One in 5 Americans are taking at least 1 psychotropic medication.1 Elderly dementia patients in extended care facilities are the most likely population to be prescribed psychotropic medication: 87% of these patients are on at least 1 psychotropic medication, 66% on at least 2, 36% on at least 3, and 11% on 4 or more.2 Psychotropic medications alleviate the symptoms of mental illness, such as depression, anxiety, and psychosis. Unfortunately, these medications often have adverse effects (AEs), including, but not limited to, excessive sedation, cardiac abnormalities, and tardive dyskinesia.
In 1987, Congress passed the Nursing Home Reform Act (NHRA) as part of the Omnibus Budget Reconciliation Act. The NHRA mandated that residents must remain free of “physical or chemical restraints imposed for the purpose of discipline or convenience.”3
In 1991, in order to meet the NHRA requirements, the Centers for Medicare and Medicaid Services (CMS) issued a guideline that nursing homes should use antipsychotic drug therapy only to treat a specific condition as diagnosed and documented in the clinical record. In 2006, CMS published guidance on the reduction of psychotropic medication usage. These CMS guidelines are the community-accepted standards for prescribing psychotropic medications, and accrediting bodies expect compliance with the guidelines. The guidelines also recommend that antipsychotics should be prescribed at the lowest possible dose, used for the shortest period, and continually undergo gradual dose reduction (GDR).4 To ensure these standards are met, a review of the use of psychotropic medications should be performed regularly.
The purpose of this project was to improve documentation of GDR and review of psychotropic medication based on CMS guidelines in the community living centers (CLCs) at the Carl Vinson Veterans Affairs Medical Center (CVVAMC) in Dublin, Georgia.
The CVVAMC provides long-term care to veterans living in CLCs in a comfortable, homelike environment with a person-centered, nursing-home level of care. During a patient’s stay, clinical pharmacy services reviews patient medication use regularly. Additionally, an interdisciplinary team (IDT) of physicians, pharmacists, nurses, recreation therapists, dieticians, and chaplains meet to discuss the medical, psychosocial, and spiritual needs of the residents at the time of admission and quarterly thereafter. Family and caregivers are invited to attend as well.
During the meeting, the IDT care plan is updated and reviewed with the veteran. Currently at the CVVAMC, care plans include discussion of pain management; however, the plan does not address psychotropic medication use. To be compliant with CMS guidelines, during IDT meetings discussion of psychotropic medication use would be advantageous, because physicians could receive input and feedback from other health care team members in determining whether psychotropic medication changes are needed.
All documentation and chart notes are recorded and stored in the Computerized Patient Record System (CPRS). The purpose of an electronic template within CPRS is to provide standardized, guided documentation in an easy-to-use format that can be integrated smoothly into the existing system. Template utilization has been shown to improve documentation of medication reconciliation, health records, and coding in the VA health system.5-7 A review of CPRS showed that no template existed for documenting psychotropic medication initiation and GDR.
The authors’ primary objective was to improve patient record documentation in CPRS through implementation of staff education and an electronic template for physicians to document the management of psychotropic medications and patients’ GDRs. The secondary objective was to implement a discussion involving the physician and other members of the team during IDT meetings about patient safety and effectiveness of psychotropic medications.
To improve the suboptimal compliance with the CMS guidelines, an electronic template was created to evaluate GDR attempts and facilitate review of prescribed psychotropic medications. The pharmacy and therapeutics committee approved the template, and the clinical applications coordinator implemented the electronic template. The template was then revised as necessary for ease of use, based on health care provider (HCP) and pharmacist feedback.
The use of the electronic template was phased in over a 1-month period. Complete implementation was achieved in January 2014. An in-service was provided for nurses, HCPs, and directors on the importance of psychotropic medication review and GDRs. A second in-service was conducted for the HCPs to learn how to properly complete the electronic template. Providers were instructed to use the template during IDT meetings when completing monthly chart reviews and changing psychotropic medications.
Additionally, resident assessment coordinators who attend all IDT meetings were requested to remind the team to discuss psychotropic medication use if appropriate in an effort to add a psychotropic medication review to the IDT care plan.
To determine whether the electronic template improved documentation, a retrospective chart review of CPRS was conducted February 2014. The study included veterans in the CLC who were prescribed psychotropic medications since January 2014. The subjects who screened positive for psychotropic medication use were further evaluated by chart review. Before and after implementation, information was collected on the number and percentage of patients who had documentation in their CPRS records of a psychotropic medication review and on whether a GDR evaluation was recorded in CPRS. Additionally, a clinical pharmacist specialist attending the IDT meeting monitored the incidence of psychotropic medication review or discussion that took place if the veteran was on an included agent.