1. National Partnership to Improve Dementia Care 1 Denise F. O’Donnell, RN, MN, GCMS-BC, MASM, NHA Nurse Consultant/ Division of Nursing Homes/Survey and Certification Group March 3, 2016

2. Presentation Goals Participants will: Be knowledgeable about the CMS National Partnership to Improve Dementia Care in Nursing Homes and achievements to date in improving dementia care and reducing the use of antipsychotic medications. Be able to identify resources that CMS and their partners have developed to assist facilities in improving dementia care. Learn about the Focused Dementia Care Surveys and how they are impacting care. Be able to utilize the information shared regarding practice issues for use in the State Veterans Homes. 2

3. Partnership Mission Mission: Improve the quality of care provided to individuals with dementia living in nursing homes. Deliver health care that is person-centered, comprehensive and interdisciplinary. Protect residents from being prescribed antipsychotic medications unless there is a valid, clinical indication and a systematic process to evaluate each individual. 3

4. Partnership Overview CMS promotes a multidimensional approach through: – Research – Partnerships and state-based coalitions – Surveyor guidance – Education – Public reporting The 3 R’s: Rethink our approach to dementia care. Reconnect with residents via person-centered care practices. Restore good health and quality of life. 4

5. CMS Collaborative Efforts Bi-Annual calls with State Coalitions MLN Connects ® (Medicare Learning Network) National Provider Calls https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events.html National Partnership resource repository – Advancing Excellence https://www.nhqualitycampaign.org/dementiaCare.aspx http://www.cms-handinhandtoolkit.info/ Grants – Use of Federal Civil Monetary Penalty Funds https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15- 34.pdf Focused Dementia Care Surveys 5

6. Measuring Progress CMS is tracking the progress of the Partnership by reviewing publicly reported measures. The official measure of the Partnership is the percentage of long-stay nursing home residents receiving an antipsychotic medication, excluding residents with Schizophrenia, Huntington's Disease or Tourette’s Syndrome. 6

7. Partnership Goals Reduce the national prevalence of antipsychotic medication use in long-stay nursing home residents: – Initial goal by 15% – By 25 percent by the end of 2015 – By 30 percent by the end of 2016 Discover ways to implement new practices: – To enhance quality of life. – To protect residents from substandard care. – To promote goal-directed, person-centered care approaches. http:// www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-09-19.html 7

8. Current Data Trends: Progress to Date 8 Source: CMS Quality Measure, based on MDS 3.0 data. For more information se the MDS 3.0 Quality Measures Users Manual

9. Quarterly Prevalence of Antipsychotic Use for Long-Stay Residents, CMS Regions 2011Q2 to 2015Q3 9 Source: CMS Quality Measure, based on MDS 3.0 data. For more information se the MDS 3.0 Quality Measures Users Manual

10. Quarterly Prevalence of Antipsychotic Use for Long-Stay Residents, CMS Regions 2014Q1 to 2015Q3 10 Region 2014 Q4 2015Q1 2015Q2 2015Q3 Percentage point difference (2011Q4-2015Q3) % Change National19.1%18.6817.9617.43-6.44-27.0% Region 0119.6 % 19.1218.4018.09-8.13-31.0% Region 0216.1%15.7214.9214.65-5.43-27.0% Region 0317.1%16.8816.1616.08-5.73-26.3% Region 0420.0 % 19.6018.7718.24-7.27-28.5% Source: CMS Quality Measure, based on MDS 3.0 data. For more information se the MDS 3.0 Quality Measures Users Manual

11. State Veterans Homes Data Q4 2015 Mean % of Reported Daily Psychoactive Drug Use (Q4 2015) Type of Psychoactive Drug Veterans Nursing Homes (N=69) All Nursing Homes (N=14,294) Anti-depressant (AD)50.2%49.2% Anti-psychotic (AP)17.4%19.1% Anti-anxiety (AX)12.4%15.9% Hypnotic (HP)2.1%2.6% 11 Data taken from CASPER and the MDS Q4 2015 for psychoactive drug use.

12. Enforcement 12 Analysis of survey citations as of March 2014 reflects: - A slight increase in % of NH residents with Schizophrenia coded on the MDS - A small decrease in use of sedatives/hypnotics used in facilities -Continued reduction in antipsychotic medication usage overall.

13. 2014 Focused Dementia Care Survey Pilot To optimize survey efficiency and effectiveness. To more thoroughly examine the process for prescribing antipsychotic medication, as well as other dementia care practices in nursing homes. To gain new insights about surveyor knowledge, skills and attitudes related to the care of people with dementia. To determine ways that the current survey process may be streamlined to more efficiently and accurately identify and cite deficient practice. To recognize successful dementia care programs. 13

14. 2015 Focused Dementia Care Survey Expansion Effort S&C Memo 15-31-NH invited States to conduct surveys on a voluntary basis. More intensive, targeted effort to improve surveyor effectiveness in citing poor dementia care and the overutilization of antipsychotic medications. Conducted as surveys of record. Deficient practices were cited and standard enforcement procedures followed, including revisits. 14

15. Surveyor Feedback 15 Facilitated compliance with dementia care standards. Deficient practices were easily identified. Provided opportunity for surveyors to “zero-in” on dementia care practices. Expected timeframe for completion of survey was reasonable, if three surveyors participated and no serious issues were identified.

16. Challenges Identified Surveyors identified the following as the most challenging aspects of the process: – Facility system problems; – Completing necessary observations; – Amount of time spent in educating; and – Lack of training. 16

17. Focused Dementia Care Survey Tools 17 CMS received feedback from stakeholders and partners. Revised survey materials were shared via Survey & Certification Memo 16-04-NH. https://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-04.pdf Facilities encouraged to use the tools to assess their own practices in providing resident care.

18. Next Steps 18 Release of final report for 2015 Focused Dementia Care Surveys. Complete additional Focused Dementia Care Surveys in 2016. – Focus on nursing homes that continue to have high rates of antipsychotic medication use. Continue review of dementia care practices in standard survey process, both Traditional and QIS.

19. State Veterans Homes Unique and challenging population Age groups Diagnoses Behavioral and psychosocial issues Resources Regulatory and survey issues 19

20. Strategies for Success in Reducing the Use of Antipsychotic Medications Commitment at all levels; Multidisciplinary approach; Increased knowledge for all levels of staff; Documentation; Utilization of all available resources; Self monitoring; and Research. 20

21. Questions? 21

22. Thank You 22 For more information about the National Partnership, please visit: https://www.cms.gov/Medicare/Provider-Enrollment-and- Certification/SurveyCertificationGenInfo/National-Partnership-to-Improve- Dementia-Care-in-Nursing-Homes.html Please send questions, via email to: dnh_behavioralhealth@cms.hhs.gov