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COUNTRY VILLA –
HEALTH
INFORMATION /
RECORD
WORKSHOP
JULY 16, 2012
Rhonda L. Anderson,
RHIA, AHIS, Inc.
Rhonda Anderson, RHIA
Anderson Health Information Systems, Inc.
940 W. 17th Street, Suite B
Santa Ana, CA 92706
Email: [email protected]
Telephone: 714 -558 - 3887
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• FOCUS OF NATIONAL AND STATE QUALITY OF
CARE INITIATIVES
• THE INFORMATION IS TAKEN DIRECTLY FROM
CAHF WORKSHOP PRESENTED BY:
– La Mer Integrative & Behavioral Medical Group (Jerry G.
Bruns MD & Debbie Herrera NP)
– CAHF (Mary Jann & Jocelyn Montgomery, RN)
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• May 27, 2008 – JAMA and Archives Journals “Shortterm Use of Antipsychotics In Older Adults With
Dementia Linked to Seniors Adverse Events.”
http://jama.amaassn.org/content/300/4/379.short?citedby=yes&legid=jam
a;300/4/379
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• 2009 – American Journal of Geriatric
Pharmacotherapeutics – “There is a statistically
significant increase in antipsychotic drug
prescriptions form 16.4% in 1996 to 25.9% in 2006.
Higher utilization rates were found in nursing
homes that were for-profit, had lower Medicare
reimbursement rates, and had lower levels of
competition.”
http://www.medscape.com/medline/abstract/19616182
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• January 2010 – Archives of Internal Medicine
– University of Massachusetts Medical School of Study (Y.
Chen, MD)
– More than 1/3 of nursing home residents were
prescribed an antipsychotic without clinical indication
– Residents in NHs with the highest prescribing rates were
1.37 times more likely to receive antipsychotic
medication
http://archinte.amaassn.org/cgi/content/short/170/1/89
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• 2011- Health and Human Services OIG Report– 14% of all nursing home residents with Medicare had
claims for antipsychotics
– 88% of the atypical antipsychotics prescribed off-label
were for dementia.
http://oig.hhs.gov/oei/reports/oei-07-08-00150.pdf
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• OIG Findings
– 22% of the atypical antipsychotic drugs claimed were
not administered in accordance with CMS standards
– 44% did not comply with CMS standards for more than
one reason
• August 1, 2011 – Senators Grassley and Kohl urge
CMS to further examine the use of antipsychotic
use in NHs
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• …My Administration is concerned about the
inappropriate use of psychotherapeutic
medications, especially antipsychotic, in skilled
nursing facilities. One recent study concluded that
over half of the residents receiving antipsychotic
therapy were being treated outside the current
Center for Medicare and Medicaid Service
guidelines.
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• … “I have instructed my Department of Public
Health to identify provider that may be
inappropriately prescribing these medications
and thereby posting a threat to the health and
safety of residents in skilled nursing facilities.
If the department’s analysis indicates that such
inappropriate prescribing behavior is occurring
and recommends statutory changes in this area, I
ask the Legislature to immediately seek changes to
correct it.”
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• CDPH and DHCS mine data to identify Medi-Cal
residents who receive one or more antipsychotic
medications
• CDPH invests consultant pharmacist resources to
conduct “complaint” visits at targeted facilities in
these District Office Areas:
– Chico, Daly City, East Bay, Fresno (Modesto only),
Sacramento, San Diego, San Jose, Santa
Rosa/Redwood Coast
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• Residents currently prescribed either:
– Two antipsychotic medications concurrently
OR
– One (or more) antipsychotic medication(s) with a
primary diagnosis of Alzheimer’s dementia with or
without a co-existing diagnosis of SMI
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• Data Summary (May 2010 thru June 2011)
– Facilities cited for inappropriate antipsychotic drug use:
20 of 31
– Facilities cited for the consultant pharmacist’s failure to
identify inappropriate antipsychotic drug use: 20 of 31
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• Exerting an effect on the mind, capable of
modifying mental activity; said especially of drugs.
(Dorland’s)
• Having an altering effect on perception or behavior.
Used especially of a drug. (The American Heritage
Medical Dictionary)
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• Drugs that are prescribed for their effects in
relieving symptoms of anxiety, depression, or other
mental disorders. (Mosby’s Medical Dictionary)
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• Antipsychotics –
typical and atypical
– Haldol, Seroquel,
Risperdal, etc…
• Anticonvulsants
• Sedative‐Hypnotic
– Ativan, Xanax, etc…
• Others
– Beta‐blockers, alpha
1‐2, Provera, etc…
– Tegretol, Depakote, etc…
• Antidepressants
– Celexa, Lexapro, etc…
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• Antipsychotics
– Psychotic behavior:
Auditory or Visual
Hallucinations,
delusional thinking
• Anticonvulsants
– Poor impulse control:
Aggressive behavior or
mood disorder
• Antidepressants
– Depression or mood
disorder
• Sedatives‐Hypnotics‐B
enzodiazepines
– Insomnia or Anxiety
• Others
– Sexually aggressive,
temper outburst,
impulsive behavior
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• August 2011 – The Department of Health Care
Services (DHCS) adds a “Code I Restriction” for all
antipsychotic medications available on the
Contract Drug List (CDL) for Fee-For-Service MediCal beneficiaries.
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• After October 1, 2011, all antipsychotic
medications listed on the CDL will include the
following restriction: “Restricted to…Federal Drug
Administration (FD) – approved indications for
those beneficiaries residing in Skilled Nursing
Facilities only.”
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• DPH Informed Consent All Facilities Letter (AFL)
issuances:
– January 7, 2011 – Obtaining informed consent for
preexisting orders
– April 12, 2011 – Q&A Document
– Key is educational acute hospital re: need for informed
consent verification
– Facility documentation verifying that informed consent
has been obtained by the MD
http://www.cdph.ca.gov/certlic/facilities/Pages/LnCAFL.aspx
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• Frequency Cited in 2011
–
–
–
–
F Tag 329 – Unnecessary Drugs (28%)
F Tag 425 – Pharmacy Procedure (25%)
F Tag 431 – Labeling of Drugs (32%)
F Tag 481 – Professional Standards of Quality (24%)
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• Medication used are routinely monitored
(therapeutic effects, ADR, side effects) according to
manufacturer’s specifications or standards of
practice;
• Necessary labs, weights, VS are taken and
recorded;
• Doses are appropriation titrated up or down for
an elderly person, including planned dose
reduction;
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• Resident with renal/hepatic impairment has
appropriate dose of adjustment and;
• Whether there is an association between Rx
and recently identified symptoms/condition
change such as fall/recurrent falls, decline in ADLs
or decreased sensorium/increased somnolence.
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• Sufficient Nursing Staff…
– Medications administered timely
– Evaluate resident response to RX
– Implement non-pharmacologic interventions when
appropriate, and
– Identify and respond to resident change in conditions
• Physician Supervision- Did the MD supervise the
resident’s medical treatment, assess the resident’s
need for RX and develop a treatment plan?
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• Did the physician/designee:
– Review the resident’s total care plan?
– Write relevant progress notes?
– Establish a treatment regimen that considers nonpharmacological interventions?
– Review Rx regimen for potential unnecessary
medications-effectiveness-potential complications?
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• Rule out all other causes for change in behavior
• If there is a proper indication for use, MONITOR
side effects, i.e, FALLS, INFECTION
• Risk of death – cardiac or pulmonary
• Benefits outweigh the risks?
• Is the medication used going to:
– Improve the quality of their life?
– Alleviate undue stress to the resident?
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• For people with dementia:
– Most approaches are “Culture change”
– Vision and leadership and the “will” to do
it differently are key
– Consistent assignments are imperative
– Assessing and accommodating prior routines, likes,
dislikes are critical
– Tasks and staff must be organized to support
individualized care
– Building empathy, and rewarding doing it right are a
must
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• Each resident’s drug regimen must be free from
unnecessary drugs, which is any drug used:
– In excessive dose (including duplicate drug therapy);
• When a resident receives duplicate drug therapy, an evaluation
should be completed for accumulation of the adverse effects.
For excessive duration;
Without adequate monitoring;
Without adequate indications for its use;
In the presence of adverse consequences which indicate the
dose should be reduced or discontinued; or
– Any combination of the above reasons.
–
–
–
–
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• Medical Provider’s progress note indicating that
the dosage, duration, indication & monitoring are
clinically appropriate and why they are clinically
appropriate;
• Carefully considered the RISK/BENEFIT to the
resident;
• A medical or psychiatric consultation and
ongoing evaluation;
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• Evaluations (e.g., Geriatric Depression Scale)
confirming the medical provider’s judgment that
use of a drug outside the guidelines is in the best
interest of the resident;
• Documentation of medical provider, nursing, or
other health professional indicating that the
resident is being monitored for adverse
consequences or complications of the drug
therapy;
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• Documentation of GDR attempts and outcomes;
• Documentation showing why the resident's age,
weight, or other factors would require a unique
drug dose or drug duration, indication, or
monitoring;
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• Documentation showing that the resident's
decline or deterioration has been evaluated by
the interdisciplinary team to determine whether
a particular drug, a particular dose, or duration
of therapy may be the cause;
• Documentation showing why the resident's age,
weight, or other factors would require a unique
drug dose or drug duration, indication, or
monitoring.
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• Long‐term care centers must ensure, based on a
comprehensive assessment of the resident, the
following:
– When an antipsychotic drug has not been used in the
past, it is not given unless antipsychotic drug therapy is
necessary to treat a specific condition as diagnosed and
documented in the clinical record. Antipsychotic drugs
should not be used unless the clinical record documents
that the resident has one or more of the specific
conditions (see next slide).
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• Schizophrenia
• Schizo‐affective
disorder
• Delusional disorder
• Psychotic mood
disorders (including
mania and depression
with psychotic
features)
• Acute psychotic
episodes
• Brief reactive
psychosis
• Atypical psychosis
• Tourette's disorder
• Huntington's disease
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• Delirium, dementia & amnesic & other cognitive
disorders w/associated psychotic and/or agitated
behaviors that have been quantitatively &
objectively documented. This documentation is
necessary to assist in:
– Assessing whether the resident's behavioral symptom
requires some form of intervention.
– Determining whether the behavioral symptom
is transitory or permanent.
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• Delirium, dementia & amnesic & other (cont.):
– Relating the behavioral symptom to other events in the
resident's life to learn about potential causes (e.g., death
in the family, adhering to the resident's customary daily
routine).
– Ruling out environmental causes (e.g., excessive heat,
noise, overcrowding).
– Ruling out medical causes (e.g., pain, constipation, fever,
infection).
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• According to the AHCA
– 1st line treatment for residents who do not present
immediate danger to themselves or others should be nonpharmacologic.
– While no drugs are approved by the FDA for the treatment of
behavioral symptoms in older adults with dementia, if
pharmacotherapy is deemed appropriate use the most
appropriate agent and the lowest effective dose, for the
shortest amount of time.
– Response to therapy should be monitored and documented
frequently and evaluated for gradual dose reduction, tapering
or discontinuation.
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• What can you do?
– Open transparent communication with patients and
their family/responsible parties (RP)
– Education (patient/family/RP/staff)
– Use your local resources (ALZ association)
– Therapeutic communication with medical providers
– Ask “is this going to improve the quality of the
residents life?”
– Interdisciplinary team meetings (IDT)
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• Run reports from the P.O. re: psychotrophic and
psychotherapeutic drugs
• Look at diagnoses
• Look at documentation
• Look at psychiatric evaluation
• Conduct comprehensive audit and follow up (see
AHIS HIM #7050 – Behavior Drugs Monitor)
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• By December 31, 2012 at 12:00 p.m. – Reduce the
off-label use of antipsychotics by 15 percent.
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Rhonda Anderson, RHIA
President, AHIS, Inc.
714-558-3887
[email protected]
Thank You!
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