Interview with Jennifer Donovan and Julie Coughran

CFHI Interview with Jennifer Donovan and Julie Coughran,
York Care Centre, Fredericton, NB

September 2015

Improvement Conversations York Care Centre

Jennifer Donovan and Julie Coughran with Anna, a resident at York Care Centre.

In a new, occasional feature, we interview leads of CFHI-supported projects currently underway. This month we profile Fredericton-based York Care Centre (YCC), one of 15 organizations taking part in CFHI’s Reducing Antipsychotic Medication Use in Long Term Care collaborative. YCC’s Jennifer Donovan, Clinical Research Coordinator and project manager, and Julie Coughran, project lead, describe their team’s progress in addressing inappropriate use of antipsychotic medications for patients with dementia since the project formally launched in September 2014. The quality improvement collaborative was created to address a serious issue in long term care (LTC) facilities, where one in three residents takes antipsychotic drugs without a diagnosis of psychosis from a doctor.

Could you please describe your initiative and your target population?

Our objective was to decrease antipsychotic use by 25% in our dementia unit, Birch Grove, for residents who were considered appropriate for reduction. Once we saw success in that unit, we would spread the reduction initiative to other units in our facility, Towers One, Two, Three and Dixon. Our residents were started on antipsychotics either while at home, or in hospital, due to aggressive or difficult behaviours.

What are their most pressing healthcare issues, in addition to dementia?

The most pressing healthcare issue at YCC is the wait time for a resident to be admitted to a nursing home, to receive the professional care they need. We have seen a growing trend of residents coming into the LTC facilities on antipsychotic medications for behaviour management at home. However, there has been no follow-up as to why they are on the medication or if the medication is still effective. Residents also come to YCC with a number of complex medical diagnoses, mostly relating to cardiac health and diabetes, in addition to a high risk of falls and aggression.

Why was this initiative important to YCC?

This initiative came at an opportune time as it was identified that these residents with dementia were not necessarily reassessed after admission. We have now developed policies for antipsychotic medication assessment, both after admission and on an ongoing basis. We wanted to improve the quality of life for residents suffering from dementia/Alzheimer’s disease. We realized that large populations were lethargic and declining while using these medications.

Had you wanted to implement this type of quality improvement prior to joining the CFHI collaborative?

At YCC, we are constantly trying to find new, innovative ways to improve the quality of life for the residents. We knew that the antipsychotic medications were on the rise, resulting in a decline in quality of life and residents’ abilities. We saw the need for formal reviews of residents receiving the medications, due to the serious side effects associated with their usage.

How did you hear about this opportunity?

It was brought forward to our former Director of Care Services, Rayma O’Donnell, by Barbara Burnett from the Atlantic Institute on Aging, as we were involved with a similar project associated with the Senior Quality Leap Initiative (SQLI). As we learned more about CFHI’s initiative, we realized that our home was the perfect place to launch this project. We were thrilled to be a part of the national collaborative.

What strategies have you been using to ensure appropriate prescribing and to improve care for residents with dementia?

Using the policy and procedures put into place, we are able to monitor more closely the residents prescribed antipsychotics. Staff were educated to use the P.I.E.C.E.S.™ (Physical, Intellectual, Emotional, Capabilities, Environment, Social and Cultural) and U-First! dementia care models, resulting in improved care and less medicinal intervention for residents suffering from dementia/Alzheimer’s disease. Understanding behaviours was key in being able to reduce antipsychotics. Other strategies included staff huddles, documentation and constant reassessment of behaviours, care plan updates and engaging residents in a variety of activities using dedicated activity staff.

Describe your results and greatest successes to date. How have patients benefited from your work? What does this project mean to the residents and families who are impacted?

We have seen a 56% reduction in antipsychotic use in Birch Grove. We have successfully spread the reduction throughout our whole facility, with, for example, 6 (or 28.6%) of our 21 Tower Two eligible residents now discontinued their antipsychotic medication. (Tower Two, the behavioural unit, had the highest number of residents on antipsychotics). Some of the greatest successes involved staff and family witnessing the positive changes in the residents as they became more alert and engaged. Seeing the quality of life improve for the resident has definitely been the greatest success.

How have you been using interRAI data for your project?

We have been using our interRAI data scales to enter the level of social engagement, depression, aggressive behaviours (physical and verbal), pain, restraint use and number of falls over a 30-day period. Tracking these statistics through our data set gave us a bigger picture of the changes that may have occurred from the antipsychotic reduction.

What have been your biggest challenges and obstacles?

Some of our biggest challenges included getting staff to be on board with the reduction. Once we informed staff of the full nature of the project, they felt more comfortable. Including staff on the team and using their valuable input gave them pride in the successes. During the spread, we faced a flu outbreak, which caused delays due to illness and staff shortages.

How engaged are the staff? Do some resist the initiative concerned that less medication means more work for them?

The staff initially resisted the initiative, fearful that it would involve more work and behavioural issues. However, once they witnessed the positive changes in their units and heard of similar benefits on other units from their colleagues, they were more receptive. Staff was also reassured that a resident’s medication level could be restored if the reduction wasn’t successful. We stress that this isn’t considered a failure, it’s simply the resident requiring the correct dose at a particular time. This provided relief to the staff. However, only a select few residents couldn’t tolerate a reduction and were reintroduced to the previous dose. Staff were very involved in providing information on the residents’ behaviour, becoming part of the team’s decision on who to reduce and how quickly or slowly to undertake the reduction.

What about physicians? Are they on board and staying actively involved?

Physicians were brought in from the beginning. Some were more actively involved, keen to be a part of the project but they have all been on board throughout the whole process, getting project updates. There is a very strong working relationship between registered staff and physicians.

Is your senior leadership supportive? How have you been keeping senior leadership engaged?

Our senior leadership have been extremely supportive. We have been fortunate to have the leadership engaged, asking for weekly updates on the project and seeing the value of this initiative being spread through the facility.

Are families and friends generally supportive? What has been their reaction to seeing loved ones suddenly become more alert?

Generally, family have been supportive. Some families don’t initially understand the purpose of the medications and the objective in reducing them. With education and awareness, families were supportive of medication changes. Although some families didn’t witness immediate changes, they all eventually were astonished to see their loved one more engaged, alert, taking part in conversation and generally exhibiting a higher level of “brightness” during visits.

How is CFHI funding and support helping you to reach your goals?

CFHI funding has been helpful in allocating time for staff and the Birch unit coordinator to review findings and do data entry. This funding has allowed staff the time to be more involved in the other units to provide education to both colleagues and families.

How do you plan to sustain the staff training and improvements for these residents?

We will continue education services and project updates. New residents will also be captured under our assessment policies.

Do you foresee the ability to spread your work to other New Brunswick facilities?

We are currently working with CFHI to roll out this initiative’s success to government, stakeholders and various nursing homes. We hope other facilities in New Brunswick will be convinced by our lower medication costs relative to theirs, but more importantly, by the improved quality of life for residents.