National Partnership to Improve Dementia Care in Nursing Homes & Quality Assurance and Performance Improvement (QAPI)

December 14, 2017

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• AHCA - American Health Care Association

• BPSD - Behavioral and Psychological Symptoms of Dementia

• CDC - Centers for Disease Control and Prevention

• CMP - Civil Money Penalty

• DON - Director of Nursing

• IDT - Interdisciplinary Team

• MVH - Maine Veterans’ Homes

• PIP - Performance Improvement Project

• PRN - Pro Re Nata

• QAA - Quality Assessment and Assurance

• QAPI - Quality Assurance and Performance Improvement

• QIN-QIO - Quality Innovation Network – Quality Improvement Organizations

• SHC - Signature HealthCARE

• SNF - Skilled Nursing Facility

• TO - Telephone Orders

• UTI - Urinary Tract Infections

Acronyms in this Presentation

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Working with Physicians to Ensure Dr. Arif Nazir, Signature HealthCARE

Compliance with the New Psychotropic

Prescribing Requirements

Putting the New QAPI Requirements Debra Lyons, CMS

into Practice Debra Fournier, Maine Veterans' Homes

Sarah Schumann, Brookside Inn (Colorado)

Agenda

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Working with Physicians to Ensure Compliance with the New Psychotropic Prescribing Requirements

Arif Nazir MD FACP CMD

Associate Clinical Professor of Family and Geriatric Medicine,

University of Louisville,

Chief Medical Officer, Signature HealthCARE

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• Describe prevalence of behaviors among residents living with dementia in Skilled

Nursing Facilities (SNF)

• List serious side effects of pharmacologic options

• Describe role of physician leaders in appropriate psychotropic prescribing

• Describe impact of facility culture and staff competence for high quality care for

dementia

Objectives

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• A 3-star urban facility with 125 beds

• Psychotropic rates are above State average

• At the QAPI meeting Director of Nursing (DON) announces “we will cut

psychotropics by 50%”

• Committee is formed and Dr. Smith (medical director) is invited

• The DON and social director are other members

• What’s the best initial advice Dr. Smith should provide?

QAPI at Happy Fellows Facility

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1. Utilize pharmacy consultant better so he can provide a taper schedule on all

residents, unless contraindicated

2. Facility assessment of quality of care and team member competence

3. Ask hospital psychiatrist to provide consulting services at the facility

4. Build a multi-sensory room by next quarter

Select Best First Step to Impact Psychotropic Use

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• Of the estimated 5.5 million Americans living with Alzheimer's dementia in 2017, an

estimated 5.3 million are age 65 and older

• BPSD affect up to 90% of those diagnosed with dementia at any given point in the

duration of their illness

Prevalence of Behavioral and Psychological Symptoms of Dementia (BPSD)

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BPSD

• Verbal or Physical

• Aggression

• Personality clashes

• Wandering

• Depression

• Resistance with activities of

daily living

• Screaming• Suspiciousness,

accusations, paranoia• Insomnia• Repetitive questions or

demands• Sexually inappropriate

1) Baumgarten M, et al. Ann Intern Med 1994

2) 2) International Psychogenic Association, Behavioral and Psychological Symptoms of Dementia Educational Pack,

Module 4, 1998

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• Impaired quality of life

• Rapid cognitive decline, and tremendous caregiver burden

• Shortened time to nursing home placement by as much as 2 years

• Some studies report increased mortality

• Higher cost of care

Effects on the Resident

Phillips VL, Diwan S, J Am Geriatr Soc. 2003;51{2}:188-193

Salzman C, Jeste DV, Meyer RE, et al. J clin Psychiatry.2008:69(6):889-898

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• Three possible strategies:• Use non-pharmacologic approach

• Use pharmacologic approach

• Use a combo

• But how to decide?

• Taking the best approach requires sound person-centered reasoning

• Besides the Interdisciplinary Team (IDT), role of physicians, other practitioners, and

medical directors is critical

Tackling BPSD in Nursing Homes

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• Collect and analyze information

• Detailed problem identification

• Decide on interventions

• Monitor and adjust

Assessing BPSD: No Different than other Clinical Conditions

Reforming Management of Behavior Symptoms and Psychiatric Conditions in Long-Term Care Facilities: A Different Perspective.

Levenson, Steven A. et al. Journal of the American Medical Directors Association , Volume 18 , Issue 4 , 284 - 289

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• Accept heterogeneity and drop “biases”

• Most symptoms are non-specific and not diagnostic

• Caution against treating prematurely (e.g. agitation)

• Premature intervention could lead to harm

• Team needs to decipher the “story” behind the complaint and its impact on the

resident and others

• Important to consider broad differential diagnosis

BPSD Assessment Key Principles:

Reforming Management of Behavior Symptoms and Psychiatric Conditions in Long-Term Care Facilities: A Different Perspective.

Levenson, Steven A. et al. Journal of the American Medical Directors Association , Volume 18 , Issue 4 , 284 - 289

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• Medical causes: delirium, medical conditions, medications

• Major psychiatric causes: psychosis, exacerbation of chronic mental illness

• Mood and anxiety disorders: anxiety, depression, demoralization, etc.

• Other: rare medical causes, substance-abuse, personality disorder

• Role of dementia and other neurocognitive disorders

• Role of environmental and psychosocial causes

Differential Diagnosis:

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Facility Factors May Contribute to BPSD

Personnel Environmental

Changes in schedule

Changes in caregivers

Rushing with care

provided

Not talking to and

comforting the resident

Surprising the resident

Noisy areas – or areas

with many sources of

noise at one time

Poor lighting

Rooms that are too hot

or too cold

Being left alone for long

periods of time

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• Vitals and detailed examination every time

• Assessing and managing pain (avoid opioid use as first-line)

• “Cleaning” diagnoses list (encephalopathies, psychosis, delirium, organic brain

syndrome, etc.)

• Comprehensive medication review with de-prescribing questionable medications

• Formal Advance Care Planning to understand resident/family/representative goals

of care

Key Broad Interventions

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• Music therapy

• Activities and physical exercise

• Light therapy

• Aromatherapy

• Interactive dolls and pets

• Cognitive rehabilitation

• Multi-sensory rooms

Individualized Non-Pharmacologic Approaches

De Oliveira AM, Radanovic M, de Mello PCH, et al. Nonpharmacological Interventions to Reduce Behavioral and

Psychological Symptoms of Dementia: A Systematic Review. BioMed Research International. 2015;2015:218980.

doi:10.1155/2015/218980.

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• Avoid generic approaches including sole focus on de-prescribing

• Individualize care plans for specified behaviors and document impact of intervention

• Modify plan as new “intel” received

• Intensify monitoring if medication is added with clear criteria to adjust/discontinue if

ineffective

• Role of consultants is key, they need to be integrated into the team

Active Monitoring of BPSD

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• Not U.S. Food & Drug Administration approved for BPSD

• Serious adverse effects (pneumonia, stroke, and death)

• >1.5 times mortality risk (atypical and conventional antipsychotic agents)

• For BPSD used after non-pharmacologic approaches maximized and detailed risk/benefit discussions

• Residents living with dementia at high risk of inappropriate use

• SNFs with large number of providers at high risk of inappropriate use

How About Antipsychotic Rx Options?

Organizational Factors Associated With Inappropriate Neuroleptic Drug Prescribing in Nursing Homes: A Multilevel Approach.

Laffon de Mazières, Clarisse et al. Journal of the American Medical Directors Association , Volume 16 , Issue 7 , 590 - 597

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• Systematic review of 23 double blind randomized controlled trials

• Conclusion: Aripiprazole and Risperidone may show benefit that may be offset by

adverse effects

Antipsychotic Medications: Are there Benefits?

Tan et al. Alzheimer's Research & Therapy (2015) 7:20;DOI 10.1186/s13195-015-0102-9

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• Review resident’s overall health/care

• Clear definition and documentation

• Regular orientation/interaction needed (just like 3 hour turning!)

• Medications will not help unless etiology addressed

• Multipronged intervention

• Recurrence is high and expected

• Stop medications once wound is healed

Think of Behavior as a Pressure Ulcer

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1. Utilize pharmacy consultant better so he can provide a taper schedule on all

residents, unless contraindicated

2. Facility assessment of quality of care and team member competence

3. Ask help from hospital psychiatrist to provide consulting services at the facility

4. Plan to build a multi-sensory room by next quarter

Back to Case: Select Best Advice By Dr. Smith

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• Review overall care practices:• Person-centered approaches, staff competence broadly and around behaviors, polypharmacy,

INTERACT etc.

• Behavior team that includes a physician, frontline staff, pharmacy, social services,

nursing

• Focus on documenting, assessing, and monitoring behaviors

• Detail history (resident/family/staff) to plan non-pharmacological measures

• Use psychotropics as last resort:• Risk/benefit discussion with resident/family/representative

• Target behaviors noted/monitored after start of treatment

• Clear documentation about side effect monitoring

• Consider gradual dose reduction once behaviors resolve

• Psychiatric consultation for difficult behaviors, only after doing “homework”

Recommended Plans for Improving Behavior Care at Your Facility

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• Psychotropic definition expansion: any drug that affects brain activities associated

with mental processes and behavior (antipsychotic, anti-depressant, anti-anxiety,

hypnotic)

• Pro Re Nata (PRN) use limited to 14 days with extension based on prescriber

rationale

• Renewal of anti-psychotic medications requires prescriber evaluation of the resident

Recent Changes to Antipsychotic and Psychotropic Prescribing-Final Rule

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Updated Pharmacy Tags

F757

Drug Regimen is Free From

Unnecessary Drugs F329

F758

Free from Unnecessary Psychotropic

Medications/PRN Use F329

F758

Free from Unnecessary Psychotropic

Medications/PRN Use F428

F759

Free of Medication Error Rates of 5%

or More F332

F760

Residents Are Free of Significant

Medication Errors F333

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• For all psychotropics: • Attempt in 2 separate quarters separated by month (unless clinically contraindicated)

• After 1 year, perform annually unless contraindicated

• Clear prescriber documentation needed for psychotropics, regardless of the

indication - dementia vs. bipolar, schizophrenia, other psychoses• Why it is being used

• What non-pharmacologic approaches have been tried

Gradual Dose Reduction Schedules

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Clinical Practice Guidelines

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Signature HealthCARE Holistic Approach

Person-centered

BPSD Care

Staff Training

Quality of Life

Initiatives

Medical Director

Role

Special Team

(Serenity Care)

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• Setting expectations around key aspects of their role

• Ongoing education through articles and webinars

• Their role in disseminating evidence-based practices

• Role in resident-side education for IDT

• Focus on polypharmacy (not just psychotropics)

• Specialized focus on Advance Care Planning discussions

• American Medical Directors Association membership and professional development

• Medical Director Scorecard (coming soon)

Engaging Medical Directors

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• iCARE approaches

• Eden Alternative registries

• Resident vacations

• Senior Olympics

• Patient surveys

• Others

Signature HealthCARE (SHC) Quality of Life Initiatives

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• Customer service training provided to all stakeholders

I-Care Approaches

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• 46 registered; 2 Milestone 4, 13 on Milestone 3, and rest on Milestone 2

Eden Alternative Registry

General Stores offer purpose! Archie’s Café is a replica of a local favorite!

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• Creating “normalcy” in resident’s lives

• Offering residents new opportunities for growth and exploration

SHC Resident Vacations

Celebrating their 60th at Disney World! First time at Fenway Park!

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• Increases/improves self-esteem and confidence

• Competition is part of normal life!

Senior Olympics

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• Summer Camps

• After school groups

• “Snow Days” groups

Intergenerational Connectedness

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• Serenity Development Model• Behavioral specialists

• Free-Standing Behavioral Health Centers (nursing facilities specializing in behavioral health)

• Behavioral Risk Management Center – a call center to assist residents with the management of

chronic behavioral health

Serenity HealthCARE

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• BPSD are burdensome for residents and staff

• Physicians and medical directors are key team members

• Focus on facility culture and competence for high quality care lays the foundation

• Detailed history and assessments are key to individualized care for BPSD

• If used, antipsychotic medications should be regularly reviewed and dose-

reduction performed

Summary

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• Arif Nazir MD

anazir@shccs.com

989-906-3932

Thank You!

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Putting the New QAPI Requirements into Practice

Debra Lyons, CMS

Debra Fournier, Maine Veterans' Homes (MVH)

Sarah Schumann, Brookside Inn - Colorado

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Phase 2 QAPI Requirements – Effective November 28, 2017

F865 – QAPI Plan Describe the process for conducting Quality Assessment and Assurance (QAA)

activities (identifying/correcting quality deficiencies)

F866 – QAPI/QAA Data

Collection &

Monitoring

Phase 3 (November 28, 2019)

F867 – QAPI/QAA

Improvement Activities

Facilities must identify and correct their own quality deficiencies/issues

F868 – QAA Committee Be composed of:

• Director of Nurses

• Medical Director (or designee)

• At least 3 other staff (one must be Administrator, Owner, Board Member,

or other person in leadership role)

• Infection Preventionist – Phase 3 (November 28, 2019)

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MVH:• An independent non-profit organization caring for Maine’s Veterans and their families

• 5 skilled nursing care centers ranging from 40-120 beds each

• Core values of excellence, team, and lead the way are driving direction of programs

• Strategic priority is hardwiring excellence

• American Health Care Association’s (AHCA) Quality Award Program

• Performance Excellence Framework from Malcolm Baldrige Quality Program

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Where did we start?

• Structure• QAA committees were in place at the homes

• Began applying for AHCA Bronze Level Quality Award

• Organizational profile

• Formed a corporate steering committee: QAPI Workgroup

• Senior leaders from 6 homes and central office

• Developed charter for the workgroup

• Develop and implement MVH QAPI plan

• Develop and implement a results dashboard

• Develop a data driven decision making culture that is transparent without blame

• Implemented governing body oversight and reporting structures

Putting QAPI into Practice

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What tools did the MVH QAPI

Workgroup use to develop the

QAPI Program and Plan?

• QAPI self-assessment

• QAPI at a glance

• Performance Excellence FrameworkR

• Prioritization and key measure matrix

tools

Tools for QAPI Program and Plan Development

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What tools were used to operationalize

QAPI?

• Standardized QAPI education

• MVH Results Dashboard

• Plan Do Check Act methodology for

improvement

• Performance Improvement Project (PIP) tools

and education

• Root Cause Analysis tools and education

• Prioritization Matrix tool

• Data Monitoring Matrix tool

• Staff town hall meetings

Tools to operationalize QAPI

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• Education – 21 times to learn new behaviors and hardwire

• Data Analysis

• PIP Facilitation

• Champion

• Leadership, Leadership, Leadership

• Importance of Improvement Mindset

Challenges

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• Best in class resident and family satisfaction

• 4 AHCA Silver Quality awards

• 1 AHCA Gold Quality award

• 4 – 5 star facilities

• 2017 recognized as Best Place to

work in Maine

Successes

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Next steps• Facility Assessment

• Continued hardwiring of systems for sustaining excellence

• Celebration and acknowledgment of achievements and successes

Next Steps

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• Debra Fournier, MSB, CPHQ, NHA

Chief Operations Officer

Maine Veterans’ Homes

dfournier@mainevets.org

mobile: 207-671-1996

Contact Information

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• Independently owned, serving 120 residents

• Commitment to Quality• QAA monthly meetings since inception (20 years)

• Recipient of Silver Award based upon Baldrige Criteria through AHCA

• CMS Five-Star Quality Rating

Brookside Inn Skilled Nursing Facility

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• Identify a Champion

• Involvement and commitment from Board for QAPI

• “We have data, lots of data”

• “Now what do we do???”• Review data and compare to the QAPI dashboard goals

• Do a root cause analysis and PIP if appropriate

• Review daily at IDT meeting, weekly to subcommittees and/or QAPI as appropriate

• Communication to and involvement of staff, residents and family about QAPI PIPs

QAPI Evolution at Brookside Inn

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• Telligen – Colorado Quality Innovation Network – Quality Improvement

Organizations (QIN-QIO)

• AHCA

• Colorado Medicaid Pay for Performance Program

• CMS resources – QAPI tools, QAPI self-assessment

• Team training by Board, each other and by consultant

• Colorado Department of Public Health and Environment – Epidemiology Division

• Electronic Medication Administration Record and Software Systems

Resources Utilized to Implement QAPI

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Establish a process and educate to that process• Identify a Champion – Director of Nursing Services available 24/7 to support staff

• Constant communication and education to staff, physicians, residents

• Commitment of Brookside Inn for non-pharmacological interventions

• High psycho-social staffing pattern (1:12 ratio)

• Complementary and Alternative Modalities

• Spiritual Services program

• IDT reviews telephone orders (TO) daily

• Review, track and trend data at QAPI

• Compare outcomes to established goals

• Root cause analysis and PIP as needed

• Adjust process, implement new interventions

• Monitor results and success

QAPI Projects: Medication Review and Reduction Success

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• Communication

• Abundance of Data

• Maintaining a focus on QAPI with all of the competing demands

• New Requirements of Participation: Integrating the Facility Assessment

• Changes in staff, physicians and residents• Continual education required

QAPI Projects: CHALLENGES

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• Champion

• Created and implemented process

• Dementia training

• Non-pharmacological interventions

Antipsychotic Medications: 2012 Became our Community Focus

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• Implemented Centers for Disease

Control and Prevention (CDC)

Core Elements of Antibiotic

Stewardship in long-term care

• McGeer’s Criteria implemented

for urinary tract Infections (UTI),

upper respiratory infections, skin

& soft tissue infections

Antibiotic Stewardship: 2015 Became our Community Focus

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• January 2017 began to track community usage

• Champion

• Implemented process utilized for psychotropic and antibiotics stewardship

• CMS and CDC resources for calculating the total daily dose of opioids

• Review TOs daily

• Pharmacy consultant critical to success

• Year to date success: reduction of 5 prescriptions in our community, with pain still

being managed

Opioid Medications: 2017 Became our Community Focus

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• Sarah C. Schumann, M.Div.

Brookside Inn Skilled Nursing Facility

Castle Rock, CO

sarah@bsisnf.com

720-573-4335

Contact Information

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• CDC Calculating Total Daily Dose of Opioids for Safer Dosage

• CMS Opioid Oral Morphine Milligram Equivalent Conversion Factors

• Nursing Home QAPI Webpage

• QAPI Written Plan - How To Guide

• QAPI at a Glance

• QAPI Self-Assessment Tool

• Baldrige Excellence Framework

• Locate your QIN-QIO: http://qioprogram.org/contact

QAPI Resources

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National Partnership Updates

Michele Laughman, CMS

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National Data

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Regional Data

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• Nursing homes with low rates of antipsychotic medication use are encouraged to

continue their efforts and maintain their success

• Nursing homes with high rates of use are to work to decrease antipsychotic

medication use by 15 percent, for long-stay residents, by the end of 2019

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-10-02.html

2019 Goal

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Best Practice Strategies:• Direct facility outreach

• Workshops and conferences

• Training opportunities (i.e., Hand in Hand training series)

• Use of Civil Money Penalty (CMP) funds for –

• Education/Training

• Conferences

• Implementation of person-centered intervention strategies (i.e., Music and Memory Program)

State Dementia Care Coalition Best Practice Strategies

State Dementia Care Coalitions

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• Collaboration with State Dementia Care Coalitions, CMS Regional Offices, and

State Survey Agencies

• Comprehensive focus on poor performing nursing homes

• Focused Dementia Care and Schizophrenia Surveys

• Revision of Hand in Hand training series

• Data tracking and distribution

• Federal CMP fund initiative

• Medicare Learning Network calls

What’s Ahead

65National Nursing Home Quality Improvement Campaign Webpage

Resources & Tools

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• Visit the National Partnership to Improve Dementia Care in Nursing Homes

webpage

• Contact us at dnh_behavioralhealth@cms.hhs.gov

National Partnership Resources

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Question & Answer Session

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