One really can’t blame providers for fixating on antipsychotic medication reduction. Not only is it a matter of resident care, but it is a hot-button issue for the Centers for Medicare & Medicaid Services and the largest industry associations, including the American Health Care Association/National Center for Assisted Living.
AHCA’s goal to reduce the meds’ off-label use by 15% last year was ambitious, and not met. This year, AHCA is undeterred by the missed target and still wants providers to reduce by 15%.
“What we recognize is that it’s one of those issues of clinical practice that came into being because there were problems,” says Ruta Kadonoff, AHCA’s vice president of quality and regulatory affairs. “One strategy that came to address those [clinical issues] was these medications.”
With their various associations’ encouragement and support, providers are trying — and in numerous instances — succeeding at reducing unnecessary meds’ usage. Successful providers have found the key to antipsychotics’ reduction begins with viewing “behaviors” in residents as symptoms of a disease.
For example, one facility in Minnesota, within the Ecumen Awakenings network, had a new resident, fresh from the hospital. She was confused. She had a urinary tract infection and was, of course, on a cocktail of medications. While staff members began to question the necessity of her antipsychotics use, they also searched for a remedy to take the meds’ place.
They found what they were searching for during a 100th birthday celebration. A hired Elvis impersonator captivated the woman, and observant staff soon discovered her passion for Elvis music. Now, whenever she needs a moment to calm down, an iPod full of Elvis tunes is nearby and ready. With her headphones on, any undesirable behavior stops, and she’s relaxed and at ease.
“Comfortable people don’t generally react in ways that would end up with them having a medication,” says Tena Alonzo, education and research director at Beatitudes Campus in Phoenix.
For this reason, Alonzo and other providers stress the idea of addressing unmet needs. Residents who act out often don’t require medicine to quell their nerves; they simply require understanding from staff.
“They have a need that we have not met,” explains Cathy McKay, RN, CRN, DNS, director of nursing at Lakewood Continuing Care Center in Waterville, ME. “If we can figure out what they need, we can eliminate the behavior.”
McKay’s facility had a 6.6% antipsychotics usage rate in June, down from 24% in 2006, the year her facility first focused on their reduction.
“A lot of times, there’s something in the environment [making the residents uncomfortable],” McKay notes. “It’s a symptom of an unmet need and knowing the disease inside and out will help you.”
Recipe for agitation
Environmental stressors commonly cause unwanted behaviors, providers say. Dining rooms particularly induce certain behaviors and irritate residents. With the clanging of dishes, the noise of conversations and the large number of residents in one place, that isn’t really surprising, providers explain. Nick Bridges, administrator of Durgin Pines in Kittery, ME, saw the dining room as his top priority when he became the facility’s administrator last year.
Instead of having one dining time for all residents, he created two shifts. Residents requiring less assistance ate first, while the staff prepared for the second shift. The new system allowed diners to receive their food faster and interact more easily. Previously, Bridges says, residents were too overstimulated to eat. He and others discovered that the reduction of environmental triggers decreased the need for antipsychotics.
When Bridges took over as administrator, 25% of his residents were on an antipsychotic. A year later, in July 2013, that rate was down to 4.2%.
The dining changes helped in the reduction, Bridges says, but he stresses the important role staff play in finding environmental triggers and potential remedies for individual residents.
“The same staff work with the same residents day in and day out,” agrees AHCA’s Kadonoff. “They can anticipate residents’ needs and nonverbal cues, and understand what upsets them.”
All staff members have the potential to offer ideas about care, Alonzo says. Housekeepers might offer an observation about a resident’s room, and CNAs often have the best insight because of their intimate resident care. With the staff working as a team, Alonzo’s facility lowered its antipsychotic use by 27% in five years.
“We try to empower all the staff to have that voice on behalf of the person we’re caring for, so we get those clues on an ongoing basis,” Alonzo says.
Educate first, reduce later
Staff empowerment begins with education, experts emphasize. Before anyone can note triggers and actively help lower antipsychotics usage, he or she needs to learn the reasoning behind the push for change.
“Meet with nursing staff to make them understand where this initiative is coming from, the efficacy for these meds,” Bridges says.
Nurses also need to be held accountable, he adds. Instead of calling a doctor immediately when a resident acts up, Bridges tells nurses to go through options. If they call a doctor, he will always follow up and ask what they did to get to that point. What techniques or alternative approaches did they try? Nurses should explore whether changing residents’ environments, getting them out of their rooms and redirecting their attention will help.
“It took some time because [calling the doctor] was ingrained in them,” Bridges says. “It still tended to be that in the heat of the moment that was the common response. But when we stuck to our guns with what our expectations were, the nurses got to know they weren’t going to call the doctor until they know what they’ve attempted.”
Bridges and his medical director, Jabbar Fazeli, M.D., specifically concentrate on educating weekend and evening staff because the majority of calls come during those shifts.
Educational reminders, not just initial training, are essential.
Tarsha Rodrigue, the nurse manager at the Cove Neighborhood, for example, uses candy as a teaching tool.
She put sweets out for the staff to nibble on throughout the day, with advice on each wrapper. For instance, one piece of candy might read, “I’m cold,” to remind staff to consider this possibility when treating a behavior.
Rodrigue also hosted a daily “Myth Busters” session during the morning meetings when she began her initiative. She encouraged staff to share their concerns about the removal of antipsychotics, and then she used research to “bust” the myths they had heard.
“Being very open like that has helped people get on board,” Rodrigue says. “We educated on the side effects. For instance, some residents hoard and wander. There was a myth that these meds really help our residents stop. There was no research on that, so we focus on education.”
This focus on education has helped Rodrigue bring her facility’s antipsychotics’ usage rate down from nearly 47% in 2011 to 16.2% in July 2013.
Bridges, on the other hand, attributes much of his facility’s success to his usage of teachable moments. He and Fazeli talk directly to the staff when a phone call is made to a doctor.
“If we receive a call overnight, and I feel that was a call that needs to be reviewed, we use those cases to constantly give feedback to the nurses,” Fazeli says. “With that kind of constant feedback, we have constant education.”
Doug Esperson, R.Ph., vice president of Consulting Services for Millennium Pharmacy Systems, says staff should always be able to answer the question, “Is the resident actually improved with the use of these meds?”
Teamwork for success
The nurses and entire facility staff work together to make the initiative work, many providers emphasize. The antipsychotics reduction team doesn’t stop within the facility’s walls; it includes pharmacists, the medical director and doctors, as well.
Multiple providers instated monthly full-staff meetings to outline residents’ care plans and reduction strategies. Often, these meetings involve identifying each resident on antipsychotics and evaluating reduction efforts.
Curt Bicknell, president of operations at Guardian Mid-South Pharmacy, uses this teamwork strategy to foster relationships with important team players.
Through the meetings, he’s gotten to know one nurse practitioner particularly well. So well, in fact, she feels comfortable calling, texting and emailing regularly to ask questions and keep him updated on residents’ conditions.
When a nursing home involves so many individual staff members, sitting down once a month to collaborate can create effective and innovative results.
At one facility, Laurie Herndon, director of clinical quality at the Massachusetts Senior Care Foundation, says the staff thought beyond typical techniques to help residents. They found residents were having late afternoon behavior disturbance because of boredom. To combat this, the staff went to Home Depot and requested old copies of wallpaper, paint and curtain books. A staff member also brought in screws, nuts and bolts. With these supplies, the staff members sat down with female residents and asked for their help in planning a hypothetical room. The men sorted through the nuts and bolts. Meanwhile, conversation about home life and décor flowed and kept the residents engaged.
W. Gary Erwin, senior vice president of clinical services at Omnicare, also finds staff teamwork essential.
“This is a relationship business that requires optimal communication paths and mutual respect between all parties,” he says.
If meetings are not an option, Herndon recommends rounding.
“The geriatric psychiatry teams come in and do behavior rounds,” she says. “They go around and talk as a team. Come at it as a team, not with a one-by-one approach.”
Having pharmacists and nurses regularly do a med-pass round together also helps.
“Med-pass can be stressful for many facility nurses, and pharmacists can help them improve accuracy and efficiency,” said Heather Hudson, LPN, a medication compliance specialist with Parata Systems.
Other providers suggest working hand-in-glove with doctors to distribute CMS handouts and information sheets. They also stress that everyone should be able to speak at meetings and question the use of antipsychotics.
Jennifer Hardesty, regional director of clinical services, Mid-Atlantic Remedi SeniorCare, reminds: An antipsychotic removal often leaves staff with an unruly resident.
“Give these folks ways they can manage the behaviors,” she says. “Make sure the facility caregivers and the staff have ways of working together to make sure a resident is taken care of.”
Successful providers say they require more than nurses’ understanding and help from clinicians. A facility’s management must buy into the initiative. Without support from an administrator or director of nursing, use of antipsychotics tends to remain at a steady level.
Bridges says administrators should not be afraid to promote the benefits of antipsychotic reduction.
“Gather some of the information about what’s going on out on the floor; talk about some of the advantages to pursuing this initiative,” he advises.
Leaders of other facilities echoed Bridges. Herndon said management doesn’t need to lead the initiative, but they need to at least endorse it.
“There are two key components for an effective team,” she says. “[There needs to be] support at the top and the right person leading the team. Without the administrator’s support, it’s impossible to get it off the ground.”
Within her facility, Herndon had a particularly passionate activities director who took the lead. She was persistent and collaborative, which gained the nurses’ support.
With all staff on board, the concentration on antipsychotics reduction came easily.
“If everyone throughout the facility isn’t bought in to the same set of beliefs and understanding about why we’re doing what we’re doing, there’s a real challenge to that,” Kadonoff says. “Take time to build that understanding. Changing practice doesn’t happen overnight.”
And as many providers note, it’s important to remember that everyone is entitled to a bad day every now and then. Residents are people, like anyone else. They just might need more help to get through the day — without unnecessary added medications.