Appropriate Use of Antipsychotics (AUA)

in LTC

Mollie Cole, Manager Seniors Health SCN

April 23, 2019

• Goal: Support LTC sites in Alberta to use antipsychotics appropriately;

improve dementia care in Alberta

• WHY: Much evidence that long-term use of antipsychotics in older adults

with dementia is hazardous (increase stroke, mortality, decrease quality of

life); Unexplained variation in use between zones, sites

• OUTCOME: Alberta now has lowest use in Canada (as reported by CIHI)

• HOW – focus of this presentation – what worked well in our implementation

AUA project in LTC

AUA project implementation timeline

2013/14

11 Early Adopter Sites

175 LTC sites provincially

Over 100 sites attended Learning Workshops – asked to submit data over 9 months 50 attended education sessions

2014/15 2015/16

2 additional workshops (sleep and preventing delirium) Offered for all 175 sites

10 Early Adopter sites for DSL

Edmonton, Central and Calgary Zones

150 DSL 4/4D (Edmonton, South, Central, North, Calgary) DSL3 in South, Central, North Zones

2016/18

Site and leader engagement Resource development

Positive deviance: “better solutions to a problem than their peers”

• Site tours of 3 sites with VERY LOW use (innovators)

• Medication review processes (required by CCHSS) (became KEY INTERVENTION)

• Team communication – engaged HCAs; pharmacists, etc.

• Engaged leaders; stable leadership; stable teams

Learned from Innovators

• Call for volunteers to participate - wide spread interest/motivation • Criteria: “higher use” sites

• Meetings with leaders/site teams to get ready

• Identification of readiness to change • Leaders support (corporate, site, local)

• Baseline education (dementia competence)

• Data Collection established (RAI Coordinators)

Early Adaptor Sites (EAS)

Innovation Learning Collaboratives • IHI breakthrough series

• 3 x Full day, face-to-face Learning Workshops

(over 9 month period: June, Oct, Feb)

• Action periods: reduce use of antipsychotics

• measured progress on ‘score card’ (measures of success)

Knowledge Translation strategy

• Awareness (hazards of antipsychotics)

• Desire (good news stories of success)

• Knowledge and Ability (behaviour maps; non-pharm

approaches; how to do monthly med reviews; consent with

family;)

• Reinforcement (measurement!!!)

Change management: Prosci© ADKAR

• Positive feedback

from teams, families

• Course corrections

(score card simplified

for provincial spread)

Success of the EAS phase

• Divided LTC sites into ‘high use’ and ‘lower use’ (RAI 2.0 QI for AUA)

• Multiple meetings with zone leaders to negotiate implementation

• 100+ higher use sites participated in Innovation Collaboratives • Series of 7 face-to-face Innovation Collaboratives (3 Edmonton; 2 Central; 2 Calgary)

• Modified IC’s: teleconferences; video links; face to face (North and South zone) (late majority)

• 50+ “lower use” sites attended education sessions (one time session on the resources, no ‘primary data’ collected)

• 5 sites received information (laggards) (invited to IC and education)

Provincial Spread

• Prior to each series of Innovation Collaborative met with Leaders • Reviewed objectives/content

• Expectation of the teams/who to invite

• Resources available (Practice Lead; AUA Toolkit)

• Role of leader in supporting change

• Met with Leaders at end to determine role in “sustaining the gains”

• Senior leaders informed of progress of teams

Leader’s Launch

AUA Toolkit (web-based)

• Strategies for reducing medications (learned during EAS phase)

• Forms for medication reviews

• Education materials (self study modules; power points; posters, pamphlets, video clips)

• Materials to use with family (obtaining consent; pamphlets)

Centrally developed resources

Measures of success • primary data collection

• Submitted monthly to Practice Leads

• 6 areas (appropriate, efficient, effective, safe, acceptable, accessible)

• Excel spread sheet/automated graph so teams could post progress each month: (two required

measures)

Measurement – unit data

OUTCOME: key measure of success • RAI 2.0 Quality Indicator on AUA

• Collected by all LTC sites in Alberta quarterly and submitted to ACCIS (CIHI)

• Publically available on CIHI web page

• able to track impact on other indicators RAI indicators (25 indicators!)

• Un-intended: e.g. physical restraint use

• Intended: communication increased

PROCESS: key clinical intervention • CCHSS – monthly inter-professional medication review required when medication

is a restraint

• AHS audits LTC/DSL sites to CCHSS q 2 years

Measurement: System level data

RAI 2.0 AUA QI from CIHI – 2012 to 2018 (Q2)

0%

5%

10%

15%

20%

25%

30%

35%

40%

2012Q4

2013Q1

2013Q2

2013Q3

2013Q4

2014Q1

2014Q2

2014Q3

2014Q4

2015Q1

2015Q2

2015Q3

2015Q4

2016Q1

2016Q2

2016Q3

2016Q4

2017Q1

2017Q2

2017Q3

2017Q4

2018Q1

2018Q2

AUA - Adjusted Numbers for Rolling Quarters

North Zone

EdmontonZone

Central Zone

Calgary Zone

South Zone

Alberta

Canada

17%

April 23, 2019

Created proxy measure for DSL

DSL Provincial average: 2015-16: 20% 2017-18: 17%

• Quality improvement efforts were valued

by staff and families

• Communication • Project bulletins

• Meetings

• Media releases

“residents are waking up”

1. Unit – ongoing individual and team actions to reduce reliance on antipsychotic medications to help manage behaviours: med reviews; care-planning; family engagement; staff education

2. Site & Organization

Actions to support individuals and team:

monitoring antipsychotic use/corporate indicator;

Fostering a culture that supports person-centred

dementia care

Staff competencies

Successes celebrated

3. Zone – actions to support sites to sustain outcomes

Maintain awareness of AUA project – standing agenda items; auditing

Geriatric Mental Health Consulting teams; physician and pharmacy support

4. System

(AHS, AH) broader system supports

Policy established: CC Standards; AUA Guideline

(updates)

Ongoing monitoring strategy established

Embed AUA concepts in P.I.E.C.E.S. and Supportive

Pathways

Medication Reconciliation

Low antipsychotic

use continues

Supporting AUA Sustainability Post Project

April 23, 2019

• AH – Continuing Care Health Service

Standards (CCHSS) • Requires monthly review restraints including medications

• Consent

• Sites audited for compliance

• AHS – Restraint as a Last Resort

Policy Support

April 23, 2019

• Population needs: older adults with dementia living in LTC/DSL

• Evidence informed decision-making based on:

• data: RAI 2.0 AUA QI

• real experiential evidence: innovators, team learning

• engagement managers and providers to create a culture of

improvement: Innovation Collaboratives

• creating supportive policies and incentives: CCHSS

• building organizational capacity: QI and Change Management

• meaningful engagement with patients/families: consent/care planning.

CFHI’s 6 levers

Questions? Discussion?

April 23, 2019