Event ID: 2857057 Event Started: 2/2/2016 1:46:15 PM ET

[Please stand by for real time captions].

We have a lot to talk about today so we will get started. Will come back to the dementia antipsychotic reduction quality care series. This is our partnership between Vanderbilt medical Center, Vanderbilt Center aging and Qsource. Mrs. Session 5, Implementation of Behavorial Plans & Management of Pharmacological Interventions. If you have missed a session before this, you can view them all on our website. In a moment that will send you the information through the chat. She will monitor chat so if you have questions for the presenter, be sure to communicate with us that way. If you could go ahead and enter your facility name and the number people currently viewing the webinar. We have a lot of information to cover today so we will get moving. The implementation of behavioral strategies and management of pharmacological interventions. We are lucky to have with us today, Dr. Jim Powers, head of geriatric Fellowship program at Vanderbilt and does a lot of geriatric education outreach. Jennifer Kim, in the school of Miller's -- nursing a Vanderbilt and co-director for gerontological nursing. Her expertise of long-term -- long-term care and [Indiscernible] education will come in handy later today. We are also joined by Dr. Ralph Haberman, another geriatrician at Vanderbilt with a great deal of long-term care experience. I will turn it over to him.

Hello, everybody. This is Jennifer Kim. Thank you for coming to the webinar. Our objective, we are going to be viewing Step two that we had addressed in the last webinar which includes selecting and implying interventions for behavioral problems. We will talk about some case examples and we are also going to be introducing Step three which is monitoring outcomes of the behavioral interventions and plan of care is needed. We will also have Q&A session for any questions you may have related fork step number two and step number three. We will also talk about managing pharmacological therapies. Just a quick review of our session that we had last month. In looking at step two, we discussed identifying and describing behaviors as well as [Indiscernible] and treating [Indiscernible] factors. We talked about developing non- pharmacological approaches but we really just sketched that and we will talk more about today. We will also talk more about implementation. Also in review from our last webinar, we talked about developing a plan of care and giving best evidenced -based intervention but we did not talk about training staff on how to use these interventions. That is something we will cover today in the webinar. Our final reviews like, these are some of the behaviors that are commonly seen in patients with dementia in the long-term care facility, as well as evidence-based intervention. A quick review for agitation or irritability, important to look for enjoyable activities that patients enjoy or have enjoyed in the past, implementing some kind of exercise or activity routine, redirecting and distracting is also very important. Then when looking at wandering or restlessness, trying to provide rest stations in pacing path. Again, physical activity is also very good for this behavior. And then finally, when looking at resisting care, it's really important to remember that they staffed oftentimes needs to change the approach to the residence. Also looking at potentially changing the resident routine. Here is a case example from your homework that was assigned for session four. Mary, a female nursing home resident with late-stage dementia. The problem is she is consistently trying to get up unassisted from her wheelchair and out of bed at night. This is a common issue in long-term care. The issue is she becomes very agitated when staff tries to a sister. She come -- sometimes because mildly combative with staff tried to help her into the wheelchair and into bed at night. When looking at the frequency, she does it most days of the week, five days of the week. The combative behavior usually lasts a few minutes before staff can help her get back to a calm state. The staff identifies the intensity as moderately disruptive and possible safety risk to others, as well as herself and staff assisting her and possible harm to herself while she is in that agitated state. When looking at these triggers, possible triggers to this behavior, staff realizes quite possible during the day she is bored. Also quite possible she is depressed. Also in looking at medical history she has macular degeneration and hearing deficit which may make it difficult for her to interpret stimulation or stimuli. There is also the question at night if she could possibly be having some urinary urgency causing her to want to get up and go to the bathroom. When the staffed looks at Mary and looks at her interaction knows she is tactile and likes to touch things. She is also curious and very friendly. When they engaged in conversation with her daughter, her daughter states she is very social. When her daughter was taking care of her at home, Mary had a lot of straddling behavior. In other words, followed her daughter around the house and liked to be in the mix of things. After looking at all of these factors and talking through this with staff, deciding a good intervention for Mary would be to assist her with the use of a Merry Walker which is an ambulation device used for safe ambulation inappropriate residence. This would allow her to pace throughout the facility at her own rate and provides her opportunity for rest because it does have a seat within the Merry Walker.

We are at our first polling question, a true/false question.

A resident with dementia may get agitated when asked to perform a task that has many steps. True/false. Be sure to select submit after you have entered your answer.

It looks like everyone who chose an answer chose, too. Good job, congratulations. Paying attention early on. We will go ahead and move on. We have a second polling question.

Effective management of agitation in a patient with dementia may include all of the following nonpharmacologic interventions except:

Reenter --

Reorientation and reassurance, physical restraint, structured activities, modifying the environment. After you select your answer, he sure to hit the submit button.

Everybody who chose an answer charge physical restraint. Yes, that's correct. That is not a non- up opiate nonpharmacologic intervention.

We will move forward to talk about staff training. We talked a lot about great evidence-based interventions that you can use for differ behavioral problems. We want to talk about how you would train staff in these behavioral interventions. Our recommendation is organized the training by the role that staff member does provide the facility. If you look at a CNA and RN and therapy, they all have different roles and [Indiscernible] they bring to the table. Good idea to organize training such as that. Also organize training by shift. Afternoon and evening shift often have differ behavioral issues then the morning shift. Also before you start applying these interventions are doing staff training sessions, important to assess what your staff members know about dementia and about delirium or about any behavioral issues. This can be done through a formal assessment or could also be done informally or you ask them what they know on the topic and if they have had training. It's also important to ask what they know about sensory changes with aging or any abnormal changes of aging to get a good baseline to know where to start with education and training sessions. When thinking about the logistics of the training, it's a good idea to identify any informal leader in the greater. Somebody that might be really tricky good at problem solving or somebody that has a specialized interest in providing care for patients with dementia. I think it's also important to incorporate staff ideas and their input, give them a forum to talk about any issues that they have. Anything they have used in the past that has really helped them be successful with managing some of these behaviors. In identifying educational materials, NYU Institute for geriatric nursing is excellent. Has quite a few free tools accessible. I believe all you have to do is register at their site. There is another site as well, [Indiscernible] that provides free training material. There have been some recent research that shows online modules are quite cost-effective. There are some facilities that use computerized based training as well. It would be my recommendation to start training on a small scale, perhaps to the unit on a staff particularly motivated. Or perhaps they have specific problematic issues that you feel would need to be addressed first. It's always good to start on a smaller scale and then graduate some of the training sessions to be facility wide. Some things to think about as you are developing a training plan or even implementing it. Consider turnover. I know some facilities are [Indiscernible] with turnover more than others. There are also shifts that have problems with turnover more so than others. You want to make sure its frequent enough that staff is retaining all of the principles they learned during the session. You also want to make sure you are not creating in-service fatigue as has been the problem in the past in some facilities where staff does not see the value of in-service because they have so many of them. We are going to be talking about barriers during our Session. Quickly, to introduce, it's difficult for some folks to change old habits or old ideas or opinions about how you work with patients with dementia. Sometimes this could be a barrier. There are also some patients that are really difficult and can cause staff to be discouraged. I think it's important to acknowledge that. You will have difficult patients and together you need to work through some of those difficult situations. Also thinking about staff coverage during training services. Whenever you are training whether they are nurses, nursing assistants, you need to think about who is going to be covering the floor during that time. I have worked in some facilities where they stagger the in-service so that there is appropriate coverage at all times. And been any kind of competing agendas or improvement projects also would be demanding the attention of staff. A key question here and I would invite input from all of you is, what would be a good way to improve staff buy-in?

If you have thoughts on that, please send it through brick through the chat pane. We would love to hear how you do that already or how you think you could do that.

Something that I think I have found to be important in buying and is having and service the a short length of time, no more than 20 minutes, inviting all members to participate and provide their input. And taking it interactive. Computer-based programs our great because it provides more flexibility but there is really that lack of interaction. My own personal experience with training found staff really enjoy the interaction with each other and interaction with the leader.

This is Jim Powers. We are going to come up with another example for you. These are authentic, very real examples. This involves step number three, monitoring outcomes and adjusting the course as needed. And revealing at institutional level quality improvement project. We were asked to consult at 100 bed facility. The reason we were asked to consult is they had just received information that they were prescribing 25% of patients we're getting Antipsychotic medications. They received benchmark information that they were at the 30 percentile compared to regional. Facilities. In other words, poor performance. We developed a series of in services in educational programs very similar to that which you are receiving right now through webinars. This was designed with the goal of increasing staff awareness and knowledge of nonpharmacologic intervention for managing disruptive behaviors. And also ways to improve communication between the patient and staff about these behaviors and providing staff with additional tools for managing these behaviors and ensuring their efforts in this endeavor were recognized. We had mentioned previously about my end, I think staff to buy into this, we found quickly they did not want to be lectured to work in fact, they very much turned our presentations and to stump the chomp where they would bring us to see patients they were having challenges with and see if we could come up with some examples of plans as well as strategies to help manage the behavior. It was a very interactive and dynamic type of relationship that we had with the staff. We developed nine, 20 minute sessions to get to all of the staff in all of the units and shifts. The in services if a sized most behavioral disturbances were provoked through interactions with the caregivers and the patients. The patients that had dementia had very limited ability to change behaviors. That change had to come from the caregivers. We discussed behavioral strategies, in fact, very much related to the individual cases that they presented to us and environmental changes that might be possible. The participants were encouraged to bring up more cases, not only their challenges but their successes from their experience. Regarding monitoring outcomes, we were very keen to see this strategy was effective. We looked at staff perception of the program, satisfaction, barriers to change and intention to change practice and a monthly review of quality indicators such as balls every straight use as well as antipsychotic prevalence. We were able to track this. Results were quite astounding. Over six month follow-up period, antipsychotic prevalence declined to 18%, which put them at the 90 percentile compared to regional. Benchmark scoring. There was a 20% reduction in other behaviors such as proportion of patients taking nine or more medications, as well as 23% decline in proportion of patients who fell. Asking the staff what they thought about the program, they said they reported it was well received. They did have barriers to change which were very constructed to us. In some patients the progression of the venture was such they were not able to carry through with some of the behaviors. The patients either could not cooperate or remember and it was very difficult to get those patients to perform new tasks, do activities. Occasionally, there were review staffing levels which led to communication challenges and also a need to train new staff on the facility. Communication between shifts was an ongoing barrier. Implementing similar behavioral treatment plans as well. We learned a lot from that. We found that we were able to use that information to provide to the Administration, as well as to the actual staffing, as well about how to adjust and monitor outcomes. Basically, PDSA cycle, again and again to improve activities. One of the institutional outcomes that came from this was improvement in the community dining experience where they had new furniture brought in with rounded tables, rather than long tables. It was more of a dining experience that was more conducive, I think, to community and the patients also appeared to eat better as well. That was and environmental influence that was helpful for the whole facility. We used also be tracking tool very similar to that which we showed you from the adapt program, University of Iowa adapt program worked to adopt you meant -- to document frequency of behavior, target behavior and the techniques used to address these concerns. This was an ongoing change and the care plan which was documented in part of the patient's record so that out of this institutional change, we also instituted care plan changes that were specific to the individual patients. In terms of the intensity and scale, this is important because occasionally, we found the combative behavior did have a disruptive effect. It was on the intensity scale of four with significant safety risk too not of that -- not only other residents but staff. That is material for another case we present. It was very important for the staff to be able to document just how serious some of these behaviors were. In terms of how consistently the staff apply the intervention, we were consulting to this particular facility for only six months. However, we know the prevalence of the antipsychotic prescribing remained within an acceptable range, at least as far as the region is concerned. I don't have further information to report to you but at six but we know that things we're going very well. We made sure that all staff realized they had to communicate and collaborate with others on the ship, others on the floor in order to make any of these care plans be effective, be helpful. We also found that reinforcing the staff training was necessary. We basically trained the trainer which meant the RNs, LPNs who worked in the facility helped carry on this project. We -- with continuous staff development and support of services. Some of these recommendations were not always successful. Trial and error was necessary. Sometimes it involved knowing more about the individual residents anymore information about personal preferences and family from other visitors and communicating this to the different shifts so the interventions to be consistent and effective.

Going back to marry, if you recall she was our agitated nursing home resident who started using a Merry Walker to increase her activity and durability to interact with others within the facility. In assessing this again, and again in Step three, monitoring behaviors and they looking at your outcomes and adjusting your intervention as needed. In looking at her agitation, she had if you recall before the Merry Walker she was agitated most days of the week, five days of the week. Now she is reporting the guy agitated one, two days per week. Her agitation is still approximately seven minutes but staff is able to get her back to a calm state. Intensity of her agitation has lessened quite a bit. If you look at the intensity scale it is a minimal effect on her self and others. If you look at other measures, other elements of the chart, you see she is not receiving as many PRN Klonopin doses as she had prior to this intervention. We know that her agitation is much better and being controlled using Merry Walker. She is also having better sleep at night and has not received as many PRN. Another element of safety that we see is she has had no falls since she started using the Merry Walker. We know oftentimes increased agitation does result in false. In assessing this, we see this is a really good intervention to manage marries agitation. In looking at our plan we think it's appropriate using the Merry Walker. Given Mary's, knowing Klonopin [Indiscernible] and ability to ambulate will probably decline. We want to consider moving her where there are more small group stimulation activities -- I am sorry, stimulation activities knowing she may not be able to ambulate as much in a Merry Walker at that time. Looking at the combination of both of these interventions is something else we will look at in our plan. When looking at documenting all of your findings, it's important to document what interventions you have used and include what has worked. Also what hasn't worked. This is it good to review as you were looking at your plan and looking for two, perhaps, changing intervention. It's really important as well to communicate between different shifts and different staff members on how to manage the patient's problem behaviors. It will also allow you key evaluation of efficacy for your QAPI data.

Remember, Merry Walker is considered [Indiscernible] in long-term care facility. You need to have the right care planning and documentation so that you are using it as enabling device and not restraint. It's as an important because [Indiscernible] use restraints and [Indiscernible - low audio] exercise. It just needs to be documented the right way. Otherwise we could get in trouble.

Excellent point, excellent point.

We reached are third polling question, another true and false.

A one-time training in non-pharmacological interventions is adequate for staff.

True/false.

Just remember to hit submit after you have selected your answer.

Everyone who responded shows, false. That is the correct answer. The correct answer is false. As Jennifer and Dr. Powers had said, it's important too continually have staff training. With new staff coming on as well as adjusting and refreshing.

Before we move on to pharmacological, managing pharmacological approaches, we have some time for Q&A. If you have specific questions about the material so far, please feed those to Britt. We welcome your questions.

We also invite your questions about challenging cases and even your success stories. We will be identify them and use them for discussions in our next webinar.

Just to whet your appetite, and a few minutes, Dr. Haberman is going to go over response to a question submitted last time which is very germane to pharmacologic management. We will go on them.

Even when attempting your best to use non- nonpharmacologic strategies, there are times when pharmacologic approaches our necessary. Remember the previous webinar and Dr. Newhouse had mentioned antipsychotics, after you have attempted nonpharmacologic approaches. For persistent and severe cases and for certain diagnoses. We will go over those in just a second. Treatment with an antipsychotic requires that you have documentation. What is the behavior being addressed? Is this behavior permanent or temporary? Has the behavior been evaluated for certain things that might escalate it such as social or situational issues? Have you ruled out environmental causes for the behavior? Have you ruled out medical causes, remembering some of these behaviors might actually be delirium, manifestation of acute medical illness or paying? Make sure that you understand if the patient has persistent symptoms, despite the use of nonpharmacologic measures. Are these symptoms unpreventable? Are they part of the patient's underlying condition and that you have failed with non-pharmacological management? We realize that does happen. We realize that certain organic mental syndromes can be associated with psychotic or agitated behaviors. We are required to attempt a gradual dose reduction of antipsychotics every six months. Ellis a patient has one of the approved conditions for using antipsychotics. These include severe bipolar disease, Schizo-affective Disorder, treatment resistant depression, autism, Tourette syndrome, so she'll we effective disorder and mania. Realize the use of antipsychotics outside of these diagnoses for a while may be necessary at times remains off-label. We have to justify it's use. Remember that in reviewing the individuals medication history, we have to find evidence two previous attempts have been made in the last year to establish has been reduced to the lowest level 2 reduce symptoms and document that in consideration of other extenuating circumstances and risk-benefit analysis. And we do have sessions where we discuss with families, discuss with staff about barriers to implementing nonpharmacologic management, we realized reluctance to change, something that has been working is, unfortunately, not an acceptable reason to avoid a dose reduction or attempt at dose reduction. This is very important.

Now we have a very long polling question and read it as quick as I can giving you as much time to answer.

A resident with past history of agitation and striking out was controlled on olanzapine 5 milligrams twice daily. The dose has not been changed for previous six months, although he had exhibited no outbursts during that time. The family is reluctant to consider any medication changes. Which approach is preferred? A, respect the family's wishes and leave the antipsychotic dose unchanged?

B, respect staff concerns for safety and leave the antipsychotic dose unchanged.

C, educate family and staff regarding person-centered care and medication safety and initiate an antipsychotic dose reduction plan with frequent reviews of outcomes and family and staff reports.

If we can get WebEx to post the questions?

Go ahead and select your answer and hit the submit button.

Everyone chose trend one, educate family and staff regarding person-centered care and medication safety.

Excellent job. We have a good group of people paying attention today. We have some examples of pharmacological or combining pharmacological and non-pharmacological approaches before we get to those we want to address a question that was asked in our last session. The question was, we have extremely difficult resident we have not been able to manage. She becomes extremely anxious as soon as she awakens. [Indiscernible] against to increase and remains that way until she goes to sleep around can be an. She has been treated in several inpatient centers too no avail. She is in constant panic mode and focuses on dying and going to hell. She cannot be redirected by staff or family. There are no triggers or distractions. She is continuously [Indiscernible - low audio]. She is currently taking [Indiscernible] three times a day as needed, lorazepam 100 milligrams [Indiscernible] as needed and [Indiscernible - low audio] on 50- milligram at bedtime or [Indiscernible - low audio] at bedtime. And [Indiscernible] or effect so [Indiscernible] at night and ambient, to milligrams in the evening. She is now losing weight and too anxious to eat. We would like some advice.

That is an extremely difficult and not uncommon patient in the way she had been in several psychiatric institutions and they could not fix it. That tells us something is seriously wrong. There are a couple of things to consider. First of all, consider the diagnosis. This is [Indiscernible] severe when you see this anxiety disorder but it can be the case. The question is, and she psychotic? Describe focus on dying and go to hell me describe delusion and underlying [Indiscernible]. [Indiscernible - heavy accent] underlying paranoia or delusion. If that's the case, [Indiscernible] would not be expected to help. At digits should focus on antipsychotic medication and she might need higher doses of all lines up and or use a different antipsychotic, a different psychotic medication. Actually need to go up with the doses. If she is [Indiscernible] and purely anxiety, focus should probably remain on serotonin or epinephrine medications and, often the treatment of anxiety need high doses. [Indiscernible - heavy accent] titration of effects of two maximum dose which can be 225, 300-milligram per day. I don't know how old the patient is or the [Indiscernible - heavy accent] is. If she is a small tiny person with poor kidney function and is already on maximum dose. It's important to look at that or you can look at other agents like different SSI and switch maybe to [Indiscernible - low audio], fluoxetine or if XOR. Sometimes could add a small dose of [Indiscernible] and see if that would help anxiety. Or does she have an unexpected reaction to the bins those she's getting on in all. She is giving them for a few days and the next two days, nurse said let's hold it. I think one should do a single agent. Either you -- do not use Xanax. Ativan or value, Ativan better than value for pharmacological effect. If you knew the longer acting agent, clonazepam would be ideal. You need to be very careful. Then if it's going on all the time, I would schedule it regularly and not do PI. Schedule and titrate up or down as needed. Then you need to have better coverage. You need to look at the pharmacological effects of the half-life if you give it and it stops working and three hours later you give it again would not be helpful. That's why the lorazepam are the clonazepam could be helpful. Need to be very careful if you have to do that, monitor for fall risk and sedation. The other, if this is a dementia patient also, sometimes Colace inhibitor could help, potentially [Indiscernible] patch or low-dose Aricept in the evening with appetite. Perhaps the [Indiscernible] patch would be helpful. I would also cut down on [Indiscernible - heavy accent] 25 B ID. Or if she has [Indiscernible - heavy accent]. She knows she is at the end of her life. Maybe we need to call the chapter for special care and after a couple of times she may not be as afraid and thinking going to help my be okay. Call palliative care or Hospice people. Sometimes we can think about music therapy if she likes music or aroma therapy have help with anxiety and some people. We need to rule out medical reasons. I would assume it's done because she was [Indiscernible] but never assume. Just check for hyperthyroid, that she doesn't have [Indiscernible - heavy accent] or severe pain or constipation. Perhaps small dose of pain medication or [Indiscernible - heavy accent] before narcotic could help. It could be highly complex. You need to look at the patient. Thank you, Dr. Haberman.

The other thing, it's a lot of medication. Let the psychiatrist look at it several times. That's why [Indiscernible - heavy accent] if you can.

We will do our best to post a summary of this case. Some of these corresponding recommendations as well on our projects website for reference. It's a lot of information.

We will go on. We have two sure cases that combined the non-pharmacologic and pharmacologic approach. As we realize that may be necessary as well. These were submitted by some of our colleagues, nurse practitioners to practice in are long-term care facilities. This is a case of an individual calling out, help me, help me, help me. Has had a history of mood disorder, dementia complicated by psychoses and hallucinations and anxiety. Her behavior was manifested by increased anxiety and yelling which was inconsolable. Measures that had been tried included family support, reassert inch -- reasserts -- reassurance, validation, reorientation, distraction, redirection, reapproach. She was on several medications trazodone, Zoloft, Aricept, Namenda, Neudexta. The psychiatric Nurse Practitioner had recommended increase in clonazepam in previous weeks. Upon reviewing her follow-up, there were no physical problems apparent causing these behaviors. Some laboratory was done targeted to rule out more common causes of behavioral problems such as agitation and delirium which is with urinary tract infection not found to be the case here. And psychiatric evaluation was performed with a plan to increase the clonazepam during the day and night, treating the anxiety disorder with her mix of diagnoses here and to continue the non-pharmacological measures and social support. I will stop for a moment for questions. With that, the patient remains stable we understand and it may be very similar to some that you have.

She still has bipolar disorder. Does she need the mood disorder?

If continue, [Indiscernible] is appropriate. [Indiscernible - low audio]

Going on we had another submitted in some of our affiliated Nursing Facilities by a consultant Nurse Practitioner. This one dealing with physical aggression. There is a medical history of dementia, sexual acting out with anxiety and also depression. Underlying diabetes, hypertension, some heart failure and emphysema as well. This woman had been in an altercation with another and the staff quickly intervened so there was no injury, no patient on patient injury. However, there was a concern for acting out behavior. Her medications were also quite extensive Paxil, Seroquel, Tegretol, lorazepam, Aricept, medroxyprogesterone. Reviewing for medical problems and medication dosages, start dates to be sure everything was accurate and the medication history was well documented was performed. Their appeared to be no new medical problem contributing to the physical aggression. Behavior modification measures we're instituted, including to educate all staff to approach her calmly, to provide emotional support, to confront inappropriate behaviors but to also provide verbal praise for behaviors that were conducive to a safe environment for all concerned. The care plan included to continue all medications and continue behavior modification measures and follow-up with mental health psychotherapy. This is a case where the acting out behavior was not apparent, the cause was not apparent non- pharmacological measures were added to a patient who was already getting pharmacologic management without changing pharmacologic management to manage her behavior. I will stop. I am happy to entertain any comments or questions. Perhaps, this is a patient that is similar to others that you have treated as well.

It seems we've got a quiet crowd today. Although, you have done very well with the polling question's. We will wrap-up what you are thinking of more questions because I know you have them. You've got a panel of experts sitting here anxiously waiting for something.

I will give you a summary of the session. Three steps are involved. Three steps are involved of management of behavioral disorders in dementia. First of all, identify and assess the individual. Try to treat contributing factors, identifying those contributing factors is dependent on knowing as much as possible about the person which will include staff, reports from all shifts and also family information. The more information you have, the more appropriate you will be in your response. Select and apply nonpharmacologic interventions first. You have some tools that have been provided for specific behaviors. Truly, there are scores of non-pharmacological interventions. Not all of them will work each time for every individual but there are some that may be very appropriate and tailored to your patient and can be part of a person-centered care plan. Monitor the outcomes and if you find the intervention is not effective, change course. Document this on the care plan. That's very important. Try a different course of action. Perhaps, new information might be available that will lead you to a more appropriate intervention. It's important to do this before resorting to Pharmacologic Interventions.

Again, we will be here if you have questions. You have time to send those to brick to the chat pane. I want to let you know about Session which will have all of these lovely panelists back year with us to talk about barriers to change from all of the different perspectives. We will also have our colleagues from geriatric psychiatry, Paul Newhouse and Warren Taylor back. March 8 and March 10. Again we will have an afternoon session and a morning session. We will wrap-up and the finale to our series. We appreciate your participation and helpful feedback. We will have WebEx post the final evaluation question.

Again, the link to NYU school of nursing tool, as well as geriatric nursing tool will be on our website under Session 5. The homework assignment and an example will be posted under session four and Session 5. The case example we've reviewed today submitted during session four will also be posted there. All of these resources will be available to use.

For every facility that participates in any of the training and especially for those who have participated in all six, we will be raffling off a couple of gift cards. You get raffle tickets for your participation by showing up and up by asking questions. Maybe a little encouragement to come to Session with lots of questions, or by giving us a case example which you can send to either Brett, [email protected] , or myself, [email protected] u , links and our project website page, www.VanderbiltAntipsychoticReductio n.org. Final session will be incorporating what we have learned from focused groups we have been doing parallel to this webinar series about barriers from specific [Indiscernible] facilities. I encourage you to come with questions. We will have lots of time for those and get great advice from the panel of experts. If WebEx can post the final evaluation question so people can do that before they logout. Thank you for hanging on the line with us. We will try to get WebEx to post the evaluation question so you can complete that. Before you logout, give us some helpful feedback. We would appreciate it.

Again, you can find all of this information, the slides, the resource link mentioned on our project website under Session. If you have other staff who would like to are you on them to see this presentation, we will be back next Thursday morning at 10:00 a.m. Central time.

[Event Concluded]