Megan Sheppard, DNP, PMHNP- BC Carrie Plummer, PhD, ANP- BC Vanderbilt School of Nursing

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1 Megan Sheppard, DNP, PMHNP- BC Carrie Plummer, PhD, ANP- BC Vanderbilt School of Nursing

2 This project is supported by funds from the Bureau of Health Professions, Health Resources and Services Administration, Department of Health and Human Services under Grant number UB4HP19055 (Meharry Consortium Geriatric Education Center). Collaboration with Q- Source

3 8:30am 9:30am Overview of Dementia, Difficult Behaviors, Antipsychotics, CMS, Partnership Initiative 9:40am 10:40am Introduce affective and physical assessment, non- pharmacological interventions 10:50am 11:50am QAPI and Small group Case Study 11:50am 12:00pm Wrap up and survey of future needs

4 2010 US Census 13% of population were people age 65 In Tennessee, 13.4% of population were people age 65 In the U.S. there are 24 million people with dementia. This number is estimated to double by 2020 (Jeste et al., 2012).

5 Alzheimer s Disease (AD) Estimated 5.2 million Americans have AD in 2014 One in nine (11%) people 65 One in three (32%) people age 85 By 2050 the number of people ages 65 and older with AD may nearly triple from 5 million to 16 million content/uploads/2012/08/elderabuse.jpeg

6 Vascular Dementia Difficult to calculate actual cases, due to overlap with other forms of dementia and also question of diagnostic process, but approximately 10 20% of dementia cases. Parkinson s Disease In community- based studies of PD, prevalence of dementia with PD is as high as 41% Frontotemporal Lobar Degeneration (FTLD) More common causes of early- onset dementia and accounts for up to 10 15% of dementia cases. Dementia with Lewy Bodies (DLB) Increasingly recognized as second most common type of dementia after AD, 10 22% of dementia cases. disease- dementia?source=search_result&search=parkinson%27s+disease&selectedtitle=6~150 pathology- and- pathogenesis- of- dementia- with- lewy- bodies?source=see_link temporal- dementia- ftd- symptoms.asp

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8 Direct costs to society of caring for people with dementia total $214 billion, including $150 billion in costs to Medicare and Medicaid. In 2050, estimated cost = $1.2 trillion Average Medicare spending is 3x higher Out- of- pocket spending for patients with dementia is estimated at $36 billion.

9 In 2013, American caregivers provided 17.7 billion hours of unpaid care for people with AD and other dementias, this is the equivalent of $220.2 billion Dementia caregivers had $9.3 billion in additional health care costs of their own in 2013 (Alz.org) 8_things_not_to_say_to_your_aging_parents_ jpg

10 Of Medicare beneficiaries residing in Nursing Homes, 64% have AD or other dementias. 78% of nursing home patients with dementia exhibit behavioral and psychological symptoms of dementia (BPSD) 41% of patients with BPSD exhibit symptoms of psychosis (Van der Lind et al., 2012).

11 Caring for a person with dementia requires an average of 197 more care hours per year than caring for someone without dementia This number increases as the severity of cognitive impairment increases

12 Difficult Behaviors: Agitation Crying Abnormal/repetitive vocalizations Aggression Wandering Sexual inappropriateness Repetitive motor activity Anxiety/Depression Psychosis (delusions and/or hallucinations) Sleep disturbances

13 Alzheimer s Disease Irritability Self- centeredness Delusions Hallucinations Apathy Depression Insomnia Agitation and aggression Vascular Dementia Emotional lability Severe depression Apathy Disinhibition Frontotemporal Dementia Decline in interpersonal skills Apathy Decline in personal hygiene Mental rigidity/inflexibility Distractibility Hyper- orality Stereotyped behavior Dementia with Lewy Bodies Depression more common Anxiety and irritability Apathy/amotivational states Aggressivity/violent behavior Nocturnal confusion/insomnia REM behavior disorder Vivid hallucinations

14 Pain Under treatment of pain is a serious problem in the LTC (and other) settings. Patients with dementia often may not be able to verbally communicate their pain nor demonstrate typical pain behaviors. Effective pain assessment tools for non- verbal patients Co- morbid conditions Depression/anxiety Other mental health 9GCdXNBWxGo/T1rpAt5I6EI/AAAAAAAAD5g/rt8pQqxvhDA/s320/ OlderManCane.jpg

15 Sub- acute and acute delirium 2/2: Pain Dehydration Electrolyte imbalance Sensory impairment Infection Iatrogenic (medication) Decreased O2 sats Sleep deprivation Sensory deprivation

16 A Brief History Centers for Medicare and Medicaid Services (CMS) Initiative released in April 2012 Food and Drug Administration (FDA) Alert in 2005 and 2008 OIG report- overuse of antipsychotics in nursing homes The Agency for Healthcare Research and Quality (AHRQ) July 2012 systematic review release

17 The average percentage of long- stay residents on antipsychotics: 20.3% in reporting nursing homes in the Unites States (CMS, 2013) 23.4% in Tennessee (CMS, 2013) drugs.jpg

18 CMS has developed a national partnership to improve the quality of care provided to individuals with dementia living in nursing homes This partnership is focused on delivering health care that is person- centered, comprehensive, and interdisciplinary. Reduce use of unnecessary antipsychotic medications in LTC setting

19 When antipsychotics are necessary how do we appropriately document this necessity? CMS guidelines for long- term care facilities Must present a danger to the person with dementia or others, or cause the person with dementia to experience one of the following: Inconsolable or persistent distress A significant decline in function Substantial difficulty receiving needed care

20 Take a break and come back to hear about affective and physical assessment and behavioral interventions.

21 Describing the behavior(s) and quantifying them assessment/csca Nursing Home Behavior Problem Scale: QM_QI_Tools_Behavior.pdf When do I assess my patient? Establish baseline Change in type, frequency, or severity of behavior

22 CAUSE Infection (UTI, URI, PNA, Wound) Dehydration Electrolyte Imbalance Constipation Pain Sensory deprivation EVALUATION Physical examination Labs: UA, CXR, CBC, BMP Physical examination Labs: BMP Medication Review, I s/o s Labs: BMP History of recent bowel regimen, physical examination Review patient history (co- morbid conditions) and physical examination Ensure resident has eye glasses, hearing aids, well- lit rooms/hallways

23 CAUSE Overstimulation Sleep deprivation Iatrogenic (medications) Decreased O2 sats EVALUATION Does patient s behavior appear linked to environmental noises, sounds, smells, clutter? Documentation of sleeping schedule, excessive daytime napping/sleepiness Review of medications, recent admissions to ED or Hospital (change of meds) O2 saturation, Physical examination of lung fields, coughing? Review patient history (COPD, asthma, lung disease, smoker, PE, DVT, clotting disorder, cancer, infection)

24 Nursing home Toolkit: m/#!managing- specific- behaviors/ctie What is the behavior? What are possible causes of behavior? Suggested non- pharmacological interventions?

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29 Interventions must be person- centered Hand in hand: handinhandtoolkit.info/ Document what non- pharmacological interventions you used, what worked, what didn t as this will help with: Communication to other staff members on how to manage the patient s problem behaviors Will allow for evaluation of efficacy in the QAPI process Extra Resource re: CMS training for surveyors videos. Focus on hot spots what are surveyors looking for in a survey of a LTC? AntiPsychoticMedHome.aspx

30 Take a break and come back to discuss QAPI and a small group Case Study.

31 Enrollment- and- Certification/QAPI/ Downloads/ProcessToolFramework.pdf Enrollment- and- Certification/QAPI/downloads/qapifiveelements.pdf

32 5 minutes to read Case Study 25 minutes to outline 20 minutes to discuss as large group

33 Mrs. J is a 75 year old AAF with history of Alzheimer s dementia, s/ p MI (2001) with stents placed, COPD, recurrent UTIs, hypercholesterolemia, HTN, osteoarthritis and DM Type 2. She has been a resident at your facility x 3 years. Over the last year she has had increasing episodes of aggression towards staff and other residents. Over the last month she has struck staff, at least once a week, during mealtime. Today she attempted to strike another resident in the dining room. Medications: Lisinopril 20mg PO qday, Metoprolol 25mg PO bid, HCTZ 25 mg PO qday, Atorvastatin 20mg PO qhs, Plavix 75mg PO qday, Metformin 1000mg PO bid, Advair 250/50 nebs bid and Albuterol nebs PRN, Cranberry OTC 2 pills PO qday, Zyprexa 2.5mg PO qhs, Ativan 0.5mg PO bid PRN for agitation. Mrs. J s Health Care and Financial POA is her daughter, Mrs. Smith, who lives locally and is supportive and involved in her care.

34 Identify event to be investigated and what questions to ask Establish leadership team to review Describe what happened Identified the contributing factors Identify root causes Enrollment- and- Certification/QAPI/ downloads/qapifiveelements.pdf content/uploads/2012/12/causeeffect.gif

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36 STEP 1: Who will assume leadership responsibility and accountability for the project? Which staff members will be involved and how? How do you involve residents and family?

37 STEP 2: Develop a clear purpose Defined roles for each team member Defined commitment from each team member

38 STEP 3: Self- Assessment of readiness for change and how will you measure progress? What type of data collected and what tools will be used to collect data? How often will you measure progress?

39 STEP 4: Using your organization s established Mission/ Vision statement write your organization s Guiding Principals (i.e. beliefs and philosophy pertaining to QAPI) = What Why How

40 STEP 5: Conduct a QAPI Awareness Campaign by: How will you communicate with all staff, consulting/ visiting health care providers, residents, and family members? Type of training for staff? Ongoing and consistent? Messaging that QAPI = systems of care. How will you ensure your facility is a safe haven for staff, family, and residents to raise quality concerns?

41 STEP 6: What is your plan for data collection with regards to: type of data, frequency, documentation/storage, and analysis? Examples of types of data: Clinical indicators? Medications? Complaints? Readmissions? Resident/Family satisfaction? Staff satisfaction? State survey results? Administrative staff turnover

42 STEP 7: Plan, conduct and document PIPs

43 Share and discuss small group results

44 Pilot test intervention(s): Choose one unit/floor/wing to implement QAPI process and evaluate outcomes Use staff who are regularly assigned to that particular unit/ floor/wing as they will be most familiar with residents baseline behaviors and therefore best able to judge changes/outcomes Requires ALL staff be a part of process from care partners/ techs, nursing staff, housekeeping, managers, DON, NPs, Pharmacy, and Medical Director

45 Thank you for your time and attention

46 Pass out survey asking for input from participants as to what additional content they felt they would benefit from having at the webinars in May and June.

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