National Partnership to Improve Dementia Care in Nursing Homes & Quality Assurance and Performance

Improvement (QAPI)

June 15, 2017

Disclaimer

This presentation was current at the time it was published or

uploaded onto the web. Medicare policy changes frequently so

links to the source documents have been provided within the

document for your reference.

This presentation was prepared as a service to the public and is

not intended to grant rights or impose obligations. This

presentation may contain references or links to statutes,

regulations, or other policy materials. The information provided

is only intended to be a general summary. It is not intended to

take the place of either the written law or regulations. We

encourage readers to review the specific statutes, regulations,

and other interpretive materials for a full and accurate statement

of their contents.

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Agenda

Appropriate Assessment and Dr. Susan Levy, Medical

Evaluation for the Accurate Director/Consultant

Diagnosis of Schizophrenia

and Other Mental Disorders

National Nursing Home Quality Kaylie Doyle, Telligen

Care Collaborative Kelly O’Neill, Stratis Health

National Partnership & QAPI Michele Laughman, CMS Updates Debbie Lyons, CMS

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Welcome

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Appropriate Assessment and Evaluation for the Accurate Diagnosis of Schizophrenia and

Other Mental Disorders

Susan M. Levy, MD, CMD

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Susan M. Levy, MD, CMD: Disclosure

Current Immediate Past President AMDA: The Society for Post-Acute and Long Term Care Medicine

Facility Medical Director, Sussex County, DE

Chief Medical Officer, Linked Senior

Health Quality Innovators, Consultant

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CMS Quality Measures and Federal Requirements

Five Star Antipsychotic Medication Quality Measures • Short-stay nursing home residents

• Long-stay nursing home residents

Federal Long-term Care (LTC) Requirements and Interpretive Guidelines

• 483.45 Unnecessary Drugs

• F329

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Antipsychotic Medication Quality Measure: Long-stay Residents

Numerator: Long-stay residents with a selected target assessment where the following condition is true: antipsychotic medications received. This condition is defined as follows: • For assessments with target dates on or before

03/31/2012: N0400A = [1] • For assessments with target dates on or after

04/01/2012:N0410A=[1,2,3,4,5,6,7]

Denominator: All long-stay residents with a selected target assessment, except those with exclusions

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Antipsychotic Medication Quality Measure: Long-stay Residents

Exclusions:

2.0 Any of the following related conditions are present on the target assessment (unless otherwise indicated):

2.1. Schizophrenia (I6000 = [1]) ϮϬϮϬ ϸ ββϯ ϲήβ Iϱϯϱ = ϭ]) ϮϬϯϬ ϸ ββϯ ϲήβ Iϱϯϱ = ϭ Ϯβ ϱ

assessment if this item is not active on the target

assessment and if a prior assessment is available

ϮϬϰϬ HϱϤϯ DϱβΖβ IϱϮϱ = ϭ])

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Diagnosing Nursing Home Residents with Schizophrenia

• Incorrect interpretation of the federal requirements and interpretative guidelines

To improve dementia care and decrease antipsychotic medication use

• Failure to follow the care process:

Recognition

Assessment

Then Diagnosis

Monitoring

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Joint Summary Statement - Diagnosing Schizophrenia in Nursing Homes

• Concerns were raised that diagnosis of ϲΤϮϱϮβϱΖ Ζ ΣβϱϤ Ζήβ ϳϽϱμϳ Ϯβ β of antipsychotic medications.

• American Health Care Association convened stakeholder organizations and after discussion a joint summary statement was developed and approved.

http://www.paltc.org/newsroom/joint-summary-statement­diagnosing-schizophrenia-skilled-nursing-centers

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Joint Summary - Supporting Organizations

American Association for Geriatric Psychiatry American Association of Nurse Practitioners American Geriatrics Society American Health Care Association AMDA The Society for Post-Acute and Long-Term Care Medicine American Psychiatric Association American Society of Consultant Pharmacists Gerontological Advanced Practice Nurses Association Leading Age Society of Hospital Medicine

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Joint Summary Statement

• The development of schizophrenia is uncommon in older adults.

A diagnosis of new onset schizophrenia in a post-acute and long-term care setting should be made by a qualified health professional, with mental health training, using DSM-5 criteria.

• The diagnosis should be made only after underlying causes of the symptoms have been excluded through a careful review process.

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Joint Summary Statement (cont.)

• Clinicians need to be mindful of and avoid labeling patients with diagnoses to justify the use of medications or other treatments.

• It is important to acknowledge that some patients with dementia may benefit from treatment with psychotropic medications if they are clinically indicated and non-pharmacological approaches to care have been ineffective or are contraindicated.

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Primary Mental Health and Substance Use Disorders

• Bipolar

• Major depression with psychosis

• Schizophrenia

• Schizoaffective disorder

• Brief psychotic disorder

• Drug abuse/intoxication

• Drug withdrawal (alcohol/opioids/other)

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General Medical Conditions (secondary)

• Neurologic Disorders:

Dementia ϱϬβϬ !Ϯβϱβϯ DϱβΖβHϱϤϯ Lβ body dementia)

Stroke

Brain tumor

Acute and chronic infections

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General Medical Conditions (cont.)

• Nutritional Deficiencies:

B 12

Pellagra

Wernicke-KΖμμϯ encephalopathy

• Systemic illnesses

• Adverse drug effects

• Delirium

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A Guide to the Management of Psychotic Disorders and Neuropsychiatric Symptoms of Dementia in Older Adults

From the American Geriatrics Society

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Primary Mental Health Disorders and Psychosis

Schizophrenia is a major mental health disorder that has specific diagnostic criteria outlined in the DSM-5. • Key criteria are the presence of psychotic symptoms,

hallucinations, and delusions. • Other major mental health disorders may also have psychotic

symptoms, such as bipolar disorder, schizoaffective disorder, and delusional disorder.

• Psychotic symptoms can also occur in the course of other medical illnesses, including dementia and delirium.

• Residents with long standing mental health disorders can also develop dementia as they age and have associated symptoms related to dementia, that are superimposed on their chronic mental health condition.

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Overlap of Psychotic Disorders

Primary Mental Health

Disorder

DeliriumDementia

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Nursing Home Residents and Primary Mental Health Disorders

• Typically admitted at a younger age than residents without major mental health disorder.

• Maybe stable on long-term medication management, but when additional medical problems develop may exacerbate.

• Diagnosis may not be clear from preceding hospital stay and may not be included, or may be Ζ ϱΖΤΤΖβ ϲΖΣβϳ ϱμ βΖβή Ϯβ βΖ for admission.

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New Diagnosis of Primary Mental Health Disorder

ϲNβϳ Ζήήβή ήϱΖϤϱ Ζ ΤΤ ϱ ϱϤ homes when:

• Initial psychosocial assessment reveals missed information.

•Escalation of symptoms as part of the course of illness leads to identifying prior history.

Nβϫ ϲNβϳ diagnosis, late in life without prior symptoms is unlikely.

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Evaluation of a Schizophrenia Diagnosis

• Review old records from the hospital, community mental health center, primary care, or outpatient psychiatry;

• Look for prior psychiatric diagnostic evaluations, hospitalizations, and prior psychiatric treatment, including antipsychotic medication use and the use of other psychotropics.

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Evaluation of a Schizophrenia Diagnosis (cont.)

If there is no history of psychiatric treatment, and the first symptoms or deterioration occur when the resident is in a nursing home, it is more likely the onset of a Minor or Major Neurocognitive Disorder (Dementia), rather than a Psychotic Disorder, such as schizophrenia.

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Elements of a thorough Diagnostic Evaluation:

• History from record review, facility staff, resident, family, and/or resident representative

• Medical evaluation, including physical exam and laboratory assessment, and psychiatric evaluation from mental health professional

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Evaluation of the Treatment Process after Diagnosis:

• Discussion about the diagnosis, including advance care planning

• Discussion about treatment options, including informed consent if an antipsychotic medication is started

• Close monitoring of beneficial and/or adverse effects after the start of any psychotropic medication

• Reassessment of need to continue medication

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Better Approach to Behavioral Health in Nursing Homes

• Behavioral health rounds/meeting

• Medical/Behavioral co-management

• Who manages the diagnosis list?

• Who manages psychotropic medications?

• Role of the Consultant Pharmacist

• Discussion of psychotropic medication usage in QAA meetings

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Support for Behavioral Health Needs

Medical Director

Attending/Nurse Practitioner/

Physician Assistant

Mental Health Practitioners

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National Nursing Home Quality Care Collaborative (NNHQCC)

Aligned with other national nursing home quality initiatives, led by Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs),

79% of nursing homes participating

Kaylie Doyle, MBA, Telligen

Kβ OϯNβϱϩ RNϩ �ϲNϩ MP!ϩ Stratis Health

QIN National Coordinating Center (NCC)

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Questions We are Hearing

• What are the nursing home focus areas of QIOs? • What is the NNHQCC? • How does the QIN-QIO work support and align with the

National Partnership for Dementia Care and QAPI? • What tools and resources are available to nursing

homes, partners, and other interested persons?

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QIN NCC

• The QIN NCC supports a national network of 14 QIN-QIOs as they implement the national quality initiatives of the QIO Program.

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QIN-QIOs

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QIN-QIOs work with Nursing Homes: Alignment with National Initiatives

• Work with nursing homes to improve quality of resident-centered care and safety. • NNHQCC Support recruited nursing homes: ◦ In using QAPI as a framework to achieve system wide improvement ◦ In reducing inappropriate use of antipsychotics ◦ In implementing antibiotic stewardship and preventing and managing

Clostridium difficile infections (CDI)

Use Quality Measure Composite Score to monitor progress.

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QIN-QIOs work with Nursing Homes: Alignment with National Initiatives

• QIN-QIOs are sharing information and resources with nursing homes to guide successful implementation of NNHQCC and the regulation. Focusing on QAPI methods and techniques to improve

systems and processes and meet the intent of the regulation.

• QIN-QIOs are aligning efforts with partners, To provide support and education for nursing homes, and to

promote and share consistent messages.

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NNHQCC: CDI Cohort

• Utilizing the QIN-QIO led Collaborative, the CDI Cohort will: Increase the number of nursing homes that are consistently

reporting data into the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) database. Establish a QIN-QIO-derived national Nursing Home CDI

baseline. Improve quality of care outcomes for nursing home residents

through tracking CDIs, implementing antibiotic stewardship, and effectively preventing and managing CDIs.

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Progress to Date – Recruitment

• As of March 2017 12,217 nursing homes are recruited to participate in the NNHQCC. 79% of the nation’s nursing homes

• Of the 12,217 2,630 one-star nursing homes are recruited to participate in the NNHQCC.

• As of April 10, 2017 2,341 nursing homes are enrolled ϱ Ϯβ �D�ϯ NHϲN ήΖΖΣΖβϬ

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Progress to Date – Nursing Home Quality Measure Composite Score

Data based on rolling six-month QIES data.

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Progress to Date – Antipsychotic Measure

August 2014: 18.73%

February 2017: 15.34%

Data based on rolling six-month QIES data.

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NNHQCC – Change Package

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Change Package Strategies

• Lead with a sense of purpose. • Recruit and retain quality staff. • Connect with residents in a celebration of their lives. • Nourish teamwork and communication. • Be a continuous learning organization. • Provide exceptional compassionate clinical care that

treats the whole person. • Construct solid business practices that support your

purpose.

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Change Package

• Success story template • Bundles Avoidance of Unnecessary Antipsychotic Medications in

Nursing Home Residents Living with Dementia Encourage Nursing Home Rβϱήβϯ MΣϱϱ Prevent Healthcare Acquired Infections Prevent CDIs in Nursing Home Residents QAPI

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Resources

http://qioprogram.org/nursing-home-training-sessions

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Topics Covered in the Online Training Sessions

• TeamSTEPPS® in LTC: Communication Strategies to Promote Quality and Safety • Exploring Antibiotics and their Role in Fighting Bacterial

Infections • Antibiotic Resistance: How it Happens and Strategies to

Decrease the Spread of Resistance • Antibiotic Stewardship • Clostridium Difficile (C. Difficile) Part One: Clinical

Overview • C. Difficile Part Two: Strategies to Prevent, Track, and

Monitor C. Difficile

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Purpose of the Online Training Sessions

• To provide nursing home leaders with a set of training materials that they can use to enhance understanding of important concepts and practices that promote stewardship and C. difficile prevention, and to provide information, tools, and resources to take action to improve practices. • To develop and disseminate materials that can be

accessed and used by LTC partners and stakeholders interested in these topics.

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Use of the Online Training Sessions

• Nursing home leaders can decide: Which components would be helpful for themselves and

which to include in educating other staff. The appropriate staff to include for different components. How to use the materials during education sessions or self

study. How to customize the content to work for their audience; all

content is optional and may be adapted. How to best provide this training over time; the intent is not

to review this content all at once.

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Each Online Training Session Includes

• Welcome and overview • Objectives • How you can use this session • Orientation (list of sections and content) • Topic information presented via text/narrative, video,

PowerPoint presentations with notes, or links to website pages • Interactive activities and scenarios, including discussion

questions • Informational handouts • Take home messages • Links to additional optional resources • Opportunity to apply for a certificate of participation or

nursing continuing education credits

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Thank You

• Kaylie Doyle, MBA, Telligen Kaylie.Doyle@qinncc.hcqis.org

• Kelly OϯNβϱϩ RNϩ �ϲNϩ MP!ϩ ϲΖϱ Health koneill@stratishealth.org

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National Partnership & QAPI Updates

Michele Laughman

Debbie Lyons

Centers for Medicare & Medicaid Services

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Question & Answer Session

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Acronyms in this Presentation

• CDC: Centers for Disease Control and Prevention • CDI: Clostridium difficile infections • C. Difficile: Clostridium difficile • LTC: Long-term Care • NCC: National Coordinating Center • NHSN: CDC’s National Healthcare Safety Network • NNHQCC: National Nursing Home Quality Care

Collaborative • QAPI: Quality Assurance & Performance

Improvement • QIN-QIO: Quality Innovation Network Quality

Improvement Organization

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• For more information about the National Partnership to Improve Dementia Care in Nursing Homes, please visit http://www.cms.gov/Medicare/Provider-Enrollment­andCertification/SurveyCertificationGenInfo/National-Partnership-toImprove­Dementia-Care-in-Nursing-Homes.html or send inquiries to dnh_behavioralhealth@cms.hhs.gov

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