CALTCM: A Collaborative Partner

Debra Bakerjian, PhD, MSN, FNP, FAANP

John Fullerton, MD, AGSF, FACP, CMD

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

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

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!

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

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

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.”

Why are antipsychotics used in patients with dementia?

1. They do work in some patients for acute behavior problems and patients with dementia—NOT ALL USE IS INAPPROPRIATE

2. Behavioral interventions and programmatic interventions are anecdotal – little evidence that they are helpful

3. Comfort (resident/family/staff) may override function or longevity as primary goal for many patients with advanced dementia and other advanced illnesses

4. Prescribing physicians are often distant from the site of care and have limited information

5. 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

6. Patients come to SNFs from hospitals and home while on antipsychotics; with no good reason and these medications are never discontinued

7. SNF nurses need help to manage patients who have behavioral problems that are out of control

CALTCM Proposal:Drive Performance Improvement

with QAPI 1. 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

2. Provide greater incentives for behavior change; Continued combination of sanctions and documentation

requirements Rewards for excellent outcomes

CALTCM Proposal:Drive Performance Improvement

with QAPI 1. 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

2. 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

Change the Process and Monitor Outcomes

1. Use a “readiness for change” approach; establish leadership group of SNFs who will commit to change and are ready to follow through

2. Partnership of all groups working together-CAHF, HSAG, CDPH, CCCC, others

3. Must have dedicated leadership (DON, administrator, DSD, Pharmacist, prescribers)

4. Include other medical organizations including American College of  Physicians, Society of Hospital Medicine, American Academy of Geriatric Psychiatry, GAPNA

5. SNF leadership (QAPI) team should meet frequently

6. Training programs in the SNF should include CNAs and other front-line staff

7. 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?

Essential Goals for Success

• Establish strong collaborative partnerships that leverages each organization’s 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