Reducing Off-Label Use of Antipsychotics in New Jersey Long-Term Care Settings

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Medications offer a variety of benefits, but they can come with great risk when not prescribed, administered or managed properly. Older adults are twice as likely to visit the emergency department and seven times more likely to be hospitalized due to adverse drug events (ADEs) than people under age 65. The Centers for Medicare & Medicaid Services has even set a national goal to prevent and eliminate ADEs in 265,000 lives per year.

Healthcare Quality Strategies, Inc. (HQSI), the Quality Improvement Organization (QIO) for New Jersey, is leading the charge in New Jersey to decrease ADEs by supporting local team participation in the national Patient Safety and Clinical Pharmacy Services Collaborative (PSPC). HQSI is convening interdisciplinary community teams statewide that are dedicated to improving health outcomes and patient safety by curbing ADEs in seniors, a major source of preventable patient harm.

To encourage local improvement initiatives that target ADEs, HQSI developed an ADE team roadmap – Getting Started: Your Roadmap to Forming a Patient-Centered Care Team. The roadmap includes step-by-step instructions for developing and maintaining a team, expected responsibilities of team members, and useful websites and resources.

The roadmap also explains the benefits of participation, including access to a statewide Learning and Action Network (LAN), and contains links to tools for assessing and implementing safer practices, support for rapid-cycle improvement, and strategies for spreading success within the community.

The document is intended to help health care providers and stakeholders that are interested in forming new ADE teams with the QIO to get organized and up-and-running quickly. According to Nicole Skyer-Brandwene, Clinical Program Manager at HQSI, the roadmap has been shared nationally and has been adapted by at least two other QIOs for their own use.

HQSI currently supports five local ADE teams – two focused on diabetes and three focused on antipsychotic use in long-term care (LTC) settings. After a year of work, the LTC teams have reported great successes. About 25 percent of the teams’ residents are off antipsychotics completely and another 25 percent have had dose reductions. Also, one diabetes-focused ADE team was able to help two-thirds of their patients move from out-of-control to in-control diabetes within one year.

The newer LTC ADE teams have been actively collecting data over the past year, looking at reducing unnecessary antipsychotic use. We are focusing on antipsychotics because it’s a nice complement to other initiatives in the community and our national LTC work,” Brandwene said. It also aligns with person-centered care.”

At a recent LAN meeting, Brandwene shared one story about a resident who was taking three unique antipsychotics and a sleep medication. This person was often sedated during the day, restless at night, agitated and resistant to care. At times, it was difficult to calm him down.

As part of their ADE work, the LTC facility implemented a strategy that involved taking extensive personal histories in an effort to find out a resident’s interests. In collecting this data, the team learned that the resident was an avid music fan and enjoyed bands such as Pink Floyd and The Who. The facility gave the resident an MP3 player loaded with his favorite songs. After implementing this strategy, the team was able to successfully remove the sleeping pill and one of the three antipsychotic medications.

The team reported that after the medication reduction, the patient was more active during the day, slept better at night, and was less likely to become agitated. This is a great example of the importance of involving a person in his or her own care,” Brandwene said. There were a couple of different factors at play, including possible side effects of medications. But it’s clear that getting to know a person can make a significant difference in their care and quality of life.”

The staff in the nursing home also benefited greatly when they saw the patient’s demeanor and mood improve. It was empowering to the staff because they witnessed firsthand how they really can improve someone’s life,” Brandwene said. It’s not about a medication; it’s about making a connection with the person.”

HQSI also collaborated with Delmarva Foundation, the QIO for Maryland and Washington, D.C., to develop an Antipsychotic Medication Reference to be used as an aid for appropriate prescribing and monitoring of antipsychotic medications. The guide is being spread nationwide through emails, events, and the Advancing Excellence in America's Nursing Home Campaign and HQSI websites.

Looking ahead, HQSI is working with other health care providers on community efforts to reduce ADEs. HQSI works closely with the New Jersey Local Area Networks for Excellence (LANEs), the statewide coalition that helps participating nursing homes achieve Advancing Excellence campaign goals. Working closely with the organization has helped in the spread of the QIO’s success stories and best practices.

If we work together and continue spreading best practices, we can make dramatic and sustainable reductions in the misuse of antipsychotics in long-term care facilities,” Brandwene said.