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) facilities 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 facilities 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.
At almost 40 percent, Newfoundland and Labrador had the highest rate in the country of antipsychotic medication use among LTC residents and the province’s Central Health Regional Health Authority joined the CFHI collaborative.
The Central RHA is home to many small communities spread out over a large geographic area: 177 communities with a total population of 94,000 in an area that comprises half the land mass of Newfoundland. When the collaborative began, there were a total
of 519 LTC beds in the RHA’s 11 scattered and relatively small long term care homes.
This reality presented challenges for the RHA in September 2014 when it joined the CFHI initiative. Geographic distances, the number of physicians involved with the various facilities, and scheduling issues meant it was difficult for the physician champion
of the antipsychotic reduction initiative to meet with peers.
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.
The Central Health team decided to focus initially on four LTC homes where the antipsychotic use rates among residents ranged from 22 to 60 percent.
Supported by the CFHI quality improvement collaborative, the team set a goal to, within a year, reduce antipsychotic medication use among a selected cohort at those four sites by 15 percent and, at the same time, enhance quality of care, and improve patient
and family satisfaction.
The team consisted of: Executive Sponsor, Heather Brown; Project Lead, Mimie Carroll; Measurement Lead, Natalie Howell; MDS Champion, Melissa Miller; Clinical Champion, Dr. Jody Woolfrey; Pharmacy Champion, John King; Family Advocate, Dr. John Trend;
and Therapeutic Recreation Lead; Doug Keough.
A key component of the approach was staff education: All staff received education and training in the Gentle Persuasive Approach (GPA). In addition to GPA training, three clinical champions (e.g., registered nurses, registered social workers, and therapeutic
recreation workers) at each site along with regional consultants, were selected to participate in P.I.E.C.E.S™ training, which addresses the “physical, intellectual, emotional, capabilities, environment ,and social and cultural”
needs of people with dementia.
Leadership at the four selected sites – Gander, Botwood, New-Wes-Valley and Lewisporte – were supportive. Staff at the homes selected a cohort of residents and, with family consent, enrolled them in the medication reduction and discontinuation
program. The leadership also engaged the residents’ families through education sessions and handouts.
Surveys were administered to new residents and their families so staff would know more about residents’ likes and dislikes, and what scared or comforted them. Based in part on those surveys, recreational therapists created individualized intervention
kits, containing objects and activities that were familiar to residents and that calmed and distracted them. For example, the kit for a retired baker contained a recipe book, bowl and wooden spoon.
The leadership teams took a “go slow” approach with the changes so that staff, many of whom were concerned about a possible increase in aggressive behaviour, would gain confidence from seeing improvement in residents for whom medication
was successfully reduced or discontinued.
Monthly check-ins were held with each site through leadership team huddles, and standardized monthly or quarterly medication reviews were introduced.
The Results
Among the 43 residents who were selected for the initiative from all four facilities, 27 remained in the cohort after nine months (16 passed away). Of those who remained, six (22 percent) had their medication discontinued and nine (33 percent) had their
dosage reduced.
About 10 percent of the residents in the cohort had been identified for potential “very severe aggressive behaviour” at the start of the initiative, and that dropped slightly. There were also fewer falls among the residents in the cohort –
a drop from about 22 percent of the target residents to about seven percent.
Ada, a resident at North Haven Manor in Lewisporte, had been taking an antipsychotic drug at bedtime for the three years since she was admitted. After a medication review in 2014, her dosage was reduced and, eventually, the drug was discontinued. Ada
became more alert, cooperative and active; her family said she became “more like her old self.”
One of the most effective ways of slowly changing the attitudes of staff who are skeptical about reducing medication is by sharing stories like Ada’s, observed project lead Mimie Carroll.
Central Health was successful in reducing antipsychotic use among selected residents in the pilot sites far beyond the 15 percent target, but rates of antipsychotic use among residents remained relatively unchanged overall at the LTC homes. This is because
of high turnover rates among residents – the overall annual turnover rate in the LTC homes is 60 percent and during the initiative, 37 percent of the cohort residents either died or were transferred to another non-participating facility.
This was a cause of frustration for staff, given the time and resources that had been devoted to reducing medication use among those residents.
Sustainability and Spread
By the summer of 2016, the initiative had spread to three of the remaining seven Central Health long term care facilities; the other four are so small (for example Fogo Island has only six LTC beds) that the spread will be more challenging.
But it is the upstream spread to acute care facilities that may hold the most promise. The majority of LTC residents arrive from hospital and between 75 and 90 percent of them are already taking antipsychotic drugs, project lead Carroll said. “We
need to get to them before they come to long term care” so medication rates aren’t so high when they are admitted.
Just before the CFHI pan-Canadian collaboration began, a dedicated 15-bed “transitional unit” was created at the hospital in Grand Falls Windsor (the Central Newfoundland Regional Health Centre). Previously, patients waiting for LTC were scattered
among different wards in the hospital.
“The idea is that if people are waiting for long term care, we should have long term care programming in place,” says Carroll. There’s no formal antipsychotic reduction program at the transition unit, but there has been a “soft
spread” through educating staff and giving them tools. As well, medication review is easier there than in LTC homes because the hospital has an on-site pharmacist.
To sustain the initiative at the Central Region’s LTC homes, a standardized Medication Reconciliation Form has been developed and implemented. It highlights antipsychotic medications taken by residents upon admission, and when they are transferred
or discharged to/from long term care homes. In addition, an electronic standardized order entry set (“LTC Deprescribing of Antipsychotic Medications Order Set”) has been developed and implemented for all nurse practitioners and physicians
who work in LTC.
Since the formal end of the CFHI collaborative, Central Health has continued to further reduce the rates of potentially inappropriate use of antipsychotic medications, not only at the four pilot sites, but also across all of its 11 LTC homes. The Canadian
Institute for Health Information (CIHI) report shows that the overall rate for Central Health in the first quarter of 2016 (January to March) was 38 percent, down from 47 percent in the first quarter of 2015.
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