CALTCM: A Collaborative Partner

1
CALTCM A Collaborative Partner

• Debra Bakerjian, PhD, MSN, FNP, FAANP
• John Fullerton, MD, AGSF, FACP, CMD

2
CALTCM Who We Are

• California State Chapter of AMDA with 400
  members
• Interprofessional membership
• Focus on interprofessional collaboration
• Effective collaboration with stakeholders (CDPH,
  CAHF, CCCC, POLST, CHCF)
• Interdisciplinary membership (leaders within
  SNFs) with academic and clinical expertise with
  QI focus the past 6 years

3
Collaboration of the Future

• Value of CMD, MD/NP teams is proven
• Improved quality with CMDs and MD/NP teams BUT
  it is not enough
• Need NHAs, DONs, DSDs, CAHNR, others
• Need pharmacists, hospitalists, social workers,
  discharge planners
• Proponents of action oriented behavioral
  interventions
• Need organizational change to adopt QAPI
• Need support at the organizational and consumer
  levels

4
CALTCM Perspective

• We agree that antipsychotic medications are often
  overused in patients with dementia, and are
  dangerous in this population
• Efforts to reduce use have had limited success
• We support the CMS and CDPH measurable goals of
  15 or more reduction
• We believe a QAPI approach is needed to achieve
  this goal
• We are a significant part of the CA team that
  addresses this issue!

5
What Does CALTCM Bring to the Table?

• CALTCM offers significant medical and QI
  leadership for this initiative
• We are an interprofessional and collaborative
  organization
• We have proven systems and processes that can be
  shared and adapted to this effort

6
History of QI Technical Expertise

• CALTCM is a national leader in SNF quality
  improvement
•         INTERACT-II-III project
•         Depression CQI project
•         POLST statewide leadership in
  collaboration with other state organizations
•         Teaching and academic leadership
•         Nationally renowned leaders/clinicians

7
The Problem

• Antipsychotic medication prescribing is driven by
  multiple factors that must be addressed before
  outcomes can be expected to change
• Resident conditions, diagnoses, behaviors
• Organizational factors (staffing, policies and
  procedures, knowledge of staff, organizational
  culture)
• Leadership
• Experience with QAPI
• Every system is perfectly designed to produce
  exactly the results it achieves.

8
Why are antipsychotics used in patients with
dementia?

• They do work in some patients for acute behavior
  problems and patients with dementiaNOT ALL USE
  IS INAPPROPRIATE
• Behavioral interventions and programmatic
  interventions are anecdotal little evidence
  that they are helpful
• Comfort (resident/family/staff) may override
  function or longevity as primary goal for many
  patients with advanced dementia and other
  advanced illnesses
• Prescribing physicians are often distant from the
  site of care and have limited information
• The need for a short term solution - the culture
  of the US (SNFs in particular) is to provide
  immediate response to problems leading to more
  prescriptions
• Patients come to SNFs from hospitals and home
  while on antipsychotics with no good reason and
  these medications are never discontinued
• SNF nurses need help to manage patients who have
  behavioral problems that are out of control

9
CALTCM ProposalDrive Performance Improvement
with QAPI

• Training
• Educate the prescriber community widely
• Include training for frontline staff charge
  nurses, CNAs, others
• Work with acute care hospitals to improve
  discharge planning
• Include consumers (families) in the education
• Train SNFs in alternatives to antipsychotics and
  link that to outcomes to determine what works
• Provide greater incentives for behavior change
• Continued combination of sanctions and
  documentation requirements
• Rewards for excellent outcomes

10
CALTCM ProposalDrive Performance Improvement
with QAPI

• QAPI Interventions develop QAPI process based
  on the 5 principles
• Design and scope
• Governance and leadership
• Feedback, data systems, and monitoring
• Performance improvement projects
• Systematic analysis and systemic action
• Application to reducing antipsychotics
• Rapid and more frequent antipsychotic medication
  taper trials
• IDT review of every patient on antipsychotic
  medication without FDA indication
• Include attending primary care prescriber,
  medical director and pharmacist when possible
• Determine when they are available to maximize
  participation
• Improve monitoring of behaviors prior to
  initiation of antipsychotics when feasible
• Be precise about non-pharmacological
  interventions what actually works?
• Enhanced activities programs

11
Change the Process and Monitor Outcomes

• Use a readiness for change approach establish
  leadership group of SNFs who will commit to
  change and are ready to follow through
• Partnership of all groups working together-CAHF,
  HSAG, CDPH, CCCC, others
• Must have dedicated leadership (DON,
  administrator, DSD, Pharmacist, prescribers)
• Include other medical organizations including
  American College of  Physicians, Society of
  Hospital Medicine, American Academy of Geriatric
  Psychiatry, GAPNA
• SNF leadership (QAPI) team should meet frequently
• Training programs in the SNF should include CNAs
  and other front-line staff
• Reward those who achieve 25 reduction or have
  antipsychotic rates at more than 25 below the
  mean
• Possibly quality certification of some kind from
  CDPH and CMS?

12
Essential Goals for Success

• Establish strong collaborative partnerships that
  leverages each organizations expertise
• Work in true collaboration
• Keep activities person-centered and evidence base
• Follow QAPI process and use AE and other evidence
  based tools and resources
• Follow principles of interprofessional
  collaborative practice