1. UPDATE ON F329/309 AND DEMENTIA CARE Lisa Venditti, CEO Long Term Solutions Inc. 845 208 3328 1

2. OBJECTIVES  Become familiar with changes in F329 and F309  Discuss how to comply with regulatory changes  Discuss non pharmacological interventions for Addressing Mood and Behavior 2

3.  March 29, 2012 – CMS launched the national partnership with the goal to reduce unnecessary antipsychotic drug use in nursing homes AKA The Partnership to Improve Dementia Care in Nursing Homes NATIONAL PARTNERSHIP

4. Optimize the quality of life and function of residents in nursing homes by improving approaches to meeting the health, psychosocial and behavioral health needs of all residents, especially those with dementia. NATIONAL PARTNERSHIP: GOAL

5. CHALLENGE OF “BEHAVIORS” EASY – QUICK FIX  Psychopharmacological medications  Often ineffective  May cause harm HARD – CHALLENGE of assessment  WHY IS THERE A BEHAVIOR:  MEDICAL  PHYSICAL  FUNCTIONAL  PSYCHOLOGICAL  EMOTIONAL  PSYCHIATRIC  SOCIAL  ENVIRONMENTAL

6. IS THERE A BALANCE??

7. F 329 UNNECESSARY MEDICATIONS Any drug used -Without appropriate indication -For excessive duration -In excessive dose -Without adequate monitoring -In the presence of adverse effects

8. Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo FDA BLACK BOX WARNING

9.  Schizophrenia  Schizo-affective disorder  Schizophreniform disorder  Mood disorders: Bipolar/severe depression refractory to other therapies  Psychosis IN THE ABSENCE OF DEMENTIA  Medical illnesses with psychotic symptoms (neoplastic disease) and/or treatment related psychosis or mania (high dose steroids)  Tourette’s Disorder  Huntington’s Disease  Hiccups  Nausea and vomiting associated with cancer or chemotherapy ANTIPSYCHOTIC MEDICATIONS INDICATIONS FOR USE

10. WHAT IS PSYCHOSIS? PSYCHOSIS A serious mental disorder (as schizophrenia) characterized by defective or lost contact with reality often with hallucinations and delusions HALLUCINATION Hallucinations involve sensing things while awake that appear to be real, but instead have been created by the mind. DELUSION Delusions are irrational beliefs, held with a high level of conviction, that are highly resistant to change even when the delusional person is exposed to forms of proof that contradict the belief. 10

11. ANTIPSYCHOTIC MEDICATION INDICATIONS FOR USE Behavioral or Psychological Symptoms of Dementia (BPSD) ONLY AFTER MEDICAL, PHYSICAL, FUNCTIONAL, PSYCHOLOGICAL, EMOTIONAL, PSYCHIATRIC, SOCIAL AND ENVIRONMENTAL CAUSES HAVE BEEN IDENTIFIED AND ADDRESSED MUST BE PRESCRIBED AT THE LOWEST POSSIBLE DOSAGE FOR THE SHORTEST PERIOD OF TIME AND ARE SUBJECT TO GRADUAL DOSE REDUCTION 11

12. INADEQUATE INDICATIONS FOR USE  Wandering  Poor self care  Restlessness  Inattention or indifference to surroundings  Impaired memory  Fidgeting  Nervousness  Insomnia  Uncooperativeness/refusal of care or difficult receiving care 12

13. DOSE THRESHOLDS  Minor updates and revisions (Maximum total dose of zyprexa is now 5mg instead of 7.5mg)  Newer Atypical Agents Added 13

14. CRITERIA FOR USE  DIAGNOSIS ALONE DOES NOT WARRANT THE USE OF ANTIPSYCHOTICS  BEHAVIORAL SYMPTOMS MUST  PRESENT DANGER TO RESIDENT OR OTHERS AND  SYMPTOMS ARE DUE TO MANIA OR PSYCHOSIS  BEHAVIORAL INTERVENTIONS ATTEMPTED AND INCLUDED IN PLAN OF CARE 14

15.  Clinical condition/diagnoses meets criteria  Prior to initiation / titration of an antipsychotic medication for enduring conditions, the target behavior/s must be clearly and specifically identified and documented and MEDICAL, PHYSICAL, FUNCTIONAL, PSYCHOLOGICAL, EMOTIONAL, PSYCHIATRIC, SOCIAL AND ENVIRONMENTAL CAUSES HAVE BEEN IDENTIFIED AND ADDRESSED ANTIPSYCHOTIC MEDICATIONS: ENDURING, CHRONIC OR PROLONGED CONDITIONS

16.  For residents who are admitted on an antipsychotic medication: Facility must re-evaluate the use/GDR of the antipsychotic medication at the time of admission, and/or within 2 weeks of admission NEW ADMISSIONS

17.  When an antipsychotic medication is being initiated or used to treat an emergency situation (acute onset or exacerbation of symptoms or immediate threat to health or safety of resident or others), additional requirements for use include: 1. The acute treatment is limited to 7 days 2. A clinician in conjunction with the interdisciplinary team must evaluate and document the situation within 7 days to identify and address any contributing and underlying causes of the acute condition and verify the continuing need 3. If the behaviors persist, non-pharmacological interventions must be attempted, unless clinically contraindicated ANTIPSYCHOTIC MEDICATIONS: ACUTE OR NEWLY INITIATED

18. OTHER HIGHLIGHTS  SURVEYORS ARE ADVISED TO SPEAK TO PRESCRIBER AND /OR CONSULTANT PHARMACIST WHEN ANTIPSYCHOTIC IS USED FOR DEMENTIA  FACILITY AND PRESCRIBER MUST DOCUMENT RATIONALE FOR DECISION TO USE ANTIPSYCHOTIC  FAMILY MEMBER/RESIDENT/OR LEGAL REPRESENTATIVE IS AWARE OF AND INVOLVED IN THE DECISION TO CONTINUE THE MEDICATION 18

19. OTHER HIGHLIGHTS  POTENTIAL ADVERSE CONSEQUENCES OF ANTIPSYCHOTICS:  ANTICHOLINERGIC: CONSTIPATION  NEUROLOGIC: AKATHISIA/PARKINSONISM/TIA/STROKE  CARDIOVASCULAR: ORTHOSTATIC HYPOTENSION/CARDIAC ARRYTHMIA  METABOLIC: INCREASE IN CHOLESTEROL/TRIGLYCERIDES/WEIGHT GAIN/ POORLY CONTROLLED BLOOD SUGARS 19

20. OTHER HIGHLIGHTS  FOCUS ON RESIDENT IF MORE THAN ONE ANTIPSYCHOTIC PRESCRIBED  ANTIPSYCHOTIC DISCONTINUED AND REPLACED WITH OTHER PSYCHOPHARMACOLOGIC DRUG 20

21. SURVEY READY!

22.  Use facility QM Report to preselect concerns for any QM that is flagged at the 75 th or greater national percentile  If either of the QM’s for residents on antipsychotic medications are flagged, include the questions related to dementia care and antipsychotic medication use during the ENTRANCE CONFERENCE OFF –SITE PREP

23. SURVEY SAMPLES  SAMPLE MUST INCLUDE AT LEAST ONE RESIDENT ON AN ANTIPSYCHOTIC FOR A COMPREHENSIVE OR FOCUSED RECORD REVIEW  REQUEST A LIST OF RESIDENTS WITH DEMENTIA AND WHO HAVE:  RECEIVED AN ANTIPSYCHOTIC IN THE PAST 30 DAYS  ARE CURRENTLY RECEIVING AN ANTIPSYCHOTIC  HAVE OR HAD A PRN ORDER FOR AN ANTIPSYCHOTIC IN THE LAST 30 DAYS 23

24. SURVEY SAMPLES  DNS AND ADMINISTRATOR WILL BE ASKED:  HOW DOES FACILITY PROVIDE INDIVIDUALIZED CARE AND SERVICES TO THOSE WITH DEMENTIA  WHAT ARE YOUR POLICIESRELATED TO THE USE OF ANTIPSYCHOTICS FOR THOSE WITH DEMENTIA. 24

25.  Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care  This includes, but is NOT limited to, care such as CARE OF A RESIDENT WITH DEMENTIA, end-of-life, diabetes, renal disease, fractures, congestive heart failure, non-pressure related skin ulcers, pain and fecal impaction F 309: QUALITY OF CARE

26. THE CARE PROCESS OVERVIEW  A. Recognition and Assessment  B. Cause Identification and Diagnosis  C. Development of Care Plan  D. Individualized Approaches and Treatment  E. Monitoring, Follow-up and Oversight  F. Quality Assessment and Assurance (QAA) 26

27. RECOGNITION AND ASSESSMENT  Medical record must include past life experiences description of behaviors preferences for daily routines/food/music/exercise oral health presence of pain medical conditions cognitive status medications 27

28. RECOGNITION AND ASSESSMENT “CMS expects that the resident and family/representatives, to the extent possible, are involved in helping staff to understand the potential underlying causes of behavioral distress and to participate in the development and implementation of the resident’s care plan.” 28

29. RESIDENT/FAMILY/REPRESENTATIVE INVOLVEMENT  How have you involved them in discussions about:  – Potential approaches to address behaviors?  – Potential risks and benefits of psychopharmacological medications (including boxed  warnings)?  – Expected duration of use of a medication?  – Use of individualized approaches?  – Plans to evaluate the effects of treatment?  – Pertinent alternatives?  – Necessity of informed consent (only applicable in some states)  All discussion should be documented in the resident’s record 29

30. CAUSE IDENTIFICATION AND DIAGNOSIS  Identification of co-existing medical or psychiatric conditions and adverse consequences from medications  Establish root cause of behaviors 30

31. DEVELOPMENT OF CARE PLAN  For any medications the care plan must include: Indication/Rationale for use Dosage Monitoring for efficacy or adverse consequences Specific target behaviors and expected outcomes Duration Plans for Gradual Dose Reduction 31

32. INDIVIDUALIZE APPROACHES AND TREATMENT  Identify and document specific target behaviors, expression of distress and desired outcomes  Implement appropriate, individualized, person –centered interventions and document the results  Communicate and implement plan of care, over time and across all shifts.  Mandatory training on the care of individuals with dementia must occur at hire and annually thereafter for all nursing assistants. 32

33. MONITORING /FOLLOW-UP/OVERSIGHT  Review progress towards defined goals  Adjust interventions accordingly  Notify prescriber of concerns regarding effectiveness/adverse consequences  Prescriber must respond timely 33

34. QUALITY ASSURANCE AND ASSESSMENT  Medical Director and QAA committee must - oversee resident care policies -monitor compliance with policies -provide sufficient training to insure that medications are not used instead of pertinent non pharmacological interventions. 34

35. 1. Provide Person-Centered Care 2. Maintain Quality and Quantity of Staff 3. Thorough Evaluation of New or Worsening Behaviors 4. Use Individualized Approaches to Care 5. Critical Thinking Related to Antipsychotic Drug Use 6. Prepare prescriber and other disciplines for Interviews with Surveyors 7. Engagement of Resident and/or Representative in Decision- Making ESSENTIAL ELEMENTS FOR COMPLIANCE

36.  Find the balance between quality of life and improvement in outcomes  Documentation is critical  Communication is key  F309 and F329 are tied together SUMMARY

37. INDIVIDUALIZED, PERSON-CENTERED INTERVENTIONS MUST BE IMPLEMENTED TO ADDRESS BEHAVIORAL EXPRESSIONS OF DISTRESS IN PERSONS WITH DEMENTIA and USE OF ANTIPSYCHOTICS IS NOT FIRST LINE TREATMENT FOR BSPD BOTTOM LINE

38. QUESTIONS