A 70% drop in
Anti-psychotic usage in a
Texas Nursing Home
It can be done!
Texas Conference on Aging
July 29, 2015
Joann Murtagh, RPh
Fern Silva, RN
Linnie Martin, MPA
Presenters
Joann Murtagh, RPh
Pharmacist Quality Monitor, TX DADS
Quality Monitoring Program
Fern Silva, RN
Director of Nursing Services
Town and Country Manor
Genesis Healthcare
Linnie Martin, MPA
Ombudsman Program Manager
Alamo and Bexar Area Agencies on Aging
AACOG
Texas Long-Term Care
Ombudsman Program
 Protecting Resident Rights
 An Ombudsman advocates for quality
of life and care for people living in
nursing homes and assisted living
facilities.
Person-Centered Care
Incorporate personal preferences
• Wake-up times and bedtimes are not rigid
• Mealtimes offering more alternative choices:
appetizers, beverages, condiments
• Shower/bathing times with flexibility for time
of day and days of the week
Get feedback from residents
• Is the environment boring?
• Are there meaningful and
purposeful activities?
• Does the resident feel like the staff care?
What’s
with
Antipsychotics
Aripiprazole (Abilify®)
Chlorpromazine (Thorazine®)
Olanzapine (Zyprexa®)
Paliperidone (Invega®)
Clozapine (Clozaril®)
Quetiapine (Seroquel®)
Fluphenazine (Prolixin®)
Risperidone (Risperdal®)
Haloperidol (Haldol®)
Thiothixene (Navane®)
Lurasidone (Latuda®)
Ziprasidone (Geodon®)
1987 OBRA Legislation
 Residents must be free from physical and chemical restraints
imposed for the purposes of discipline or convenience
 Chemical Restraints—any drug used for discipline or
convenience and not required to treat medical symptoms
 Discipline: action taken by the facility or staff for the
purpose of punishing or penalizing
 Convenience: action taken by the facility or staff to
control or manage a resident’s behavior with a lesser
amount of effort that is not in the resident’s best
interest
Reference: http://www.cdph.ca.gov/programs/LnC/Documents/CAHPS-HSAG-White-Paper-Chemical-Restraint-Use-Final.pdf
Looking at the Big Picture
 Antipsychotics do not improve the overall quality
of life in dementia.
 Antipsychotics can contribute to other risk factors
for older individuals such as: pressure ulcers,
worsening hydration and nutrition, decreased
independence, decreased socialization, and higher
risk of falls.
 Antipsychotics used in dementia care can also lead
to staff members that are disengaged.
Supportive
independence
with
preference &
choice
Less reliance
on the staff
for ADL cares
The Negative Cycle
Improved
staff
satisfaction
with work
environment
Decreased
resident
frustrations
Less
likelihood of
complaints
Texas: A Journey of Change
500
Number of Nursing Homes
450
400
350
300
Q1 2013
250
Q4 2014
200
150
100
50
0
0
10
20
30
40
50
60
Long-stay Antipsychotic Quality Measure Percentages
70
80
90
Stories of Success
 Q1 2013 data to Q4 2014 data showed that 726
nursing homes out of about 1200 had reduced
their antipsychotic percentages.
 Texas no longer has the highest rate of
antipsychotic prescribing in the long-term care
setting.
The Long Road Ahead
 388 nursing homes had an increase in their
antipsychotic percentage.
 Do you know where you are with your current
percentage?
 If you don’t know, go to Nursing Home Compare
to find out.
 Start a performance improvement project (PIP) as
specified under QAPI.
The Future of Antipsychotics
 CMS has set another national goal for a national
percentage not higher than 16.7% by the end of
2016.
 275 nursing homes are currently at or below this
percentage as of the Q4 2014 data point released
in April 2015.
Music and Memories
Video
Music
Emotional and psychosocial benefits:
 Reduces depression
 Promotes relief from pain and anxiety
 Reduces the body’s response to stress
 Can increase the brain’s ability to
concentrate
 Prompts the brain to experience and
re-live positive memories
Music
 Lower blood pressure
 Boost immunity
 Ease muscle tension
 Improve breathing
 Reduce pain levels
 Has been shown to reduce antipsychotic
prescribing in the nursing home setting
Making It Happen
Town and Country Manor in Boerne, TX
Q1
2013
54.4%
Q2
2013
49%
Q3
2013
46.1%
Q4
2013
34.5%
Q1
2014
22.5%
Q2
2014
16.7%
Q3
2014
16.1%
Q4
2014
16.1%
 54.4% to 16.1% represents a 38.3 point drop in 2
years.
 This is an overall 70.4% reduction in the use of
antipsychotics!
Reducing Antipsychotics: A Story of Hope
Texas Department of Aging
and Disability Services - Video
Town and Country
Results
The Nursing Process and
Psychotropic Reductions
 Nursing/Interdisciplinary assessment
 Clinical Judgment
 Outcomes/Planning
 Implementation
 Evaluation
 Recommended Physician GDR’s
Poll Question
 Are you currently involved in actively
reducing antipsychotic use in your
facility?
 A. Yes
 B. No
Assessment
Behaviors = Unmet Needs
 Conduct focused assessment on behavior related
conditions and medication side effects (AIMS)
 Review recent changes in condition:





Infections
Abnormal labs
Pain Management
Nurses Notes
Previous GDR’s and Pharmacist Recommendations
 Consult IDT members: Social Worker, Activities,
Dietician, Psychologist, Charge Nurse , C.N.A.
Challenges in medication
reduction
Our challenges in reducing medications are typically
negatively influenced by:
A. Lack of physician support
B. Family fears and lack of support
C. Assessment skills of staff
D. All the above
E. A and B
F. B and C
G. None of the above; it’s something else
Clinical Judgment
 Is the individual at optimal function
and does the individual have quality
of life?
 What symptoms are not managed?
 Will a GDR or medication elimination
improve the individual’s symptoms
and functioning?
Outcome/Planning
 Gather all Assessment data
 Medications including dose and time of
administration
 What medications may be contributing to issues /
concerns
 Identify non-pharmacological approaches that work
Implementation
 Complete your quarterly assessment
 Passport Into My Life (Know your residents)
 Make recommendation to the physician.
 Physician was more open to recommendations when coming
from the nurse rather than the pharmacist
 Involve the family/ RP in the GDR and education of the risks
associated with psychotropic use
 Only Adjust/Change one Medication at a time
 If the residents is on multiple psychotropic medications,
start with the Anti-psychotics, then move to
sedative/hypnotics, and finish with anti-depressants
Getting to Know You
The Passport Into My Life
provided us with essential
personal and historical
information to better
understand and get to
know each resident.
Understanding the resident
helped staff provide the
best care possible by
preventing behaviors and
having information about
the resident to help
manage their behaviors.
Timing of Assessment
 Start your Assessment process 3-4 weeks before
the residents next ARD date in the MDS cycle.
 Have all GDR’s and discontinuations completed
before the 7 day look back period for
psychotropic medications.
 Timing is everything to show and achieve rapid
results and improved Quality Measures.
Evaluation
 Monitor for the effects / Benefits of the GDR or
medication discontinuation.
 Always consider pain as possible cause of
“behaviors.”
 If QOL improved and symptoms decreased or had
no change consider further reduction.
The importance of pain
How often have you found that addressing and
treating pain has decreased behavior challenges?
A. Approximately 10% of the time or less
B. Between 10% and 25% of the time
C. Between 25% and 50% of the time
D. Above 50%
E. None of the above
T.R.A.I.N.
Taking a Different Track
Get on the Right Track
For more information about the ongoing initiatives
of the Quality Monitoring Program please visit:
http://www.dads.state.tx.us/qualitymatters/
Email the DADS Quality Monitoring Program:
TQM@dads.state.tx.us