When a new Director of Nursing, Unit Managers, and an Activities Director were all hired and began working at a long-term care facility in New Hampshire, they discovered that previous leadership had approached residents’ behavior issues by relying heavily on the use of antipsychotic medications to sedate and control them. This new leadership at Hanover Terrace Health and Rehabilitation Center worked together to devise a plan that began to revolutionize the culture of the facility and drive down the antipsychotic usage rate.
It is a common practice to prescribe antipsychotic medications to treat dementia symptoms, and in some cases, this is the right choice for the resident. However, Hanover’s 26.3% antipsychotic usage rate among long-term care patients was very high by industry standards and the facility’s increase of antipsychotic usage by 5.6% for short stay patients was a point of concern. It appeared that medication was the first response to residents who argued or behaved inappropriately. Pharmacological interventions were being overused, and the resulting side effects of these medications on residents also contributed to numerous falls.
As a first step, the new facility leaders worked with consultants from the New England QIN-QIO to take a close look at current and existing programs. The quality improvement team found some weaknesses that could be addressed. For example, there were no evening activities in place for residents; and residents in the memory unit were not engaging in activities at all, often wandering aimlessly on the unit. Nursing staff were also still using alarms to alert them when residents were at risk of falls.
Changes began to occur slowly but progressively at Hanover Terrace Health and Rehabilitation Center. All alarms were discontinued on the floor. The activity program was revised to involve residents in small group and individual activities; and increased staffing and activities were provided for memory care residents. Concurrently, all staff received education in dementia care and the rehabilitation staff evaluated residents for pain. A walking program was instituted for residents who liked to pace. The courtyard in the facility was renovated to provide a space for residents to spend time outdoors in a secure area. Hanover also partnered with local veteran’s groups and hospices to become a Level Two “We Honor Veterans” facility, and became a certified “Music and Memory” facility.
Along with these changes, staff education has been a significant part of moving the facility’s culture to managing residents to a non-pharmocological approach. Staff have been educated to deal with and remove the underlying “triggers” for aggressive behavior rather dealing with the behavior reaction to the trigger. Music has become an important intervention with residents as staff have met with families and caregivers to discover residents’ favorite songs and artists. In addition, a geriatric psychiatrist comes to the facility three days a month, and meets with the Medical Director and all social services, activities, and nursing staff to discuss non-pharmacological approaches to care.
The concept of “team” in reducing and eliminating antipsychotic use for residents has been rejuvenated at Hanover, and the boundaries of the team have extended to include family members. In addition to establishing a formal family council to share updates, staff have discovered how important it is to share positive stories about residents with families on good days. A special phone call to a family member with the message “Mom had a great day today, she went out to the courtyard for a walk,” or a picture of their loved one at an activity, fully engaged and smiling has made a big difference for family members.
As these changes have become embedded in the new culture at Hanover, residents have gradually been weaned from antipsychotics and other medications and significant improvements have occurred. Although Hanover Terrace Health and Rehabilitation Center was under scrutiny by CMS in 2016 because of its 26.3% antipsychotic usage rate among long-term residents and 5.6% usage rate with short stay patients, the facility has taken a journey of incremental change. In May 2018, the long-term stay antipsychotic use rate had decreased to 11.35% and the short stay rate is at 0%. In October of 2017, Hanover Terrace Health and Rehabilitation Center was deficiency free and because of planned quality improvement interventions and outcomes, was awarded the Bronze in Quality Award from the American Health Care Association in May 2018.