Sample Psychotropic Medication Policy And Procedure
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Summary
Sample Psychotropic Medication Policy and Procedure May Also Be Used To Improve Care to Dementia ResidentsThe following attached tools are available on the CMS Advancing Excellencewebsite www.nhqualitvcampaign.org 1. Sample Psychotropic Medication Policy and Procedure 2. Sample Psychopharmacologic Interdisciplinary Medication Review 3. Provider Checklist Suggestions for Improving Dementia Care in Nursing Homes 4. Questions to Consider in Interdisciplinary Team Review of Dementia Care Cases 5. Self-Assessment State Coalition Provider Question Worksheet 6. Provider Dementia Care Implementation Flow Diagram Developed under the Partnership to Improve Dementia Care in Nursing Homes SAMPLE POLICY AND PROCEDURE PSYCHOTROPIC MEDICATIONSample Psychotropic Medication Policy and ProcedureShared with Permission of Karyn Leible, RN, MD, CMDPolicy:Physicians and mid-level providers will use psychotropic medications appropriatelyworking with the interdisciplinary team to ensure appropriate use, evaluation andmonitoring
Standards: 1. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits
2. The facility supports the appropriate use of psychopharmacologic medications that are therapeutic and enabling for residents suffering from mental illness
3. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as psychopharmacological medications can be utilized to meet the needs of the individual resident
4. The facility supports the goal of determining the underlying cause of residents having difficulty sleeping so the appropriate treatment of environmental or medical interventions can be utilized prior to psychopharmacologic medication use
5. Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing, as appropriate, for the clinical situation
6. Psychopharmacological medications will never be used for the purpose of discipline or convenience
7. Psychotropic medications include: anti-anxiety/hypnotic, antipsychotic and antidepressant classes of drugs
SAMPLE POLICY AND PROCEDURE PSYCHOTROPIC MEDICATIONResponsible Party — Actions Required: Primary Care Physician, PA or APN 1. Orders for psychotropic medication only for the treatment of specific medical and/ or psychiatric conditions or when the medication meets the needs of the resident to alleviate significant distress for the resident not met by the use of non-pharmacologic approaches
2. Documents rationale and diagnosis for use and identifies target symptoms
3. Documents discussion with the resident and/or responsible party regarding the risk versus benefit of the use of these medications included in the discussion and documentation must be the presence of any black box warning or off label use of the medication affecting the prescribing of the medication to the resident
4. Evaluates with the interdisciplinary team, effects and side effects of psychoactive medications within one month of initiating, increasing, or decreasing dose and during routine visits thereafter
5. Monitors the resident for lack of drug efficacy clinically and in discussions with the interdisciplinary team within one month of initiating and during routine visits
6. Attempt a gradual dose reduction (GDR) decrease or discontinuation of psychotropic medications after no more than 3 months unless clinically contraindicated. Gradual dose reduction must be attempted for 2 separate quarters (with at least one month between attempts). Gradual dose reduction must be attempted annually thereafter or as the resident's clinical condition warrants
7. Sedative/ hypnotics will be reviewed quarterly for gradual dose reduction. GDR must be attempted quarterly unless clinically contraindicated
8. Orders for PRN psychotropic medications will be time limited (i.e., times 2 weeks) and only for specific clearly documented circumstances
9. Obtains psychiatric consultation as resident's clinical condition requires
SAMPLE POLICY AND PROCEDURE PSYCHOTROPIC MEDICATIONPsychiatrist/mental health (When available to a facility)1. May assist the facility in establishing appropriate guidelines for use, dosage and monitoring of psychotropic medications
2. Uses the above standards (1-9) in recommendations to physicians
3. Provides in service training to nursing, medical, and other staff as appropriate
4. Is available for consultation
5. Helps develop behavior management plans
Nursing1. Monitors psychotropic drug use daily noting any adverse effects such as increased somnolence or functional decline
2. Will monitor for the presence of target behaviors on a daily basis charting by exception (i.e., charting only when the behaviors are present)
3. Reviews the use of the medication with the physician and the interdisciplinary team on a quarterly basis to determine the continued presence of target behaviors and or the presence of any adverse effects of the medication use
4. AIMS will be performed on any resident on and antipsychotic on a quarterly basis changes will be reported to the physician
5. May develop behavioral care plans
Social Services1. Maintains a list of residents in the facility on psychoactive medications
2. Coordinates the interdisciplinary team resident reviews of psychoactive medications
3. May develop behavioral care plans
Pharmacist and/or consulting pharmacist1. Monitors psychotropic drug use in the facility to ensure that medications are not used in excessive doses or for excessive duration
2. Participates in the interdisciplinary quarterly review of resident's on psychoactive medications
3. Notifies the physician and the nursing unit if whenever a psychotropic medication is past due for review
SAMPLE POLICY AND PROCEDURE PSYCHOTROPIC MEDICATIONMedical Director1. Reviews psychotropic medication policy with the interdisciplinary team at least annually
2. Monitors the overall use of these medications in the facility through the QAPI process
3. Identifies any resident care or potential regulatory issues with the use of psychotropic medications in the facility and discusses with the medical staff as appropriate
4. Participates in the interdisciplinary quarterly review of resident's on psychoactive medications and facilitates communications with attending physicians of any recommendations from the IDT
Psychopharmacologic Interdisciplinary Medication ReviewShared with Permission of Karyn Leible, RN, MD, CMDResident: ____________________________________ Date of review:_____________________Reason for Review: _____ Initiation _____ Dose reduction consideration _____ Dose reduction review _____ Change in conditionDiagnosis for psychopharmacologic medication use: ______________________________________Other diagnosis: ___________________________________________________________________Medication to be reviewed: __________________________________________________________Date started _______________ Last review _______________ Last GDR attempt ____________Other Medications: _________________________________________________________________Target behavior/symptom __________________________________________________________ _____ Decline in frequency _____ No longer present _____ No changeTarget symptom/behavior non-pharm interventions present in care plan _____________________Documentation of effectiveness __________________________________________________Evidence of adverse effects or functional decline: _____ Falls _____ Increased assistance for ADLs _____ Somnolence _____ Weight loss _____ Decreased oral intake (fluids) _____ Decreased mobility _____ Insomnia _____ Restlessness Other: ____________________________________________________________________Recent Pain Assessment ___________________________________________________________Recent sleep study (if indicated) _____________________________________________________AIMS _____ Date _____ Score BIMS _____ Date _____ ScorePHQ 9 _____Date _____ ScorePertinent laboratory studies: ________________________________________________________Risk/benefit discussion with resident or MDPOA documented at initiation of medication:__________________________________________________ Date ______________________ SAMPLE POLICY AND PROCEDURE PSYCHOTROPIC MEDICATIONCommittee Recommendations:Response:Practitioner Signature and date:Committee Members: SAMPLE POLICY AND PROCEDURE PSYCHOTROPIC MEDICATION Partnership to Improve Dementia Care in Nursing Homes Suggestions for Provider Checklist % of residents in facility on atypical antipsychotics: _____ Quality Measure State Percentile Rank — antipsychotics: _____ YES NOStaff in all departments, are trained in person-centered care and how to respond effectively to behaviors (accesssample training programs on Advancing Excellence website; Hand in Hand)
In addition to medical and psychiatric history, recent changes in behavior or cognition and other standard clinicalevaluations, at admission information is obtained from the resident, family, and/or caregivers on the resident'spreferences, routines, pre-dementia personality, social patterns, responses to stress and effective interventions
The information obtained on during the admission process is conveyed to direct caregivers
This admission information is integrated into the care plan and may be revised over time as theresident's condition and needs change
Interviews with staff demonstrate that they have implemented and are following the care plan, continue to seekinput from family members or care givers for unresolved issues, and communicate with practitioners regardingchange in condition or new or persistent symptoms
If a resident is placed on an antipsychotic medication, there is documentation in the record that the residentor appropriate legal representative was involved in the decision
Facility has consistent staff assignments (same Certified Nursing Assistant to same resident 5 days/week)
Certified Nursing Assistant to Resident Ratio 1st shift/2" shift/3`d shiftSenior leadership (Nursing Home Administrator, Director of Nursing, Medical Director) attend care plan meetingsperiodically for residents with unresolved behavioral or psychological symptoms of dementia
Interdisciplinary team seeks input at care plan meetings from the Medical Director, Consultant Pharmacist andCertified Nursing Assistants for residents with behavioral or psychological symptoms
Providers conduct outreach and education to the resident's family and strongly encourage their participation incare plan meetings (offering to flex the schedule or use conference calls when the family cannot physically be inattendance)
Nursing Home Administrators and Directors of Nursing review quality measures (e.g., monthly) and use theQuality Measures report to identify residents who may need alternative interventions and oversee theirimplementation
Each month, Nursing Home Administrators and Directors of Nursing review Quality Measures report, alongwith the Pharmacy Consultant report, to identify residents appropriate for possible reduction/elimination ofantipsychotics. The review of aggregate data should be combined with real-time, case-based information andinput from practitioners
Nursing Home Administrators and Directors of Nursing review Pharmacy Consultant's report quarterly withConsultant Pharmacist and Medical Director to track and trend data
Direct caregivers (Certified Nursing Assistants), together with the family and care plan team, is involved in theprocess of developing and implementing effective, person-specific interventions to address behavioralsymptoms
If any resident is admitted on an antipsychotic or is started on an antipsychotic after admission, theConsultant Pharmacist, along with the practitioner, reviews that resident's care plan, including allmedications, within 24-48 hours
A documented process is in place and is utilized when initiating an antipsychotic prescription (e.g., standardorder set, decision support algorithm, routine monitoring recommendations, etc.)
"Yes" answers require supporting documentation and visual confirmation by quality improvement personnel
Developed under the Partnership to Improve Dementia Care in Nursing Homes SAMPLE POLICY AND PROCEDURE PSYCHOTROPIC MEDICATION PARTNERSHIP TO IMPROVE DEMENTIA CARE IN NURSING HOMES *Questions to Consider in Interdisciplinary Team Review of Individual Dementia Care Cases• If the behavioral symptoms represent a change or worsening, was a medical work up performed to rule out underlying medical or physical causes of the behaviors, if appropriate?• Were current medications considered as potential causes of the behaviors (i.e., those with significant anticholinergic or other side effects)?• If a medical cause (e.g., UTI) was identified, was treatment (if indicated) initiated in a timely manner?• If medical causes were ruled out, did the staff attempt to establish the root causes of the behaviors, using a careful and systematic process and individualized knowledge about the resident when possible? Were family caregivers or others who knew the resident prior to his/her dementia consulted about prior life patterns, responses to stress, etc.?• Was the initial clinical indication for the medication valid?• Were non-pharmacologic, person-centered interventions tried before medications (other than in an emergency)? Were the results documented?• Were specific target behaviors identified and desired outcomes related to those behaviors documented? Were caregivers aware of the target behaviors and desired results of the medication?• Was the resident or appropriate legal representative consulted about the decision to use an antipsychotic medication and was that discussion documented?• If a drug is continued for more than a few weeks, is the original clinical indication still valid (are the behaviors still present)?• Is appropriate monitoring in place and is the team aware of the potential side effects?• If new symptoms or changes in condition occurred after an antipsychotic medication was started, was medication use considered as a potential cause of a change or symptom?• If on a medication, did the pharmacist perform a medication regimen review and identify related signs and symptoms, or did the staff inform the pharmacist if symptoms occurred after the last pharmacist visit? Developed under the Partnership to Improve Dementia Care in Nursing Homes SAMPLE POLICY AND PROCEDURE PSYCHOTROPIC MEDICATION Partnership to Improve Dementia Care in Nursing Homes State Coalition Provider Question Worksheet (Self-Assessment Tool)Appropriate dementia care includes more than managing individuals with dementia-related behavior. It also requires minimizing and managing the various factors thatmaintain overall health and physical stability and optimize function in residents who areoften complex and may suffer from multiple chronic conditions. How do caregiverscollaborate with practitioners to properly assess behavior carefully and systematically, tohelp rule out critical underlying causes, including (but not limited to) environmental,functional, and other possibly correctable causes or serious medical conditions such asdelirium? Does the facility have detailed process guidance for staff regarding theassessment, documentation, and reporting of all symptoms and changes in condition,including behavior? Are they reviewing and addressing staff performance in these areas,based on individual cases?Direct Caregivers 1. How does staff address behavioral responses by persons with dementia in your facility, such as anxiousness or aggressiveness? 2. Do you know if your facility has policies and procedures in place that you are supposed to follow when a resident with dementia exhibits certain behaviors, or those behaviors worsen? 3. What training have you received about how to care for persons with dementia? a. Who provides the training? b. Do you know what materials are used? c. Does the training give you a chance to practice how you would respond? 4. When a resident with dementia demonstrates certain behaviors such as anxiety or aggression, is he or she given a medication to treat them? a. Do you know whether the team at your facility is trying to reduce the use of these drugs? 5. Are residents and families given information about care options for persons with dementia, including those that do or do not use medications?Leadership- (Nursing Home Administrator, Director of Nursing, Medical Director) 1. How will your facility measure success in improving dementia care and reducing or optimizing antipsychotic drug use? 2. What do you see as the major barriers to accomplishing this? SAMPLE POLICY AND PROCEDURE PSYCHOTROPIC MEDICATION3. Are you currently reviewing data related to antipsychotic drug use for all residents, including residents that are returning or were recently discharged from an acute care setting?4. Are there tools/resources/support that would assist you in analyzing and interpreting data? For example, telephone or in-person support from: a. A member of your state nursing home association; b. A consultant; c. A quality improvement organization; d. Other state-based nursing home specialist?5. If your facility is part of a corporation, does the corporation provide educational materials, clinical support or data analysis related to dementia care and/or antipsychotic drug use?6. Is staff in all departments educated on person-centered care for individuals with dementia?7. How is the Consultant Pharmacist involved in the overall care of residents? For example, does the Consultant Pharmacist routinely engage in: a. Data analysis; b. Staff education; c. Routine interaction with residents and/or families?8. How is the Medical Director involved in the overall care of residents with dementia Developed under the Partnership to Improve Dementia Care in Nursing Homes SAMPLE POLICY AND PROCEDURE PSYCHOTROPIC MEDICATIONPARTNERSHIP TO IMPROVE DEMENTIA CARE IN NURSING HOMES Provider Implementation Flow Diagram Engage leadership team (DON, administrator, medical director, consultant pharmacist) Leadership team meets with direct caregivers to conduct facility self-assessment and establish goals Leadership team and direct caregivers review current policies and procedures related to dementia care Use actual care situations to review caregiver and practitioner performance regarding implementation of desired practices (see questions to consider) Review data an rates of antipsychotic use in the facility Review utilization of antipsychotic medications and other psychopharmacological medications throughout the facility Identify residents who could benefit from modification of their current treatment regimen, including (but not limited to) attempted reduction' of current antipsychotic medications Establish ongoing meetings, rounds or other means of continuous staff engagement at all levels on individualized approaches to care Analyze and trend data regarding both outcomes and underlying processes related to dementia care and to facility-wide systems for review and action Follow up with State partners to share challenges, successes, resources Developed under the Partnership to Improve Dementia Care in Nursing Homes
SAMPLE POLICY AND PROCEDURE PSYCHOTROPIC MEDICATION Sample Psychotropic Medication Policy and Procedure Shared with Permission of Karyn Leible, RN, MD, CMD …
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Frequently Asked Questions
What are the psychotropic medication guidelines for 2008?
PSYCHOTROPIC MEDICATION GUIDELINES December 2008 ASSESSMENT AND TREATMENT ISSUES II. ISSUES IN THE ASSESSMENT AND TREATMENT OF SPECIALIZED POPULATIONS: C. CO-OCCURRING MENTAL HEALTH/SUBSTANCE ABUSE DISORDERS: Except for younger children, clients of any age should be assessed for potential substance
Is there a formulary for psychotropic medications?
PSYCHOTROPIC MEDICATION GUIDELINES December 2008 MEDICATION FORMULARY RCDMH has not established a specific medication formulary for the Department. Instead, RCDMH refers to the Medi-Cal approved list for formulary medications. Psychiatrists are free to prescribe any psychotropic medications that are on the approved
What does psychotropic mean?
Psychotropic Medications: Guidelines and Policies - Child Welfare Information Gateway Some children and youth in child welfare may be prescribed psychotropic medications to treat emotional and/or behavioral symptoms associated with mental health diagnoses and/or trauma.
Can a psychiatrist prescribe psychotropic medications under rcdmh?
PSYCHOTROPIC MEDICATION GUIDELINES December 2008 MEDICATION FORMULARY RCDMH has not established a specific medication formulary for the Department. Instead, RCDMH refers to the Medi-Cal approved list for formulary medications. Psychiatrists are free to prescribe any psychotropic medications that are on the approved Medi-Cal formulary.