monitoring for inappropriate use of antipsychotic medications f428 – drug regimen review process...

Monitoring for Inappropriate

Use of Antipsychotic Medications

F428 – Drug Regimen Review Process

F329 – Unnecessary Medications

Margie Huguet, RN, MCSDHH Health Standards Section

Long Term Care Supervisor

10 Steps to Eliminate Off-Label Antipsychotic Use1. Establish A Leadership

Team 2. Review CMS Survey

Guidance to Understand Why and How

3. Analyze MDS CASPER Resident Level Quality Measure Report to Identify Target Population and Coding Errors

4. Triage: Review Why Each Resident is Receiving Antipsychotics and Take Care of Easy-to-Act-On Situations

5. Train Staff on Why and How to Reduce Antipsychotics

6. QI Closest to the Resident – Track and Trend and Care Plan

7. Engage Physicians, Prescribers, Consultant Pharmacist

8. Engage Families9. Update your policies,

procedures and forms 10. Sustain and Spread

©B&F Consulting 2015www.BandFConsultingInc.com

Objectives:1. Discuss the Drug Regimen Review

(DRR) process (F428) and its role in assisting NHs in monitoring the inappropriate use of antipsychotic medications.

Pharmacy Consultant

F425- Pharmacy ServicesConsultant Pharmacist

F425 - Pharmacy Services in a Nursing Home

Overall Goal is to ensure safe and effective use of medications; (b)Service Consultation

The Licensed pharmacist:collaborates with facility leadership and

staff to coordinate the services;helps the facility identify, evaluate, and

address/resolve pharmaceutical concerns and issues that affect resident care, medical care or quality of life.

F425- Pharmacy Services

The pharmacist is responsible for: Helping the facility obtain and maintain

timely and appropriate pharmaceutical services that support residents’ healthcare needs, that are consistent with current standards of practice, and that meet state and federal requirements.

Participating on the ID Team to address and resolve medication-related needs or problems.

Developing procedures and guidance regarding when to contact a prescriber about a medication issue and/or adverse effects, including what information to gather before contacting the prescriber;

F425- Pharmacy ServicesConsultant Pharmacist

Nursing

Safeguards against Med Issues

The physician providing and reviewing the orders and total program of care on admission and the prescriber reviewing at each visit;

The nurse reviewing medications when transmitting the orders to the pharmacy and/or prior to administering medications;

The interdisciplinary team reviewing the medications as part of the comprehensive assessment for the Resident Assessment Instrument (RAI) and/or care plan;

The pharmacist reviewing the prescriptions prior to dispensing; and

The pharmacist performing the medication regimen review at least monthly.

F425- Pharmacy Services

F428 – Drug Regimen Review1. The drug regimen of each resident must

be reviewed at least once a month by a licensed pharmacist.

2. The pharmacist must report any irregularities to

1. the attending physician, and 2. the director of nursing, and

these reports must be acted upon

F428- Drug Regimen Review

What is a Medication Regimen Review? A thorough evaluation of the medication

regimen of a resident, with the goal of promoting positive

outcomes and minimizing adverse consequences associated with medication.

The review includes preventing, identifying, reporting, and

resolving medication-related problems, medication errors, or other irregularities,

and collaborating with other members of the interdisciplinary team.


What is an irregularity? Refers to any event

that is inconsistent with usual, proper, accepted, or right approaches to providing pharmaceutical services, or

that impedes or interferes with achieving the intended outcomes of those services.


True or False


Regulatory Language – F329(I)Drug Regimen must be Free from Unnecessary Drugs

Any drug when used:I. In excessive dose (including duplicative

therapy); orII. For excessive duration; orIII. Without adequate monitoring; orIV. Without adequate indication for its

use; orV. In the presence of adverse

consequences which indicate the dose should be reduced or discontinued; or

VI. Any combination of the reasons above.

F329- Drug Regimen Free from Unnecessary Drugs

Identification of Irregularities

The pharmacist’s review considers factors such as:

Whether the physician and staff have documented objective findings, diagnoses and/or symptom(s) to support indications for use;

Whether the physician and staff have identified and acted upon, or should be notified about, the resident’s allergies and/or potential side effects and significant medication interactions (such as medication-medication, medication-food, medication-disease, medication-herbal interactions);

Whether the medication dose, frequency, route of administration, and duration are consistent with the resident’s condition, manufacturer’s recommendations, and applicable standards of practice;



Whether the physician and staff have documented progress towards, or maintenance of, the goal(s) for the medication therapy;

Whether the physician and staff have obtained and acted upon laboratory results, diagnostic studies, or other measurements (such as bowel function, intake and output) as applicable;

Whether medication errors exist or circumstances exist that make them likely to occur; and



possible medication-related causes of recent or persistent changes


Monitoring The ongoing collection and analysis of

information (such as observations and diagnostic test results) and comparison to baseline date in order to: Ascertain the response to treatment and

care;

Detect complications/adverse consequences;

Support decisions about modifying, discontinuing, or continuing any interventions.


F329 - Antipsychotic Drugs2. Antipsychotic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that: (i) Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and (ii) Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.


GDR – Gradual Dose Reduction

Seeking an appropriate dose and duration and minimizing the risk of adverse consequences;

To find an optimal dose or discontinue dose; When clinical condition has improved/ stabilized,

When underlying causes of the original target symptoms have resolved, and/or

When non-pharmacological interventions, including behavioral interventions, have been effective


GDR - for Antipsychotics Within the 1st year in which a resident is

admitted on an antipsychotic medication or after the facility has initiated an antipsychotic medication, the facility must attempt a GDR in two

separate quarters (with at least one month between the attempts), unless clinically contraindicated

After the first year, a GDR must be attempted annually, unless clinically contraindicated


GDR – Clinically Contraindicated

Continued use is in accordance with relevant current standards of practice and ;

physician documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident’s function or increase distressed behavior; or

target symptoms returned or worsened after the most recent attempt at a GDR


If we don’t medicate what else can we do?

Non-pharmacological interventions are approaches to care that do not involve medications, generally directed towards stabilizing or improving a resident’s mental, physical or psychosocial well-being.

“Behavioral interventions” are individualized non-pharmacological approaches (including direct care and activities) that are provided as part of a supportive physical and psychosocial environment, and are directed toward preventing, relieving, and/or accommodating a resident’s distressed behavior.


Surveyor Triggers- Possible Irregularity

Drug Regimen ReviewA form of

Quality Assurance & Performance Improvement


Drug Regimen Review Findings The pharmacist is expected to document

either that no irregularity was identified or the nature of any identified irregularities.

The pharmacist is responsible for reporting any identified irregularities to the attending physician and director of nursing.


Drug Regimen Review Findings Considered part of each resident’s clinical

record.

Maintained within the facility and is readily available for review.

The ID team is encouraged to review the reports and to get the pharmacist’s input on resident problems and issues.


Response to Irregularities The physician either accepts and acts

upon the report and potential recommendations

or rejects all or some of the report and

provides a brief explanation of why the recommendation is rejected, such as in a dated progress note.


DON addresses/documents actions taken for: recommendations that do not require a

physician intervention, such as one to monitor vital signs or weights


Think About It

Policy’s and Procedures Do you have one? Is it consistent with current Standards of

Practice?

AMDA Letter to Medical Directors – P&Ps that promote: a process of person-centered care learning the story behind each resident evaluating the behavior changes and excluding potential medical

causes of the behavioral symptoms

P&P should direct the staff to identify resident specific needs, optimize

choices, and promote consistent assignments Foster education of staff to ensure understanding of dementia-

related behavior as a form of communication Use of non-pharmacological interventions to address behaviors Address proper monitoring

Sample Psychotropic Med P/P – Advancing Excellence Website – Under Physician Tools

Step 9Updating Policies , Procedures, and forms

Sample Form: Psychotropic Medication Tracking Tool

AHCA/NCAL Quality Initiative – Antipsychotic Management Tool

Step 9Updating Policies , Procedures, and forms

monitoring for inappropriate use of antipsychotic medications f428 – drug regimen review process...

Documents

use of antipsychotics

pharmacy consultants

resident care

f425 pharmacy services

pharmacy services requirement

f425 pharmacy servicesf425

nursing home setting

nursing home residents