the care process related to considering and acting upon an adverse consequence related to medications? The surveyor may need to contact the attending physician or consultant pharmacist regarding questions related to the medication regimen. 17
F329 Investigative Protocol ~ Determination of Compliance Six aspects to the unnecessary medication requirement. The facility must assure medication therapy is based upon: 1. An adequate indication for use; 2. Use of the appropriate dose; 3. Provision of behavioral interventions and gradual dose reduction for individuals receiving antipsychotics (unless clinically contraindicated) in an effort to reduce or discontinue the medication; 18
F329 Investigative Protocol ~ Determination of Compliance − continued 4. Use for the appropriate duration. 5. Adequate monitoring to determine whether therapeutic goals are being met and to detect the emergence or presence of adverse consequences; and 6. Reduction of dose or discontinuation of the medication in the presence of adverse consequences, as indicated. 19
Tapering of a Medication Dose/Gradual Dose Reduction (GDR) ) • Considerations Specific to Antipsychotics. The facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated. • Tapering Considerations Specific to Sedatives/Hypnotics. For as long as a resident remains on a sedative/hypnotic that is used routinely and beyond the manufacturer’s recommendations for duration of use, the facility should attempt to taper the medication quarterly unless clinically contraindicated 20
Tapering/GDR − continued • Considerations Specific to Psychopharmacological Medications (Other Than Antipsychotics and Sedatives/Hypnotics). During the first year in which a resident is admitted on a psychopharmacological medication (other than an antipsychotic or a sedative/hypnotic), or after the facility has initiated such medication, the facility should attempt to taper the medication during at least two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a tapering should be attempted annually, unless clinically contraindicated. 21
IM IMPROVIN VING G CA CARE AND QUALIT LITY Y OF LIF IFE E FOR PATIENT IENTS S WI WITH DE DEMENTI ENTIA A IN IN L LONG- TERM M CA CARE Rick Foley, PharmD, CPh, CGP, FASCP, BCPP Consultant Pharmacist – Omnicare Clinical Professor of Geriatrics – UF College of Pharmacy President – Florida Chapter American Society of Consultant Pharm 22
The Pharmacist’s Perspective • First do no harm • The regulations • Trends in the field • Recognizing prescribing patterns that lead to antipsychotic (AP) use 23
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