January 1st, 2014

States make progress reducing nursing home antipsychotics use

Rhode Island leads the region with the lowest use of antipsychotic medications among long-term nursing home patients with dementia, according to the latest data from Nursing Home Compare on Medicare.gov, the federal government’s official Medicare Web site. The site tracks quality of care information on the more than 15,000 Medicare and Medicaid-certified nursing homes in the country.

The lower the rate of antipsychotic drug use among dementia patients, the better. The data excludes nursing home residents diagnosed with schizophrenia, Huntington’s disease or Tourette’s syndrome. While such medication is an important treatment for these conditions, the FDA warns they also have side effects and can increase the risk of death when used in elderly dementia patients.

The rate for the Ocean State’s 84 certified nursing homes was 19.33 percent in October, besting the national average of 21.14 percent. Vermont at 20.22 percent is the only other New England state rating lower than the national average while N.H. matched it exactly at 21.14 percent. The rates were 21.57 percent in Conn., 21.69 percent in Maine and 22.24 percent in Mass.

Last year, the Centers for Medicare & Medicaid Services (CMS) announced the National Partnership to Improve Dementia Care to track publicly reported measures with the goal of reducing the inappropriate use of antipsychotics in nursing homes by 15 percent by the end of 2012. The national rate dropped only nine percent by that deadline, although 11 states hit or exceeded 15 percent, including Rhode Island and Vermont. But by the midpoint of 2013, every New England state had exceeded the target through efforts to pursue more patient-centered care.

“We will use the antipsychotic medication if it’s appropriate … because you want to keep people safe,” says Christina Sokoloff, RN, MSN, PCNS, director of the Geriatric Behavioral Health Long-Term Care Program at Miriam Hospital in Providence. “The goal absolutely is to use the least amount of medication.”

Miriam Hospital’s program provides geriatric psychiatric consultations, support and education to nursing homes, rehabilitation and assisted living facilities to provide treatment for patients’ individual mental health needs. The consultation team works with nursing home staff to identify and minimize the triggers that can prompt a patient’s aggressive behavior. These efforts involve reducing noise and sleep disturbances, minimizing disruptions during staff shift changes, improving lighting and involving patients in varied and meaningful activities.

“Basically you need staff that need to be in tune with the patient and with what’s going on. They need to be willing to include family members. They need to be thinking about medical and environmental factors that could be triggers for behavioral problems. It really becomes a perfect example of individualized medicine,” says Rhode Island Hospital research psychologist Thomas Sheeran, Ph.D., M.E., who has worked with Sokoloff’s geriatric mental health consultation team.

“That’s all psychological. That’s all behavioral. That’s all person-oriented. There’s no meds at all in that discussion.”

Sheeran is currently leading a research study at St. Antoine’s Residence in North Smithfield, R.I., to train social workers and other staff to improve the care patients receive for depression and anxiety and document clinical improvement. Consults may include management of psychotropic medications.

“Every patient is different and that’s particularly true for seniors,” Sheeran adds. “Pediatricians don’t always agree with me on this but if you’ve seen one 10-year old, you’ve seen them all, but if you’ve seen one 80-year-old, then you’ve seen one 80-year-old.”

In Connecticut, a state coalition led by the Wethersfield-based health care consulting and research firm Qualidigm meets regularly to work on outreach efforts to educate nursing homes about the risks of using antipsychotic drugs to treat dementia-related behaviors and alternative interventions. Qualidigm partnered with the University of Massachusetts Medical School to develop an online toolkit for nursing home leadership, nurse educators, certified nurses’ aides, prescribers, RNs and LPNs.

Ann Spenard, MSN, RN, C, RAC-CT, WCC, vice president for consulting services at Qualidigm, says she was confident Connecticut would hit the CMS 15 percent reduction target this year as most nursing homes in the state want to pursue alternatives to prescribing antipsychotics. The rate of nursing home antipsychotic prescribing was 25.72 percent in early 2011. So the state’s percent change is -17.16 percent in achieving the 21.57 percent rate, according to CMS data for the period ending June 30, 2013.

“We do a lot of peer sharing and that’s been really positive,” Spenard says. “So facility to facility and then they’re calling each other and saying, ‘Hey, how did you do that?’ or ‘I’m struggling’.”

By Janine Weisman

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