John M. Parrot Centre met and surpassed their target for reducing potentially inappropriate use of antipsychotics among their long-term care resident population, as outlined in their Quality Improvement Plan progress report from 2017/18.
Health Quality Ontario was impressed by this great work and had a chance to catch up with Carol Corcoran, Manager of Nursing, Carolyn McConnell, RAI Supervisor, and Angela Malcolm, Director to gain a better understanding of what strategies were effective in achieving this success.
What strategies helped you reduce antipsychotic use so successfully?
We attribute much of the success to our collaborative multidisciplinary approach. Our team meets monthly and includes input from our medical director, geriatric psychiatrist, nurse practitioner, pharmacist, activation coordinator, other front line staff members, and ad hoc family representatives. Behavioural Supports Ontario (BSO) members of our team include a case manager, mobile resource team (MRT) representative, and psychogeriatric resource consultant (PRC).
We also have weekly rounds to discuss how to best manage residents’ diagnoses and whether a reduction in antipsychotic medication is feasible and appropriate.
At both our monthly and weekly meetings, we consider Montessori interventions/programs that might meet our residents’ needs, we discuss residents’ physical issues and their potential impact on responsive behaviours, and we analyze Resident Assessment Instrument (RAI) Outcome Scores and incorporate clinical and social interventions as appropriate.
What other strategies did you use?
There are a number of other strategies we’ve used to reduce antipsychotic medication use in our home.
Monitoring medication use:
We have a medication monitoring tool for medications such as antipsychotics, anti-depressants and hypnotics. This tool helps our nurses better understand the effects of medications on residents, to know what behaviours to monitor, and to provide recommended alternatives to pharmacological interventions.
Our pharmacy consultant is highly involved in analyzing psychotropic usage in our home and provides recommendations to our physicians for possible reductions and alternative treatments. When residents are first admitted, our physician and pharmacist work together to complete medication reconciliation.
From a strategic perspective, our medical director is very focused on reducing polypharmacy to decrease all unnecessary medication use.
Engaging residents and families:
Working with residents and families has also helped us be successful. At admission, our RAI coordinator is responsible to build solid relationships with new residents and maintain a connection with the family throughout the residents’ entire stay. This relationship building is key to goal planning, developing care plans, and implementing interventions being recommended to residents and families.
We further engage with families and residents through our Residents and Family Council and annual resident care conferences. Once they are familiar with “why” reducing antipsychotic use is so important, they are on board with us. When families have questions or concerns, our medical director is available to provide further information.The care team will readily arrange a care conference at any time throughout the year to support informed decision-making processes.
Implementing non-pharmacological interventions:
We have provided training to over 100 staff on the use of the Montessori program to mitigate responsive behaviours without the use of medication. This training is available to all staff members. We also work with our in-house Gentle Persuasive Approach (GPA) coach when faced with challenging behaviours. The GPA coach is very valuable to our staff. Our medical director has expressed a keen interest in attending the GPA program, which will be occurring this spring.
We have a mobile BSO team that comes to our home to help staff understand responsive behaviours and how to best manage them. The BSO team allows all our staff to have the same base knowledge and education about managing responsive behaviours. Our staff really enjoy collaborating with the BSO team and having honest conversations about what they’re doing right and what improvements could be made. The BSO team really invests their time to help our staff. We applied for in-house BSO support and it was recently granted. We hope that this will allow us to continue to make improvements.
We are working on developing individualized non-pharmacological care plans for all our residents as a means of avoiding the administration of antipsychotic medication where possible.
Did any of your initiatives focus on changes to coding?
To ensure accurate coding in our RAI tool, only two staff members complete the coding - the RAI supervisor and the RAI coordinator. Both are considered experts in RAI coding.
The RAI supervisors chair the weekly Resident Assessment Protocol (RAP) meetings.They bring residents’ Outcome Scores and are prepared to discuss the reasons behind their coding choices.With this information the team collaborates on initiatives that we can do to improve residents’ quality care delivery.
Do you have advice for Long-Term Care homes looking to reduce the use of antipsychotics?
Our advice would be to use a collaborative team approach and encourage transparency and engagement. Have open and honest conversations with staff, families and residents. Listen to their concerns, feedback, and comments. They have valuable information to share.
Reducing antipsychotic use is a complex issue that requires a multi-pronged approach to make a difference. We found it valuable to engage pharmacy, the physician and our nurse practitioner in our quality improvement efforts. As well, including our Professional Advisory Committee as part of the team was invaluable in helping residents and families understand the importance of reducing the inappropriate use of antipsychotics for residents without psychosis.
Do you have questions or advice for reducing antipsychotic use in long-term care? Add your comments below to share with the QI community.
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