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