Event ID: 2766131 Event Started: 10/22/2015 10:48:53 AM ET

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All right it is 10:00 will get started. Good morning and welcome to dementia and antipsychotics in the long term care setting, quality improvement initiative. We are excited to have you with us for this new web-based training series, a collaboration between the medical center the Medical Ctr., Vanderbilt, and resource, quality improvement agency here in Tennessee. This is the first in a series of six training sessions, one session per month. November will be dementia and behavioral services, then psychopharmacology in December and on down. We have modified the titles for the last three presentations and you will receive that in a schedule of training dates and a follow-up email to the training sessions.

Also we will do to presentations every session, and a.m. in a PM, and that will be listed in the email. Also you can find this information at our project website, the link is in your chat pane. And Brett will modify it our future today, I want to go over some housekeeping. We have the phone lines needed that provides better listening experience by eliminating back on ice, we won't open the phone lines, we ask that you use the chat box feature type depending on how your window is set up will be located on the right-hand side or the top of your screen. As I mentioned Brett will monitor the feature during the presentation if you've a question or comment posted in the chat and we will respond there or on the call.

So we can verify everyone understands how to use the chat feature these post in the chat box which facility you are calling in from and how many people are viewing the webinar there.

We would like you to keep a record of attendance for who attends at your facility in either email it or fax it to us. If you should have gotten the attendance record sample in the invitation, if you didn't you can go to our website and click on the session one tab and it will be right there on your right-hand side.

Also while you are posting facility in the chat I would like to inform you that during the presentation you will be asked to participate in some polling questions, stay engaged in the fun and when you answer a question hit submit so we can capture your answer.

We will try that out.

The polls will open after I read the question.

How would you describe your facilities current procedure of reducing and this exotic use? A how we are just started to do this in trying to do more. [poll]

And now the poll is open go ahead and select your answer and make sure you hit submit when you finish.

We appreciate you answering. It looks like everyone is in a slightly different place, most are trying or have started this process, we hope this series of six will get you further along in the process. We appreciate you taking the time to answer, it will help us tailor our future sessions to your needs, with that said it's get underway.

Today will do an introduction to dementia care and quality assessment and performance improvement, for those that have participated in the initiative, hopefully it will be a refresher and some new information. We have great speakers for you today, Dr. Jim Powers from Vanderbilt, Carrie Plummer from the school of nursing and Beth Hercher.

I will turn it over to carry.

-- Carrie.

If you can't hear me please let us know in the chat box and we will let you know and adjust accordingly.

To do a quick overview, many make sure we haven't.

There we go, the objectives for today are to provide a quick and brief overview of dementia and problem behaviors associated with dementia and nursing home settings. And then to have a discussion about the potential adverse effects associated with use of antipsychotic medication and managing these problem behaviors. And finally to do a brief overview and introduction of copy and how we can apply it in the long-term care setting to reduce antipsychotic use in this population.

Most of these statistics won't be a surprise to any of you since you are in the mixed of it all. But when their servers are polls on looking at Medicare beneficiaries in long-term care settings reason studies have shown approximately 64% of these residents and long-term care settings have Alzheimer's disease or other form of dementia. 70% of nursing home residents with dementia exhibit behavioral and psychological symptoms of dementia. 41% of those often have symptoms of psychosis which can complicate care for those patients.

Caring for person with dementia requires an -- a significant amount of effort on behalf of the long-term care staff from care partners to nurses to nurse practitioners etc. As cognitive impairment increases you see an increasing hours required to care for the person.

Some of the difficult behaviors we see associated with dementia are things such as wondering, sleep disturbances, sexual inappropriateness, verbal agitation, physical agitation, aggression, crying and psychosis which includes delusions and/or hallucinations. And will touch briefly on why this topic is so important.

Thank you Carrie. Thank you to all the nursing homes that are dialed in for this webinar today to participate in this series. I want to thank Dr. Powers and his team for this collaboration, you are part of our leading and sustaining systemic change collaborative, our collaborative and many of you have been getting QAPI techniques shared through that webinar. Series that we have, this collaboration with Vanderbilt will enhance your work around your performance improvement project, so we appreciate your attendance today. I do think Vanderbilt for the opportunity for us.

Why is this topic important? As you know being a part of the nursing home collaborative, this is a hot topic, antipsychotic reduction, and we all been working on it for several years it seems. With a long-term care setting. I wanted to give you a timeline, we have some of this information posted on our dedicated webpage for the leading and sustaining collaborative, and 2011, the Office of Inspector General, the OIG, Department of Health and team and services, you probably know this, they released a report underscoring the high use of atypical antipsychotic medication, the key word is off label indications among nursing home residents. According to the report, as Carrie shared with you, 83% of a typical antipsychotic drug claims were for elderly nursing home residents who had not been diagnosed with the condition for which antipsychotic medication was approved by the FDA. Because of that report, in early 2012, as a result of the findings CMS launched a nationwide initiative. I will share that in a moment, launched in April 2012. That was the national partnership to improve dementia care in nursing homes. As result, all of the states became. Aware -- very aware of the school of around antipsychotic reduction. Here in Tennessee as an example we formed long-term care coalition. THC a, QIO, Vanderbilt was a part of it, we started this discussion around the antipsychotic reduction. That leaves for the next slide, around the CMS partnership, we have been working on this for a while. This particular webinar series is to continue our work as I mentioned with the nursing home collaborative. Part of our goals is to reduce unnecessary antipsychotic medication. We are sharing with you, I'm sorry go back to the last like.

-- Last slide.

We are sharing with you overarching principles and concepts to our collaborative. With the subject matter experts that Vanderbilt is bringing to us we can start to form those performance improvement projects around this topic. Also another reason this is important, as we know, with the long-term care proposed rule around QAPI, when it is enacted we will have to have proof of one performance improvement project, and affected improvement performance project showing measurable outcome. This is a great way for us to align what we are doing with nursing home collaborative and also with Vanderbilt in this national initiative around dementia care, to start work on this. Thank you can Carrie I will turn it back to you.

Thank you that's.-- Looking at statistics from a state level in Tennessee, comparing it to national levels you can see we are lagging behind a bit. This is thanks to Beth and her group, recently updated information data we have here in terms of the average percentage of long stay residents on antipsychotics in a long-term care setting, nationally 18.7%. Here in Tennessee it is at 21.6%. You can see we are ahead of the curve and not in a good way. CMS's goal is to reduce antipsychotic use to 15% nationally, here in Tennessee we are looking at reducing to 17%. We have a ways to go.

Part of the effort, is because of our understanding of the adverse effects associated the use of these antipsychotics. In particular and are older adult population vulnerable to some of these side effects. For example, I'm sure you've seen in your patient population issues with sedation or over sedation with these medications, worsening of cognitive status, worsening of psychotic symptoms, restlessness, movement disorders, change in gait and in particular increased fall risk, weight gain and blood sugar issues.

This is a handy table that the University of Iowa has put together, comparing side effects of different psychotics that were seen and long term care settings. This is a nice way to compare them in terms of the actual side effects. They are comparing these different drugs, and you can see some have, for example Seroquel has a higher sedation rate than Abilify or Haldol, piquancy with the vast majority of these antipsychotics, sedation is a side effect you will see with this medication. This is a recent comparison done, combination of different studies done over the last decade. Put into a nice comparison table.

All of this said, we understand there are occasions where we do have to use antipsychotics. In the long-term care setting. There are some handy guidelines CMS put together, for prescribers that help define when these situations allow for the use of antipsychotics. When they are appropriately documented. The CMS guidelines are in particular the person must present a danger to themselves or others. Or causes a person with dementia to experience one of the following, inconsolable or persistent distress, significant decline in function or substantial difficulty receiving needed care from the long-term care staff.

I will emphasize cut the important thing is to make sure if this is the situation, the nursing staff, or nurse practitioners or physicians, document it clearly in the long-term care documentation.

Moving forward, how will we Institute these improvements that your facility?

This is where we start getting into talking about QAPI and CMS cycles. To give you an overall long-term view, in terms of fundamental improvement questions, we're looking at developing an aim, what are we trying to accomplish? We'll talk in more detail about each of these. After you have established your aim how will you measure there are changes happening, how do we start out with a baseline, and show there's a measurable improvement in your facility.

How we go about making the change?

I'm sure all of you have heard, but we will review this. In terms of the aim at helps to use the acronym smart. Which means we make it specific, measurable, attainable, relevant in timeout. An example here to reduce the percentage of residents receiving routine antipsychotics by 10% in the next six months. Even see specifically we are saying we want to reduce antipsychotic use and what are particular population as, we are specific. In terms that are measurable, we want to reduce this by 10%, time bound in terms we want to do it in the next six months. It is relevant because this is issues we have recognized nationwide and in Tennessee and was CMS. Taken a close look at this it is a relevant issue. It is up to the facility to discern whether it is attainable. Is this something we think we are able to do, I joke around with my students that sometimes I have days where my to do list, I will say my top number one thing is to get out of bed because I can check it off my list and feel like I've accomplished something. It isn't that we want to make it overly simple or easy, but we want to make an so we aren't shooting ourselves in the foot from the get-go, something you think is doable in the context of your facility.

In terms of measurement, a key thing and something you see whether it is quality improvement or research, want to make sure that what you are measuring is data that is easily obtainable. This would ease the burden of designing and doing this QAPI project at your facility, if you identify data that is easy to obtain that is already been collected maybe for a different reason but in your chart. What data can you use to monitor this change starting at your facility? Develop a data collection plan. Who will be the person collecting the data and who will review it to make sure the data is collected in a timely manner and reported as it needs to be. How often will you check to see if it is being collected.

We need to go ahead and ask -- and establish a baseline, this is stating the obvious, we need to know where we are starting from to see there is a difference. It gives us an opportunity to look and see are there other parts of this process that may be we need to be measuring or observing more closely. Balancing measures, there is always the possibility we will start a PDSA cycle and our goal is to reduce antipsychotic use, there are other added benefits to the process. It is good to keep an eye on that and make sure you are tracking all changes.

Root cause analysis, tried and true way of looking at issues that pop up in a healthcare setting, long-term care or hospital. Analyzing what particular factors contribute to development of particular problems. We'll talk about how to to of root cause analysis and how it integrates into the plan, do, study, act cycle.

Route call -- root cause analysis helps identify the primary causes of a problem. What happened, why, what factors contributed, and how do we go about changing things so it doesn't happen again. There are different tools provided to you, RCI -- RCA 5Y, an official program which I think we have. Here's an example of a fishbone diagram. This is true in the hospital setting, you want to make sure, it isn't that we identified one problem that this one person didn't to this one particular thing, the reality is, when you work in a system as complicated as our healthcare system it is it usually just one person who is the problem. There processes in place that contribute to the issue. An example I can think of is when we have medication errors in the hospital setting, looking at what are the symptoms that failed that got to that point to allow the wrong medication to be given to this patient. You look at who are the people involved, the patient, healthcare providers, what their particular issue in the context of equipment, like in the room, were there things contributing to this person's confusion. Policies, where their ways and are being done in the facility, the way the healthcare is being done that contributes to the problem. And procedures. You look at the event that is happen and you have a conversation around why it happened and what the factors work. It is important to make sure you have a team discussion and not just one or two people that everyone involved.

-- But everyone involved. The PDSA cycle, plan, too, study, act. We are talking about the planning part right now. Beginning to look at, what is our objective in specific aim, what are we hoping to measure and how our planning to go about making this change. Who will be involved, when we start this particular intervention, and what will it be.

Again talking about fundamental questions of the specific aim, as we said earlier, a SMART game , looking at something specific, measurable, attainable, relevant and time bound.

Do we have any questions coming up?

Again to review we made a specific name, how we measure it, how will we know there is an actual improvement that is happen. For example here, this delivered -- this facility says we will track this incident of antipsychotic use among high-risk residents by conducting weekly behavioral assessments.

As far as what changes can we make that will lead to improvement we will document and implement nonpharmacological interventions for residents with behavioral disturbances.

The important thing to remember with the PDSA, it is a cycle that is continuous. The hope is, you start off with an initial plan, even implemented, and measure it and see if you have changes, whether facilities and barriers were for the implementation, and what your results were, and you continue and build the next cycle. The reason we have this graphic showing an upward slant is the reason is you won't start from scratch with the second cycle but build on the first cycle you have done. With the ultimate goal, you will have increasing success in implementing the plan even if it is modified. To highlight the fact that even if something isn't successful the first time that you are starting from scratch and throwing it out. You are building upon that. That first implementation.

So we have another polling question.

[Audience is asked polling questions]

Make sure you click submit so we can see it at the end.

Best, were you going to speak to this requirement?

I certainly Kennecott you want to wait for them to submit their answers?

-- I certainly can, do you want to wait for them to submit their answers?

There we go. Okay. This is a trick question, because it read, QAPI is a new regulatory requirements facilities must adopt to avoid penalties. It is a pending, a new proposed regulation, it is coming, it hasn't been enacted yet.The good news is with collaboration with this Vanderbilt series and are nursing home quality care collaborative, you can practice with trying to reduce your antipsychotic reduction. You can practice equipping your team to conduct an effective performance improvement projects around this topic. We want you to know it is coming and it will be a new regulatory requirements, the rule has not been finalized, but it is coming down the flake quickly.

Thank you Beth -- down the flag quickly.

Thank you Beth.

Next Dr. Powers will lead us through the case example. We will play an audio file for you, however the full video file is up on our website under section 1, after if you would like to revisit you can visit the website listed there.

Hello I am did that -- I am Dr. Jim Powers cost certified medical tractor, my practices that Vanderbilt as well as with the veterans administration. We have chosen an authentic case to present to you, the full version with the DVD is available on the website as you heard. We will play excerpts of this for you, and I will let our team speak for themselves. This is our team demonstrating what we hope is a high-quality team-based dementia care for patients with agitation.

With stages and process undergone between home and facilities.

I see the families go through the stages and processes, stages of guilt, and grief. Grief is underlying, and knowing what is happening with their loved one, and educating them that they are still the caregiver. It is just a different type of caregiving, and they can concentrate more on being an emotional caregiver rather than the burden of taking care of the physical part of caregiving. A lot of times we see patients come in and out of the hospital, in acute care settings, takes the family several admits into an acute care setting before families realize the patient is more safe and better cared for in a long-term care setting. Then they are at home. Sometimes it takes several stages for the family to realize that this is better for them and especially the patient.

One psychotropic drugs are applied, we best choose for long-term safety?

It goes back to which psychotropic drug we are using. There are so many. We're talking much specifically antidepressants again, what we use energy are! Patients will be a class of medications called selective terror tone and risk inhibitors those serotonin risk inhibitors, we tracked -- we keep track of how they respond, are they sleeping, increased sedation or more active. Based on those factors we can move the medication to the morning or evening and those can be done by other caregivers and they can help us by communicating with us how can adjust the medication to better care for the patient as well. Monitoring factors deciding how the patient responds, and laboratory parameters we check for, sodium levels and things like that. It was antipsychotics, we talked about earlier, those have more metabolic risks that we have to take into consideration. They can affect their blood glucose or blood sugar sweet have to monitor that. They can cause weight gain if they are on too long. Several other things, movement disorders that can because we need to consider especially if they are kept on the medication long-term. Various testing we may do at baseline and ongoing if they need to remain on the medications for long. Sedation is a big one that we monitor and older patients, they have a harder time removing the medications from their system or eliminating them. As we get older our bodies have a harder time getting rid of them. They tend to hang around longer because they are on so many medications they of drug interactions and other medications can cause sedation as well, all of those stacking on top of each other and accumulating increases the risk of drug interactions and increases sedation as well. Those are issues we have to look out for.

As the patient's primary medical provider how would you approach this?

When we think about dementia and the trajectory of the illness we think of an interesting unique trajectory, with things like cancer and heart failure we think of a slow downward trajectory that is fairly linear, what we see with dementia is stages of stability followed by events such as medical complications caused the patient to go into more rapid state of decline. Followed by another. Of stability. In these cases I find it is useful to speak with family, caregivers, workpeople and other staff, and provide them support and education about what they are seeing. What your family members, and with this instance we will have an opportunity to provide them with support by giving them education about the medical underpinnings of what they witnessed.

This is Jim Powers again, I realize we hadn't giving you the case. Let me read it to you. This is a 79-year-old dental men with advanced dementia who recited in the facility for more than six months. Widow with no family he remained dead to share functionally, dependent -- independent for daily living but symbol, medication. Early each evening he would become uncontrollably educated -- agitated, staff trying to react to discomfort, providing comfort, investigations were unsuccessful in explaining or alleviating his distress. On one occasion an old family member acquaintance came to visit, the staff nurse on inquiring what might cause the patient to become distressed every evening learned that he was a former long-distance trucker devoted to his wife and had a habit of calling her at 6 PM every night giving his location and expected time of arrival home. Staff use this information to develop a person centered approach and initiated a nonpharmacologic management plan for him, and developed scrapbook of memories of the patient's wife to utilize it -- every evening to successfully prevent the patient's agitation.

This is an authentic case, I hope and some like patients you have cared for. The answer could not have come without personal information about the resident, which came from a longtime family friend. Managing residents with dementia can be challenging, especially residents with behavioral disturbances such as verbal and physical aggression, anxiety, agitation and those who resist care. The use of antipsychotic medications is now used as a nursing home quality indicator, and publicly recorded for all homes nationwide, with the rationale that the use of the medications should be kept to minimum. Alternatively numerous behavioral approaches to the management of dementia are available. We hope to show you many of these examples in the series. Nursing homes in Tennessee and nationwide are under increased pressure to reduce the prevalence of antipsychotic use.

That leads us to our next polling question. [Audience is asked polling questions]

It looks like people were paying attention, good job, true is the right answer. At this point Kerry will give us a summary, and then we will open the floor to questions.

Okay, thank you very much for attending this webinar. A summary for this particular session, we're looking at how antipsychotic medications are commonly in those commonly used to manage patients with dementia especially in the long-term care setting, and currently in Tennessee are as 21.6% and the goal is 17%. There are numerous adverse effects with these medications, some are problematic such as sedation, confusion and can contribute to falls, which we know can lead to further complications. In the QAPI framework PDSA cycle air -- our key goals to use in long-term care setting to provide framework for which your team can identify how to reduce the use of antipsychotics in their population. We have a second presentation of this session that will be next Tuesday at 1 PM Central standard Time, 2 PM Eastern time, on October 27. If you of other staff you would like to attend feel free to log on to the webinar and have them take part.

Do we have questions for Dr. Powers or Carrie ? You can send them to Britt Kuertz in the chat box .

Also, if you visit our project website you can email us questions if your questions between sessions. You will find Britt contact information, my contact information that we will be your primary contact people for the session. While questions are coming in hopefully, we'll in our November session, understanding dementia and the nature of behavioral disturbances, will have a morning and afternoon presentation for attending. These will be led by Dr. Paul Neuhaus, geriatric psychiatrist here at Vanderbilt. A great deal of experience in this area.

Again, this is my contact information, and Britt , contact information, project website, and Vanderbilt enter for quality aging which has other resources for nursing homes. I will say about our project website the slides for this presentation are posted there as well is the video we played. Once the presentation is over the audio presentation will be up on the website as well.

Also they are you can find a sign-up sheet, attendance sheet in a way to send it back to us. have anything else?

I just want to let our audience know that this series will build upon itself, I don't know if you want to go back to the schedule of the topics that will be offered during the series, this particular session was an introduction to get you prepared for your performance improvement project around this topic. Some of this information I know from our collaborative, you could about -- you heard about the performance improvement techniques Carrie shared like PDSA and recrossed -- root cause, this is an introduction to set your aim statement around your goals, and as you see on the schedule this series will continue to build on itself to get into the subject matter content. Thank you so much, I think this will be a great collaboration, and thank you to Dr. Powers and Carrie for this wonderful presentation. Again if you a follow-up questions for presenters feel free to contact myself or Brett -- or Britt If no one has any questions, we will see you either again next Tuesday for the second presentation of second -- a session 1 or in November. I forgot there is one more polling question before you sign off.

[Audience is asked polling questions]

If you could answer that before you log off we would appreciate it. Any other feedback, feel free to email us.

Thank you for participating, we will see you either next Tuesday for the second purchase -- presentation of this or in November for session number two. Have a good day.

[Event Concluded]