monitoring for inappropriate use of antipsychotic medications f428 – drug regimen review process...
TRANSCRIPT
Monitoring for Inappropriate
Use of Antipsychotic Medications
F428 – Drug Regimen Review Process
F329 – Unnecessary Medications
Margie Huguet, RN, MCSDHH Health Standards Section
Long Term Care Supervisor
10 Steps to Eliminate Off-Label Antipsychotic Use1. Establish A Leadership
Team 2. Review CMS Survey
Guidance to Understand Why and How
3. Analyze MDS CASPER Resident Level Quality Measure Report to Identify Target Population and Coding Errors
4. Triage: Review Why Each Resident is Receiving Antipsychotics and Take Care of Easy-to-Act-On Situations
5. Train Staff on Why and How to Reduce Antipsychotics
6. QI Closest to the Resident – Track and Trend and Care Plan
7. Engage Physicians, Prescribers, Consultant Pharmacist
8. Engage Families9. Update your policies,
procedures and forms 10. Sustain and Spread
©B&F Consulting 2015www.BandFConsultingInc.com
Objectives:1. Discuss the Drug Regimen Review
(DRR) process (F428) and its role in assisting NHs in monitoring the inappropriate use of antipsychotic medications.
Pharmacy Consultant
F425- Pharmacy ServicesConsultant Pharmacist
F425 - Pharmacy Services in a Nursing Home
Overall Goal is to ensure safe and effective use of medications; (b)Service Consultation
The Licensed pharmacist:collaborates with facility leadership and
staff to coordinate the services;helps the facility identify, evaluate, and
address/resolve pharmaceutical concerns and issues that affect resident care, medical care or quality of life.
F425- Pharmacy Services
The pharmacist is responsible for: Helping the facility obtain and maintain
timely and appropriate pharmaceutical services that support residents’ healthcare needs, that are consistent with current standards of practice, and that meet state and federal requirements.
Participating on the ID Team to address and resolve medication-related needs or problems.
Developing procedures and guidance regarding when to contact a prescriber about a medication issue and/or adverse effects, including what information to gather before contacting the prescriber;
F425- Pharmacy ServicesConsultant Pharmacist
Nursing
Safeguards against Med Issues
The physician providing and reviewing the orders and total program of care on admission and the prescriber reviewing at each visit;
The nurse reviewing medications when transmitting the orders to the pharmacy and/or prior to administering medications;
The interdisciplinary team reviewing the medications as part of the comprehensive assessment for the Resident Assessment Instrument (RAI) and/or care plan;
The pharmacist reviewing the prescriptions prior to dispensing; and
The pharmacist performing the medication regimen review at least monthly.
F425- Pharmacy Services
F428 – Drug Regimen Review1. The drug regimen of each resident must
be reviewed at least once a month by a licensed pharmacist.
2. The pharmacist must report any irregularities to
1. the attending physician, and 2. the director of nursing, and
these reports must be acted upon
F428- Drug Regimen Review
What is a Medication Regimen Review? A thorough evaluation of the medication
regimen of a resident, with the goal of promoting positive
outcomes and minimizing adverse consequences associated with medication.
The review includes preventing, identifying, reporting, and
resolving medication-related problems, medication errors, or other irregularities,
and collaborating with other members of the interdisciplinary team.
F428- Drug Regimen Review
What is an irregularity? Refers to any event
that is inconsistent with usual, proper, accepted, or right approaches to providing pharmaceutical services, or
that impedes or interferes with achieving the intended outcomes of those services.
F428- Drug Regimen Review
True or False
F428- Drug Regimen Review
Regulatory Language – F329(I)Drug Regimen must be Free from Unnecessary Drugs
Any drug when used:I. In excessive dose (including duplicative
therapy); orII. For excessive duration; orIII. Without adequate monitoring; orIV. Without adequate indication for its
use; orV. In the presence of adverse
consequences which indicate the dose should be reduced or discontinued; or
VI. Any combination of the reasons above.
F329- Drug Regimen Free from Unnecessary Drugs
Identification of Irregularities
The pharmacist’s review considers factors such as:
Whether the physician and staff have documented objective findings, diagnoses and/or symptom(s) to support indications for use;
Whether the physician and staff have identified and acted upon, or should be notified about, the resident’s allergies and/or potential side effects and significant medication interactions (such as medication-medication, medication-food, medication-disease, medication-herbal interactions);
Whether the medication dose, frequency, route of administration, and duration are consistent with the resident’s condition, manufacturer’s recommendations, and applicable standards of practice;
F428- Drug Regimen Review
Identification of Irregularities
Whether the physician and staff have documented progress towards, or maintenance of, the goal(s) for the medication therapy;
Whether the physician and staff have obtained and acted upon laboratory results, diagnostic studies, or other measurements (such as bowel function, intake and output) as applicable;
Whether medication errors exist or circumstances exist that make them likely to occur; and
F428- Drug Regimen Review
Identification of Irregularities
possible medication-related causes of recent or persistent changes
F428- Drug Regimen Review
Monitoring The ongoing collection and analysis of
information (such as observations and diagnostic test results) and comparison to baseline date in order to: Ascertain the response to treatment and
care;
Detect complications/adverse consequences;
Support decisions about modifying, discontinuing, or continuing any interventions.
F428- Drug Regimen Review
F329 - Antipsychotic Drugs2. Antipsychotic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that: (i) 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 (ii) Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.
F329- Drug Regimen Free from Unnecessary Drugs
GDR – Gradual Dose Reduction
Seeking an appropriate dose and duration and minimizing the risk of adverse consequences;
To find an optimal dose or discontinue dose; When clinical condition has improved/ stabilized,
When underlying causes of the original target symptoms have resolved, and/or
When non-pharmacological interventions, including behavioral interventions, have been effective
F329- Drug Regimen Free from Unnecessary Drugs
GDR - for Antipsychotics Within the 1st year in which a resident is
admitted on an antipsychotic medication or after the facility has initiated an antipsychotic medication, 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
F329- Drug Regimen Free from Unnecessary Drugs
GDR – Clinically Contraindicated
Continued use is in accordance with relevant current standards of practice and ;
physician documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident’s function or increase distressed behavior; or
target symptoms returned or worsened after the most recent attempt at a GDR
F329- Drug Regimen Free from Unnecessary Drugs
If we don’t medicate what else can we do?
Non-pharmacological interventions are approaches to care that do not involve medications, generally directed towards stabilizing or improving a resident’s mental, physical or psychosocial well-being.
“Behavioral interventions” are individualized non-pharmacological approaches (including direct care and activities) that are provided as part of a supportive physical and psychosocial environment, and are directed toward preventing, relieving, and/or accommodating a resident’s distressed behavior.
F329- Drug Regimen Free from Unnecessary Drugs
Surveyor Triggers- Possible Irregularity
Drug Regimen ReviewA form of
Quality Assurance & Performance Improvement
F428- Drug Regimen Review
Drug Regimen Review Findings The pharmacist is expected to document
either that no irregularity was identified or the nature of any identified irregularities.
The pharmacist is responsible for reporting any identified irregularities to the attending physician and director of nursing.
F428- Drug Regimen Review
Drug Regimen Review Findings Considered part of each resident’s clinical
record.
Maintained within the facility and is readily available for review.
The ID team is encouraged to review the reports and to get the pharmacist’s input on resident problems and issues.
F428- Drug Regimen Review
Response to Irregularities The physician either accepts and acts
upon the report and potential recommendations
or rejects all or some of the report and
provides a brief explanation of why the recommendation is rejected, such as in a dated progress note.
F428- Drug Regimen Review
DON addresses/documents actions taken for: recommendations that do not require a
physician intervention, such as one to monitor vital signs or weights
F428- Drug Regimen Review
Think About It
Policy’s and Procedures Do you have one? Is it consistent with current Standards of
Practice?
AMDA Letter to Medical Directors – P&Ps that promote: a process of person-centered care learning the story behind each resident evaluating the behavior changes and excluding potential medical
causes of the behavioral symptoms
P&P should direct the staff to identify resident specific needs, optimize
choices, and promote consistent assignments Foster education of staff to ensure understanding of dementia-
related behavior as a form of communication Use of non-pharmacological interventions to address behaviors Address proper monitoring
Sample Psychotropic Med P/P – Advancing Excellence Website – Under Physician Tools
Step 9Updating Policies , Procedures, and forms
Sample Form: Psychotropic Medication Tracking Tool
AHCA/NCAL Quality Initiative – Antipsychotic Management Tool
Step 9Updating Policies , Procedures, and forms