In 2011, the Office of the Inspector General (OIG) of the Department of Health and Human Services released a report underscoring the high use of atypical antipsychotic medications for “off-label” indications among nursing home residents. According to this report, 83 percent of atypical antipsychotic drug claims were for elderly nursing home residents who had not been diagnosed with a condition for which antipsychotic medications were approved by the Food and Drug Administration (FDA).
The high rates of antipsychotic medication use were deemed a persistent threat to quality and safety by the Centers for Medicare & Medicaid Services (CMS), so the National Partnership to Improve Dementia Care in Nursing Homes was established. It focuses on reducing the use of antipsychotic medications to improve comprehensive dementia care and enhance the use of non-pharmacologic approaches and person-centered dementia care practices.
Tasked with carrying out the National Partnership’s mission, atom Alliance—the Quality Innovation Network-Quality Improvement Organization serving Alabama, Indiana, Kentucky, Mississippi and Tennessee—created a collaborative to share resources and provide support to nursing homes as they work to improve the care they deliver.
“Our team looked at a couple reports from the past year, including our atom Alliance Composite Score report, and we noticed an opportunity for improvement around these kinds of medicines to provide better care for our residents,” said Jeff Tambornini, administrator at NHC Oak Ridge.
The facility reported an almost 20 percent reduction in antipsychotic medication use, from 28.6 percent during the first quarter of 2015 to 8.9 percent during the first quarter of 2017. The statewide rate in Tennessee for the first quarter of 2017 was 17 percent while the average among collaborative participants was 16.8 percent.
Tambornini says they average about 100 residents at their facility. The population fluctuates due to a variety of reasons. Therefore, the number of residents on antipsychotic medications fluctuates. But overall, they have seen positive results in response to their interventions.
“Our quality improvement efforts have seen ups and downs, but we’re proud of our success over the past two years,” said Tambornini. “We were able to improve the lives of more than 10 residents by taking them off of antipsychotic medications and giving them the care they need in alternative ways.”
The Right Staff for the Job
The medical director for NHC Oak Ridge hired a psychiatrist in 2015 to assist with gradual dosage reduction for antipsychotic medications in the long-term care residents.
“Adding a psychiatrist to our team gave us an advantage,” said Angie Sumner, director of nursing for NHC Oak Ridge. “We had a dedicated person reviewing charts for these kinds of medicines and following up with staff and family members to create a plan to reduce the dosage.”
The psychiatrist educated the residents, family members and other caregivers involved on the benefits of removing the medication and how the gradual dose reduction process works. She followed up on a weekly basis to get feedback on how the resident was feeling. She also met with the nursing staff to listen to their concerns and questions. The pharmacy provided a list of residents on antipsychotic medications, so the care team could monitor any new prescriptions.
Sumner believes open communication between the psychiatrist and the nursing staff alleviated fears, gave the staff a stronger knowledge of antipsychotic medication use and showed them the benefits of reducing medications.
“She spent a lot of time communicating with everyone involved,” said Sumner. “Fear can be overwhelming to staff and family members, so we emphasize education and communication.”
NHC Oak Ridge also hired a licensed social worker to visit residents weekly and discuss their fears or concerns. The psychiatrist and nursing staff provide a list of residents to the social worker each week based on behavior they observe for each resident.
“If there’s a resident that has been crying or acting out, we address it with talk therapy first before considering medication,” said Sumner. “This has helped us sustain our improvement, and it gives our residents the person-centered care we strive for."
Increasing communication among the care team, placing the right staff in the mix and reviewing data regularly helped NHC Oak Ridge reduce the number of residents on antipsychotic medications.
“atom Alliance assisted us by providing regular Composite Score data reports that we monitored,” Sumner said. “I also attended the webinars hosted by the atom Alliance collaborative, which were really helpful.”
The care team put a process in place to ensure sustained improvement, including reviewing monthly data reports on reducing antipsychotic medications and sharing findings in a monthly team meeting. They continue to review the list of residents on these kinds of drugs, having the psychiatrist and social worker visiting residents regularly and keeping the lines of communication open.
“It’s rewarding to see the residents becoming more active and attending events provided by the facility,” said Sumner.
atom Alliance, the Quality Innovation Network-Quality Improvement Organization serving Alabama, Indiana, Kentucky, Mississippi and Tennessee, originally published this story. To learn more, visit their website, or contact Jackie Sourek at Jsourek@qsource.org.