Aging & Mental Health, 2015 Vol. 19, No. 6, 507 516, http://dx.doi.org/10.1080/13607863.2014.952710

Assessing approaches and barriers to reduce antipsychotic drug use in Florida nursing homes Michelle L. Ellis*, Victor Molinari, Debra Dobbs, Kelly Smith and Kathryn Hyer School of Aging Studies, University of South Florida, Tampa, Florida; Florida Policy Exchange Center on Aging, University of South Florida, Tampa, Florida (Received 7 May 2014; accepted 30 July 2014) Objectives: Antipsychotic medications have been federally regulated since 1987, yet research suggests they continue to be used inappropriately to alleviate behavioral symptoms associated with dementia. In 2012, the Centers of Medicare and Medicaid launched a new initiative to reduce antipsychotic medication in nursing homes by 15% nationally. The aim of this study was to examine qualitative data to explore strategies that have been implemented, to assess which strategies are evidence-based, and to make recommendations to improve upon practices to reduce antipsychotic medication use. Method: A convenience sample of 276 nursing home professional staff members were surveyed about these topics using open-ended questions. Results: Theme-based content analysis yielded three main themes. The themes related to changes in practice included the following: (1) increased review of resident behavior and antipsychotic medication regimens; (2) reduction in antipsychotic medications or dosage; and (3) increased use of nonpharmacological interventions. The main themes relevant to needed assistance included the following: (1) education; (2) clinical support; and (3) increased financial resources and reimbursement. Discussion: Overall findings indicate that the majority of facilities are actively responding to the initiative, but challenges remain in education, finding mental health support, and in reimbursement. Keywords: antipsychotic medications; nursing homes; qualitative methods; survey

Introduction Long-term care is a common outcome for older adults with Alzheimer’s disease or related dementias. Symptoms of dementia progressively worsen over time and result in the loss of physical and cognitive independence. A recent report sponsored by the National Alzheimer’s Project Act estimated that the cost for dementia care in 2010 was between $157 billion and $215 billion for both formal and informal care (Hurd, Martorell, Delavande, Mullen, & Langa, 2013). It is estimated that national prevalence of dementia for those aged 70 and older is 13.9%, with the prevalence increasing to 37.4% for those 90 years of age and older (Plassman et al., 2007). The most intensive and expensive form of long-term care occurs within nursing homes (NHs). Because there are ongoing concerns about the quality of NH care for residents with dementia, the Centers for Medicare and Medicaid (CMS) have had a long history of regulation to improve resident safety and quality of care (Hughes & Lapane, 2005; OBRA, 1987). In 2012 CMS launched the National Partnership to Improve Dementia Care in Nursing Homes to reduce national antipsychotic medication (APM) rates by 15% over 18 months. APM has been federally regulated in NHs since the mid-1980s (OBRA, 1987), yet research suggests these medications are still used inappropriately in spite of evidence for the increased risk in mortality when given to persons with dementia (Schneider, Dagerman, & Insel, 2005; Schneider et al.,

2006). Two previous Black Box warnings in 2005 and 2008 issued by the US Federal and Drug Administration provided only temporary relief to the problem by briefly reducing the number of NHs residents on APM (Bonner, 2013; Chen et al., 2010; Dorsey, Rabbani, Gallagher, Conti, & Alexander, 2010; Lester, Kohen, Stefanacci, & Feuerman, 2011). A national initiative thereby was launched to promote awareness of the consequences of using APM among populations with dementia. According to a 2010 CMS Minimum Data Set Quality Measure and Quality Indicator report, 39.4% of NH residents nationwide who exhibited either behavioral problems or cognitive impairment received APM without a warranted diagnosis, as measured through the Psychotropic Drug Use quality measure. (For a detailed review of NH quality measures, see Castle & Ferguson, 2010; CMS, 2014.) In 2011, 23.9% of long-term stay residents (those who reside in a NH for greater than 90 days) were prescribed APM (Bonner, 2013). Specifically, in Florida, previous research details that pharmacotherapy is a leading mental health treatment within NHs. It is estimated that upon three months of admission 71% 85% of residents received at least one psychoactive medication and 15% 19% of residents received four or more psychoactive medications, of which approximately 25% were APM (Molinari et al., 2010, 2011). By the end of 2013 APM rates declined nationally by 15.1% with 28 states individually meeting the targeted reduction (Tritz, Laughman, &

*Corresponding author. Email: [email protected] This article was originally published with errors. This version has been corrected. Please see Erratum (http://dx.doi.org/10.1080/ 13607863.2014.998484). Ó 2014 Taylor & Francis

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Bonner, 2014). Florida ranked 37th nationally in its 13.3% total reduction of APM (Mullaney, 2013; Tritz et al., 2014). During this period, 22.1% of long-stay residents and 3.2% of short-stay residents received an APM in Florida (CMS, 2014). The aim of the present study is to determine, through qualitative data analysis, the typical strategies that have been implemented to reduce APM, to better understand what is still needed, and to make recommendations to improve practices. The National Partnership to Improve Dementia Care in NHs stems in part from frequent off-label APM use, or the use of APM for purposes outside of the FDA-approved drug label, for residents with dementia exhibiting behavioral symptoms viewed as problematic or challenging for caregiving staff. The ‘prescribing culture’ of NHs is an especially challenging environment to decrease medication usage due to its structural complexity (e.g., financial, regulatory), and the various disciplines (e.g., nursing staff, social workers, pharmacist, physicians) that must communicate regularly to ensure proper care and the judicious use of medications (Tjia, Gurwitz, & Briesacher, 2012). There is ample evidence to support the notion that APMs are prescribed to reduce the behavioral symptomology associated with dementia (Briesacher, Limcangco, & Simoni-Wastila, 2005; Chen et al., 2010; Kales et al., 2011; Kamble, Chen, Sherer, & Aparasu, 2008, 2009; Kontezka, Brauner, Shega, & Werner, 2014; Molinari et al., 2011), an outcome likely resulting from multiple structural and market factors (Castle, Hanlon, & Handler, 2009; Hughes, Lapane, & Mor, 2000) that persist in spite of evidence of the dangers (Carson, McDonagh, & Peterson, 2006; Schneider et al., 2005, 2006) and ineffectiveness (Briesacher et al., 2005) of APMs as a therapy for the behavioral symptomology associated with dementia. It is important to note that APMs are FDA-approved to treat the psychotic symptoms of patients with schizophrenia, schizoaffective disorder or delusional disorder and to treat bipolar disorder, major depressive disorder, and Tourette’s syndrome. It is estimated that 3.6% of longterm care residents nationwide have schizophrenia (Seitz, Purandare, & Conn, 2010), and approximately 10% are diagnosed with a serious mental illness (Becker & Mehra, 2005). Both of these estimates are significantly lower than the 23.9% of NH residents prescribed APM in 2011 (Bonner, 2013). Although delusions may be associated with the presence of dementia, there are marked differences between the delusions of individuals with schizophrenia and those stemming from dementia. Older adults with schizophrenia or similar disorders are likely to have a history of complex delusional episodes and the hallucinations experienced are primarily auditory (CohenMansfield, 2003). Those with dementia are more likely to have visual hallucinations whose content reflect distrust, abandonment, and paranoia (Cohen-Mansfield, Taylor, & Werner, 1998; Cummings, Miller, Hill, & Neshkes, 1987; Reisberg, Borenstein, Salob, & Ferris, 1987). Hallucinations and delusions developing from a dementia or related disorder commonly occur from environmental triggers, mental health issues, discomfort, pain, or a need for stimulation. They thereby may respond to environmental

modifications or nonpharmacological interventions in lieu of APM (Cohen-Mansfield, 2003; Rapp et al., 2013; Van Haitsma et al., 2013; Vernooij-Dassen, Vasse, Zuidema, Cohen-Mansfield, & Moyle, 2010; Volicer, 2012). The 2012 CMS initiative aimed to reduce APM use by promoting person-centered care and individualized care plans for behavioral issues (Bonner, 2013). The present study evaluates the progress of NHs in reducing APM use through analysis of a 19-item survey distributed to Florida Directors of Nursing, administrators, and other professional NH staff. The primary objective of this study was to describe how Florida NHs are responding to the initiative in their current practices, to identify challenges in reducing inappropriate APM use, and to recognize what is still needed to accomplish this goal. The specific aims of this study were to perform theme-based content analysis of two open-ended questions to provide specific details of the strategies and experiences of NH staff. As the CMS initiative continues, qualitative feedback is an essential component for building upon and advancing typical practices as it yields the unique, first-perspective of NH staff tasked with reducing these medications. Method Setting Participants were recruited from the 2013 Florida’s Joint Trainings sponsored by LeadingAge, with the assistance of the major regulatory body for NHs, the Agency for Health Care Administration and the Florida Health Care Association. The annual, legislatively mandated Joint Trainings were held at four sites throughout Florida (Orlando, Ft. Lauderdale, Tampa, and Tallahassee) and served to inform NHs of regulatory updates and survey expectations for the coming year. The present study’s questionnaire was distributed to conference attendees at the four sites before the talk titled, ‘Reduction of Antipsychotic Drug Use for NH Residents with Dementia.’ Participants were invited to complete the survey if they were currently working in a NH. The conference host reported 337 unique NHs were present at the 2013 Joint Trainings, accounting for approximately half of the 682 licensed NHs in Florida (AHCA, 2014). Participants A total of 276 surveys were collected at the Joint Trainings, a 34% response rate from the registered 805 conference attendees. This estimate, however, is conservative of the total number of individuals represented in our survey responses. At the last two data collection sites the researchers requested only one survey per NH be completed as it was determined that there were often more than one staff member per site attending. We estimate that collected surveys represent approximately a third of the total NHs in the state of Florida in 2013. Participants’ employment position was the only personal information collected. Respondents were not compensated for their participation financially or otherwise. Participants reported their job title as either Director of Nursing (DON) (n D 109), NH administrator (n D 95),

Aging & Mental Health social worker (n D 7), or ‘other’ (n D 65). Four participants did not report a job title. Subsequent qualitative analysis of ‘other’ yielded subgroups of NH staff such as managers (n D 28), nurses (n D 11), consultants (n D 6), minimum data set coordinators (n D 4) and other titles (n D 15) that did not appropriately fit an above category such as CEO, a discharge planner, or medical records coordinator. The subgroup managers could be further broken down into unit managers (n D 8), risk managers (n D 7), or other (n D 6) with duties ranging from dietary manager to regional manager.

Survey and measures Our survey instrument was adapted from The Advancing Excellence in Nursing Home Campaign, an online resource of clinical assessments and guides from the Centers of Medicare and Medicaid. The present study’s 19-item survey consisted of both descriptive and openended qualitative questions to produce a comprehensive assessment of APM use. The survey was exploratory in nature and developed for the purpose of this study alone. Theme-based content analysis was conducted for two open-ended questions described in detail below. The survey further consisted of six dichotomized ‘yes/no’ questions, four multiple answer questions with an openended ‘other’ choice, five multiple choice questions, one ranked response question, and one question asking participants to list their licensed bed capacity. Descriptive details are presented for the NH characteristics, current policies and barriers, and attitudes towards the CMS initiative.

Open-ended questions To assess the current approaches that NHs have implemented to monitor and reduce APM use, participants were first asked whether they are currently doing anything different to reduce their APM usage. When participants responded ‘yes’ they were asked to describe how they are currently reducing their APM rates. The second openended question asked, ‘What would be the best assistance that you could receive to achieve this goal?’ Participants were not limited in the length of their responses.

Facility characteristics Questions were included based on authors’ prior research and review of the literature that indicates an association between the quality of NH care and structural characteristics such as profit status, chain membership, and percentage of pay from Medicare (Harrington, Woolhandler, Mullan, Carrillo, & Himmelstein, 2001; Mor, Zinn, Angelelli, Teno, & Miller, 2004; O’Neill, Harrington, Kitchener, & Saliba, 2003). Profit status was measured as either ‘for-profit’ or ‘not-for profit’; chain membership was measured as ‘yes/no’ and the percentage of Medicare residents was measured by indicating one of the following: 0% 10%, 11% 20%, 21% 40%, or 41% and

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higher. Participants were also asked to list the number of licensed beds in their facility. Capacity for dementia care was assessed through four questions. First, respondents were asked to identify the percentage of residents with cognitive impairment or some type of dementia as either between 0% and 25%, 26% and 50%, 51% and 75%, or 76% and 100%. Second, a ‘yes/no’ question asked if their NH had beds designated for the care of residents with dementia. Culture change was measured with two ‘yes/no’ questions: whether staff was currently trained on person-centered care and if consistent assignment was practiced. Current policies and barriers Two multiple answer questions probed how the consultant pharmacist is involved in the care of residents and what data on APM is consistently reviewed. Participants were also asked to rank noted barriers to reducing APM use from 1 to 5 (with 1 being the least difficult and 5 being the most difficult). Additional multiple answer questions were presented asking which of the following tools/resources/ support (e.g., state NH association, CMS, private consultants) are utilized in interpretation of facility data and, if applicable, what additional assistance is provided by the corporation or chains for which they belonged. Attitudes towards CMS initiative One question was presented to gauge participants’ estimation of the likelihood of reducing APM by 15% in their facility, and two ‘yes/no’ questions asked if the respondents felt the national goal was realistic and worthwhile. Analysis Primary data was validated by two investigators. Frequency estimates and descriptive statistics were calculated using SAS 9.2. Content analysis methods were used as recommended by qualitative methods experts (Berg & Lune, 2012) to analyze open-ended survey response items. Open-ended survey responses were copied verbatim and text-based data were entered into Atlas.ti version 6, a qualitative software program. The primary investigator (gerontology doctoral trained student) conducted line-byline coding to develop an open coding scheme. A second coder (PhD trained qualitative expert in aging studies) reviewed the open coding scheme and made recommendations for collapsing of themes and subthemes. The open coding scheme was further analyzed and grouped into what resulted in three main themes related to changes in current practice to reduce APM, and three main themes related to recommendations for best assistance to reduce APM use. To ensure no single facility perspective was overrepresented in the qualitative analysis, each of the responses coded for themes and subthemes were checked for duplication by examination of three descriptive variables collected within our survey: licensed bed capacity, facility profit status, and how many people from your facility attended today’s talk. We excised one quotation

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that had a similar profile based on the three collected variables. Results Facility characteristics Participants reported their NHs had a median licensed bed capacity of 120, with 53.6% not-for-profit (n D 148) and 40.5% for-profit (n D 112). One hundred and fifty-three (55.4%) were part of a chain or corporation, and 88 respondents (31.8%) were employed in free-standing NHs. In comparison to data reported in 2010 about the characteristics of all Florida NHs (Harrington, Carrillo, Dowdell, Tang, & Blank, 2011), our sample is typical in average number of licensed beds (121 reported state average) and percentage as part of a chain or corporation (57.8% as part of a chain). Our sample, however, has a greater number of not-for-profit facilities when compared to the state average (25.3% not-for-profit). The rates of residents with cognitive impairment or some form of dementia were high with (n D 121) participants reporting rates of 51% 75%, and (n D 51) reporting 76% 100%, for a combined 87.9% of the sample identifying at least half of their residents as cognitively impaired or with some type of dementia. This is higher than the state average in 2010 for Florida NHs (46.7% of residents had dementia) (Harrington et al., 2011). It is important, however, to note that our survey question included cognitive impairment and dementia whereas the state average only included dementia. NHs listed high rates of both person-centered care practiced and consistent assignment (77.5% and 92.7%, respectively). Interestingly, only 33.3% of participants noted having beds specifically designated to handle the care of residents with cognitive impairment or dementia. For a comprehensive breakdown of NH characteristics, see Table 1. Table 1. Florida nursing home survey facility characteristics. Facility characteristic

N

For-profit status 148 Part of a chain 153 Percent medicare 0% 10% 55 11% 20% 95 21% 40% 85 41% or higher 36 Percent of residents with cognitive impairment 0% 25% 26 26% 50% 71 51% 75% 121 76% 100% 51 Beds specified for dementia care 92 Person-centered care 214 Consistent staff assignment 256

% 53.6 55.4 19.9 34.4 30.8 13 9.4 25.7 43.8 18.4 33.3 77.5 92.7

Notes: Due to missing data, N varies from 241 to 271 for facility characteristics. Missing data were reported as follows: for-profit status (n D 16), chain membership (n D 35), medicare (n D 5), cognitive impairment (n D 7), beds specific for dementia care (n D 8), person-centered care (n D 8), and consistent staff assignment (n D 9).

Current policies and barriers NHs overwhelmingly stated their consultant pharmacist was tasked with monitoring psychoactive medications and just over half of the sample reported their pharmacist also provided staff education about psychoactive medications. Sixty percent of the NHs sampled indicated their current practice to monitor APM included ongoing data analysis, assessment of quarterly quality measures, individual evaluation within the minimum data set, and routine review of residents hospitalized or rehospitalized. Furthermore, 59% of NHs routinely conducted monthly review of residents on APM. Reflective of corporate concern and oversight, the following additional tools were noted if the NH belonged to a chain or corporation: education materials (37.6%), clinical support (42.5%), and data analysis (28.6%). A breakdown of resources utilized is provided in Table 2. Of the possible barriers to reduce APM, ‘too busy with other demands’ was ranked the most difficult barrier (a ranking of 5) and ‘inadequate staffing’ was listed as the least difficult (a ranking of 1). Other barriers had mixed ratings, with 31.9% of respondents reporting reimbursement as their least difficult barrier, while 23% of participants rated it as the second most difficult. See Table 3 for a list of these ranked responses. Attitudes towards CMS initiative Participants’ expectations about the likelihood of achieving the national goal was encouraging with 76.8% of respondents reporting the goal was ‘very likely’ or Table 2. Reported resources utilized to reduce antipsychotic medication. Resource

N

%

Pharmacist Monitoring psychoactive meds Staff education Routine interaction with family/friends Interdisciplinary care meetings Data analysis Quarterly quality measures for ATP use Individual evaluation during MDS Review Routine review of residents on ATP Daily Weekly Monthly Quarterly Admission/readmission to hospital

264 150 49 88

95.6 54.3 17.7 31.8

215 190 240 13 31 163 32 180

77.9 68.8 77.5 4.7 11.2 59 11.5 65.2

Tools/resources State NH association Quality improvement organization Florida Health Care Association (FHCA) FACA or LeadingAge CMS A private consultant

77 125 84 30 144 91

27.9 45.2 30.4 10.8 52.1 32.9

Notes: Due to missing data, N varies from 243 to 276 for reported resources. Missing data were reported for the following: frequency of resident review on APM (n D 33) and Florida Health Care Association (n D 33).

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Table 3. Ranked barriers to reducing antipsychotic medication.

Possible barrier Inadequate staff Lack of training Poor coordination Reimbursement Too busy

1 n (%)

2 n (%)

3 n (%)

4 n (%)

5 n (%)

60 (41.9) 23 (15.4) 28 (19.8) 47 (31.9) 16 (10.8)

24 (16.7) 41 (27.5) 27 (19.1) 21 (14.2) 27 (18.2)

23 (16.0) 37 (24.8) 41 (29.0) 14 (9.5) 29 (19.5)

22 (15.3) 23 (15.4) 21 (14.8) 31 (21.0) 32 (21.6)

14 (9.7) 25 (16.7) 24 (17.0) 34 (23.0) 44 (29.7)

Total 143 149 141 147 148

Notes: Missing data were reported for the following: inadequate staff (n D 124), lack of training (n D 118), poor coordination (n D 126), reimbursement (n D 120), and too busy (n D 119). Participants were asked to rank barriers from 1 (least difficult) to 5 (most difficult).

‘somewhat likely’ to be achieved. Importantly, when asked if the goal was realistic, 69.2% responded yes, and 81.5% agreed the goal was worthwhile.

medications.’ With increased monitoring of clinical staff, a NH administrator (#3) stated: We have renewed our focus and utilize an interdisciplinary team approach to reduce [APMs].

Qualitative themes for current APM policies Changes in practice Out of the 192 respondents who answered ‘yes’ to the question ‘Are you currently doing anything different to reduce antipsychotic medications?’, 181 participants provided written responses detailing their current practices. The three overarching themes related to this question are as follows: (1) increased review of residents and APMs, (2) reduction in number of APMs or dosage, and (3) use of nonpharmacological interventions. In the following analyses, quotes are listed by subject IDs and job titles to distinguish individual perspectives. Theme 1: frequent review of residents and medications The most commonly reported change in practice within NHs was more frequent review of resident behavior and resident medication patterns. Residents beginning a new APM, continuing use of a prior APM, or adjusting to a new dose of an APM were of particular interest. Enhanced record keeping of residents permitted staff greater oversight to potentially avoid unwarranted usage. NH representatives’ stated weekly standard of care meetings and required consultation for any medication change were strategies to reduce APM use. Within this main theme of more frequent review of residents and APMs, subthemes of increased monitoring by clinical staff and additional mental health support were of note. Subtheme 1: increased resident monitoring by clinical staff. Survey respondents clearly stated that they increased the hours of mental health clinical staff relative to nurse aides, who typically provide the majority of resident care. NHs included clinical staff more often in resident care meetings, or in the case of one NH, the DON stated the Medical Director and Advanced Registered Nurse Practitioner evaluated residents in partnership with the NH psychiatrist who visited weekly. Pharmacy consultants were also frequently listed as additional clinical staff in attendance at monthly staff meetings, in the review of ongoing medications, or in the recommendation of medication reductions. A discharge planner (#4) stated that their NH now uses ‘our pharmacy consultant [to] review

A DON (#18) noted the use of joint collaboration in patient care as a changed practice in response to the CMS initiative: [We currently have] monthly psychoactive meetings with Medical Director and psychiatrist and interdisciplinary team training.

Subtheme 2: mental health support. Facilities increased their residents’ access to mental health professionals by either hiring or contracting new staff with mental health qualifications or having mental health professionals’ consult and evaluate residents more often. Inability to find adequate mental health support is often cited as a barrier for mental health care in NHs, making this observation an important indicator for potential success in reducing APM. A NH Administrator (#1) attested to new staffing stating, ‘[We] hired [an] ARNP with psych/mental health training.’ A supervisor (#11) stated: Patients seen and evaluated by a psych doctor as often as possible to reduce psych meds.

Theme 2: reduction in number of medications or dosage The next most frequently employed method within NHs was attempts to reduce dosage of APM for residents. NH administrators and DONs often stated they want residents to be on the lowest dose possible. However, one NH administrator (#38) captures the tension in dose reductions as a method for reducing APM rates within a NH, [We try] gradual dose reductions when appropriate, but a lot of these fail. Residents with appropriate diagnostic criteria for APM may not respond to altered dosages, therefore targeting inappropriate or unwarranted use for APM is a more viable option to reduce rates. Of concern, many facilities employ dose reductions as a strategy to comply with rate reduction. Theme 3: nonpharmacological interventions Various nonpharmacological interventions were listed as new methods to better engage residents, particularly those

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with ‘challenging behaviors.’ Under-stimulation within NHs may lead to agitation and unrest (Camp, Cohen-Mansfield, & Capezuti, 2002; Volicer, 2012), and the movement to reduce APM has prompted NHs to engage residents more with activities and alternative interventions. The following are examples listed by job title reporting: DON (#38): [We are] trying organic measures, aromatherapy and relaxing teas. Social Worker (#4): Intervention-relaxation; compassionate touch massage-relaxation/meditation room. NH Administrator (#11): iPod music and memory program; wellness & exercise. Blanket warmers, dolls, etc. specific and assigned for likes/dislikes.

Best needed assistance Of the respondents who participated in this survey, n D 129 responded to the opened ended question, ‘What is the best assistance that you could receive to achieve this goal?’ Both reviewers agreed that three themes emerged from this question (see Table 4). An overarching latent theme was the need for all stakeholders to be knowledgeable and invested in the new CMS initiative. Theme 1: education Respondents most frequently named education as the best assistance they could receive to reduce APM. Three subthemes emerged within the main theme of education: physician education; staff education; and family and general education for the NH. Subtheme 1: physician education. The most frequently cited educational area specifically highlighted physicians prescribing APMs. Participants stated that physicians ‘are not fully buying in the program’ and felt a dissonance between their efforts and physician prescribing behavior. Concerns were voiced that physicians were not aware of Table 4. Themes and subthemes for open-ended survey questions. Changes in current practices Theme: frequent review of resident and APMs Subtheme: increase resident monitoring by clinical staff Subtheme: mental health support Theme: reduction in APMs or dosage Theme: nonpharmacological interventions Best assistance themes Theme: education Subtheme: staff education Subtheme: physician education Subtheme: family and general education Theme: clinical support Subtheme: general clinical support Subtheme: mental health support Subtheme: coordination and communication Theme: More financial resources and reimbursement

the dangers of APM for residents with dementia and did not promote nonpharmacological interventions for residents with dementia. An exemplar quote of the responses from one risk manager (#16) included the following: [We need to] educate physicians that the use of antipsychotics are not the answers for residents with dementia/ behaviors. . . more understanding that activities are needed on a regular basis for dementia residents.

Other recommendations were to educate physicians on proper diagnosis for specific medications, and to emphasize the importance of follow up visits. Subtheme 2: staff education. Survey respondents addressed many facets for staff education. Participants indicated the need for direct care staff education as well as the need for area specific education on behavior management and mental health training. One administrator (#28) specified the need for new strategies and tools: Need to develop tools for NH staff to use to help reduce the percent of psych meds- then educate and target reduction.

Subtheme 3: family and general education. Participants said that families should be educated about the risk of APMs and that the education of families plays a critical role for approving the adjustment of medications. One risk manager (#7) explicitly stated that for success in decreasing medications, ‘families need to be open to reductions.’ Participants also noted that education was needed for all parties involved and educational materials should be provided. One DON (#37) noted the need for comprehensive education at the NH level concerning: How to deal with advanced dementia and maybe behavioral issues, activities non-pharmacological approaches to be part of the process.

Theme 2: clinical support Another dominant theme related to assistance in reducing APM use was clinical support. Request for support ranged from general clinical support, to mental health support, to coordination among all institutions involved in resident care. Subthemes echo the desire for commitment from all parties, and the need for additional professional assistance within NHs. Subtheme 1: more clinical and mental health support. Participants identified need for assistance from consultant pharmacists, attending physicians, and medical directors. Those who identified a need for mental health support mentioned difficulty in finding these services. An administrator noted that more mental health providers were needed in the area and that there were ‘few available.’ A Director of Nursing (#19) responded we have difficulty getting a psych MD [to the facility]. Additionally, a DON and administrator mentioned support on the community and state level would be the best assistance they could receive: Geriatric psych support in the state of Florida (DON, #8).

Aging & Mental Health Subtheme 2: coordination. Improvements in coordination between hospitals, assisted living facilities, physicians, and NHs were cited as ways to help NHs achieve their reduction in antipsychotic rates. Survey responders were acutely aware of the impact of transitions of care between institutions. Reflecting on the community impact one administrator (#29) wrote the best assistance they could receive would be: [Increase] Physician [and] community awareness of appropriate medication use, especially in community and ALF patients. Therefore, reducing patients referred to SNF with history of anti-psychotic usage.

Another administrator (#2) noted common practice with hospital discharge practice: Get the doctors in the hospital to not send a resident to us on two or more antipsychotic meds to start with just so they meet hospital d/c [discharge] criteria.

A DON (#10) listed the problem of medication coordination within resident transitions: I would like to see hospitals be part of this process. Too often residents come to us with anti-psych meds and they seem to remain with the resident.

One DON (#5) stated a main problem relating to the new CMS initiative was coordination within the NH with current diagnosis and treatment plan for residents: Accurate analysis and dx of residents in a nursing home [is needed]. Many are treated for years for a dx they do not have.

Theme 3: financial resources and reimbursement Respondents acknowledged improved dementia care could be achieved, but financial support was needed to properly allocate for increased one-on-one focused care and proper training of staff. One DON (#7) stated: [We need] improved reimbursement to allow additional staffing to provide around the clock person-centered care in our dementia unit.

Similarly, an administrator (#5) stated what was needed was: [Higher] reimbursement to allow staff to provide behavior mod [modification] in addition to direct care.

Discussion This study explores how NHs responded to the 2012 CMS initiative to reduce inappropriate APM use among residents. The aim was to examine strategies that have been implemented and determine what is still needed to reach the prescribed goal. Respondents of our survey were largely employed in leadership positions (e.g., NH administrators and DONs) and primarily involved in the

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execution of patient care, operating procedures, facilities policies, and management and education of all staff members. Results confirm the majority of NHs are actively working to reduce unnecessary antipsychotic medications, with over three-fourths of respondents reporting the goal was ‘very likely’ or ‘somewhat likely’ to be achieved. Within the first theme of more frequent review of residents and medications, a prominent change in practice was the addition of a pharmacist or mental health professional to either an existing interdisciplinary team or as a consultant to staff. NHs actively sought additional clinical staff and reported adjusting roles of current staff to monitor changes in behavior or function. Surprisingly there was little to no mention of the role of certified nursing assistants. It is possible that participants felt certified nursing assistants were already part of the interdisciplinary team and therefore their contribution was not captured when asked about current changes in practice. It is important, however, to emphasize the exclusion of certified nursing assistants from care teams is one of the greatest impediments to person-centered care and alienates one of the richest sources for the promotion of person-centered and individualized care. Certified nursing assistants with access to information, resources, and support show a positive, significant correlation with the ability to perform individualized care (Caspar & O’Rourke, 2008) and NHs without support or respect for certified nurse assistants experience high turnover and compromised resident care (Castle & Engberg, 2005; Collier & Harrington, 2008). Alternatively, models of care that promote interdisciplinary dialogue and training for patient care, such as the STAR-VA system, find greater staff buyin and commitment, two fundamental components that yield staff stability and person-centered care (Karlin, Visnic, McGee, & Teri, 2014). In regard to reducing medication, the practice of dose reduction was commonly employed as a vehicle to reduce medication rates. Dose reduction may be an appropriate approach for residents with serious mental illness warranting an APM treatment reduction plan, but unfortunately there has been no evidence to support APM dose reduction per se as a method to diminish the risk of mortality for persons with dementia (Lester et al., 2011). Other pharmacological treatment (e.g., antidepressant medication) or a combination of pharmacological and nonpharmacological interventions may be most appropriate for reducing the behavioral symptomology associated with dementia (Cohen-Mansfield & Jensen, 2008; Porsteinsson et al., 2014; Volicer, 2012; Volicer, Frijters, & Van der Steen, 2011). Results detail the growing interest in nonpharmacological interventions that are effective and feasible for residents with dementia. Participants in our survey increased resident engagement in activities and nonpharmacological interventions specific to resident preferences. Interventions individualized to the preferences of residents with dementia have been effective in reducing behavioral symptoms (Cohen-Mansfield, Libin, & Marx, 2007; Van Haitsma et al., 2013), and even more standardized general nonpharmacological interventions showed modest success (Cohen-Mansfield, Thein, Marx, & Dakheel-Ali, 2012).

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Increased control of environmental triggers has also been a successful method for reducing behavioral symptoms, and research regarding the association between depression and dementia (Volicer et al., 2011) yields an underlying rationale for treatment of some types of co-morbid mental health conditions among residents with dementia. Many respondents in our survey described various nonpharmacological approaches they now employ in their NHs, and although the literature on nonpharmacological interventions greatly varies in method and study design, there is a common theme that increased attention and stimulation, ideally tailored to the needs of a resident, can improve a resident’s condition and quality of life. Without proper knowledge of methods to reduce APM, staff may feel inadequately prepared to reach the national goal. Although educational information is available through multiple federal and state agencies (e.g., CMS, Quality Improvement Organizations, NH Associations), ensuring that pertinent and quality training is given to all staff is challenging, particularly when NHs are not compensated for the extra time needed to educate staff. As echoed in our findings, system-wide education for the adverse side effects of APM must be reinforced. Misconceptions among all levels of NH staff (e.g., directors and certified nursing assistants) concerning the risks and benefits of APM to enhance behavioral management for persons with dementia is still a pressing issue in NH care (Lemay et al., 2013). Education, however, is insufficient when given alone as an intervention. In concurrence with research findings determining that general staff education by itself yields minimal favorable outcomes for persons with dementia, comprehensive skills training presented within a systematic framework is required for meaningful, sustained for improvements in care practices. Skills training must be ongoing, involve hands on supervision (Burgio et al., 2002; Cohen-Mansfield, 2001), and be provided immediately to all new NH staff due to high volume of staff turnover. Meaningful changes may be ineffective without clinical or mental health specialists available to assist in the training or review of difficult cases. This theme is most pressing in geographic areas where few trained professionals are available in geriatrics and mental health specific to long-term care. Most prescriptions for NH medications are written by non-psychiatrists, nongeriatricians, and very few meet the gold standard of a geriatric psychiatrist specifically trained for long-term care. Although most would agree that involving trained mental health professionals improves outcomes for residents, limitations in staff resources and finances restrict this option as echoed in our findings. Our respondents highlight an important tension within NH care; the challenges of improving care within current budgets. Limited reimbursement dictates the available resources and potentially inhibits NHs’ ability to adapt new practices and to acquire staff with mental health expertise. The number of respondents reporting that education is the best assistance they could receive for reducing APMs indicates a comprehensive, community partnership is necessary to foster meaningful and lasting

change in prescribing habits, better support from staff, and enhanced attention to resident and family preferences. Coordinating linkage in care transitions between institutions could potentially help prevent the harmful continuance of unneeded medication usage. This study speaks to the challenges of changing the culture of care within NHs. The inappropriate use of APM can be partly attributed to systemic problems within the traditional, institutional care of NHs. The movement of ‘culture change’ aims to deinstitutionalize NH care though the establishment of collaborative decision making, closer relationship with residents, and resident directed care (Koren, 2012). Interestingly, our study had high-response rates of participants stating their NHs practice person-centered care (77.5%) and consistent assignment (92.7%), two main objectives of ‘culture change’. However, these response rates may have been unintentionally inflated due to the ambiguity in defining components of ‘culture change’, an ongoing issue in the field (Rahman & Schnelle, 2008). Even so, structural elements such as resources, staffing levels and high turnover rates are persisting barriers preventing NHs from fully committing to individualized, patient-centered care (Zimmerman, Shier, & Saliba, 2014). Although research exploring the outcomes of ‘culture change’ is preliminary, recent studies show the potential for improvements in resident quality of life and quality of care (Grabowski et al., 2014; Shier, Khodyakov, Cohen, Zimmerman, & Saliba, 2014). There are several limitations to this study that should be noted. The survey was created for purposes of this study alone and therefore estimates of validity and reliability cannot be provided. Additionally, the survey instrument did not differentiate between short-stay and long-stay resident and these populations may require alternative strategies and resources to reduce APM not discussed in this study. Participants were recruited from a convenience sample with limited information collected regarding individual NHs, resulting in an inability to separate multiple surveys that might represent a single facility. Despite our efforts to examine the qualitative data for duplication and facility overrepresentation, multiple informants from the same NH might be present within the data. Absent informed consent we cannot differentiate individual NHs precisely; however, we can assume at a minimum that our qualitative data represent differing staff perspectives that oversee various operations of patient care for a third of Florida NHs. A wide range of professional staff was represented in our survey, but the perspective of certified nursing assistants was noticeably absent. There were only two certified nursing assistants registered for the Joint Trainings out of the 805 total attendees, a result of the audience targeted for these meetings. Lastly, there is potential for bias in our results as all data were self-reported. Despite these limitations we believe this study furthers our understanding of how NHs are successfully reducing antipsychotic medications. Respondents provided detailed qualitative feedback on their approaches and strategies. Our results are encouraging because they detail specific approaches to reducing antipsychotics including

Aging & Mental Health monitoring medication changes as residents move to and from hospitals and community settings. Indeed these findings reinforce the realization that long-term reduction of APM will be the product of a sustained multifaceted national system change. Certainly within the structure of long-term care, initiatives such as the National Partnership to Improve Dementia Care encourage nonpharmacological approaches to troubling behaviors of NH residents, but these approaches need to be provided in hospitals and in other residential long-term care supports and services. NH staff members are aware of the necessity to reduce APM and are working to reduce inappropriate use. We hope that their widely held positive attitudes towards the initiative will be reinforced in hospitals, community settings and within the primary care office where many elders with cognitive impairment first receive care for dementia. Acknowledgement The authors would like to acknowledge and thank LeadingAge for their support in this project. The authors would also like to specifically thank Janegale Boyd and staff for their assistance in obtaining registration data for the 2013 Joint Trainings.

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