Harmony Healthcare Blog

Quality Measures # 16: Residents Who Received an Antipsychotic Medication – Long Stay (Part 2)

Posted by The Harmony Team on Thu, Oct 20, 2016

Edited by Kris Mastrangelo


Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

Steps to Develop a Behavior Monitoring Process 

Pills.jpgIn Part 1 of our Quality Measure #16 series, Harmony Healthcare International (HHI) discussed the Quality Measure Item Sets for Triggering Residents who received an Antipsychotic Medications. After identifying a resident that has triggered for this quality measure what is the next step? The Harmony HealthCARE Specialists work alongside their clients to identify the residents at risk, as well as assist in strengthening the development of a Behavioral Root Cause Analysis Process. 

  1. Where to Begin? Develop a Detailed Care Plan: Once the Interdisciplinary team has identified an issue that affects the patients’ mental health (depression, behaviors, sleeplessness, etc.), the first step is to develop a detailed plan of care specifically addressing the issue with patient specific and measurable goals.
    • The key to developing this care plan is to develop non-medication interventions from all disciplines and to be flexible in developing new interventions if some do not work.
    • Some conditions will require immediate medication intervention, and when the team determines it is clinically appropriate to do so, medications will be started.
    • The use of any psychoactive medication requires that the Care Plan team develop a detailed and patient specific Care Plan addressing the issue that the medication is treating, and the plan for decreasing the dose or discontinuing the use of the medication once the condition has stabilized or resolved.
    • Patients who have dementia should have a detailed and resident-specific care plan for managing their behaviors, which includes resident-specific non-pharmacological approaches for managing adverse behavior. 
  1. The Next Step: Medication and Non- Medication Intervention: Despite all non-medication interventions, the patient may continue to demonstrate the need for medication intervention. Once this decision is made, it is critical to address the use of the medication and how it will be monitored for both positive effect and adverse consequence. 
    Current regulation requires ongoing monitoring for adverse consequences of medication use and GDR when clinically appropriate. To assist with this, Harmony (HHI) strongly encourages facilities to develop policies and procedures relating to how these tasks will be accomplished. Below are some strategies:
    • Patients receiving any psychoactive medication shall have the effect and potential adverse consequence monitored routinely by the Interdisciplinary team.
    • This monitoring should be documented and reviewed by the attending MD on a regular basis who will then make a decision regarding the clinical appropriateness of a GDR and document that decision in detail.
    • Ensure that the Pharmacy Consultant is involved in this process and makes recommendations as indicated.
  1. Monitoring Antipsychotics: While all psychoactive medications are closely monitored, the use of antipsychotics requires even more diligence as they can have potentially significant adverse consequences for the elderly. Harmony (HHI) recommends the additional steps to ensure adequate monitoring and GDR:
    • Use of antipsychotics should be at the recommendation of the Interdisciplinary team, a Mental Health Professional or MD.
    • All patients who receive an antipsychotic should have routine screening for extrapyramidal effects. This screen should be initiated within 72 hours of starting medication to establish a baseline. There is a multitude of assessment tools available for this purpose.
    • Notify the appropriate medical personnel of any changes in the patient’s condition.
    • As part of the review process to determine if a GDR would benefit the patient the team may consider completing a risk vs. benefit analysis. The entire clinical team, including the physician, should review the analysis.  The analysis can be shared with the family during interdisciplinary team meeting, and the entire team can sign the analysis once it has been reviewed. 
  1. Understanding Survey Risks: The following are some of the specific areas that surveyors are required to cite per the State Operations Manual F329:
    • Inadequate Indications for Use: Examples of noncompliance related to a medication being used without adequate indications include, but are not limited to:
      • Failure to document a clinical reason or demonstrate a clinically pertinent rationale, verbally or in writing, for using medication(s) for a specific resident.
      • Prescribing or administering a medication despite an allergy to that medication, or without clarifying whether a true allergy existed as opposed to other reactions (e.g., idiosyncratic reaction or other side effect).
      • Failure to provide a clear clinical rationale for continuing a medication that may be causing an adverse consequence.
      • Initiation of an antipsychotic medication to manage distressed behavior without considering a possible underlying medical cause (e.g., UTI, congestive heart failure) or environmental or psychosocial stressor.
      • Initiation of a medication presenting clinically significant risks without considering relative risks and benefits or potentially lower risk medications.
      • Concomitant use of two or more medications in the same pharmacological class without a clinically pertinent explanation.
      • Failure to re-evaluate the rationale for continuing antipsychotic medication initiated in an emergency after the acute phase has stabilized.
  2. Assessing for Adverse Consequences: Examples of noncompliance related to adverse consequences include, but are not limited to:
    • Failure to act upon (i.e., discontinue a medication or reduce the dose or provide clinical justification for why the benefit outweighs the adverse consequences) a report of the risk for or presence of clinically significant adverse consequence(s);
    • Failure to respond to actual or potentially clinically significant adverse consequences related to the use of warfarin when the PT/INR exceeds the target goal. 
  1. Antipsychotic Medications without Gradual Dose Reduction and Behavioral Interventions unless Clinically Contraindicated: Examples of noncompliance related to this requirement include, but are not limited to:
    • Failure to attempt GDR in the absence of identified and documented clinical contraindications.
    • Prolonged or indefinite antipsychotic use without attempting gradual dose reductions.
    • Failure to implement behavioral interventions to enable attempts to reduce or discontinue an antipsychotic medication. 

They key to successful management of all medications in a long term care setting is in the development of a detailed Care Plan that involves the entire Interdisciplinary team, including the primary Physician and patient. The facility must ensure adequate documentation of all interventions, patient monitoring of medication efficacy, and if a GDR is clinically warranted.  Providing the best clinically appropriate services for the patient is the driving force behind all that we do. Documenting all of these steps not only reflects those services, but also allows staff to better track where they are at in the process. 

Failure to support the need for medication therapy in the medical record can lead to significant regulatory and financial penalties. 

Harmony Healthcare International (HHI) is available to provide onsite analysis and associated medical record reviews to help you improve your Quality Measure Scores.   Please contact Harmony Healthcare International by clicking here or calling our office at 1.800.530.4413.


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Tags: Quality Measures, Antipsychotics

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