August 24th, 2012

Pilot program for nursing homes to curb antipsychotic use

Published reports in recent months have focused on the over-use of antipsychotic drugs on nursing home residents whose behavior may disrupt patients, staff and the general environment, but whose diagnoses don’t warrant scripts. An investigation led by The Boston Globe highlighted data showing that 185,000 nursing home residents across the country had received antipsychotics in 2010 against federal nursing home regulations and that antipsychotics can be harmful if taken by people who don’t need them. This is particularly true for dementia patients who aren’t diagnosed with conditions for which the antipsychotics are typically prescribed like schizophrenia.

For the last year, Massachusetts has been working to curb this inappropriate use of antipsychotics for dementia patients and the negative press that’s come along with it.

“I would have to say that the perception that nursing facility staff are ‘drugging and sedating’ residents is hard to hear and read about in the papers,” says Laurie Herndon, MSN, GNP-BC, ANP-BC, director of clinical quality at the Massachusetts Senior Care Foundation. However, says Herndon, “we do not argue with the numbers. There is an issue with too many medications in skilled nursing facilities. We agree, and want to see these numbers come down.”

In June 2011, UMass Medical researchers developed a proposal to apply for federal money by the Centers for Medicare and Medicaid Services, which was offering $772 million to fund more than 100 projects across the country that would help save the healthcare system more than $2 billion over the next three years.

The proposal sought to expand and disseminate a pilot project that was already underway in 11 Massachusetts skilled nursing facilities (it wrapped in August after 12 months), where Herndon says everyone from nurses to housekeepers were learning to better communicate with dementia residents by learning to delve into the “whys” behind a resident’s bad behavior before opening a pill bottle to quell them.

“The entire curriculum is based on the idea that residents with dementia may lack the skills that you and I have to convey needs and emotions,” explains Herndon, who has worked as a general nurse practitioner in skilled nursing facilities for more than 15 years. “I can easily let my family know that I am overtired and when I am overtired, the loud TV really bugs me. A resident with dementia might have the same problem with a noisy TV when they are overtired but lack the verbal skills to say, “Hey – could you please turn the TV down? I’m tired.”

Simply put, “When staff members know who the resident is, it helps them to decipher what the behavior means,” says Herndon.

According to Herndon, the pilot program’s curriculum helped the staff use different activities to get to know each resident’s personal history. The information was recorded and used to develop a resident-centered plan of care that meets the needs of each individual. Five different modules covered topics like better learning patients’ backgrounds; characteristics of dementia and related behavior; information about psychoactive medications; non-pharmacological approaches to behavior disturbance; and crisis intervention.

A “train the trainer” approach was used at each facility whereby one or two key staff were coordinators for their buildings. Data collection included, among other things, surveys from staff, monthly medication use reports and qualitative feedback from coordinators.

When the pilot program wrapped last month, Herndon says the change in facility staff attitude was dramatic, with survey feedback namely noting that the more nursing staff knew their patients, the better they could analyze their needs before bad behavior escalated.

The proposal to continue the pilot program didn’t receive the grant money (Massachusetts-based Vinfen Corporation and Northeastern’s Healthcare Systems Engineering Institute did). Herndon says the Senior Care Foundation will monitor funding opportunities from federal and local foundations.

As for a takeaway for psychologists, Herndon stresses the need for a behavioral care plan for any patient at a skilled nursing facility especially one that uses non-pharmacological approaches.

By Jennifer E Chase

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