To ensure every nursing home resident receives the highest quality of care, Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) like atom Alliance—the QIN-QIO for Alabama, Indiana, Kentucky, Mississippi and Tennessee—participate in the Centers for Medicare & Medicaid Services’ (CMS) National Nursing Home Quality Care Collaborative (NNHQCC). The NNHQCC, CMS’s core strategy for nursing home improvement, is carried out by a breakthrough “all teach, all learn” collaborative methodology.
The use of antipsychotics in older adults may present high risk for serious adverse consequences, including altered mental status, increased confusion, stroke, falls and even death. These risks are especially prevalent in persons with dementia. As a result, reducing the use of antipsychotics in nursing homes is a key focus for CMS Quality Improvement Organizations. Through the collaborative, atom Alliance’s quality improvement advisors in Tennessee helped NHC Oak Ridge, a long-term care facility in Oak Ridge, Tennessee, lower the number of residents on antipsychotic medications and improve their quality of life.
“Our team used the atom Alliance composite score reports from the previous 12 months to identify opportunities for improvement. We saw an opportunity to reduce these kinds of medicines and provide better care for our residents,” said Jeff Tambornini, administrator at NHC Oak Ridge.
Commonly used strategies to decrease the use of unnecessary antipsychotic medications include routine provider and pharmacist reviews of patient medication charts, weekly psychiatric evaluations and recurring multidisciplinary meetings to discuss antipsychotic medication issues and trends. Ongoing education for staff around accurate charting, behavioral changes and alternative therapies is also helpful.
“atom Alliance assisted us by providing us regular Composite Score data reports that we monitored,” said Angie Sumner, director of nursing for NHC Oak Ridge. “We also attended the Collaborative webinars, which were really helpful.”
As a result of the nursing home’s participation in the collaborative, NHC Oak Ridge staff began analyzing monthly reports of patients who were prescribed antipsychotic medications. The nursing home also sought to prevent unnecessary prescriptions with more accurate chart keeping. They used daily report data to determine which residents might be ready for a medication reduction and where they might employ alternative solutions for behavioral issues.
“We’re proud of our success over the past two years. As a result of this work, we have been able to take residents completely off of antipsychotic medications while still giving them the care they need.”
NHC Oak Ridge hired a psychiatrist to assist with gradual dosage reduction (GDR) for antipsychotic medications.
“Adding a psychiatrist to our team gave us an advantage,” said Sumner. “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 GDR process works. She followed up on a weekly basis to get feedback on how residents were feeling. She also met with the nursing staff to listen to their concerns and questions.
NHC Oak Ridge also hired a licensed social worker to visit residents weekly and discuss their fears or concerns. The psychiatrist and nursing staff provided a list of residents to the social worker each week based on behavior they observed for each resident.
These actions led to an almost 20 percent reduction in antipsychotic medication use, from 28.6 percent during first quarter 2015 to 8.9 percent during first quarter 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 said they have seen additional benefits to the nearly 100 residents at their facility, including improved communication between residents and providers. This has helped their staff humanize patient data and arrive at solutions that are best for everyone involved.
“We’re proud of our success over the past two years,”said Tambornini. “As a result of this work, we have been able to take residents completely off of antipsychotic medications while still giving them the care they need.”
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