Nursing Home Initiative on Behavioral Health & Antipsychotic Medication Reduction

{music} {music} (Dr. Patrick Conway): Good afternoon and welcome to the introductory event for CMS' National Initiative to Improve Behavioral Health and Reduce the Use of Antipsychotic Medications in Nursing Home Residents. I'm Dr. Patrick Conway, Chief Medical Officer for the Centers for Medicare & Medicaid Services (CMS) and Director of the Office of Clinical Standards and Quality. CMS is developing a national action plan to improve behavioral health and to safeguard nursing home residents from unnecessary antipsychotic drug use. We are attacking this problem by raising public awareness, using regulatory oversight and technical assistance or training, public reporting to increase transparency and by conducting research. CMS hopes to enhance person-centered care for all nursing home residents, particularly those with dementia-related behaviors. Along with our partners, we have set a goal for this national initiative to reduce the use of antipsychotic drugs in nursing home residents by 15% by the end of calendar year 2012. For example, if rates are currently around 20%, a 15% reduction would mean a goal of 17% for our initiative. This means, that approximately 18,000 fewer residents per year will be on these drugs. The official start date of this initiative, the point at which we will begin to collect baseline measures, will be April 1st. We anticipate that data on each nursing home's antipsychotic drug use will be posted on Nursing Home Compare by July. In addition, the initiative will also look to reduce the use of anti-psychotic agents in short stay residents. CMS will continue to work closely with Advancing Excellence and many other national health care associations to align on a common set of goals for this initiative. Some questions that we hope to answer are: How can nursing homes work with families and residents to optimally address certain behaviors through non-drug interventions and using environmental modifications, and how can we measure this? How can we make these efforts and successes known to families who are seeking long-term care for their loved ones? CMS will focus on developing training opportunities for providers, clinicians and surveyors, and disseminating those trainings through our partnerships with many other organizations. Hand in Hand, a training series developed for CMS, provides nursing homes with a high-quality training program that emphasizes person-centered care, prevention of abuse and care of persons with dementia. CMS will distribute this DVD and the instruction guide to all nursing homes this spring. Specifically for state and federal surveyors, we will offer a series of trainings with a focus on behavioral health and person-centered care. We are grateful for the active engagement and strong support for this work by the advocacy community. Several organizations have come forth and pledged their support for this initiative. They are valued partners, representing nursing home residents and their families in this endeavor and ensuring that the voice of residents with dementia is always heard, and their needs are not forgotten. I hope you find today's kick-off event to be both exciting and energizing. We challenge all of you to become involved in this national initiative at your local, community level. It is only through your ongoing commitment, leadership and grass roots support that we will reach our goals. CMS looks forward to your partnerships in the critical work that lies ahead. Thank you very much for your ongoing efforts to improve the lives of nursing home residents. (Moderator - Nicki Brandt): Hello. My name is Nicole Brandt, I'm a Consultant for the Division of Nursing Homes in the Office of Clinical Standards and Quality within the Centers for Medicare & Medicaid Services, as well as an Associate Professor at the University of Maryland, School of Pharmacy and consultant pharmacist at a continuing care retirement community. I will be the moderator for today's discussion on CMS' National Initiative to Improve Behavioral health for nursing home residents. Our experts today are divided into two groups. The first group includes: Dr. Susan Levy, Medical Director and Vice President of Medical Affairs at Levindale Hebrew Geriatric Center and Hospital; Sarah Greene Burger, Coordinator for the Hartford Institute's Coalition of Geriatric Nursing Organizations and Thomas Clark, Director of Clinical Affairs for the American Society of Consultant Pharmacists and ASCP Foundation and Executive Director for the Commission for Certification in Geriatric Pharmacy. To begin our panel discussion, we are pleased to have Dr. Peter Rabins, who is currently Richman Family Professor for Alzheimers and Related Dementias and the Director for the Division of Geriatric Psychiatry and Neuropsychiatry at Johns Hopkins. He is well known for his extensive clinical work and advocacy on the care of patients with dementia. Dr. Rabins thank you so much for sharing your expertise as well as a case that illustrates a typical scenario seen in nursing homes. (Dr. Peter Rabins): Thank you Nicki. Every day in nursing homes across the country, residents, families, clinicians and staff members work together in an effort to provide a safe, comfortable, nurturing environment for residents and their caregivers. Frequently, residents with dementia and related conditions demonstrate behavioral symptoms that suggest they are experiencing an unmet need - something in the environment that is confusing or upsetting, in essence, a lack of comfort. The resident may only be able to communicate this through non-verbal behaviors, sometimes known as Behavioral or Psychological Symptoms of Dementia, or BPSD. Today, we're going to present a typical, yet fictional scenario; following the depiction of this setting, you'll hear from a panel of residents, advocates, clinicians and policy-makers about how we can work together to optimize care for residents like this. Margaret Jackson is an 84 year old long term care resident who has lived at Stone Valley Manor Nursing Home, a fictitious facility, for 2 years. Mrs. Jackson has a diagnosis of dementia, and a history of aggressive behaviors, including striking out at other residents and staff, causing physical harm, and refusing care. Stone Valley Manor does not have a dedicated dementia unit; therefore, residents with dementia live on units with residents who do not have dementia as well. It is 12:30 in the afternoon; lunch has just ended. Mrs. Jackson tries to get up and leave the dining room but is very unsteady. It is noisy and the food carts are near her table. She tries to move one of them, and another resident starts yelling, which upsets Mrs. Jackson. As Mrs. Jackson raises her hand to strike the woman, Gloria, a CNA approaches her in a calm manner, speaking quietly and mentioning her daughter's name. Gloria reminds Mrs. Jackson that they were going to take a walk outside after lunch, it's time to get their coats. Mrs. Jackson turns to say a few last words and shake her fist at her tablemate, but Gloria (who knows the resident well because of the facility's use of consistent assignment) continues to speak calmly and redirect her, knowing that Mrs. Jackson loves being outside and usually responds to the offer of a walk. This non-pharmacologic intervention is in her care plan as an intervention to try when she demonstrates these behaviors. The situation de-escalates and Mrs. Jackson returns to a calm state. Later that evening, at about 10:00 pm, Mrs. Jackson is up wandering the halls, now even more unsteady. With her poor vision and the low lighting, she misperceives shadows and other objects in the environment. She is anxious and fearful, going in and out of other residents' rooms. Laurie, a nurse on her med pass for 30 residents, hears screaming coming from one of the rooms. Upon entering, Laurie observes Mrs. Jackson turning over the bedside stand and throwing the water pitcher (narrowly missing her roommate), saying, "these things are no good, we have to get rid of them!" The other resident in the room appears very frightened. Laurie asks a CNA to come and stay with Mrs. Jackson while she calls the physician. Laurie tells the physician that the resident has been exhibiting behavioral symptoms all day, and that the situation appears to be getting worse. The physician asks if the nurse has tried any non-pharmacologic interventions, whether anything in particular has worked in the past with this resident. Laurie says that they have fewer staff on evenings, and she is worried that she doesn't have enough people to monitor the resident, who has a history of striking other residents and staff. The physician suggests that the CNA try walking with the resident for a while, since that seemed to work before. The physician also says that if that doesn't work, the nurse should call back and the physician would consider other alternatives (such as a medication). After 10 minutes, the resident is still yelling and the staff has not been able to calm her down with the usual techniques (her favorite snack, mentioning her daughter's name, walking). The physician says that she is going to prescribe an antipsychotic medication at a low dose for just 72 hours (through the weekend) until the resident's primary care team can re-evaluate her and determine whether or not the medication should be continued. The nurse agrees with the plan. The physician and nurse discuss how the staff will monitor the medication for potential side effects and also to determine whether or not it is working to reduce the resident's symptoms. The physician tells the nurse that she will contact the resident's family to review the decision and ensure that they agree with the plan of care. At the care planning conference the next week, Mrs. Jackson's daughter and the team review the recent incident that led to the use of the antipsychotic medication. The daughter points out that she had been away the previous week, and that her mother often has an escalation of behaviors when the family misses their daily visits with her. After reviewing other potential factors, the team determines that the antipsychotic medication should not be resumed on a long term basis, but develops a plan to monitor Mrs. Jackson's behaviors. (Nicki Brandt): Thank you very much, Dr. Rabins. At this time, let's get some input from our panel. Dr. Levy, as a practicing geriatrician, what factors do you consider when assessing a resident like Mrs. Jackson? (Dr. Susan Levy): Sure, Nicki. What's really important is that we discuss the need to actually get the whole story, with enough details about why the behaviors may be happening with this individual resident - could the environment actually be causing or contributing to the behaviors? And also while the team did use a medication in this case, perhaps non-pharmacological interventions would have worked also, and would have been safer. So in this case, one might make the argument that more information could have been gathered first, before the team decided to use a medication. We want to look for environmental triggers of the behavior. Typically, residents with dementia have lower thresholds for developing anxiety and agitation. Creating a positive environment may reduce some of these behaviors. Sundowning is common in residents with dementia and may be managed by increasing exposure to light, structuring different activities, staffing differently, particularly around shift changes. Again, there's a lot we can do to create a positive environment. (Nicki Brandt): Dr Levy, can you share with us the importance of staff training and the different approaches that you've seen at the facilities where you have worked? (Dr. Susan Levy): We need to train our nursing assistants to identify changes early... as well as train our nurses to do a thorough assessment to help to identify the reason for the changing condition. There are evidence-based programs for this, such as the INTERACT II program, with free, online resources available. (Nicki Brandt): Could you give us an example of how you work with the interdisciplinary team and effective ways to communicate not only with the nursing staff but also the family and caregivers? Do you encourage the nursing staff to contact you with any change in behavior (even if it's a minor one) and how do you communicate this? (Dr. Susan Levy): I encourage frequent and early communication if the nurses are seeing behaviors indicating that the resident may not feel a sense of comfort or that there could be something else going on, they need to be in touch early. Conducting periodic behavioral rounds in the facility is another way of sharing information. If we determine that it is most likely related to the dementia, then first we try non-pharmacological interventions - some other panelists will speak more about that today. Also, we may consider that if there are hallucinations or delusions and they're pleasant, they might not need to be medicated! But if a medication is needed, if we identify that it may be needed, there are some things doctors should consider, for example: Ensure lowest dose is used for the appropriate (shortest) time period; Coordinate with other prescribers to ensure appropriateness; Always engage and involve the family/caregiver, as well as all of the interdisciplinary team members, in the care planning and decision-making process. (Nicki Brandt): Dr. Levy, as a practicing geriatrician specializing in caring for individuals with dementia, you have much training and experience. What about practitioners or prescribers who don't have that experience - what resources exist out there to help them in working in nursing homes and addressing these behaviors? (Dr. Susan Levy): Physician education about what to do when you're called about behavioral changes is extremely important. Many of our attending physicians do lack knowledge about what to do. So, behavioral management interventions and competency of providers in doing this is certainly important. There are a number of professional organizations that have great resources - the American Medical Directors Association, the American Association of Consultant Pharmacists, AGS - many professional organizations that have resources to help train physicians, and other prescribers who don't have experience in this setting. (Nicki Brandt): Thank you Dr. Levy for sharing your experiences as well as really wonderful resources. Now let's hear some thoughts from Sarah Burger, a geriatric nurse for many years and an advocate working on behalf of nursing home residents and their families. Sarah, as a nurse and advocate, this scenario raises many questions. Can you explain what the staff did well, or other areas they might improve upon in caring for Mrs. Jackson? (Sarah Burger): Sure Nicole, Stone Valley Manor staff practice consistent assignment, so that each resident has the same caregiver every day. Knowing Mrs. Jackson allowed the caregiver to respond quickly, soothingly and meaningfully to Mrs. Jackson's expression of unease. Was consistent assignment practiced on all shifts? What changes might be needed in order to increase the percentage of time that Mrs. Jackson has consistent assignment on all shifts? What are the opportunities for her to do care practices? Mrs. Jackson has had a history of being upset for two years including refusing care. Why is she refusing care? Refusals often occur around bathing. Sometimes if the experience is bad or frightening, the distress can last for many hours. What was her lifelong habit? Did she bathe at night when living independently? If she did, then a snug warm towel bath might prepare her for winding down. What details of her bedtime routine are important to prevent this situation from occurring? Has someone on the IDT asked her family? Even in an emergency, contacting the family is the most helpful thing to do. (Nicki Brandt): Sara, nursing home staff may be concerned about the safety and care of their residents. From your perspective, what can the staff do to balance stress and challenges they may face when dealing with behaviors such as witnessed with Mrs. Jackson? (Sarah Burger): Mrs. Jackson is described as unsteady, yet she is wandering the halls at 10 pm unaccompanied. What is she trying to find? Is she having pain? Is she hungry, thirsty, lonely, needs to go to the toilet, or all tired out? Or is she just not sleepy enough to want to lie down? Could the CNAs take turns being responsible for her safety if walking is her usual evening routine? The nurse says there is not enough staff on the evenings. The same may be true on the weekends since the antipsychotic was ordered over the weekend. This brings up the issue of staffing and everyone working together to determine the staffing needed and how to make it happen. It isn't just nursing, non-nursing staff can be extremely valuable and effective as well. Every staff member in every department is responsible for the safety of residents 24 hours a day. (Nicki Brandt): Could you please talk about the importance of family or support system involvement? (Sarah Burger): Mrs. Jackson's daughter held the key to her behavior. Apparently Mrs. Jackson is always more upset when the family goes away. It is important that the staff know that important detail about Mrs. Jackson and prepare for her increased unease. Shortly after admission, staff should know what is likely to happen when the family is away and put preventive care in place as much as possible. Do the staff involve Mrs. Jackson's daughter to find out what would ease her mother's distress in her absence? Residents and families may be extremely helpful in asking everyone on the team, including physicians, if non-medication practices have been tried. The physician should also ask if there is enough staff to care for residents like Mrs. Jackson, and if the staff caring the resident, have received enough training in dementia care and behavioral interventions. (Nicki Brandt): Thank you, Sarah for sharing your experiences with this case. We've talked a lot about non-pharmacological interventions. But what about the role of the pharmacist when medications are being considered? Tom, from your experience what is the role of the consultant pharmacist in nursing homes with respect to medication management? (Thomas Clark): Well Nicki, the consultant pharmacist has two basic functions: At one level, the consultant pharmacist is involved in direct patient care -- This role can be somewhat limited by the fact that the consultant pharmacist is not present in the facility every day. Acute behavior issues, such as the incident in the case study, may not have direct involvement by the consultant pharmacist initially. But the second role of the consultant pharmacist is at the facility level -- This involves education of staff, helping to develop policies, procedures, and protocols; tracking patterns of drug use (including antipsychotics) throughout the facility to explore potential problems; and providing reports back to the quality committee with findings and recommendations. One of the challenges in dealing with behavioral issues and antipsychotic drug use is that every situation is different. This is why the interdisciplinary team approach is so important. A consultant pharmacist colleague shared an actual case with me recently about a female nursing facility resident who was over 100 years old. , however Despite her advanced age, her mind was clear as a bell. In checking on her recently, however, the pharmacist found that she had been placed on an antipsychotic. He discovered that the resident had started complaining of seeing snakes, and was having hallucinations and delusions that were distressing. Upon checking further, he found that these symptoms started a day or two after she was sent to the ophthalmologist for an eye examination. The ophthalmologist had started her on timolol eye drops for glaucoma. The pharmacist knew that timolol is medicine that can be absorbed systemically and easily crosses into the central nervous system. He contacted the ophthalmologist and got the eye drops changed to a different medication. He then got the antipsychotic discontinued. Within a day or two, the resident was back to her usual self. (Nicki Brandt): Tom, you are correct every case is unique, that's why it's important that we look at every medication, for each and every resident, when there is a change in behavior. From your perspective Tom, what is the role of the consultant pharmacist in staff training and care planning? (Thomas Clark): The involvement of the pharmacist in care planning may vary depending upon the situation. It is not usually feasible to have the consultant pharmacist directly involved in care plan team meetings for every resident. Input is provided through written comments (usually), and the pharmacist may meet with the interdisciplinary team in selected cases. Oversight of antipsychotic use involves the consultant pharmacist at both of the levels we talked about earlier: At the resident level, the consultant pharmacist is working with the interdisciplinary team, including the resident and family, to provide recommendations on appropriate use of antipsychotics, including gradual dose reductions. At the facility level, the consultant pharmacist is evaluating patterns of care, including compliance with applicable survey guidelines. One of the key functions of the consultant pharmacist at both levels is monitoring. The pharmacist can review documentation to ensure that the medication is effective (actually helping the resident to improve) and is not producing significant adverse effects. (Nicki Brandt): How can the pharmacist become more involved in gradual dose reduction and helping to discontinue medications? (Thomas Clark): In this particular scenario, the medication was stopped after a few days. But in other cases, if a medication is continued after a particular event, the consultant pharmacist might get involved at the next monthly visit, and might notice that a resident had an event, but that the medication was continued without a stop date. The consultant pharmacist could consult with the nurses and CNAs, ask what is going on now with the resident, ask about non-pharmacological interventions that have been effective, ask about family involvement, and could recommend a gradual dose reduction. If the pharmacist and interdisciplinary team determine that a gradual dose reduction isn't appropriate or indicated at this time, then the pharmacist could flag the resident in the system and ask about her again on the next 30 day visit. It is also important to remember that the facility staff may request a review by the consultant pharmacist at any time, in some cases, it might be important to have the pharmacist involved earlier rather than waiting for the next routine or monthly consultant pharmacist visit. Pharmacists are essential team players helping to monitor medication use patterns in the facility by working with the team and through quality assurance processes. Consultant pharmacist involvement in care planning is often underutilized, but can be vital when working with complex care situations involving medications. (Nicki Brandt): Thank you, Tom for sharing your perspective on the role of the pharmacist as a member of the interdisciplinary team. So far we've heard from a physician, a nurse and advocate, and a pharmacist. All of them have mentioned the importance of the nursing home resident and family in decision-making around behavioral health and medication use in residents with dementia. To help us understand a resident's point of view, we have a short video clip of Mr. Michael Tucker, a resident at Levindale Hebrew Geriatric Center and Hospital here in Baltimore, Maryland. Mr. Tucker shares some thoughts and insight on the importance of autonomy and choice for people living in nursing homes. He discusses how personalized care and individualized daily routines are essential for quality of life in a nursing home facility. Although Mr. Tucker has not been diagnosed with dementia, these issues affect the lives of residents with dementia as well. Let's watch... {music} (Dr Levy - off camera): What about some of the activities, do you all get some say in the activities? (Michael Tucker): It's your choice, yes. You're not forced or anything. It's you're choice. If you like early exercises. Sometimes, I used to have Yoga. All depends on what's better for you. (Dr Levy - off camera): What's your favorite time of day? (Michael Tucker): Well I guess morning is my... early morning is beautiful to me, and then I just start my day. (Dr Levy - off camera): Anything special in your routine during the day, which you like? (Michael Tucker): Well the routine after breakfast, then lunch, then to read, and peace and quiet, solitude. That 's perfect. (Dr Levy - off camera): What about the afternoons? Anything make them pass? (Michael Tucker): Normally... Oh yeah, well if it's happy hour (laughs)... Happy hour - it's over around 3:30 or 4:00. (Dr Levy - off camera): So what happens at happy hour? (Michael Tucker): Nice libation, beer a nd wine, pretzels, potato chips. It's just camaraderie with the residents. You're all together, yes. (Dr Levy - off camera): Do you go to your own care plans? (Michael Tucker): Yes. They 'll let me know, I guess, a week ahead of time when it's going to be and make sure that I'm ready for my care plan. (Dr Levy - off camera): At care plan are there some issues that come up? (Michael Tucker): Well when I have questions, they will tell me. You know. And then again they go through every detail, medication, or what might be done. It 's a great help. (Dr Levy - off camera): How do you feel that we 're letting you make decisions about your future? (Michael Tucker): Well with the help of my social worker, or my doctor, or nurse practitioner, everything coincides and gives you much help, really. (Nicki Brandt): So in caring for residents with dementia, many of whom may not be able to express themselves as clearly as Mr. Tucker, this video illustrates the importance of resident-centered approaches to activities and care planning for all residents. We want to keep the concepts of individualized, person-centered care in mind. We will now continue the discussion with our next group of panel members. Morris Kaplan, Operating Partner of Gwynedd Square Center for Nursing & Convalescent Care; Debra Lyons, Registered Nurse Consultant for the Division of Nursing Homes in the Office of Clinical Standards and Quality within the Centers for Medicare & Medicaid Services; Alice Bonner, Director for the Division of Nursing Homes in the Office for Clinical Standards and Quality within the Centers for Medicare and Medicaid Services; and Dr. Shari Ling, Deputy Chief Medical Officer serving in the Office of Clinical Standards and Quality, Centers for Medicare and Medicaid Services. Thank you all. Mr. Kaplan, you 've worked with your team to improve behavioral health and dementia care in your facility over many years. Based on your home's experiences, could you share how your team would approach a resident like Mrs. Jackson? (Morris Kaplan): Nicki, programs for residents like Mrs. Jackson aim to prevent or address behavioral symptoms through level-appropriate behavioral management programs and interventions with significantly less use of medications. Our resident population is typical of most nursing homes - about 63% have dementia. But for more than a decade we have been able to consistently maintain levels of psychotropic medication use that are significantly lower than the state and national averages. The components of our program include: First, leadership - the active involvement of ownership and management and the regular participation by the director of nursing and administrator in care plan conferences... Second, adequate staffing - on the first shift there should be one CNA to no more than 8 residents, on the second shift there should be one CNA to no more than 9 residents, and on the third shift there should be one CNA to no more than 16 residents. Equally as important is permanent assignments. Permanent assignments are vital to enabling the caregiver to know and anticipate the needs of the resident, and to respond to them appropriately and effectively. Third, the involvement of a geriatric psychiatrist in addition to the attending physician is critically important, as is ongoing communication between the psychiatrist and the nursing home staff. Finally, keeping people active and engaged through behavioral management programs. Gwynedd Square offers 5 different programs, each geared toward a different type of resident. Each meets twice a day (one meets all day), plus there is an evening activity. For 181 residents, we employ 11 full time activities staff every day. Activities staff are more cost effective, and all are trained and work as feeding assistants in our dining programs. Each of our programs has individualized types of activities with unique goals: The Friendship Club is geared toward residents with early stage dementia. The Sunshine Club is geared toward residents with late stage dementia. The Rising Stars Program is for residents at high risk of falls, and generally have advanced dementia. This program meets all day. Our Korean Program of Korean activity and worship is for our Korean residents. I must note that our Korean residents participate in all five programs. Finally, is our Alert & oriented group and functions for the whole community. In addition to programming throughout the day and evening, our facility has 3 different dining programs, based on the level of assistance provided. They meet from 50 to 90 minutes, two times a day. We have found that keeping people active and engaged and monitored throughout the day in level-appropriate programming is the key to preventing or minimizing behavioral symptoms in residents with dementia and reducing reliance on psychotropic medications. In speaking with colleagues from around the country, we have seen that other facilities have achieved similar results using similar approaches. (Nicki Brandt): Can you explain how the team, including the family, would work together to develop a plan for a resident like Mrs. Jackson? And specifically, when residents participate in these non-pharmacologic programs, who monitors the interaction of direct care staff with the residents? (Morris Kaplan): If a resident is not easily assisted or redirected using interventions that usually work with this resident, the CNA would seek assistance from the nurse. If they were unsuccessful, they would involve the Director of Nursing and the Administrator. They would seek input from activities and social service staff and put into place a plan of new interventions. If the new interventions did not work, we would continue to seek alternatives. We would hold special care plan meetings to involve the family and all departments in trying to develop appropriate resident-specific interventions. If the staff and family felt that the resident was not functioning at his/her highest level and might benefit from the input of a geriatric psychiatrist, a psychiatric evaluation would be ordered. The aim would be to use the least amount of medication possible and to keep the resident alert and high functioning. We communicate closely with our geriatric psychiatrists and nursing staff to ensure that this philosophy is followed. One key element of our program's success is that the Director of Nursing and Administrator are out on the floor every day, interacting with residents, staff and families. (Nicki Brandt): Morris, that's very important. How do you address behavioral symptoms that may impact other residents? (Morris Kaplan): First, we take immediate steps to reduce the resident's anxiety and to eliminate any source of agitation, such as noise or other residents, and provide reassurance in a calm voice. Next, we determine the resident's needs. What have we failed to provide this resident? Is she hungry, in pain or in need of toileting? We determine any possible medical conditions such as any signs of urinary tract infections that might require additional testing. We determine if there are any significant psychosocial issues affecting the resident such as recent loss of a loved one. Then, based on knowing the resident, we would use interventions to distract the resident and engage him or her in a meaningful or at least harmless activity (anything from reading together, to going for a walk in the garden to putting newspapers or bottles in the trash or going to get an ice cream sandwich). Each of these individuals and situations is unique; using strategies to prevent the behaviors as much as possible, and seeing them as a form of communication (that the resident is trying to tell us something!) is crucial to managing these behaviors. (Nicki Brandt): Thank you, Morris for sharing your facility's perspective on caring for residents like Mrs. Jackson. So we've heard about one specific facility that uses a programmatic approach to behavioral health and dementia care - but nursing homes are often concerned about the response of the state surveyors when they conduct their annual survey. Debra, based on CMS guidelines and the survey process, what are some of the behavioral health and medication issues that a surveyor would look at in evaluating this type of program for a resident such as Mrs. Jackson? And what do you hear about in Mrs. Jackson's case that as a surveyor, you would want to consider in reviewing? (Debra Lyons): Thanks Nicki. I'd like to first give a brief overview of the role of the surveyor for those who might not be familiar with that. Surveyors are professionals such as nurses, dietitians, social workers, sanitarians and pharmacists. They work for either the federal government or state agencies, and their job is to ensure compliance with federal requirements and oversee the quality of care and services provided to nursing home residents by performing inspections. Nursing home inspections occur at least annually, and also when a complaint is filed. When it comes to behavioral health and the use of anti-psychotics, the surveyor would look at several things. First, as part of the survey team, the surveyor would look facility-wide at practices and policies to ensure the facility has systems in place that comply with relevant regulations. This is done by observation, medication review, interviews of staff, residents and families, and record review. If a concern is identified by the team, the surveyor will perform an in-depth investigation into those residents identified, to determine if a deficient practice exists. If a deficiency exists, the surveyor will cite that deficient practice and appropriate enforcement action will be taken. The relevant regulations that relate to this scenario are the resident's right to be free from chemical restraints; the facility's responsibility to ensure that residents do not receive unnecessary medications; and the facility's responsibility to ensure that residents receive adequate supervision to prevent accidents. A chemical restraint is any drug that is used for discipline or convenience and not required to treat medical symptoms. Of course there are other regulations that might warrant investigation such as sufficient staffing, resident assessment and care planning. I think in this scenario, the facility did many positive things, such as adopting consistent assignment which increases staff familiarity with the resident, although, it's not clear that there was consistent assignment on this particular shift. They had developed a care plan that included non-pharmacological interventions. The physician encouraged staff to try those non-pharmacological interventions first, and then when ordering anti-psychotic medication, ordered it for a limited time, in order to specifically treat the behaviors that appeared to put the resident and others at risk. This was followed by a re-evaluation of the effectiveness during the care plan meeting, which included members of the resident's family. (Nicki Brandt): How do surveyors look for the appropriate use of antipsychotic medications in residents with dementia but without other psychiatric diagnoses such as schizophrenia? (Debra Lyons): Surveyors will look to see that the resident and/or family, to the extent possible, have been involved in the decision-making process and that the resident's goals for care are aligned with the treatments prescribed. They will look to see that the physician or nurse practitioner has assessed the resident for a possible change in condition, considering potential medical diagnoses that might explain the resident's behaviors, and that they have communicated with the staff. The surveyor will also look to see that non-pharmacological interventions have been attempted, and that if an anti-psychotic medication is ordered, there is documentation that it is ordered for a specific, clinically appropriate indication and for specific behaviors. They will look to see that the resident's care plan reflects the use of the medication, the goal and time period for the use, and how the resident's behavioral symptoms will be monitored. Another important aspect is that the surveyor should be able to see documentation that the physician or nurse practitioner, along with the interdisciplinary team attempts gradual dose reductions. (Nicki Brandt): Thanks, Deborah. So you've spoke about documentation. How is it documented that the resident or family or caregiver has received information and they have agreed to the plan of care, including a psychopharmacological medication such as an antipsychotic? (Debra Lyons): Well, many states (over half) currently have state laws that specifically require informed consent for some or all medication use. CMS has federal regulations that require the facility to fully inform the resident or his or her representative in advance about their care and treatment and of any changes that may affect the resident's well-being. Current care planning regulations reflect that prescribers should discuss new medications with residents or families or caregivers at the time that they are being prescribed, and document those conversations including the resident's or family's agreement with the plan of care. (Nicki Brandt): Deborah, earlier in this session, the other panel talked about the role of the consultant pharmacist in monitoring medications. How should the facility be monitoring the resident's outcomes when medications are prescribed? (Debra Lyons): Well, as I mentioned earlier, the care plan should reflect the behaviors or symptoms the resident exhibited, the interventions used by staff and whether or not they were effective. The care plan should also reflect goals for reducing the resident's symptoms, as well as identify how staff will monitor to see if the symptoms are reduced. For anti-psychotic medication use, the surveyor would look for evidence that the facility is aware of potential adverse reactions. This might be found in the care plan, but during interviews with a surveyor, staff caring for the resident should know what to look for. (Nicki Brandt): Within this case scenario, what additional investigation is required? (Debra Lyons): Well Nicki, a surveyor's job is to be a good investigator. This scenario, and many similar ones we encounter, does not provide all the information necessary to determine compliance. I would further investigate the "episode" experienced by Mrs. Jackson at 10pm. Specifically, I would want to know if the facility had provided an adequate level of supervision to Mrs. Jackson. As a surveyor, I would look at things like staffing sheets to see who was working at that time, and then I'd interview the staff to determine how they were providing supervision to this resident. I'd also want to know how the facility was able to determine effectiveness of the non-pharmacological interventions after only 10 minutes. And I would want to know why the physician ordered the anti-psychotic for the entire weekend instead of for 1 dose only. I would also probe to find out how staff communicated the resident's escalating behaviors to each other between shifts, what they did early on and when they notified the family. Early identification of a change in condition or early precipitants of behavioral change are areas that surveyors should consider, and should look for documentation of this. These are not easy issues and we need to work together to find the right balance for resident safety, quality of life, and optimal freedom to make choices to the extent possible. (Nicki Brandt): Thank you Debra, and thank you all panel members for your involvement on this team. Indeed working together as illustrated from this panel discussion is essential to meet the needs of the most important person, the nursing home resident. To wrap up, let's hear from Dr. Shari Ling and Alice Bonner, about CMS' new initiative to enhance behavioral health and reduce the unnecessary use of antipsychotic medications in U.S. Nursing Homes. Dr. Ling... (Dr. Shari Ling): Thank you, Nicki. And thank you to our team of experts here today. Several of us from the CMS leadership team have been traveling around the country. And we are encouraged by the energy, the expertise and the commitment of providers, advocates, surveyors, residents and families who are passionate about this issue. There is a lot of work to do - we cannot suddenly or drastically reduce the use of these drugs without putting other interventions in place, such as staffing, prescriber training, team communication and resident and caregiver/family engagement. Together, we believe that we can improve the care of dementia residents in our nursing homes, and as a result, we will be able to reduce the use of antipsychotic medications in cases where they are not necessarily useful or helpful. You heard today that this is a complex issue, but that some facilities have been able to enhance non-pharmacologic strategies, reduce medication use, involve families and residents, reduce staff turnover and improve the experience of care. The CMS survey process supports these improvements. There are three additional points I would like to make. First, we are not alone in this effort. This initiative will align and synergize with other efforts included in the National Action Plan to Address Alzheimer's Disease. Second, our efforts will need to embrace a new culture - one that values interdisciplinary and system-focused interventions, and one that is grounded upon evidence and data-guided improvement. Finally, and most importantly, the efforts we are initiating today are crucial and critical to fulfilling our goal of improving the safety and health, and well-being of nursing home residents - a highly vulnerable segment of our population. Thus, this concerted strategy importantly provides emphasis that CMS is fulfilling our responsibility as a trustworthy partner in achieving this goal. Quality Improvement Organizations are also gearing up to provide technical assistance to nursing homes related to dementia care. Many of our partner organizations such as the American Health Care Association, Leading Age, American Medical Directors Association, Alzheimer's Association, Consumer Voice, Advancing Excellence and others are preparing programs and materials that facilities may wish to consider to strengthen existing programs, or to get started in some of these areas. Providers, individuals, surveyors, consumers or prescribers interested in receiving additional information related to this initiative, or resources to help work on behavioral health approaches and reduce antipsychotic use may view this information and links to available resources on the Advancing Excellence website. Alice, what other plans do our CMS and partners in this initiative have, in terms of next steps? (Alice Bonner): Shari, one aspect that's particularly important as nursing homes work on quality improvement initiatives like this is for them to have data available. CMS will make data publicly available on our Nursing Home Compare website, so that consumers can view rates of antipsychotic use for long-term stay residents with dementia for each nursing home. This means that nursing home leaders will also be able to view these rates, and will see how their facility compares with other facilities in that community, state and nationally. Of course there may be facilities that are caring for certain populations, such as people with high rates of Huntington's disease or other disorders where the use of antipsychotics would often be considered appropriate. But by providing these data, each facility will be able to set their own quality improvement targets and work together with their teams to reduce the use of unnecessary medications over time. State survey agencies will also have this information, and surveyors will be receiving additional training over the next several months on how to evaluate behavioral health strategies, including both non-pharmacologic and pharmacologic approaches in dementia residents. Surveyors will enforce current regulations to ensure that all residents with dementia receive care that complies with federal standards. As many facilities are beginning to consider the new Quality Assurance Performance Improvement or QAPI regulation in development that is part of the Affordable Care Act, we are encouraging facilities to re-evaluate their current quality assessment and assurance or QA&A programs to include documented policies and practices on behavioral health and psychoactive medication use such as: Resident and family involvement and documentation of care planning discussions around medication use; The role of the consultant pharmacist on the interdisciplinary team (and we talked a lot about that today); Involvement of the physician, nurse practitioner or primary care provider in care planning and decision-making around medication use; Approaches that address and balance resident choice and autonomy with safety for both the resident and others; And the role of leadership in promoting a comprehensive, behavioral health program and resident safety. CMS has also developed a DVD called "Hand in Hand," it's a training program for nursing assistants on abuse prevention and principles of person-centered dementia care. That DVD will be distributed, along with an instructor's manual, to every nursing home in the country by this summer. On behalf of all of us at CMS and our partners, thank you for listening in today, and for joining us on this journey. We would also like to thank all of our panel members for their discussion in this "Kick-Off" event. If you registered for the event, there are handouts that can be downloaded that include websites and other resources that you may wish to consider as you begin to work on this issue. And please check back, as additional resources will be added over the next several months. As Dr. Conway stated earlier in the introduction, we believe that by working together, we can accomplish our first year goal of reducing antipsychotic use in nursing homes by 15% by the end of this calendar year - by December 31st, 2012. We will be developing our 2013 goals and sharing those goals in the near future as well. We greatly appreciate your commitment to this goal, your dedication, and your partnership in this important endeavor. We look forward to hearing about your challenges and your successes over the coming months. Thank you very much.