Intervening on Antipsychotics to Improve Dementia Care

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Antipsychotic drugs are increasingly overprescribed for dementia patients in nursing homes. According to a report from the U.S. Department of Health and Human Services’ (HHS) Office of the Inspector General, 14 percent of older Americans living in nursing homes take at least one antipsychotic prescription. Moreover, 83 percent of Medicare claims for antipsychotics are prescribed for off-label conditions, including dementia.

Great Plains Quality Innovation Network—the Quality Innovation Network-Quality Improvement Organization (QIN-QIO) serving Kansas, Nebraska, North Dakota and South Dakota—is working to reduce antipsychotic use in nursing homes, most recently through a pilot program that researched the driving factors behind antipsychotic over-prescription, and established interventions to eradicate unnecessary use.

“Many times when dementia patients move into nursing homes, there are a lot of lifestyle changes for the patient that they do not know how to deal with,” said Michelle Lauckner, quality improvement specialist at Great Plains QIN. “We want to see more caregivers learn about the person—what has worked in the past, and ways to take care of patients other than giving them an antipsychotic pill.”

In partnership with the University of North Dakota School of Medicine & Health Sciences, the North Dakota Partnership to Improve Dementia Care, and representatives from nine rural nursing homes and a local hospital, Great Plains QIN looked at the fundamental forces that drive caregivers in nursing homes to prescribe antipsychotic medications.

Through this research, they identified one community in southeast North Dakota that had higher rates of antipsychotic prescriptions, and the community hospital’s readmission rates had not improved. One nursing home reported that antipsychotic treatments started during an acute hospital stay were a root cause of this anomaly in prescriptions and readmission rates.

“We want to see more caregivers learn about the person—what has worked in the past, and ways to take care of patients other than giving them an antipsychotic pill.”

With this information, Great Plains QIN implemented interventions to evaluate the need to continue patients’ antipsychotic treatment upon discharge to a skilled nursing facility. Interventions included improving communication between nursing homes and hospital staff following a patient’s discharge; engagement with nursing home residents and families during care transitions supporting educated decision making; behavior mapping for residents transferred to nursing homes to assess antipsychotic need and individualize non-pharmaceutical interventions; and education of hospital staff around treatment of acute delirium.

In addition, Great Plains QIN conducted a series of four monthly webinars for participating nursing homes to educate them about the intervention program and explain how they could use Quality Assurance and Performance Improvement methodology to reduce the unnecessary use of antipsychotics in the care setting. One webinar, for example, included information about educating families on how to advocate for residents while they are still in the hospital.

Results: Participating nursing homes have seen a 16 percent relative improvement in antipsychotic quality measures compared to three percent improvement in the rest of North Dakota. The collaboration among area hospitals, nursing homes and Great Plains QIN has started an ongoing conversation on how nursing homes can incorporate members of the patient’s family into the dementia care process.