Transcript Drug Regimen Review

F428 – Drug Regimen Review Process
F329 – Unnecessary Medications
Margie Huguet, RN, MCS
DHH Health Standards Section
Long Term Care Supervisor
Monitoring for
Inappropriate
Use of
Antipsychotic
Medications
©B&F Consulting 2015
www.BandFConsultingInc.com
10 Steps to Eliminate Off-Label Antipsychotic Use
1.
2.
3.
4.
Establish A Leadership
Team
Review CMS Survey
Guidance to Understand
Why and How
Analyze MDS CASPER
Resident Level Quality
Measure Report to
Identify Target
Population and Coding
Errors
Triage: Review Why Each
Resident is Receiving
Antipsychotics and Take
Care of Easy-to-Act-On
Situations
5.
6.
7.
8.
9.
10.
Train Staff on Why and
How to Reduce
Antipsychotics
QI Closest to the Resident
– Track and Trend and
Care Plan
Engage Physicians,
Prescribers, Consultant
Pharmacist
Engage Families
Update your policies,
procedures and forms
Sustain and Spread
Objectives:
1.
Discuss the Drug Regimen Review (DRR)
process (F428) and its role in assisting NHs
in monitoring the inappropriate use of
antipsychotic medications.
F425- Pharmacy Services
Consultant Pharmacist
Pharmacy Consultant
F425- Pharmacy Services
F425 - Pharmacy Services in a
Nursing Home
 Overall
Goal is to ensure safe and effective
use of medications;


(b)Service Consultation
The Licensed pharmacist:
 collaborates
with facility leadership and staff
to coordinate the services;
 helps the facility identify, evaluate, and
address/resolve pharmaceutical concerns
and issues that affect resident care, medical
care or quality of life.
F425- Pharmacy Services
Consultant Pharmacist
The pharmacist is responsible
for:

Helping the facility obtain and maintain timely
and appropriate pharmaceutical services that
support residents’ healthcare needs, that are
consistent with current standards of practice, and
that meet state and federal requirements.

Participating on the ID Team to address and
resolve medication-related needs or problems.

Developing procedures and guidance regarding
when to contact a prescriber about a medication
issue and/or adverse effects, including what
information to gather before contacting the
prescriber;
Nursing
F425- Pharmacy Services
Safeguards against Med Issues

The physician providing and reviewing the orders and
total program of care on admission and the prescriber
reviewing at each visit;

The nurse reviewing medications when transmitting the
orders to the pharmacy and/or prior to administering
medications;

The interdisciplinary team reviewing the medications as
part of the comprehensive assessment for the Resident
Assessment Instrument (RAI) and/or care plan;

The pharmacist reviewing the prescriptions prior to
dispensing; and

The pharmacist performing the medication regimen
review at least monthly.
F428- Drug Regimen Review
F428 – Drug Regimen Review
1.
The drug regimen of each resident must be
reviewed at least once a month by a
licensed pharmacist.
2.
The pharmacist must report any irregularities
to
1. the attending physician, and
2. the director of nursing, and

these reports must be acted upon
F428- Drug Regimen Review
What is a Medication Regimen
Review?

A thorough evaluation of the medication
regimen of a resident,


with the goal of promoting positive outcomes
and minimizing adverse consequences
associated with medication.
The review includes


preventing, identifying, reporting, and resolving
medication-related problems, medication
errors, or other irregularities,
and collaborating with other members of the
interdisciplinary team.
F428- Drug Regimen Review
What is an irregularity?
 Refers


to any event
that is inconsistent with usual, proper,
accepted, or right approaches to providing
pharmaceutical services, or
that impedes or interferes with achieving
the intended outcomes of those services.
F428- Drug Regimen Review
True or False
F329- Drug Regimen
Free from Unnecessary Drugs
Regulatory Language – F329
(I)Drug Regimen must be Free
from Unnecessary Drugs
Any drug when used:
I.
In excessive dose (including duplicative
therapy); or
II.
For excessive duration; or
III.
Without adequate monitoring; or
IV. Without adequate indication for its use; or
V.
In the presence of adverse consequences
which indicate the dose should be
reduced or discontinued; or
VI. Any combination of the reasons above.
F428- Drug Regimen Review
Identification of Irregularities
The pharmacist’s review considers factors such as:



Whether the physician and staff have documented
objective findings, diagnoses and/or symptom(s) to
support indications for use;
Whether the physician and staff have identified and acted upon, or should be
notified about, the resident’s allergies and/or potential side effects and
significant medication interactions (such as medication-medication, medicationfood, medication-disease, medication-herbal interactions);
Whether the medication dose, frequency, route of
administration, and duration are consistent with the
resident’s condition, manufacturer’s
recommendations, and applicable standards of
practice;
F428- Drug Regimen Review
Identification of Irregularities
 Whether
the physician and staff have
documented progress towards, or
maintenance of, the goal(s) for the medication
therapy;


Whether the physician and staff have obtained and acted
upon laboratory results, diagnostic studies, or other
measurements (such as bowel function, intake and output)
as applicable;
Whether medication errors exist or circumstances exist that
make them likely to occur; and
F428- Drug Regimen Review
Identification of Irregularities
 possible
medication-related causes of recent
or persistent changes
F428- Drug Regimen Review
Monitoring

The ongoing collection and analysis of
information (such as observations and
diagnostic test results) and comparison to
baseline date in order to:

Ascertain the response to treatment and care;

Detect complications/adverse consequences;

Support decisions about modifying,
discontinuing, or continuing any interventions.
F329- Drug Regimen
Free from Unnecessary Drugs
F329 - Antipsychotic Drugs
2. Antipsychotic Drugs. Based on a comprehensive
assessment of a resident, the facility must ensure
that:
 (i) Residents who have not used antipsychotic
drugs are not given these drugs unless
antipsychotic drug therapy is necessary to treat a
specific condition as diagnosed and documented
in the clinical record; and
 (ii) Residents who use antipsychotic drugs receive
gradual dose reductions, and behavioral
interventions, unless clinically contraindicated, in
an effort to discontinue these drugs.
F329- Drug Regimen
Free from Unnecessary Drugs
GDR –
Gradual Dose Reduction

Seeking an appropriate dose and duration and
minimizing the risk of adverse consequences;

To find an optimal dose or discontinue dose;

When clinical condition has improved/ stabilized,

When underlying causes of the original target
symptoms have resolved, and/or

When non-pharmacological interventions, including
behavioral interventions, have been effective
F329- Drug Regimen
Free from Unnecessary Drugs
GDR for Antipsychotics

Within the 1st year in which a resident is
admitted on an antipsychotic medication or
after the facility has initiated an antipsychotic
medication,

the facility must attempt a GDR in two separate
quarters (with at least one month between the
attempts),


unless clinically contraindicated
After the first year, a GDR must be attempted
annually,

unless clinically contraindicated
F329- Drug Regimen
Free from Unnecessary Drugs
GDR – Clinically Contraindicated

Continued use is in accordance with relevant
current standards of practice and ;

physician documented the clinical rationale
for why any additional attempted dose
reduction at that time would be likely to
impair the resident’s function or increase
distressed behavior; or

target symptoms returned or worsened after
the most recent attempt at a GDR
F329- Drug Regimen
Free from Unnecessary Drugs
If we don’t medicate what
else can we do?

Non-pharmacological interventions are
approaches to care that do not involve
medications, generally directed towards stabilizing
or improving a resident’s mental, physical or
psychosocial well-being.

“Behavioral interventions” are individualized nonpharmacological approaches (including direct
care and activities) that are provided as part of a
supportive physical and psychosocial environment,
and are directed toward preventing, relieving,
and/or accommodating a resident’s distressed
behavior.
Surveyor Triggers- Possible Irregularity
F428- Drug Regimen Review
Drug Regimen Review
A form of
Quality Assurance &
Performance Improvement
F428- Drug Regimen Review
Drug Regimen Review Findings
 The
pharmacist is expected to document
either that no irregularity was identified or
the nature of any identified irregularities.
 The
pharmacist is responsible for reporting
any identified irregularities to the


attending physician and
director of nursing.
F428- Drug Regimen Review
Drug Regimen Review Findings
 Considered
part of each resident’s
clinical record.
 Maintained
within the facility and is
readily available for review.
 The
ID team is encouraged to review the
reports and to get the pharmacist’s input
on resident problems and issues.
F428- Drug Regimen Review
Response to Irregularities
 The
physician either accepts and acts
upon the report and potential
recommendations
or
 rejects all or some of the report and
provides a brief explanation of why the
recommendation is rejected, such as in a
dated progress note.
F428- Drug Regimen Review
DON addresses/documents
actions taken for:
 recommendations
that do not require a
physician intervention, such as one to
monitor vital signs or weights
Think About It
Step 9
Updating Policies , Procedures, and forms
Policy’s and Procedures

Do you have one? Is it consistent with current Standards of
Practice?

AMDA Letter to Medical Directors – P&Ps that promote:

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a process of person-centered care
learning the story behind each resident
evaluating the behavior changes and excluding potential medical
causes of the behavioral symptoms
P&P should




direct the staff to identify resident specific needs, optimize choices,
and promote consistent assignments
Foster education of staff to ensure understanding of dementiarelated behavior as a form of communication
Use of non-pharmacological interventions to address behaviors
Address proper monitoring
Sample Psychotropic Med P/P – Advancing Excellence Website – Under Physician Tools
Step 9
Updating Policies , Procedures, and forms
Sample Form: Psychotropic
Medication Tracking Tool
AHCA/NCAL Quality Initiative – Antipsychotic Management Tool