12 steps to reducing antianxiety/hypnotic meds

Most nursing homes have already embarked on the journey to reduce unnecessary antipsychotic medication use. Providers that also want to target antianxiety medications (anxiolytics) and hypnotics don’t need to reinvent the wheel: The basic how-tos are available online, thanks to a new publicly reported quality measure (QM), the Percentage of Long-Stay Residents Who Received an Antianxiety or Hypnotic Medication.

However, providers can implement program management strategies to maximize the effectiveness of nonpharmacological approaches as they follow the Centers for Medicare & Medicaid Services’ (CMS) prompt “to re-examine their prescribing patterns.” Here are some key techniques that providers can use to invigorate their efforts to reduce any of these medication classes in their resident population.

1. Know where you stand

Providers need to have some basis of evidence in order to focus their efforts, says Barbara Bates, RN, MSN, C-NE, RAC-CT, a nurse consultant and dementia care specialist in Rochester, N.Y. “Look at your statistics: Find out how many residents you have on antipsychotic, antianxiety, or hypnotic medications; what drugs they are using; and how your staff are administering them.”

Once providers identify that baseline data, they should dig a little deeper, suggests Linda Kluge, RD, LD, CPHQ, director of IDIQ for Atlanta-based Alliant Quality, the QIN-QIO (Quality Innovation Network-quality improvement organization) for Georgia and North Carolina. “One of the first things we do is have facilities complete what is called a Discovery Assignment. The goal is to develop a picture of how big your problem is and how much work you need to do, for example: What behaviors most often trigger antipsychotic drug use in your facility? Do you meet regularly on this issue? What meeting do you use? Who is on your team?”

2. Start small

Programs to reduce or stop antipsychotic, antianxiety, and hypnotic medications shouldn’t tackle every resident on these medications at the same time, Bates says. “This isn’t a one-size-fits-all situation. You have to really think about who your residents are as individuals so that you can design an effective program of reduction, look at what activities are involved, and ensure that your staff know, for example, what to do for a diversion when a resident is having an episode of restlessness, agitation, or other troubling behavior. With whole-house reductions, you set yourself up for failure because you won’t have enough eyes to keep track of everything.”

3. Establish a strong review process for drug reductions

When residents are being tapered off of medications, providers should use a solid team process that includes medicine and pharmacy for the review “so that you can decide, for example, whether you need to consult a psychologist to develop a behavior plan or whether the family can provide information about what worked at home for a newly admitted resident,” Bates says. “Then you implement a standard nursing process: Put a plan in place, make sure it is communicated to the care team, evaluate whether or not it is working, and if not make a change.”

Note: Appendix PP of the State Operations Manual includes separate tapering considerations specific to antipsychotics, sedatives/hypnotics, and psychopharmacological medications other than antipsychotics and sedatives/hypnotics.

Providers should make medication reduction one of their quality assurance and performance improvement (QAPI) goals, Kluge suggests. “We try to get facilities to start their process of looking at this from the moment of admission.”

4. Hire a recreational therapist to create individualized activities

One center where patients have primarily psychiatric diagnoses added a recreational therapist to fulfill two roles, says Janice Tolman, RN, BSN, director of clinical services for Ethica in Gray, Georgia. “First, the recreational therapist ensures that all facility staff have core competencies in the management of behaviors. Second, based on the patients’ histories—where they have been and who they are—she creates many individualized, small-group activities. These activities range from cooking clubs to gardening, and they are tied to a strong behavior management program that clearly communicates the behaviors of these patients.”

Using a recreational therapist helps providers offer meaningful activities, as well as providing individualized physical exercise that helps residents intentionally exert energy so they have a more regular day and want to sleep at night, Tolman adds.

CMS recognizes the importance of activities as a nonpharmacological approach to resident care. Via survey-and-certification (S&C) memo 16-15-NH, the agency added F-tag 248 (activities) to its Appendix PP list of examples of potential tags for additional investigation when surveyors find facilities noncompliant with F329 (unnecessary drugs).

Specifically, CMS advises surveyors to “review whether the facility provides activities that address a resident’s needs and may permit discontinuation or reduction of psychopharmacological medications. Review also whether adverse consequences of medications interfere with a resident’s ability to participate in activities.”

5. Personalize redirections/diversions

Individualized activities can be a useful redirection technique as well, Bates says. “You want to determine what you have available that you can build from the resident’s past history to, for example, bypass a period of restlessness.”

Bates offers this example from her experience as a director of nursing services: Every day at 3 p.m., a resident with dementia got up and rattled the door. “We looked at this woman’s history and learned that she was a teacher who always left school at 3 o’clock, went to the grocery store, and then went home to cook dinner. So when this resident saw our staff leaving at the 3 p.m. shift change, she thought she should leave too,” she explains.

“Our first step was to make sure this resident wasn’t sitting where she could see the afternoon shift change every day,” Bates notes. “However, we also planned in an afternoon walk. Staff strolled the building with her, and sometimes a supervisor might even pick her up and take her on rounds. We had to take the time to know the resident, develop a specific nonpharmacological diversion, and care plan it.”

6. Try telemedicine for psychiatric services

Many Ethica-supported facilities have a psychiatrist overseeing programming thanks to telemedicine, Tolman says. “Some of the centers are in rural communities. With psychiatry such a limited field in Georgia, telemedicine has been a very much-needed adjunct that has significantly enhanced our ability to manage difficult behaviors.”

Staff hold telemedicine clinics with psychiatrists twice a week, Tolman explains. “They review the patients’ histories, medications, and types of behaviors exhibited. Then the staff go back and update care plans as needed, making sure they clearly communicate the interventions that need to be put in place, updated, or eliminated. So having this overlying program helps with staff education as well.”

Note: CMS maintains a list of Medicare Part B-payable telehealth services, including certain psychiatric services, here and provides information about payment in Section 190, Medicare Payment of Telehealth Services, in Chapter 12 of the Medicare Claims Processing Manual.

7. Consider using Hand in Hand for staff training and education

In 2012 CMS sent every nursing home in the United States a free copy of Hand in Hand: A Training Series for Nursing Homes Toolkit, a person-centered approach for training nurse aides and other staff members on dementia care and abuse prevention.

“With Hand in Hand, all the work is done for you,” Kluge says. “It is a video series that drills down to what words you say to staff about how they can react to patients, how they deal with behaviors and how to prevent abuse. It is a complete toolkit that walks you through how to ensure that every staff person in the building understands this.” (Hand in Hand is cited as a nationally recognized dementia care guideline/program in CMS’ focused dementia care survey tools.)

Providers should be clear that implementing Hand in Hand “is not a one-shot deal,” Tolman says. “Hand in Hand works best when it is the common-core belief of your facility culture. You train and educate your staff as part of your orientation process and then re-educate on a routine basis, targeting recognized needs among staff.”

Note: To learn a little bit more about Hand in Hand from the toolkit creators themselves, review the transcript, audio recording, and slide presentation from CMS’ Nov. 25, 2013, National Provider Call on Dementia Care. In addition, while CMS no longer offers free physical copies of Hand in Hand, providers can request a free download of the toolkit or purchase a DVD set here. Further, a how-to-use slide set is available from the atom Alliance QIN-QIO.

Whatever training is used, providers need to make sure staff receive sufficient education, Bates stresses. “Facilities often do a real disservice to staff by giving staff members little bits of education here and there (e.g., how to approach a resident with dementia) instead of providing a comprehensive educational program. A dementia diagnosis isn’t one-size-fits-all. There are different types of dementia with different symptomologies, and it’s the same type of situation if you have residents who have a diagnosis of depression or bipolar disorder. Staff need to have a deeper understanding of who they are dealing with so they can understand resident reactions.”

8. Designate a unit/neighborhood

“Sometimes it’s unavoidable to have residents with behaviors in the general population,” Tolman says. “However, the best-case scenario is to group them together somehow, for example, in a unit or neighborhood. For residents with behaviors, routine and structure are extremely important. Having a unit makes it easier for you to build routine activities and rest periods into the residents’ days.”

In addition, a designated unit gives providers better control over the environment, she says. “You’re often more able to decrease the noise, clutter, and distractions that sometimes upset residents and cause them to have the behaviors you’re trying to avoid.”

9. Practice consistent staff assignment

Having a designated unit for residents with behaviors also can make it easier to implement consistent staff assignment, Tolman points out. “That is an important component of any behavior management program.” In fact, the F329 draft revision of Appendix PP adds “arranging staffing to optimize familiarity and consistency for a resident with symptoms of dementia” to CMS’ list of examples of nonpharmacological approaches to resident conditions.

10. Engage direct-care staff from all shifts

When providers are figuring out which players will be on the interdisciplinary task force or committee that drives medication reduction/nonpharmacological approaches, “it’s important to involve staff members who are providing direct care for the residents,” Bates says. “In addition, you need to have a mechanism that allows all three shifts to provide input because behaviors are often different on each shift.”

Providers also will need to develop specific nonpharmacological options for off-hour shifts, she adds. “Basically, you need to ask the team, ‘OK, it’s 9 p.m., and the bulk of our resources have gone home. What kinds of resources do we need to make sure our staff have available?’”

11. Stress the importance of documentation

In addition to understanding resident behaviors and the importance of their own roles, staff need to understand the importance of documentation, Bates says. “Staff members have to do a lot of documentation, so sometimes they think some of the things you ask them to report are just a paperwork exercise. They don’t see worth in it.”

The other issue is that staff often minimize resident behaviors. “For example, a nurse aide might not report that Mr. Smith hit her because ‘He’s such a sweet old man. He didn’t mean to hit me. He was just upset,’” Bates says. “Staff members need to understand that reporting behaviors allows the team to better address these concerns and what the triggers are.”

12. Make sure nurses understand the meds

Another piece of the educational puzzle is nurses knowing the pharmacological classifications of medications taken by residents, as well as how those medications actually are used, Bates says. “With new medicines being released all the time, drug education is a moving target—and many nurses around the country are missing it.”

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Not knowing the drug classifications can result in the miscoding of MDS item N0410 (medications received). “For example, trazodone is classified as an antidepressant, but it’s often given for insomnia,” Bates explains. “So a nurse who doesn’t know trazodone’s pharmacological classification will miscode the drug in N0410D (hypnotic) instead of coding it correctly in N0410C (antidepressant).” Such miscoding could result in an inaccurate picture of the facility’s medication use in the new Antianxiety/Hypnotic Medication QM.

However, drug education is more than an MDS issue, Bates adds. “If nurses don’t understand what they’re using drugs for or how they are working, how secure are they in treating these residents? In addition, many medications prescribed to the elderly are subject to Black Box Warnings from the Food and Drug Administration. So nurses need ready resources available.”

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