Building a Statewide Task Force to Address Antipsychotic Drug Use in Older Adults

Antipsychotic medications treat symptoms associated with psychiatric and neurological conditions.^1,2 Because antipsychotics are regularly prescribed to treat the behavioral and psychological symptoms of dementia and are associated with adverse events, such as stroke, ventricular tachyarrhythmia, and sudden death, they should be used with caution in older adults.^3,7 In response to these risks, the US Food and Drug Administration mandated in 2008 that antipsychotic manufacturers add black box warnings to labels and prescribing information.⁸

Many efforts have successfully reduced inappropriate antipsychotic use among older adults, particularly those residing in US nursing homes. The US Centers for Medicare & Medicaid Services (CMS) established the National Partnership to Improve Dementia Care in Nursing Homes in 2012 because of high antipsychotic use prevalence; 24% of long-stay residents (ie, residing in a nursing home for 100 days or more) received an antipsychotic medication in the last quarter of 2011.⁹ Initiatives include enhancing monitoring and enforcement through the state survey and certification process,^10,11 addressing drug company incentives and kickbacks to doctors and long-term care pharmacies (a specialized service that includes prescription deliveries and pharmacist medication review and consultation),^12,13 publicly reporting antipsychotic use on the Nursing Home Compare website,¹⁴ and creating a CMS curriculum to improve provider education and state surveyor training.¹⁵ These efforts likely helped reduce antipsychotic use prevalence among long-stay nursing home residents to 20% by the last quarter of 2013.¹⁵

Despite progress, antipsychotic overuse continues, particularly in nursing homes, where measures are collected and monitored.^16,17 Massachusetts ranks among states with the highest quarterly prevalence of antipsychotic use in nursing homes (ninth out of 50 states and Washington, DC), despite a decrease from 27% among long-stay residents in the last quarter of 2011 to 18% in the last quarter of 2018.³ Healthcentric Advisors, the Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for New England, provided education and technical assistance to address antipsychotic use across Massachusetts to improve healthcare quality for Medicare beneficiaries. Anecdotally, nursing home leaders have expressed concerns about the current antipsychotic measures, noting that the measures do not adequately account for residents who already had an antipsychotic prescription at the time of admission, those who were started on gradual dose reduction before discharge, or younger residents with diagnoses that may clinically warrant antipsychotics.

In 2016, the QIN-QIO created the Massachusetts Antipsychotic Medication Reduction Cross-Setting Task Force (Task Force) to facilitate a cross-setting dialogue that would investigate care, regulation, and education issues and opportunities for improvement, as well as develop actionable recommendations. The QIN-QIO established 4 objectives for the Task Force:

1. Collaboration within and across care settings
2. Information-sharing through targeted topic discussion
3. Identification of current antipsychotic use practices
4. Development of best practice recommendations for adoption in each care setting

Thus, the Task Force aimed to identify root causes contributing to the high antipsychotic use prevalence in Massachusetts, particularly factors outside of nursing homes’ control, and recommend solutions that would lead to improvement.

Task Force Formation
The QIN-QIO created the Task Force plan and obtained key stakeholder support by meeting with the Massachusetts Secretary of Aging, long-term care trade associations, and the Massachusetts Department of Public Health.

Task Force Design
The QIN-QIO led the Task Force. Its time-limited design as an 18-month project (beginning in 2016) helped secure stakeholder commitment.

Framework. Quality Assurance and Performance Improvement (QAPI), a system for measuring and improving quality and safety in nursing homes that integrates quality assurance (focused on meeting standards) and process improvement (focused on continuously improving), served as the framework for the Task Force.¹⁸ High antipsychotic use was a quality concern across many Massachusetts nursing homes despite the many efforts focused on the problem (eg, regulation, training). Because existing efforts were not achieving desired results in the state, the QIN-QIO sought to conduct a broad analysis to better understand the problem, its root causes, and potential solutions: a process improvement approach.

The QIN-QIO also used the Holistic Approach to Transformational Change (HATCh) conceptual framework for nursing home quality improvement (Figure 1), focused on person-centered care.¹⁹ Applying HATCh focuses care on the individual’s needs and wants (represented at the center of the figure). For example, an institutional approach to control a problematic behavior is to medicate with an antipsychotic to alleviate care staff burden. The individual approach necessitates identifying possible causes of the behavior, such as undiagnosed pain, then providing appropriate care.

Participants. The Task Force involved many care settings to consider antipsychotic use as a broad concern, not limited to nursing homes. Sixty-five Task Force members participated, comprising professionals and stakeholders in nursing homes, assisted living facilities, hospice organizations, home health agencies, hospitals, geriatric psychiatry clinics, physician offices, academia, long-term care trade associations, advocacy organizations, state healthcare regulatory offices, the long-term care community, and hospital pharmacies. Participants were encouraged to invite other known care setting experts to join the Task Force.

Structure and administration. Five quarterly face-to-face Task Force meetings took place. Participants at the first meeting adopted a project charter, established a timeline, and volunteered to join workgroups. Ten specialty workgroups were established to facilitate efficient sharing of information among professionals and other stakeholders in similar care settings. An 11th group was later created for academia. Each workgroup identified a group leader and reporter.

The experts in each workgroup met via conference calls to complete a 11-question Setting Report Outline (Figure 2) describing antipsychotic use practices and identifying improvement opportunities. The QIN-QIO offered each workgroup assistance in facilitating discussion and completing their reports. Topics included regulations, quality metrics, training programs, care management approaches, and communication strategies. The workgroups were asked to provide information describing the practices of their care setting throughout the state of Massachusetts. The QIN-QIO instructed participants not to blame other care settings for perceived poor outcomes but to identify opportunities in their own setting that may help improve antipsychotic use. The academic workgroup used the same Setting Report Outline to provide information about antipsychotic use and dementia-related behavior management content found in basic medical and clinical education curricula, as well as curricula for specialty and certification courses.

After workgroup members submitted their completed reports, the QIN-QIO developed summary presentations to share with the full Task Force. The subsequent 3 full Task Force meetings involved presenting and discussing the workgroup findings (a 15-minute presentation from each workgroup followed by a 15-minute discussion). During the fifth meeting, participants refined the results and recommendations for a final report, which included a section for each care setting.

In August 2018, the QIN-QIO published the final Task Force report, which synthesized the findings by care setting and presented recommendations at the local, state, and national levels.²⁰ Participants were listed in the report for attribution. The report was published online and disseminated statewide by stakeholders.

Task Force QAPI Findings

Across settings, 3 improvement opportunities emerged: (1) education; (2) care transitions; and (3) system barriers, supporting the goals of the National Partnership to Improve Dementia Care in Nursing Homes.²¹

Education. The Task Force found that, despite ongoing programs and initiatives, more education for staff, patients, and families is needed. Education recommendations included the need to develop education tools for individuals and their family members that can be used by staff and residents in assisted living centers and home health locations. Also, Task Force participants recommended expanding to hospitals and other community care settings the current training  programs provided in nursing homes related to understanding and using nonpharmacological methods for resolving behaviors associated with dementia. Academia should assess the effectiveness of nursing, physician, and pharmacist training curricula on antipsychotic use and nonpharmacological approaches.

Care transitions. The Task Force identified the need for a standardized process to communicate antipsychotic use indication, start date, duration, and monitoring plan, as well as the expectation of dose reduction during care transitions. The receiving provider, with inadequate information to determine if the drug should be continued, discontinued, or evaluated for gradual dose reduction, and likely facing time constraints, may choose reflective prescribing (continuing a medication regimen previously prescribed). Physicians and nurses expressed discomfort with discontinuing antipsychotic and antidepressant medication for patients, even with well-documented indications to discontinue. Providers’ concerns focused on the potential for behavioral decompensation, which might lead to an emergency department visit or hospital admission. Communicating more information about the prescribed antipsychotic to the receiving care setting would support appropriate prescribing decisions during transitions of care.^22,23

Health care system barriers. The Task Force identified multiple system barriers, including:

• Differing guidelines and regulations for each care setting for antipsychotic use and adverse drug event reporting
• Lack of standardized guidelines for assisted living facilities that provide specialty memory care services
• Insufficient number of physicians trained in geriatric care
• Inability of independent community pharmacists (the predominant pharmacy providers in Massachusetts) to access patient information, evaluate prescription
• apropriateness, or suggest alternatives to prescribers
• Limited number of exempted diagnoses in nursing home antipsychotic use quality measures (currently, schizophrenia, Huntington disease, and Tourette syndrome),¹⁷ with no exceptions for patients with other clinical indications, such as bipolar disorder

Sustaining existing partnerships with healthcare organizations and educational institutions at the state and national level could identify and address system barriers, improving antipsychotic use and care outcomes.

The Massachusetts Antipsychotic Medication Reduction Task Force, identifying antipsychotic use as a complex health system concern and using a QAPI approach, convened key stakeholders over 18 months to collaborate, share information, increase awareness, and create actionable recommendations. The HATCh quality improvement framework (Figure 1) kept the focus on person-centered care, while stipulating that solutions extend beyond the nursing home setting. CMS has supported state coalitions to improve antipsychotic prescribing through education, resources, and outreach, but this Task Force uniquely cultivated conversations across diverse settings.¹⁶

The Task Force design and structure ensured that the findings reflected members’ collective expertise. Some themes emerged: (1) more comprehensive antipsychotic-related education, beyond the nursing home setting; (2) better communication across care settings; and (3) sustained partnerships to address system barriers.

Nursing homes represent one care setting serving older adults; all settings need to understand their contribution to inappropriate antipsychotic prescribing and how they can support solutions. Ongoing communication and collaboration with all care partners is essential for person-centered care. Other states or communities focused on reducing antipsychotic use should consider a cross-setting task force approach.

States focused on quality improvement goals, such as antipsychotic use reduction, will benefit from applying a collaborative QAPI approach that engages stakeholders from the bedside and across care, academic, and regulatory settings. Exploring varied root causes for a continued problem, then addressing those root causes (eg, constraints and knowledge gaps), can improve performance in more effective, sustainable ways compared with efforts that are limited to only one setting of care.

Authors: Sandra Fitzler, BSN¹ • Emily Patry, MS^1,2 • Rebekah Gardner, MD^1,3 • Alyssa J. DaCunha, MPH • Stefan Gravenstein, MD, MPH^1,3,4,5

Affiliations:
¹Healthcentric Advisors, Providence, RI
²College of Pharmacy, University of Rhode Island, Kingston, RI
³Alpert Medical School of Brown University, Providence, RI
⁴Brown University School of Public Health, Providence, RI
⁵Providence Veterans Administration Medical Center, Providence, RI

Disclosures:
The intervention and analyses were performed under IDIQ contract number HHSM-500-2014-QIN014I, funded by the Centers for Medicare & Medicaid Services, an agency of the US Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsements by the US government.

Address correspondence to:

Rebekah Gardner, MD
Healthcentric Advisors
235 Promenade St #500
Providence, RI 02908
Email: rgardner@healthcentricadvisors.org