Success in reducing Antipsychotic medication leads Revera to spread approach across four provinces

The Challenge

Across Canada, more than one-in-four seniors in long term care (LTC) are on antipsychotic medication without a diagnosis of psychosis. Antipsychotics are often prescribed in a bid to reduce challenging behaviours and resistance to care, but they have a sedating effect and can cause serious harms such as falls and unnecessary hospital visits.

In 2014, CFHI launched a pan-Canadian quality improvement collaborative to support the appropriate use of antipsychotic medication, working with 15 teams spanning 56 long term care (LTC) homes in seven provinces and one territory. At the time, the national average for LTC residents on potentially inappropriate antipsychotics was 28 percent.1 The evidence shows that five to 15 percent of seniors in LTC homes should be on antipsychotic medication.

The collaborative had its roots in CFHI’s EXTRA: Executive Training Program. Joe Puchniak and Cynthia Sinclair – at the time both managers with the Winnipeg Regional Health Authority Personal Care Home Program – designed an initiative to help multi-disciplinary teams of healthcare providers better use data. Based on the success of the WRHA initiative, and with the help of Joe and Cynthia, CFHI set out to spread these person-centred approaches to the appropriate use of antipsychotic medication in residential care. 

Revera Inc., which operates 76 LTC homes in four provinces – Ontario, Manitoba, Alberta and British Columbia – was interested in reducing rates at its homes. In 2014 the average prescribing rate at its homes was 39 percent. 

Provincial initiatives in both Alberta and Manitoba had already targeted high rates of the medication in those provinces, so Revera signed on with the CFHI collaborative to work on bringing down the antipsychotic medication rates at their LTC homes in Ontario and B.C.

The Solution

Teams of healthcare professionals that participated in the CFHI collaborative used patient-centred, data-driven approaches to manage the disruptive behaviours that can be associated with dementia. Frontline staff tailored services, replacing these medications with approaches such as music, pet or recreation therapy. CFHI provided the teams with training, funding, expert coaching and a platform for peer to peer learning.

Supported by the collaborative, Revera’s project leads began by focusing on training and providing education on the Montessori approach to the majority of staff. The educational approach taught staff to tailor care to the personal histories of the resident – who they are, and what for them would be a purposeful activity that could distract or calm them if they become agitated or restless. 

Revera also increased the involvement of their consulting pharmacists. The company made antipsychotic use a key performance indicator for pharmacy suppliers and had them issue monthly medication utilization reports for the homes. “We held them to the same metric as we had, and they had to report to us,” said Mary Brazier, vice president quality and support for Revera’s LTC division.

Before the initiative began, Revera had looked closely at some of its LTC homes and discovered that 98 percent of residents who were taking antipsychotics had been taking the drugs before they came to the facility.

When residents were admitted, pharmacists began meeting with them and their family members to discuss overall medication issues and the antipsychotic medication reduction initiatives. This was an innovation. Previously, it was only after residents had lived at a LTC home for six or eight weeks that admission care conferences between pharmacists, families and care staff were held. Education sessions were also held with Residents’ Councils and Family Councils. Brazier noted that family members who had been caring for the new resident at home, were often particularly fearful of reducing antipsychotics because the drugs had helped to limit hard-to-manage aggressive and agitated behaviour.

As well, pharmacists and physicians were brought together for education sessions about the initiative, which resulted in increased collaboration between physicians and pharmacists around the common goal to improve prescribing for residents.

To facilitate spread across the multiple long term care homes operated by Revera, provincial coordinators held monthly conference calls to develop a formal spread plan.

The provincial coordinators, in consultation with care staff from various sites, decided to focus on a cohort of 50 residents from three LTC homes – two in Ontario (in London and Toronto) and one in B.C. (Victoria) – and set a goal of reducing antipsychotic medication use by 10 percent during the period August 2014 to August 2015. The company also tracked a cohort of another 361 residents in 12 other LTC homes.

During the roll out of the spread, provincial coordinators had (at a minimum) monthly teleconferences to monitor progress, trouble shoot challenges, and support quality improvement methodologies. They faced a familiar Canadian challenge for holding joint meetings – the three-hour time difference between the provinces. Another challenge was finding dedicated time to obtain, enter, and analyze the data for the cohort of residents selected to participate in the antipsychotic reduction initiative.

The Results

For the selected residents at the three homes, antipsychotic use was reduced by 40 percent, 28 percent and 20 percent, respectively, and discontinued by 58 percent, 64 percent and 70 percent. 

For all 15 homes, the antipsychotic reduction averaged 15 percent and discontinuation averaged 38 percent.

There were fewer falls among the cohort of 50 residents, although there were other initiatives to prevent falls and so a strong correlation could not be made, Brazier said. Residents’ cognition was not negatively affected from reducing antipsychotic medication. Fortunately, rates of aggressive behaviours did not rise among those residents who had their antipsychotics reduced or discontinued.

One male resident in B.C. had been on antipsychotic medication to decrease his wandering and he became withdrawn. His medication was gradually eliminated and he became engaged with others, attended group activities, and began smiling regularly.

Brazier credited increased training in the Montessori approach as a key factor in the reduction of antipsychotic use. A retired mechanic with dementia had been on antipsychotic drugs and was agitated and restless. As staff got to know him they created an activity board for him, comprised of familiar tools that he could tinker with. This brought him “peace and gave him something in his long-range memory. It gave him purpose, he felt useful.” His medication was reduced and his restless behaviour diminished. Staff now routinely ask “why the behaviour?” and consider non-drug interventions. 

 As a result of the initiative, direct care staff are much more aware that using antipsychotic medications to manage behaviours for which the cause is not necessarily obvious – such as anxiety and aggressiveness—is the last line of defense. Interdisciplinary teams work more closely together when residents who have challenging behaviours. 

Sustainability and Spread

In the fall of 2015, Revera began spreading the approach to reduce inappropriate use of antipsychotic drugs to the remaining 43 Ontario homes by implementing several key improvement strategies, including in-class training for Montessori based activities for all staff, regular “huddles” of staff to discuss resident behaviour, education by webinar and monthly medication reviews of residents on antipsychotics by the interdisciplinary team.

By the summer of 2016, Revera had successfully decreased the use of antipsychotics in all four provinces where it has long term care homes to an average of 18 percent – below the then publicly available national average of 28 percent. The initiative is also sustained by monthly regional calls or meetings with provincial regional managers to monitor progress, share experiences and offer support. 

The company sees the antipsychotic collaborative as a model for further initiatives in its homes across the country, looking at infrastructure, implementation steps and data management tools. 

Reducing Antipsychotic Medication Use in Long Term Care Collaborative: Key Results Infographic

1This is the actual national average rate in 2014-15. National and provincial average data are only made publicly available for the preceding fiscal year.