Success at three long term care homes prompts Sienna Senior Living to spread antipsychotic reduction initiative to all of its 34 facilities

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: ExecutiveTraining 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.

In Ontario, the leadership at Sienna Senior Living realized, when they reviewed the Canadian Institute for Health Information (CIHI) data for last quarter of 2013, that the 33 percent of residents at their 34 Ontario facilities who were taking antipsychotic drugs exceeded the already high provincial average of 31 percent.

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 CFHI quality improvement collaborative, Sienna began work in the fall of 2014 with a cohort of seniors at Camilla Care Community in Mississauga, a 237-bed facility. Almost 40 percent of Camilla residents were taking antipsychotics. The approach was subsequently extended to Sienna’s Streetsville Care Community in Mississauga and its Cheltenham Care Community in Toronto.

Leadership at Sienna also set a longer-term goal of reducing the antipsychotic prescribing rate by 30 percent at all its facilities.

Senior executive and nursing leadership at Sienna made it a top priority to reduce the use of antipsychotics. Education and training of staff was key. Registered nurses and registered practical nurses received training in P.I.E.C.E.S.^™, an approach designed to promote a holistic view of residents (the acronym stands for “physical, intellectual, emotional, capabilities, environment, and social and cultural”).

Specialized education on non-pharmacological approaches to dementia care, such as the Gentle Persuasive Approach, was available to Sienna’s personal support care workers, registered nurses, registered practical nurses, recreational therapists, and pharmacists. Because of staff concerns about reducing antipsychotic use, a lot of time was spent dealing with change management issues.

The team at Sienna did chart reviews on existing residents and created a cohort of 95 Camilla residents who were taking antipsychotics without a diagnosis of psychosis. “We looked for quick wins, such as reviewing CIHI [Canadian Institute for Health Information] coding for accuracy and residents on ‘as needed’ dosages of antipsychotic medications, and families that would be on board to support the program”, said Metzie Lacroxi, Sienna’s Manager of Resident Services.

Once the cohort was identified, the nursing team conducted initial tracking documentation and assessments and discussed appropriate use of the medication and alternative options with the resident and family. Meanwhile, the pharmacy team conducted medication reviews to assist the physician in making decisions about reducing or discontinuing the medication for selected residents.

The pharmacists, physician and nursing teams also reviewed new residents’ antipsychotic use when they were being admitted. Previously, if a resident was taking antipsychotics when admitted, the tendency was to keep them on the drugs and wait and see, said Lacroxi.

The team adopted a “go slow” policy, working with a small number of residents at a time, so that staff could witness the improvements in residents who had their medications reduced or discontinued. A tracking sheet was created so staff could monitor any changes in behaviour as residents had their antipsychotics reduced or discontinued, and team members held care conferences with family members to explain the tracking and measurement approach.

Due to initial challenges in communication and collaboration between nurses and physicians, mainly in scheduling discussions around issues or explaining the initiative and how it could improve residents’ well being, the team began holding professional advisory meetings. This strategy worked well to engage physicians. Whenever the nurses made requests to put a resident on antipsychotic medication or increase his or her dose, physicians began asking the entire team questions about residents’ behaviour.

During the initiative, which lasted from June 2014 to September 2015, the Camilla facility benefited from having a behavioural specialist, sponsored by the province through the Local Health Integration Network.

The Results

As a result of the initiative, Sienna achieved an overall reduction in use of antipsychotics of 50 percent among the residents in cohorts at the three pilot sites.

At Camilla, the team documented a 44 percent reduction in antipsychotic use among the selected residents. By Sept. 2015, 42 of the cohort of 95 Camilla residents had their antipsychotics discontinued (of the 42, 14 died within the year) and 15 of the 95 had their dosage reduced (eight of the 15 died within the year).

The team had even greater success at the other two facilities. In the Streetsville LTC home, a 62 percent discontinuation rate was achieved (in a cohort of 29 residents, 18 had their antipsychotics discontinued and two had the drugs reduced). At the Cheltenham LTC home, the rate was 58 percent (in cohort of 24, 14 had their antipsychotics discontinued).

Patricia Brines witnessed the changes in her father, Donald Ballentyne, 78, a resident of Camilla who had been admitted there in early 2008 after a series of strokes. At the time, “dad was showing some signs of aggression,” she said. He had punched other residents and police had been called to the facility.

Brines said she trusted the doctors when her father was put on antipsychotics to control his behaviour. “But he just appeared stoned and out of it, and he always wanted to lie down and sleep.” He was also still sometimes aggressive. Since he was taken off the antipsychotics, he has not been aggressive and “he seems brighter and doesn’t always want to lie down,” she said.

Patricia Brines witnessed the changes in her father, Donald Ballentyne, 78, a resident of Camilla who had been admitted there in early 2008 after a series of strokes. At the time, “dad was showing some signs of aggression,” she said. He had punched other residents and police had been called to the facility. Brines said she trusted the doctors when her father was put on antipsychotics to control his behaviour. “But he just appeared stoned and out of it, and he always wanted to lie down and sleep.” He was also still sometimes aggressive. Since he was taken off the antipsychotics, he has not been aggressive and “he seems brighter and doesn’t always want to lie down,” she said. In its September 2015 report, Sienna noted that at the three facilities, the percentage of residents who fell decreased from 9.2 percent in the first quarter of 2014 to 7.6 percent in the first quarter of 2015. In the same time period, new pressure ulcers decreased from 1.8 percent to 0.5 percent.

In general, as a result of the initiative, the use of antipsychotics shifted from being considered as an early intervention to the last line and staff at the facilities understand that use should be short term and constantly re-evaluated.

Sustainability and Spread

Sienna has spread the initiative and provided education and training to staff throughout its 34 long term care facilities. The result has been a steady decrease in the use of antipsychotic medications. By September 2015, the rate stood at 27.4 percent, just above the then-average in Ontario. Sienna set antipsychotic reduction as one of the key performance indicators for the organization with a target of 20 percent in 2016.

The CIHI data for April to June 2016 shows antipsychotic prescribing rates at Sienna at 20.7 percent, below the Ontario provincial average of 22.2 percent, positioning them well on their way to achieving their target.

The plans to sustain the changes include: continued quarterly medication reviews of antipsychotic medications; creation of an antipsychotic reduction tool kit that includes resources and training materials adopted from CFHI; continued engagement from current staff; providing training to new staff; and continued engagement with residents and family members on the program and reduction efforts.

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.