Interview with Sharon Jackson

CFHI Interview with Sharon Jackson, Trinity Village Care Centre

“We have one resident whose depression rating scale (DRS) dropped to three from 11 after her antipsychotics were dramatically reduced. Another resident began speaking again. She hadn’t said a word in a very long time, and all of a sudden she was answering simple questions.”

May 2015

Trinity Village Care Centre

Sharon Jackson, at left, with resident Vincent.

In a new, occasional feature, we interview leads of CFHI-supported projects currently underway. This month we profile Kitchener-based Trinity Village Care Centre, one of 15 organizations taking part in CFHI’s Reducing Antipsychotic Medication Use in Long term Care collaborative.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.

Sharon Jackson, project manager, describes her team’s progress in addressing inappropriate use of antipsychotic medications for residents with dementia since the project formally launched in September 2014.

Could you please describe your initiative and your target population?

The goal of the initiative is to reduce the use of antipsychotics in the elderly population who don’t have a diagnosis of schizophrenia, Huntington’s disease or suffer from hallucinations or delusions. Frequently residents are prescribed antipsychotic medication in order to control undesirable behaviours. Our goal is to greatly decrease this prescribing practice.

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

Our residents for the most part have many co-morbidities. We deal with a frail elderly population. Some have heart disease, diabetes, cancer and many more conditions. Many are on a vast array of medications. If I were to identify one pressing healthcare issue, it would be polypharmacy. Many of these residents are on so many different medications it is difficult sometimes to know if the symptoms they experience are due to one of the medications or a physical issue.

Why was this initiative important to Trinity?

Our mission is “A Caring Community Which Values and Fosters the Worth and Lifestyle of All.” Our vision is that Trinity Village Care Centre will be a community leader, offering a dynamic, holistic lifestyle for residents and staff through best practices, innovative technology and research within an eco-friendly environment. Reducing the use of antipsychotics fits into this perfectly because reducing these potentially harmful drugs and replacing them with non-pharmacological interventions to improve the quality of life of these residents is in the best interest of all our residents. We value each and every one of our residents and would like them to have the greatest quality of life.

The use of antipsychotics often just masks a bigger issue. Our priority is to use innovative technology and best practices to improve that quality of life for each of our residents. We’re hoping that the culture in our home surrounding the use of antipsychotics will change and staff will learn to ALWAYS look first to the P.I.E.C.E.S. template rather than immediately looking for something pharmacological to assist with behaviours. (Note: The ‘Physical, Intellectual, Emotional, Capabilities, Environment, and Social care model’ or P.I.E.C.E.S™ approach encourages staff to treat residents by looking at not only their health files, but also their personal histories, such as their former careers).

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

Yes, actually we had created a work plan for our Behavioural Supports Ontario (BSO) program, providing details on how we could decrease the usage of antipsychotics in our home. When we brought the work plan forward for our PRC to review, she asked if we were doing this through CFHI funding.

How did you hear about this opportunity?

When our psychogeriatric resource consultant asked if we were doing the work with CFHI support, I immediately performed an internet search, found the opportunity and opened communication with CFHI.

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

We started off strong right from the start. I started the reductions with 2 residents from each unit, so 10 residents out of 42 who were on antipsychotics. We start by using a drug efficacy tracking tool for antipsychotics that was developed by our pharmacy. We establish a baseline of behaviours and side effects, then we request a decrease in the medication. One week after the decrease, we again track the behaviours and side effects and if nothing changed (or even better, if things improved) we request another decrease. We repeated this process until the meds were discontinued.

If, however, behaviours increased, we undertook a P.I.E.C.E.S. review to determine what the issues were and work with staff to support them with the resident. We would slow down the reductions while we worked with staff to improve our chances of success.

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

We started the project with 42 residents on antipsychotics, or 28% of our resident population. From that original cohort, we now have 18 residents on antipsychotics or 12% of the population in the home. Our current number of residents on antipsychotics at the home is a little higher, at 22, due to new admissions.

Some residents didn’t display any change in behavior at all when their antipsychotics were discontinued. This means that they are now taking one less apparently unnecessary medication which could have been causing side effects. But the best stories are those where our residents seem to “wake up” when the antipsychotics are decreased. We have one resident whose depression rating scale (DRS) dropped to three from 11 after her antipsychotics were dramatically reduced. Another resident began speaking again. She hadn’t said a word in a very long time, and all of a sudden she was answering simple questions.

Families have commented that it is so nice to have a little more quality in their interactions. They have been amazed at how much more bright and alert their family members have become.

How have you been using interRAI data for your project?

We have been using the interRAI to track changes in status, for example with the resident whose DRS level dropped dramatically. In the first quarter we didn’t see a lot of changes to the data; however in the second quarter we started to see more improvements in these numbers.

What have been your biggest challenges and obstacles?

Our biggest obstacle has been staff buy-in. The staff was not interested in decreasing medications and “waking up” residents and potential behaviors. However, most staff have now seen the benefits of this work, particularly since we used part of the grant money from CFHI to fund extra hours for our BSO team. It provides extra support for the staff as they relearn how to care for residents who were previously easy to care for, they were so sleepy.

How did you deal with the initial lack of staff engagement?

The staff just needed reassurance that we weren’t going to just come in like a whirlwind and take everyone off medication and leave them to try and manage. I think that we have done a very good job of supporting them with the residents who have had increases in behaviours. One in particular comes to mind. We started decreasing her antipsychotics in October, with a resulting increase in behaviours. We looked at all her meds, worked with staff and eventually (just last week) we were able to wean her completely off the antipsychotic.

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

One of our physicians is completely on board and has been really fantastic. He has been decreasing the antipsychotics when requested and when there is a resident with new behaviours, he will refer the resident to BSO rather than order any medications.

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

Our senior leadership is very supportive. We have been communicating regularly through emails to report on the progress of the project. We’ve published articles in our newsletter. And we just provided an update this week to our professional advisory council.

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

The families that have noticed a difference are quite pleased. As I said, some residents showed no visible change while others displayed much more obvious changes. Families are feeling that they have much better quality visits with their loved ones now. This has been a very satisfying experience.

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

We are using CFHI funding to assist mostly with personnel costs, allowing our BSO team more time to support staff with the changes. We have also used much of the funding on education initiatives to build staff capacity in dealing with behaviours non-pharmacologically.

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

The beauty of this project fitting so nicely into the BSO plan is that it won’t end when the CFHI funding is depleted. We’re working hard at putting together protocols and enhanced med reviews to flag those residents who could be decreased while we have the extra hours from the additional funding. The plan is to move to more of a supervisory role after the project is done, not needing to institute all of the future changes.

Do you foresee the ability to spread your work to other Trinity Village facilities?

Trinity village is a stand-alone facility. However, I also work at another facility, where I’ve started to spread these ideas.