Maryland Nursing Home Takes Collaborative Approach to Quality Improvement
For more than 100 years, Fahrney-Keedy Senior Living Community in Boonsboro, Maryland has maintained a commitment to enriching the lives of seniors by providing high-quality, compassionate care. Their long history has taught them that quality improvement thrives when staff work together as a team, communicate clearly and seek to understand residents’ needs and preferences.
Reducing Unnecessary Antipsychotic Medications
Five years ago, Fahrney-Keedy began their improvement journey with a focus to reduce antipsychotic medication use as part of a Quality Measure Improvement initiative.
Fahrney-Keedy started with a small but important step: the team added antipsychotic medications to an existing weekly WWF meeting (Weights, Wounds, Falls). This multi-disciplinary discussion group includes representation from nursing administration, dietary, social services, therapy, activities as well as the MDS coordinator.
“We started with the basics and built our way up from there. We identified the residents we were concerned about and started to explore their behaviors and look for patterns. Over time, these meetings have helped us identify resident concerns early and implement solutions quickly,” said Angie Keebaugh L.P.N., Director of Quality Assurance.
Gradually, these discussions helped the team identify simple steps to reduce the facility’s dependence on antipsychotic medications and equip frontline staff to meet residents’ needs. For example, if a resident becomes agitated in the afternoon, the nursing assistant can offer a snack or a calming resident-specific diversion. Nursing assistants also have the flexibility to adjust personal care such as toileting schedules to meet resident preferences.
For some residents, past traumas such as the death of a child or a divorce can contribute to feelings of distress. One resident, who continually called for her baby, had experienced multiple miscarriages earlier in her life. After learning about her history from the family, the facility provided a doll which helped the resident feel better.
“Medication should not be your first intervention. Before you prescribe, find out why the resident is displaying a certain behavior. Is the resident in pain? Are they dehydrated? Could there be an occult infection developing? It’s important to ask these questions first,” Keebaugh said. Sometimes the resolve may be as simplistic as a need for the resident to be toileted.
Other factors to consider:
- Physical Comfort: If residents are in pain or suffering from constipation, they are more likely to exhibit behaviors. Addressing these issues can alleviate the discomfort and minimize feelings of distress.
- Preferences: Does the resident not like sitting in a certain chair? Would he prefer to be seated near a window? Consider the residents’ preferences and take steps to accommodate what matters to them.
- Alternative Activities: Fahrney-Keedy developed new activities such as a cooking club, watching older television shows, or trivia that taps into their long-term memory. More activities prevent residents with dementia from wandering or becoming frustrated.
- Outside Help: A consulting geriatric psychiatrist assesses Fahrney-Keedy’s new residents and supports residents with more complex psychological needs. A pain clinic helps residents with chronic pain.
- Documentation: Nursing assistants document behaviors in the electronic health record to ensure anyone working with that resident understands their needs and preferences.
- Gradual dose reduction: Do not be afraid to gradually reduce medications. Even if the residents are doing well while taking an antipsychotic medication, they might benefit from reducing and eventually eliminating those prescriptions. Utilize the expertise of your consultant pharmacist to assist in GDR trials.
“We are encouraging all of our staff to think outside the box. No one knows the residents like our nursing assistants, and we make sure they feel valued. Unit managers are meeting with the CNA’s regularly, and they’re on the floor helping with resident care,” Keebaugh said.
Finding Success and Spreading Improvement
Fahrney-Keedy’s efforts are working. Not only have they decreased the use of antipsychotic medications, but in the process have reduced resident falls, pressure ulcers, and pain. They also have eliminated restraints.
“As a result of the habits we formed to reduce use of antipsychotic medications, we have gone totally restraint-free within our facility. We had been working on reducing the use of restraints, but progress occurred naturally when we started looking at antipsychotic medications,” Keebaugh said.
Fahrney-Keedy’s environmental services and maintenance teams have played an integral role in reducing reliance on restraints and protecting residents from falls. They have turned off alarms and are using roaming alerts to keep residents safe. Maintenance staff helped with equipment, such as installing anti-tippers. Those personnel also get to know the residents and can alert nursing staff with any concerns or changes in condition.
Their collaborative approach now extends beyond Fahrney-Keedy’s staff to include community providers. Through a partnership with the local hospital, a nurse practitioner is available onsite two days per week to see residents who may not feel well, prescribe medications and treatments, or order labs. Additionally, the hospital provides a care manager who follows skilled residents.
Fahrney-Keedy also engages primary care providers through semi-annual meetings. They review relevant quality improvement data and discuss both challenges and successes.
“Do your physicians know your antipsychotic medication prescribing rates? Your urinary tract infection rates? By engaging physicians on the front end, they better understand the issues and can see how they are contributing to improvement,” Keebaugh said.
HQI Can Help
Are you struggling to reduce the use of unnecessary antipsychotic medications in your facility? Our long-term care experts are here to help you succeed. Contact us today and review the following some of the materials available in the HQI Resource Center:
- Quality Measure Tip Sheet: Percent of Residents Who Received an Antipsychotic
- Resident Prioritization Tool
- Alternatives to Antipsychotic Medications
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