More alert. Engaged. Experiencing a better quality of life. Just some of the ways long-term care residents are benefitting from a data-driven initiative in Alberta on the appropriate use of antipsychotic drugs.
The Winnipeg Health Region, with support from the Canadian Foundation for Healthcare Improvement (CFHI), used RAI data as a measurement and assessment tool to help monitor and reduce antipsychotic medication use in long-term care. Now, Alberta is also using RAI data as a key measurement and assessment tool for the provincial Appropriate Use of Antipsychotics in Long Term Care (AUA in LTC) project.
In both projects, the result is improved patient care and a better quality of life. Antipsychotic medications are moving from first-line treatment to one of last resort for residents who have dementia and exhibit responses that challenge staff and family.
The quality indicators for both projects are derived from the Resident Assessment Instrument (RAI-MDS 2.0), a standardized clinical data set supported by CIHI. The RAI-MDS 2.0 provides a comprehensive assessment of resident care. Long-term care staff use the assessment tool to document resident reviews that include the physical side of things—such as how people dress themselves and eat—as well as the psychosocial side—such as how residents interact with others in the facility, and their cognitive patterns and medications. The assessments also produce results for more than 2 dozen quality indicators, including antipsychotic medication use.
Many residents who live in nursing homes suffer from dementia, and some of these residents exhibit responsive behaviours as a result of their condition. In many cases, these residents are prescribed antipsychotic medications to help try to manage unwanted behaviours, even though they do not have a mental health–related diagnosis. For those who are a danger to themselves or others, antipsychotic drugs can be an important part of their short-term treatment plan. But there are many more residents who don’t fall into this category, for whom a more holistic, resident-centred care approach is needed.
“In essence, this resident-centred approach encourages care providers to look broadly at residents’ histories—not just their health histories, but also their personal histories. For example, what the residents did for a living, their family life and many other pieces of information that make up who they used to be and who they are today,” explains Joe Puchniak, currently CIHI’s client affairs manager for Alberta and previously one of the leaders of the original project in Winnipeg. “All behaviour has meaning. By looking at the whole situation, care providers can figure out why residents are displaying these behaviours and then ask if there is anything that can be done to address the residents’ needs. Often when you deal with the issue causing the behaviour, the behaviour will diminish.” Caregivers can then get creative and brainstorm other approaches to support these residents, rather than prescribe a medication.
In Alberta, the program has grown from 11 early-adopter sites to 170 long-term care and nursing homes. The benefits are clear. “Nursing homes are where some people are going to live out their lives—for family members, it can be hard to see their loved ones in a debilitated way,” notes Puchniak. “For some residents with dementia, when you take them off antipsychotic medication they can become more alert. They may then be able to have more meaningful interactions with their families, care providers and other residents, which can lead to improved quality of life.”
Alberta is pursuing the AUA in LTC project as a priority provincial strategy to improve the quality of life of LTC residents and reduce the potential for harm that has been linked to the long-term use of antipsychotics. Although some cost savings are also realized with reduced use of antipsychotic medications, that is not the priority for this project. “It’s not simply a matter of focusing on the numbers,” adds Dennis Cleaver, executive director of Alberta Health Services’ Seniors Health Strategic Clinical Network and co-chair of the AUA in LTC project. “We have many accounts from family members and staff who notice that residents are more alert, more engaged—and behaviour issues have not re-emerged. More residents are enjoying a higher quality of life.”
A key success factor is involving everyone, including front-line staff and families. Strategies include regular multidisciplinary medication reviews, use of resources that are available in a comprehensive toolkit and online training tools. “Many physicians are involved and collaborate with care teams and residents’ families,” explains Dr. Duncan Robertson, a geriatrician and senior medical director with the Seniors Health Strategic Clinical Network.
Robertson says the fine-tuning process that is the result of the regular medication reviews makes the difference. As residents are assessed regularly by multidisciplinary teams and non-pharmacological measures are implemented, residents who do not require or benefit are weaned off antipsychotic medications.
The In Brief section of CIHI’s Your Health System web tool now compares data across provinces over a broad period of time. The usage rates of antipsychotic medication in long-term care homes in Alberta (25%) and Winnipeg (23%) have dropped over the past few years since the start of these initiatives. They are now among the lowest in Canada, well below the 30% national average.
This spring, CIHI will expand the In Depth section of Your Health System to report on antipsychotic indicators right down to the facility level—a first in Canada.
“It’s really about using an assessment system that is already in place to help manage resources as efficiently as possible. By looking at data across the country, leading examples of success can be identified, and these successful approaches can be shared with others,” sums up Puchniak. “Considering our aging population and the increasingly complex health and social needs of the long-term care population, it is critical that this type of data is used to maximum potential in order to help plan for the needs of these populations now and in the future.”