Medication Safety in Nursing Homes Change Package

Medication Safety in Nursing Homes

CHANGE PACKAGE

Version 1 | June 2020

WWW.TMFNETWORKS.ORG TABLE OF CONTENTS

Acronyms ...... 3 Introduction ...... 4 The Quality Improvement Process Using PDSA ...... 5 References ...... 23

Change Package Pain Management and Opioid Use 7 > Use evidence-based approaches to manage and treat acute and chronic pain ...... 7 > Educate residents, resident representatives, medical and clinical staff on safe use of opioids and alternative pain management strategies ...... 8 > Improve communication ...... 9 > Improve staff understanding of regulatory guidelines ...... 9 . . Anticoagulant Medications 10 > Reduce number of ADEs Related to Anticoagulant Medications ...... 11 > Provide reference tools for providers ...... 11. . . > Improve communication ...... 12 > Provide resident education on anticoagulation therapy ...... 12 . . > Increase staff understanding of regulatory guidelines ...... 13. . Antipsychotic Medications 14 > Implement safe use of antipsychotic drugs in the long- and short-stay nursing home resident ...... 14 > Implement safe use of antipsychotic medications for those with dementia diagnosis ...... 15 > Improve communication ...... 15 > Increase staff understanding of regulatory guidelines ...... 16. . Antimuscarinic Medications 17 > Reduce number of residents with a fall related to antimuscarinic medication ...... 17 > Improve communication ...... 18 > Increase staff understanding of regulatory guidelines ...... 18. . Diabetes Medications 19 > Eliminate sliding-scale insulin ...... 20 . . . > Safe diabetes and medication management ...... 20 . . > Improve communication ...... 21 > Reduce and prevent incidence of hypoglycemic events ...... 21 > Increase staff understanding of regulatory guidelines ...... 22. .

This material was developed by TMF Health Quality Institute, the Medicare Quality Innovation Network-Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. This content does not necessarily reflect CMS policy. 12SOW-QINQIO-NH-20-08 Published 6/2020 2 ACRONYMS

ADE Adverse drug event ADR Adverse drug reaction AHRQ Agency for Healthcare Research and Quality CASPER Certification and Survey Provider Enhanced Reporting CDC Centers for Disease Control and Prevention CMS Centers for Medicare & Medicaid Services ED Emergency department EHR Electronic health record INR International Normalized Ratio PDSA Plan-Do-Study-Act PIM Potentially inappropriate medications QAPI Quality Assurance Performance Improvement QI Quality improvement QIN-QIO Quality Innovation Network-Quality Improvement Organization SNF Skilled nursing facility TMF TMF Health Quality Institute VTE Venous thromboembolism

3 INTRODUCTION ADEs are injuries or harmful events caused by drugs used during medical care .These can include medication errors, ADRs, allergic reactions and overdoses . A medication error may or may not result in harm and can occur from the prescription, transcription, dispensing, administration, and patient adherence or monitoring of the medication . Conversely, an ADR, which is also referred to as a side effect, is harm experienced as a direct result from consuming a normal dose of a drug . According to the CDC, ADEs account for approximately 1 .3 million ED visits each year1 . In LTC facilities, an estimated 2 million ADEs occur annually, with at least 10 ADEs occurring each month in an average-size center . ADEs lead to 1 in 7 LTC residents being hospitalized 2. Yet the AHRQ Patient Safety Network reports that ADEs are the most common, preventable adverse events across all care settings3, while an estimated half of ADEs are deemed preventable . Some or many chronic health conditions in older adults (65 and older) are typically treated with multiple medications 4. Medication reconciliation and coordination of prescription/non-prescription medications can reduce the risks associated with polypharmacy, such as ADEs, drug interactions and drug duplications . By combining those with vigorous and effective QI interventions, LTC providers can mitigate medication adverse events . How to Use this Change Package The TMF QIN-QIO, under contract with CMS, is working with nursing homes and skilled nursing facilities in Arkansas, Mississippi, Nebraska, Texas, Puerto Rico and the US Virgin Islands to improve medication safety and the use of opioid medications . This change package is a resource to assist LTC providers working directly with TMF QIN-QIO experts to improve resident quality of care . It serves as a guide or menu of strategies, change concepts and actionable items that LTC facilities can choose from to begin testing changes and reducing ADEs, including opioid-related events . The TMF QIN-QIO advises against implementing all interventions at once, nor is it likely that all interventions will be applicable to your clinical setting . The included tools are best practices for improving medication safety in LTC facilities . Some clinical details may reflect treatment and management decisions that do not apply to, or differ from, your setting . However, these tools can be adapted by filtering in the evidence, practices and characteristics that are unique to your resident population . Note: Because medication-safety tools and strategies are ever evolving, this change package may be updated periodically .

1 Adverse Drug Events in Adults 2 Focus on Adverse Drug Events 3 Medication Errors and Adverse Drug Events 4 Polypharmacy Among Adults Aged 65 Years and Older in the United States: 1988–2010 4 THE QUALITY IMPROVEMENT PROCESS USING PDSA Path to Improvement Through Nursing Home Community

Determine Determine your Analyze the Data: Outcome/Process nursing home’s Prioritize the Problem(s) Define the Review your Measures and a underlying and Choose Problem: nursing home’s Timeline for Each short-term and Interventions/Tactics to Review overall assets and data to Change Concept or long-term goals. Facilitate Improvement: nursing home determine Intervention. goals. improvement areas. Review the change package to choose change concepts and interventions for improvement

PDSA Step 2: Do – Spread and Implement Solutions – Try out the test on sustain success The Action Plan: a small scale. through the Begin the PDSA cycle nursing home with the first change PDSA Step 3: Study – Set PDSA Step 4: Act – community. concept. PDSA Step 1: aside time to analyze the Refine the change Plan – Plan the test or data and study results. based on what was observation, including a learned from the test. plan for collecting data.

Define the Problem(s) This change package outlines the overall goals for this work as: 1 . Decreasing opioid-related adverse events, including overdose deaths 2 . Increasing non-pharmacological interventions to decrease antipsychotic and opioid use and to manage resident pain 3 . Reducing ADEs with anticoagulant, antimuscarinic, antipsychotic, diabetes and opioid medications 4 . Reducing falls with major injury related to the use of antimuscarinic medications Your nursing home might also have unique underlying short-term and long-term goals related to the overall goals . It is important to outline each goal to ensure your nursing home has a shared focus . For assistance, refer to the Fishbone Diagram: Select Determinants of Preventable Adverse Drug Events on page 34 of the National Action Plan for Adverse Drug Event Prevention . Analyze the Data Using the Quality Measure data for your nursing home and community, determine your strengths and weaknesses as related to the overall goals . Which areas need improvement? Prioritize the Problem(s) and Choose Interventions/Tactics to Facilitate Improvement Your facility’s unique goals and determined areas of improvement will point you to your QI objectives and related metrics . You can choose strategies from those listed in the change package that align with your objectives and have been shown to result in improvement . Prioritize these interventions and tactics as determined by your facility’s needs . 5 Read the change package tables below for a list of change concepts and ideas that nursing homes/SNFs can implement to improve clinical outcomes for their residents. Each change concept and idea are paired with tools and resources suggested by experts in the field who have successfully used them. Based on LTC industry input, support efforts in implementing change concepts, QI outcomes and process measures were developed to align with the goal of reducing ADEs. The measures most commonly draw from CASPER data, pharmacy review reports and EHRs. They track nursing home improvements toward goals, and are categorized by outcome measures (the result of an implemented strategy) and process measures (tracking the specific steps that may lead to the desired outcome). Both types of measurements are important for improvement toward the goal. Though a number of measures can be used as shown in the Change Package section, each nursing home/SNF is encouraged to develop their own measures based on their plan for improvement and their facility data outlining the opportunities for change. It is important to ensure all interventions/tactics work toward improvement in the overall goals defined by this change package. Determine Outcome/Process Measures and a Timeline for Each Change Concept or Intervention Nursing home QI teams determine their outcome, process measures and timeline for change. Model for Implement Solutions/Monitor and Evaluate Improvement Once you have selected a change idea to implement, work through a PDSA cycle with a small number of residents (i.e., a small test of change) to test the change What are we idea in your clinical setting. The PDSA cycle is part of the Institute for Healthcare trying to accomplish? Improvement Model for Improvement, a simple yet powerful tool for accelerating QI. Once a team has set an aim, established its membership, and developed How will we know that a measures to determine whether a change leads to an improvement, the next step change is an improvement? is to test a change in the real work setting. The PDSA cycle is shorthand for testing What change can we make that a change – by planning it, trying it, observing the results, and acting on what is will result in an improvement? learned. This is the scientific method, used for action-oriented learning. The steps in the PDSA cycle are: Step 1: Plan – Plan the test or observation, including a plan for collecting data Act Plan Step 2: Do – Try out the test on a small scale Step 3: Study – Set aside time to analyze the data and study the results Step 4: Act – Refine the change, based on what was learned from the test Study Do Sustain Success As the new process becomes part of your daily practice, develop a monitoring system that not only ensures you stay on track, but also gives an early warning if the process diverts from the plan. According to AHRQ, processes or improved outcomes will last within an organization after implementation has occurred. An example of sustained improvement is when an improvement has become part of the organizational culture and has been maintained regardless of workforce turnover. Steps for sustainment: 1. Establish a sustainability measurement plan 2. Recognize and celebrate success 3. Share data with leadership and frontline staff 4. Align with other QAPI efforts 5. Incorporate into new employee orientation and routine staff training 6. Identify barriers and workable solutions

6 CHANGE PACKAGE PAIN MANAGEMENT AND OPIOID USE According to the CDC, more than 191 million opioid prescriptions were dispensed in 2017 . Opioid medicines contain chemicals that relax the body and can relieve pain . Chronic pain is one of the most common reasons that adults seek medical care for relief . However, managing pain in nursing homes can be challenging . Providers must balance the risk of opioids versus untreated or undertreated pain .

GOAL – Improve Safe and Appropriate Use of Opioid Medications

Outcome Measures Percent of opioid-related overdose deaths per month Percent of opioid-related ADEs that occur with residents who are prescribed opioids by month Process Measures Percent of residents screened with PAINAD and Pain Checklist tool while tapering Number of medical and clinical staff trained on alternatives to opioids for pain management Number of residents being prescribed non-opioid analgesics and non-pharmacological treatment for pain management Number of residents receiving alternative pain treatments CHANGE PACKAGE Number of residents receiving > or = 90/MME per day Percent of training for medical staff regarding the potential for ADEs related to excessive opioid use Number of care plans written following a pharmacy review related to residents receiving opioids > or = 90/MME per day Number of residents with falls/falls with major injury who receive opioids > or = 90/MME per day Percent of residents who self-report moderate to severe pain (long-stay) Percent of residents who self-report moderate to severe pain (short-stay) Number of residents who remain on opioids after initial start of medication

CHANGE CONCEPT Use evidence-based approaches to manage and treat acute and chronic pain

Change Ideas Tools, Tips and Resources Educate physicians on the CDC Guideline for Prescribing Opioids for Chronic Pain risk of opioid use as a long- Opioids: An Epidemic Crisis term pain reliever CMS Roadmap: Strategy to Fight the Opioid Crisis TMF QIN-QIO Beers List and Screening Tool of Older People’s Prescriptions (STOPP) Criteria (This website may require creating a free account to access resources .) Train all providers in Pocket Guide: Tapering Opioids for Chronic Pain best practices for opioid Reducing Inappropriate Medication Use by Implementing Deprescribing Guidelines dosage reduction and discontinuation HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics

7 Change Ideas Tools, Tips and Resources Implement clinical CDC Resources: guidelines for prescribing Quick Reference for Healthcare Providers includes a list of clinical tools and opioids for chronic pain resources to give health care providers information and guidance related to opioids . Guideline Resources: CDC Opioid Guideline Mobile App CDC Opioid Prescribing Guideline Mobile App Calculating Total Daily Dose of Opioids for Safer Dosage Module 6: Dosing and Titration of Opioids: How Much, How Long, and How and When to Stop? Preventing An Opioid Overdose: Know the Signs . Save a Life . Promoting Safer and More Effective Pain Management Opioids for Acute Pain: Get the Facts The Prescription Opioid Pain Medication Overdose Epidemic MD+Calc: Morphine Milligram Equivalents (MME) Calculator CMS: Safer Use of Opioid Pain Medication HHS .gov/Opioids: Pain Management Best Practices Inter-Agency Task Force Report Veteran Affairs Resource: VHA Pain Management: Opioid Safety Initiative includes the Opioid Safety Initiative Toolkit . Articles: Managing Chronic Pain in Older Adults: A Long-Term Care Perspective CHANGE PACKAGE Pain Management for Nursing Home Residents Screen for chronic pain in How the Opioid Crises Affects the Elderly older adults Checklist of Nonverbal Indicators of Chronic Pain in Elderly Residents Pain Assessment IN Advanced Dementia – PAINAD Tool Offer alternative pain 8 Non-Invasive Pain Relief Techniques That Really Work management approaches Chronic Pain: In Depth

CHANGE CONCEPT Educate residents, resident representatives, medical and clinical staff on safe use of opioids and alternative pain management strategies

Change Ideas Tools, Tips and Resources Provide resources, tools TMF QIN-QIO Medication Safety Clinical Teach-Back Cards provide opioid tips and lists and education to clinical of opioid medications including long-acting, short-acting, combinations, generics and staff brand names . Scroll down to Opioid Medications on page 29 . Drug Prescribing for Older Adults Focus on Adverse Drug Events TMF QIN-QIO Pain Management & Opioids Resources (This website may require creating a free account to access resources .)

8 Change Ideas Tools, Tips and Resources Provide educational Allied Against Opioid Abuse: Consumer Resources offers a suite of resources, videos resources to resident/ and toolkits to help educate consumers about safe use, storage and disposal of resident representative prescription opioids . Scroll down the page for three short patient education videos . 1 . Managing Pain After Surgery: What You Need to Know 2 . Three Questions to Ask Your Provider: Pain Management and Prescription Opioids 3 . Three Things You Need to Know About Prescription Opioids Use a trigger tool for IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events measuring adverse events CMS Adverse Drug Event Trigger Tool Implement and educate From the Hospital to Long-Term Care: Protecting Vulnerable Patients During Handoff on the medication Medication Reconciliation Form tracks a patient’s medications at admission, transfer reconciliation process or discharge . It also provides additional resources under Featured Content, e .g ., How- CHANGE PACKAGE to Guide; Medication Reconciliation Review . (This website may require creating a free account to access resources .) Medication Reconciliation Tracking Tool (This website may require creating a free account to access resources .) Train providers on how TMF QIN-QIO Psychoactive and Opioid Drug Reference Sheet for Minimum Data to use appropriate drug Set (MDS) (This website may require creating a free account to access resources .) reference sheets CHANGE PACKAGE CHANGE CONCEPT Improve communication

Change Ideas Tools, Tips and Resources Improve communication INTERACT Version 4 .0 includes tools to support improved communication and and documentation documentation . (This website may require creating a free account to access resources .)

CHANGE CONCEPT Improve staff understanding of regulatory guidelines

9 Change Ideas Tools, Tips and Resources Educate staff on CMS LTC Survey Pathways, located on the CMS Nursing Homes Medicare and Medicaid Surveyor Critical Element Programs: Reform of Requirements for Long-Term Care Facilities webpage, includes: Pathways CMS-20056 Medication Administration CMS-20058 QAA and QAPI CMS-20062 Sufficient and Competent Staff CMS-20082 Unnecessary Medications CMS-20089 Medication Storage Understand the MDS-based MDS 3 .0 QM User’s Manual is available on the CMS Quality Measures webpage in the and claims-based quality Downloads section, Users Manuals (ZIP) . measure specifications, Nursing Home Compare Claims-Based Measures Technical Specifications is available MDS coding requirements on the CMS Quality Measures webpage in the Downloads section, Users Manuals (ZIP) . and Five-Star quality rating SNF QRP Measure Calculations and Reporting User’s Manual, available in the Downloads system section, provides information on Medicare Claims-based Measures in chapter 2 . Five-Star User’s Guide is available on the CMS Five-Star Quality Rating System webpage in the Downloads section . MDS 3 .0 RAI Manual is available on the CMS MDS 3 .0 RAI Manual webpage in the Related Links section . TMF QIN-QIO Quality Measures Video Series

ANTICOAGULANT MEDICATIONS Anticoagulant therapy is used to prevent and treat various types of blood clotting disorders . According to the National Action Plan for Adverse Drug Event Prevention, anticoagulants are a major contributor to ADEs . They are among the types of drugs related to ADEs that contribute to ED visits and hospital admissions . Unintentional overdose of warfarin or supratherapeutic effects have been noted as causes for hospitalization . Bleeding is the chief ADE relating to the use of anticoagulants .

GOAL – Improve Safe and Appropriate Use of Anticoagulant Medications

Outcome Measures Number of ADEs related to anticoagulants Number of potentially preventable ED visits related to anticoagulant ADEs Number of potentially preventable hospitalizations related to anticoagulant ADEs

Process Measures Percent of residents with bleeding risk factors related to oral anticoagulation therapy Percent of residents with non-valvular atrial fibrillation or atrial flutter who were prescribed warfarin or other FDA-approved oral anticoagulant drug for the prevention of venous thromboembolism (VTE) Percent of residents with an anticoagulation plan in place prior to surgical procedures Percent of residents with an anticoagulation plan in place post-surgical procedures Number of VTE residents with anticoagulant overlap therapy Percent of residents taking three or more medications including an anticoagulant medication Percent of residents who received vitamin K reversal Percent of clinical staff trained on procedures for elevated INR Percent of clinical staff educated on anticoagulant side effects (e .g . bleeding, bruising) Percent of clinical staff trained on epistaxis management protocol Percent of clinical staff trained on the process of notifying dietary services of residents receiving warfarin Percent of clinical and dietary staff educated on identifying possible food/drug interactions Percent of residents on warfarin receiving the correct meal plan 10 CHANGE PACKAGE

CHANGE CONCEPT Reduce number of ADEs Related to Anticoagulant Medications

Change Ideas Tools, Tips and Resources Define ADEs for high-risk Use of Medicare Administrative Claims to Identify a Population at High Risk for Medicare beneficiaries Adverse Drug Events and Hospital Use for Quality Improvement Know medications to avoid TMF QIN-QIO Beers List and Screening Tool of Older People’s Prescriptions (STOPP) in the elderly for PIM and Criteria (This website may require creating a free account to access resources .) prescriptions Establish order sets Initiation of OAC for Atrial Fibrillation Order Set provides an example of an order set . CHANGE PACKAGEUse the IHI Skilled Nursing IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events Facility trigger tool for CMS Adverse Drug Event Trigger Tool measuring adverse events Use a gap analysis tool to Anticoagulation Agent Adverse Drug Event Gap Analysis identify gaps in storage, preparation and dispensing of anticoagulants

CHANGE CONCEPT Provide reference tools for providers

Change Ideas Tools, Tips and Resources Provide anticoagulation Anticoagulant Toolkit: Reducing Adverse Drug Events toolkits Anticoagulation Provider ToolKit Anticoagulation Patient Education Toolkit Anticoagulation Toolkit: A Consortium-Developed Quick Reference for Anticoagulation Provide resources, tools TMF QIN-QIO Medication Safety Clinical Teach-Back Cards provide tips and lists of and education to clinical blood thinners including generics and brand names . Scroll down to Blood Thinners staff (Anticoagulants) on page 21 . TMF QIN-QIO Anticoagulants Resources Distribute the Blood TMF QIN-QIO Blood Thinner Zone Tool Thinner Zone Tool English | Spanish | Spanish for Puerto Rico R3 Report Issue 19: National Patient Safety Goal for Anticoagulant Therapy provides 2019 updates on anticoagulation therapy . Management of Anticoagulation in the Peri-Procedural Period App assists with monitoring anticoagulation therapy during the peri-procedural period . Optimize drug therapy for Drug Prescribing for Older Adults older adults Strategize to prevent ADE Focus on Adverse Drug Events risk

11 Change Ideas Tools, Tips and Resources Implement the medication From the Hospital to Long-Term Care: Protecting Vulnerable Patients During Handoff reconciliation process Medication Reconciliation Form tracks a patient’s medications at admission, transfer or discharge . It also provides additional resources under Featured Content, e .g ., How-to Guide; Medication Reconciliation Review . (This website may require creating a free account to access resources .) CHANGE PACKAGE Medication Reconciliation Tracking Tool (This website may require creating a free account to access resources .) Review the National Action National Action Plan for ADE Prevention Plan for Adverse Drug Event Prevention Manage VTE American Society of Hematology 2018 Guidelines for Management of Venous Thromboembolism: Optimal Management of Anticoagulation Therapy CHANGE PACKAGE CHANGE CONCEPT Improve communication

CHANGE CONCEPT Provide resident education on anticoagulation therapy

Change Ideas Tools, Tips and Resources Provide nosebleed What To Do During a Nosebleed is a brief video demonstrating what to do, education for residents on and what not to do, during a nosebleed . blood thinners Provide guidance on taking A Patient's Guide to Taking Warfarin warfarin

12 CHANGE PACKAGE

CHANGE CONCEPT Increase staff understanding of regulatory guidelines

Change Ideas Tools, Tips and Resources Routinely review regulatory Appendix PP State Operations Manual, located on the CMS Medicare and Medicaid guidance Programs: Reform of Requirements for Long-Term Care Facilities webpage, includes the following information: F641 §483 .20(g) – Accuracy of Assessment F656 §483 .21(a)(b) – Comprehensive Care Plan F726 §483 .35(a)(3)-(4) and §483 .35(c) – Staff Competencies F756 §483 .45(c)(1)(2)(4)(5) – Drug Regimen Review F757 §483 .45(d) – Unnecessary Drugs – General F865 §483 .75(a)(1) and F866 §483 .75(c)(1)-(4) – Quality Assurance and Performance Improvement F867 §483 .75(g)(2)(ii) – Addresses Adverse Events and Potentially Preventable Events related to Medication, Care, and Infections Educate staff on CMS LTC Survey Pathways, located on the CMS Nursing Homes Medicare and Medicaid Surveyor Critical Element Programs: Reform of Requirements for Long-Term Care Facilities webpage, includes: Pathways CMS-20056 Medication Administration CMS-20058 QAA and QAPI CMS-20062 Sufficient and Competent Staff CMS-20082 Unnecessary Medications CMS-20089 Medication Storage Understand the MDS-based MDS 3 .0 QM User’s Manual is available on the CMS Quality Measures webpage in the and claims-based quality Downloads section, Users Manuals (ZIP) . measure specifications, Nursing Home Compare Claims-Based Measures Technical Specifications is available MDS coding requirements on the CMS Quality Measures webpage in the Downloads section, Users Manuals (ZIP) . and Five-Star quality rating system SNF QRP Measure Calculations and Reporting User’s Manual, available in the Downloads section, provides information on Medicare Claims-based Measures in chapter 2 . Five-Star User’s Guide is available on the CMS Five-Star Quality Rating System webpage in the Downloads section . MDS 3 .0 RAI Manual is available on the CMS MDS 3 .0 RAI Manual webpage in the Related Links section . TMF QIN-QIO Quality Measures Video Series

13 ANTIPSYCHOTIC MEDICATIONS The use of antipsychotics continues to be a safety concern for elderly population, especially those with dementia diagnoses . This is evidenced by the rates of antipsychotic use published by the Dementia Care Projects across this nation and other research and opinions published by the American Geriatric Society, the American Medical Directors Association and the Alzheimer’s Association . States must review state-specific laws/regulations regarding use of antipsychotics in Nursing Homes . Additionally, federal rules are ever changing and require scanning CMS notices for any changes .

GOAL – Improve Safe and Appropriate Use of Antipsychotic Medications

Outcome Measures Number of ADEs related to the use of antipsychotic drugs in long stay nursing home residents Number of ADEs related to the use of antipsychotic drugs in short stay nursing home residents Number of residents receiving antipsychotic medication inappropriately

Process Measures Percent of short-stay residents who newly received an antipsychotic medication Percent of long-stay residents receiving an antipsychotic medication Number of resident receiving an inappropriate medication identified on pre-admission and discontinued prior to admission CHANGE PACKAGE Number of pharmacy consultant recommendations identifying residents for gradual dose reductions Number of residents identified for gradual dose reductions each month Number of residents with a successful gradual dose reduction each month Number of residents’ antipsychotic medications discontinued each month Percent of medical and clinical staff trained on appropriate antipsychotic medication use and non- pharmacological interventions Percent of residents taking 3 or more medications including an antipsychotic medication Percent of adverse drug reactions identified and reported to the clinical team monthly

CHANGE CONCEPT Implement safe use of antipsychotic drugs in the long- and short-stay nursing home resident

Change Ideas Tools, Tips and Resources Provide staff evidenced- Fracture Risk Among Nursing Home Residents Initiating Antipsychotic Medications based resources Age, Antipsychotics, and the Risk of Ischemic Stroke in the Veterans Health Administration Optimize drug therapy for Drug Prescribing for Older Adults older adults Strategize to prevent ADE Focus on Adverse Drug Events risk Use QI methods IHI’s Patient Safety Essentials Toolkit Know the medications to TMF QIN-QIO Beers List and Screening Tool of Older People’s Prescriptions (STOPP) avoid in the elderly for PIM Criteria (This website may require creating a free account to access resources .) and prescriptions

14 Change Ideas Tools, Tips and Resources Educate, support and train Dementia Care and Psychotropic Medications includes fact sheets, tracking tool staff members and trainings . Fast Facts: What You Should Know About Antipsychotic Drugs and Persons Living with Dementia TMF QIN-QIO Antipsychotic Medication Reduction Resources (This website may require creating a free account to access resources .) Provide guidelines TMF QIN-QIO Antipsychotic Alternatives provides ideas to help with reduction . for alternatives and Antipsychotic Reduction: Resident Prioritization Tools deprescribing Reducing Inappropriate Medication Use by Implementing Deprescribing Guidelines is a deprescribing implementation tool and evidenced-based case study . (This website may require creating a free account to access resources .) CHANGE PACKAGE Antipsychotic (AP) Deprescribing Algorithm Deprescribing Guidelines and Their Team Members Train providers on how TMF QIN-QIO Psychoactive and Opioid Drug Reference Sheet for Minimum to use appropriate drug Data Set (MDS) (This website may require creating a free account to access resources .) reference sheets Provide teach back cards TMF QIN-QIO Medication Safety Clinical Teach-Back Cards provide tips and lists of for staff education and blood thinners including generics and brand names . Scroll down to Antipsychotics on resource page 41 .

CHANGE CONCEPT Implement safe use of antipsychotic medications for those with dementia diagnosis

Change Ideas Tools, Tips and Resources Use updated practice Alzheimer’s Association Dementia Care Practice Recommendations guidelines for dementia care, specifically reducing the use of antipsychotics Use a trigger tool for IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events measuring adverse events Adverse Drug Event Trigger Tool CHANGE PACKAGEImplement the medication From the Hospital to Long-Term Care: Protecting Vulnerable Patients During Handoff reconciliation process Medication Reconciliation Form tracks a patient’s medications at admission, transfer or discharge . It also provides additional resources under Featured Content, e .g ., How-to Guide; Medication Reconciliation Review . (This website may require creating a free account to access resources .) Medication Reconciliation Tracking Tool (This website may require creating a free account to access resources .)

CHANGE CONCEPT Improve communication

CHANGE CONCEPT Increase staff understanding of regulatory guidelines

16 ANTIMUSCARINIC MEDICATIONS Antimuscarinic medications (Muscarinic Antagonists) are a group of anticholinergics that are associated with and increase risk of falls and impaired cognition in older adults (65 year and older) . Antimuscarinics are commonly used for a variety of conditions in older adults . Residents with dementia and receiving anticholinergics can further increase confusion and increase the risk of dementia, risk for falls and fractures, and death in the elderly .

GOAL – Improve Safe and Appropriate Use of Antimuscarinic Medications

Outcome Measures Number of ADEs related to antimuscarinic medications Number of residents with a fall with major injury who are also on antimuscarinic medication Number of long-stay residents who experienced one or more falls with major injury CHANGE PACKAGE Process Measures Percent of staff trained on potential ADEs related to antimuscarinic Percent of residents with an accurate fall assessment following daily/weekly/monthly reviews or audits Percent of residents with appropriately updated care plans following daily/weekly/monthly reviews or audits Percent of pharmacy consultant recommendations regarding potential ADEs for residents receiving an antimuscarinic medication

CHANGE CONCEPT Reduce number of residents with a fall related to antimuscarinic medication

Change Ideas Tools, Tips and Resources Educate staff on Antimuscarinics (Muscarinic Antagonists) provides a self-study resource . antimuscarinic (muscarinic antagonist) medications therapeutic uses, acute side effects, commonly used medications with antimuscarinic effects and potential harmful effects in the elderly Provide clinicians and Anticholinergic Syndrome: Presentations, Etiological Agents, Differential Diagnosis, staff with evidence- and Treatment based resources for Association Between Cumulative Anticholinergic Burden and Falls and Fractures in anticholinergic burden and Patients with Overactive Bladder: US-based Retrospective Cohort Study anticholinergic syndrome Implement strategies to The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities decrease falls and injuries STEADI: Stopping Elderly Accidents, Deaths and Injuries provides STEADI tools from the CDC . Know medications to avoid TMF QIN-QIO Beers List and Screening Tool of Older People’s Prescriptions (STOPP) in the elderly for PIM and Criteria (This website may require creating a free account to access resources .) prescriptions Optimize drug therapy for Drug Prescribing for Older Adults older adults 17 Change Ideas Tools, Tips and Resources Strategize to prevent ADE Focus on Adverse Drug Events risk Implement trigger tools IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events to identify risk factors for Adverse Drug Event Trigger Tool ADEs, implement systems and processes, and prevent recurrence Implement the medication From the Hospital to Long-Term Care: Protecting Vulnerable Patients During Handoff reconciliation process lists medications most often involved in errors during transition from hospital to nursing home . Medication Reconciliation Form tracks a patient’s medications at admission, transfer or discharge . It also provides additional resources under Featured Content, e .g ., How-to Guide; Medication Reconciliation Review . (This website may require creating a free CHANGE PACKAGE account to access resources .) Medication Reconciliation Tracking Tool (This website may require creating a free account to access resources .) Provide resources, tools TMF QIN-QIO Fall Reduction Resources and education to staff (This website may require creating a free account to access resources .) members TMF QIN-QIO Antimuscarinic/Anticholinergic Resources (This website may require creating a free account to access resources .) CHANGE PACKAGE CHANGE CONCEPT Improve communication

CHANGE CONCEPT Increase staff understanding of regulatory guidelines

18 Change Ideas Tools, Tips and Resources Educate staff on CMS LTC Survey Pathways, located on the CMS Nursing Homes Medicare and Medicaid Surveyor Critical Element Programs: Reform of Requirements for Long-Term Care Facilities webpage, includes: Pathways CMS-20056 Medication Administration CMS-20058 QAA and QAPI CMS-20062 Sufficient and Competent Staff CMS-20082 Unnecessary Medications CMS-20089 Medication Storage Understand the MDS-based MDS 3 .0 QM User’s Manual is available on the CMS Quality Measures webpage in the and claims-based quality Downloads section, Users Manuals (ZIP) . measure specifications, Nursing Home Compare Claims-Based Measures Technical Specifications is available MDS coding requirements on the CMS Quality Measures webpage in the Downloads section, Users Manuals (ZIP) . and Five-Star quality rating system SNF QRP Measure Calculations and Reporting User’s Manual, available in the Downloads section, provides information on Medicare Claims-based Measures in chapter 2 . Five-Star User’s Guide is available on the CMS Five-Star Quality Rating System webpage in the Downloads section . MDS 3 .0 RAI Manual is available on the CMS MDS 3 .0 RAI Manual webpage in the Related Links section . TMF QIN-QIO Quality Measures Video Series

DIABETES MEDICATIONS Diabetes is the seventh leading cause of death in the United States . Type 2 diabetes accounts for 90-95% of all diagnosed cases . Diabetes is a major cause of blindness, kidney failure, heart attacks, strokes and lower limb amputations . Up to 70% of people with diabetes also have hypertension, and people with hypertension alone often show evidence of insulin . Hypoglycemia in older adults (65 and older) with Type 2 diabetes is common, but underappreciated . Identifying these residents at risk for hypoglycemia as well as other comorbidities poses challenges to nursing homes in diabetes management .

GOAL – Improve Safe and Appropriate Use of Diabetic Medications

Outcome Measures Number of ADEs related to diabetic medications Number of residents transferred to ED due to adverse event related to diabetes medication Number of residents admitted due to adverse event related to diabetes medication

Process Measures Number of sliding scale insulin practices Percent of clinical staff trained on eliminating sliding scale insulin Percent of clinical staff trained on proper insulin storage Percent of staff trained on prevention, signs/symptoms, and treatment of hypoglycemia Percent of staff trained on safe diabetes medication management in maintaining glucose levels Percent of residents transferred to Percent of residents with hypoglycemic event Percent of medication reconciliations performed on admission and readmission Percent of residents with HgA1c lab results within the controlled range 19 CHANGE PACKAGE

CHANGE CONCEPT Eliminate sliding-scale insulin

Change Ideas Tools, Tips and Resources CHANGE PACKAGEEducate medical, Sliding-Scale Insulin: An Ineffective Practice consultant pharmacist Don’t Use Sliding Scale Insulin (SSI) for Long-Term Diabetes Management for and clinical staff on the Individuals Residing in the Nursing Home ineffectiveness of sliding- scale practices It’s Time to Abandon the Sliding Scale Things We Do For No Reason: Sliding-Scale Insulin as Monotherapy for Glycemic Control in Hospitalized Patients discusses a trial with diabetic long-term residents for SSI and basal-bolus insulin .

CHANGE CONCEPT Safe diabetes and medication management

Change Ideas Tools, Tips and Resources Educate clinical staff on Standards of Medical Care in Diabetes 2019 diabetes management Standards of Care App provides instructions to download the app, which offers up-to- and diabetes medication date standards, strategies, tables and algorithms (iOS, Android or view online) . management Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association TMF QIN-QIO Diabetes Zone Tool (This website may require creating a free account to access resources .) English | Spanish TMF QIN-QIO How Do My Medicines Work? is a graphic description related to diabetes medications . Optimize drug therapy for Drug Prescribing for Older Adults older adults Strategize to prevent ADE Focus on Adverse Drug Events risk Provide resources, tools TMF QIN-QIO Medication Safety Clinical Teach-Back Cards provide tips and lists for and education to clinical diabetes and medication management including generics and brand names . Scroll staff down to Antidiabetic Agents on page 23 . Follow insulin product safe TMF QIN-QIO Insulin Reference Chart and Safe Storage storage practices (This website may require creating a free account to access resources .) TMF QIN-QIO Diabetes Medications Resources Implement the medication From the Hospital to Long-Term Care: Protecting Vulnerable Patients During Handoff reconciliation process Medication Reconciliation Form tracks a patient’s medications at admission, transfer or discharge . It also provides additional resources under Featured Content, e .g ., How-to Guide; Medication Reconciliation Review . (This website may require creating a free account to access resources .) Medication Reconciliation Tracking Tool (This website may require creating a free account to access resources .)

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Reduce ADEs Related to Diabetes Medications

CHANGE CONCEPT Improve communication

CHANGE PACKAGEChange Ideas Tools, Tips and Resources Improve communication INTERACT Version 4 .0 includes tools to support improved communication and and documentation documentation . (This website may require creating a free account to access resources .) Educate staff on TMF QIN-QIO Beers List and Screening Tool of Older People’s Prescriptions (STOPP) medications to avoid in Criteria (This website may require creating a free account to access resources .) the elderly for PIM and prescriptions

CHANGE CONCEPT Reduce and prevent incidence of hypoglycemic events

Change Ideas Tools, Tips and Resources Use a gap analysis tool for Hypoglycemic Agent Adverse Drug Event Gap Analysis prescribing, dispensing and monitoring labs for hypoglycemic agents and insulin Educate staff on Preventing Hypoglycemia in Type 2 Diabetes recognizing the TMF QIN-QIO Hypoglycemia Graphic signs and symptoms English | Spanish for Puerto Rico of hypoglycemia/ hyperglycemia TMF QIN-QIO Hyperglycemia Graphic English | Spanish for Puerto Rico Hypoglycemia Quality Collaborative Strategic Blueprint provides a resource to create awareness of hypoglycemia and promote activities to reduce its incidence . Use a trigger tool for IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events measuring adverse events Adverse Drug Event Trigger Tool

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CHANGE CONCEPT Increase staff understanding of regulatory guidelines

22 REFERENCES https://www .cms .gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/ nursinghomedatacompendium_508-2015 .pdf https://health .gov/hcq/pdfs/ADE-Action-Plan-508c .pdf https://cdc .gov/medicationsafety/adult_adversedrugevents .html https://psnet ahr. q .gov/primers/primer/23/Medication-Errors-and-Adverse-Drug-Events https://www .ncbi .nlm .nih .gov/pmc/articles/PMC4573668/ https://health .gov/hcq/ade-action-plan .asp https://westessexccg .nhs .uk/your-health/medicines-optimisation-and-pharmacy/clinical-guidelines-and-prescribing- formularies/04-central-nervous-system/61-anticholinergic-side-effects-and-prescribing-guidance/file https://www .ncbi .nlm .nih .gov/pubmed/23639715 http://tmedweb .tulane .edu/pharmwiki/doku .php/antimuscarinics https://www .cdc .gov/diabetes/prevention/lifestyle-program/about-prediabetes .html https://www .ncbi .nlm .nih .gov/pmc/articles/PMC3746062/ https://www .sciencedaily .com/releases/2018/03/180305160156 .htm https://www .ncbi .nlm .nih .gov/pmc/articles/PMC5777877/