January 6, 2017
The New Horizons Care Center of Wyoming successfully reduced antipsychotic utilization rates by 89 percent. Antipsychotic medications are meant for those with schizophrenia, Huntington’s disease or Tourette’s syndrome. The medications are not intended for use in elderly populations or to manage behaviors or symptoms related to dementia. Antipsychotics carry a “black box” warning from the U.S. Food & Drug Administration because of their life-threatening risks.
Located in Northern Wyoming, the New Horizons Care Center is an 85-bed nursing home with a 23-bed secured special care unit. The facility has a high number of residents with dementia, and in September of 2013, the facility had an antipsychotic utilization rate of 23.68 percent among its entire population.
In late 2013, New Horizons took on the difficult task of reducing antipsychotic use. By May of 2016, the facility successfully reached an 89-percent reduction in antipsychotic use, bringing their utilization rate down to 2.60 percent.
Antipsychotic medications affect nursing home residents’ quality of life and rob them of their independence. They can lead to incontinence and pressure ulcers, can impact residents’ ability to take care of themselves and can cause confusion, infections, falls, strokes and death.
Forming a committee
Using a clinical, team-based approach to reduce antipsychotic rates, the facility put together a committee that met monthly. The committee included the chief nursing officer, nursing supervisors, social services and an activity professional. The staff pharmacist educated the committee about the dangers of antipsychotic medications. The committee also involved the medical director during monthly pharmacy review meetings.
The committee provided education to providers, nurses and certified nursing assistants about the facility’s use of antipsychotic medications and explained why reducing their use was important.
Process for improving utilization rates
Creating non-pharmacological approaches to manage behaviors related to dementia was a critical step. These approaches had to be in place before residents could successfully be weaned off antipsychotics. Activity aides and care staff used music therapy, massage, hand therapy, exercise, essential oils, baby dolls, outdoor activities, gardening therapy and large puzzles to work one-on-one with residents with dementia. Aides and staff also wrote up individualized sensory plans for each resident.
“Individualizing those plans was key,” said Traci Harrison, Chief Nursing Officer at New Horizons Care Center. “Family involvement was also very important. We learned what they used to do and what music they listened to so the families could give us feedback for what works for them in the home and what their lifestyle was like.”
With a plan in place to care for residents during the medication transition, the committee worked with its pharmacist to reduce antipsychotic use. The team tapered one drug or entirely removed one drug at a time, closely monitoring the resident. Multiple drug or dosage changes at once would make it hard to know what change was effective.
“We learned early to start low and go slow and change one drug at a time,” said Harrison.
The committee reviewed pharmacy-based reports and tweaked medications until they had the outcome they wanted. They used the Certification and Survey Provider Enhanced Reporting (CASPER) report Mountain-Pacific Quality Health provided to them each month to track progress. They also used the monthly resident reports from the staff pharmacist. Throughout the process, the committee made sure all staff knew the progress of each resident’s condition.
In certain cases, the committee also implemented a 72-hour temporary-only order on all benzodiazepines (sedatives) through weekends. This helped weekend staff care for residents during the transition while allowing the clinical team to evaluate individual behaviors.
Staff saw positive improvements in residents weaned off antipsychotic drugs. “Without antipsychotics, we noticed more alertness and increased socialization,” Harrison said. “We also received the same feedback from families about the changes they noticed in their loved ones.”
New Horizons continues to quarterly review all psychotropic medications for all residents.
Strategies that worked, networking for improvement
New Horizons succeeded in reducing antipsychotic medications by creating a committee of the right individuals. This team worked together to review medication reports while slowly and carefully measuring every change. Harrison recommends the following best practices:
- Talk with families early and often about taking their loved ones off antipsychotic medications.
- Make a plan to reduce antipsychotics, and discontinue use before someone is admitted into care.
- Educate staff and families early in the process.
- Reduce, change or add one medication at a time.
- Form a multi-disciplinary team that includes pharmacy and providers. Consider adding a frontline nurse and certified nursing assistant to carry messages back to their teams.
- Schedule regular meetings and divide up the workload.
- Network with an organization like New Horizons Care Center.
For more best practices or to network with New Horizons to reduce antipsychotics at your facility, contact Traci Harrison, Chief Nursing Officer at New Horizons Care Center at firstname.lastname@example.org.
About Mountain-Pacific—Mountain-Pacific is a 501(c)(3) nonprofit corporation and holds federal and state contracts that allow them to oversee the quality of care for Medicare and Medicaid members. Mountain-Pacific works within its region (Montana, Wyoming, Alaska, Hawaii and the U.S. Pacific Territories of Guam and American Samoa and the Commonwealth of the Northern Mariana Islands) to help improve the delivery of health care and the systems that provide it. Mountain-Pacific’s goal is to increase access to high-quality health care that is affordable, safe and of value to the patients they serve.