handouts - Nursing Home Help

4/8/2016
MOQI
ASUCCESS STORY
AntipsychoticEliminationinDementia
HowDoWeCareforDementiaBehavior
withoutAntipsychotics?
Dr. JoAnn Franklin, APRN,GNP-BC, FNP-BC, MHNP, FAANP
MOQI
CMSawardedanInnovationsgrantof$14.8millionto
theSinclairSchoolofNursing attheUniversityof
MissouriwhopartneredwithNationalHealthCare
(NHC)inDesloge,Missouriand15otherMissouri
nursinghomeswithgoalsof:
1) Reducingavoidablehospitalizationsbyrecognizing
illnessearly
2) ReducingantipsychoticsinDementia
3) Reducingpolypharmacy
4) Increasingadvancedirectivediscussions
AMERICAN HEALTHCARE
ASSOCIATION PRESENTATION
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4/8/2016
WHAT AN MOQIAPRNDOES
Educate
EncouragestheUseofINTERACTTools
BecomesPartoftheTeam
MedicalRecordsReviews
MedicationReviewandManagement
ModelsAssessmentSkillsandPhysicianCalls
ParticipateinEnd‐of‐LifeDiscussions
INTERACT
TOOLS
SBAR STANDS FOR
Situation
Background
Assessment
Request
bynurses
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INTERACTTOOLS
• AdvanceDirectiveCareTrackingForm
• QualityImprovementTooltodetermine
rootcauseandtrendsoftransfers
• HospitalTransferForm
• CarePathBook
https://Interact2.net/
CHALLENGES OFPROGRAM
CHALLENGES ARE WHAT MAKE LIFE INTERESTING
OVERCOMING THEM IS WHAT MAKES IT MEANINGFUL
• Fearofchange
• Fearofmorework
• Personalconflictsofwhoknowsbestforour
residents
• Recognizingvariouslevelsofeducation
• Buyinatalllevels
• Physicianliabilitiesconcerns
• Families
STUDIES SHOW AN AVERAGE NURSING
HOME PER YEAR…
Has135adversedrug
events
Credited93,000
deaths
Cost$4billion
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ANTIPSYCHOTICS
WOULD YOU GIVE THIS DRUG TO YOUR MOTHER?
Causedaspiration
Madeherdrinkless
Couldmakehermoreagitated
Increasefallingandhipfractures
Increasedaspirationpneumonia
Increasedchancesofdyingby10%
Didn’twork
SIDE EFFECTS OF MEDICATIONS
ANTIPSYCHOTIC
WARNINGS!!!!
A blackboxwarning isthe
strictest warning putinthelabelingof
prescriptiondrugsordrugproductsbythe
FoodandDrugAdministration(FDA)when
thereisreasonableevidenceofanassociation
ofaserioushazard withthedrug.
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THE FOOD AND DRUG
ADMINISTRATION WARNED IN 2005
Antipsychoticsareoff‐label in
Dementiawitha“blackbox”
warning.
Antipsychoticuseineldersincreases
mortalityriskestimatedat1.6‐1.7
timeshigherthanthosenottaking
antipsychotics.
ElderlyNHresidentsaccountfor20%.
Or($1.7million)atypical
antipsychotics.
WHY THE CONCERN FOR
ANTIPSYCHOTIC USE?
Associatedwithincreasedriskof:
• Stroke
• Falls
• Dysphagia
• AndotherNeurologicrisks
ANTIPSYCHOTICS ARE FOR
DELUSIONS AND HALLUCINATIONS
NOvalueofantipsychoticsintreatmentofbehavioral
andpsychologicalsymptomsofdementia.
CMS’sQM/QIreport(July ‐September2010)
showed39.4%ofnursinghomeresidentsnationwide
whohadcognitiveimpairmentandbehavioralproblems
butnodiagnosisofpsychosisorrelatedconditions
receivedantipsychoticdrugs.
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NEW SURVEYOR GUIDANCE
KEY PRINCIPLES
PersonCenteredCare
QuantityandQualityofStaff
ThoroughEvaluationofNeworWorseningBehaviors
IndividualizedApproachestoCare
CriticalThinkingRelatedtoAntipsychoticDrugUse
InterviewswithPrescribers
EngagementofResidentinDecisionMaking
FIGURE OUT
ROOT CAUSE OF BEHAVIOR
Commonpracticetousevarioustypesofpsychopharmacological
medicationsinnursinghomestotrytoaddressbehaviorswithout
firstdeterminingwhetherthereisa:
•
Medical;
•
Physical;
•
Functional;
•
Psychological;
•
Emotional;
•
Psychiatric;
•
Social;or
•
Environmental
“…causeofthebehaviors”
INDIVIDUAL APPROACHES
AND TREATMENT
Correctcareplanimplementation
Identifyanddocumentspecifictargetbehaviorsanddesired
outcomes
Implementperson‐centeredinterventionsdocumentresults
andcommunicate
Consistentlyimplementcareplan,acrosstimeshifts
Staffingandstafftraining
Providestaff(quantity andquality)tomeetresidentneeds
Strivetostafftooptimizeresident familiarity
QualitystaffingincludesCNAcompetencyinskills/techniquesnecessarytocare
forindividualdementianeeds;mustreceiveanannualperformancereviewand
receiveregularin‐serviceeducationbasedonoutcomes
Thefacilitymustprovidetrainingindementiacare‐ whenhiredandannually
Facilitiesmayhavesystemstoassiststaffwithcaregiverstress
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WHAT WAS THE BEHAVIOR TRYING
TO COMMUNICATE?
Whatwerethepossiblereasonsfortheperson’sbehavior?
Whatotherapproachesorinterventionswereattempted?
WasthefamilyorrepresentativecontactedpriortoinitiatingRx?
Wasthemedicationclinicallyindicatedandnecessarytotreataspecific
conditionandtargetsymptomsasdiagnosedanddocumentedinthe
record?
Wasthelowestpossibledosageused?
Weregradualdosereductionsplannedordone?
WasthePCPinvolvedinthecareplanningprocess?
Howismonitoringdone?
Ifthereisadeclineinfunction,worseningbehavior,suboptimal
improvement,orresidentrefusal/resistance,thecareplanapproaches
shouldbereviewed/revised/updatedasappropriate
KEY CONSIDERATIONS TO HELP
PREVENT BEHAVIORAL SYMPTOMS
Effectivelycommunicate:
Usecalmvoice
Offernomorethantwochoices
Donotuseopen‐endedquestions
Keepitsimple– donotover‐explainor
discussevents
Attendtoresident’snonverbal
communications
Grimacingmaybeasignofpain
Ringinghandsmaybeasignofanxiety
RELAX THE RULES ‐
NO RIGHT OR WRONG WAY,IF SAFE
Establishastructureddailyroutineforresidentthatispredictable
Keepresidentengagedinactivitiesofinterestandmatchcapabilities
Usecueingstrategies(e.g.,touch,verbaldirections)helpinitiate,
sequence,andexecutedailyactivities
Understandbehaviorsarenotintentionalbutareanerosioninthe
person’sabilitytoinitiateorcomprehendtaskorpurpose
Informphysicianimmediatelyofchanges
inbehaviorastheyoccur(e.g.,sleep
disruptions,withdrawal,
increasedconfusion)
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ASSESS BEHAVIOR
Howoftendidthebehavioroccurinthepastweek/month?
Wheredoesthebehavioroccur?
Isthereaparticularroom/settingwithinthefacilitywherethebehavioroccurs
(e.g.,duringactivities,indiningroom,inperson’sownroomwithdailycare
routines)?
Canyourecognizeanypatterns?
Doesthebehaviorhappenatthesametimeeveryday?
Whathappensrightbeforethebehavioroccurs?
Whoisaroundwhenthebehavioroccursandhowdotheyreact?
Whatistheenvironmentlikewherethebehavioroccurs?
Istherealotofstimulation(television,noise,people)?
Howwouldyoulikethisbehaviortochange?
Whenwouldyouconsidertheproblem“solved”?
DESCRIBING
BEHAVIORAL SYMPTOMS
Whatisthebehavior?
Canyoudescribethebehavior?
Whatdidhe/shedo?
Whatdidhe/shesay?
Whatdidyoudoandsay?
Whyisthisbehavioraproblem?
Whataboutitreallygetstoyouormakesyouupset?
Whendoesthebehavioroccur?
Whattimeofday?
Whatday(s)oftheweek?
CAREGIVER‐BASED FACTORS
Communicationstoocomplex
Emotionaltoneisharsh
Highlevelofdistress
Lackofavailability(staffingissues)
Poorhealthstatus
Expectationsaretoohighortoolow
Culturalexpectations/values/beliefsnotgoodfitwithcareneeds
Styleofcaregivingnotgoodfit
Poorrelationshipwithresident
Lackofeducationaboutdiseaseandbehaviors
Lackofsupportivenetworkorsystemwithinfacilityfordementiacare
Limitedopportunitiesforrespite
Strainedfinancialsituationinfluencingworkperformance
Employmentandotherfamilycareresponsibilities
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ENVIRONMENTAL FACTORS
Levelofphysicaland/orsocialstimulation(toomuchortoolittle)
Roomarrangementsoramountofclutter
Neededitemsareout‐of‐sightornotinwherepersoncanseethem
Lackofappropriatevisualcues
Safetyrisk
Toohotortoocold
Lackofneededadaptiveequipment(grabbarsinbathroom)
Poorlighting
E NVIRONMENTAL F ACTORS
•
•
•
•
•
•
•
•
•
•
Createapredictable,person‐centeredroutine
Ensurefamiliarity(samestaff,ownpossessions)
Usesimplelanguage,explainactions
Simplifytasks
Distractandredirect
Ensureasafeenvironment
Orient(clocks,calendars,etc.)
Moderatelightingindayandnight
Reduceexcessivestimulation
Groupandindividualactivates
MORE NON‐
PHARMACOLOGIC MEASURES
Physicalpainordiscomfort? Medicaltreatment;nursingintervention;change
environment
Lookingforhome?Makeplacelook/feelmorelikehome
Needforsocialcontact?Restless? Socialinteraction(realorsimulated);
identifymeaningfulactivities
Disturbingothers?Separatepeoplewhomaytriggernegativeresponsesin
eachother
Hallucinations? Checkvision/hearing;tryusingfamiliarobjects/people
Needmorecontrol? Offerchoices
RefusinghelpwithADL? PerformADLatadifferenttimeoradifferentmethod
Needforstimulation/exercise? Providelarge,enclosedenvironments;safety
devices;changelocks
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NATIONAL HEALTHCARE CENTER,
DESLOGE SUCCESS
NHCDeslogehassetthebarhigh fortheother
fifteennursinghomesintheMOQIgrantby:
• NO antipsychoticmedicationsfordementia
populationforoveroneyear!
• InJanuary2015,wewerethefirstofsixteen
homestohavezero transfersinlong‐termcare
out tothehospitalbyrecognizingillnessearly!
• Werepeatedzero inFebruary2016!
• Wehavereduced themedicationburdenforall
NHC,Deslogeresidents!
STARTING POINT
Findyourpartnersthatfit
Buildtrustearly
Communicate
Celebratesuccesses
Planttheseeds
GrowtheCULTURE
RESOURCES
Gitlin,L.N.,Kales,H.C.,&Lyketsos,C.G.(2012).Nonpharmacologic
managementofbehavioralsymptomsindementia.Journalofthe
AmericanMedicalAssociation,308(19),2020‐29.
Hand‐in‐Handisatrainingkitfornursinghomesthatcanbe
downloaded‐ www.cms‐handinhandtoolkit.info
www.nursingomehelp.org ‐ QIPMOMDShelp
Rantz,M.J.,Flesner,M.K.,Franklin,J.,Galambos,C.,Pudlowski,J.,
Pritchett,A.,Alexander,G.,&Lueckenotte,A.(2015).Bettercare,
betterquality:reducingavoidablehospitalizationsofnursinghome
residents.JournalofNursingCareQuality,30(4),290‐297.
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THANKYOU!
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