Providing care in skilled nursing facilities (SNFs) and assisted living and memory care communities includes any number of priority issues, with the role of medication management ranking at or near the top of the list, long term and post-acute care (LT/PAC) professionals say. 

Making sure residents receive necessary prescriptions on time for pain and underlying conditions, while maintaining a vigilant stance on the use of psychotropics (which includes antipsychotics) and opioids is part of a complex effort that plays a vital role in any facility’s bid to maintain and improve quality while striving for clinical excellence, these experts stress.

As the LT/PAC profession nears the end of a decade-long push that has seen the use of antipsychotics tumble dramatically, issues like coordinating care and employing patient-centered care models have also become significant drivers in how medication management helps shape the way in which providers and residents view quality of life in a facility.

Making Sure to Get it Right

Fiora Petillo

Flora Petillo, senior vice president of strategic initiatives and clinical practice at Genesis HealthCare, spearheads her organization’s care coordination efforts for both short- and long-stay residents, working collaboratively with physician colleagues. 

She says unlike most LT/PAC providers, Genesis is a member of an accountable care organization (ACO), with many residents’ care tied to the program that is now in its fourth year.

A colleague, Molly Langford, senior director of clinical practice at Genesis, is also focused on improving patient care based on delivering evidence-based solutions to clinical teams. For her, medication management is all about providing the right medication to the right patient at the right time.

“You start by having the right medication for the diagnosis of each patient,” she says. “Then you explore how well that patient can tolerate the medication and really try to make sure you are using it in a way where the benefits outweigh the risks. In geriatric care it is all about the ‘start low, go slow’ mantra that is focused on first using the lowest dose necessary to help treat the underlying illness.”

Two Types of ‘Stays’

Petillo notes that in the LT/PAC setting Genesis is really serving two patient populations. One is the short-stay cohort, grouped together by the fact that these residents are expected to return home. They also often arrive at the SNF from an acute-care hospital. 

She says on admission these patients have their medications scrutinized and possibly trimmed to reduce unnecessary doses or even entire medications. “The hospital tends to be more adventurous with meds for this population,” Petillo says.

When these short-stay residents are discharged back to the community, there are questions not only about what medications to maintain at home but also questions about the affordability of prescription drugs. “The latest and greatest meds may not be continued,” she says. “We really work hard also to connect the patient to a primary care provider and communicate with them to let them know they are leaving that facility.”

Medications Tailored to Resident

The second patient population is long-stay residents. The same philosophy holds for them, which is to make sure the medications are proper and in the right dosage. The difference, however, is that as these residents remain in the facility, their various chronic conditions may force changes in management of their drugs.

“We ask ourselves if the medication is still benefitting them or have we moved into a more palliative approach to care, like say for the later stages of dementia,” Petillo says. “There may be an opportunity to go off some medications that are not as effective in the later stages. You really have to monitor the patient trajectory when you do care.”

It is critical to be honest with the resident and take the time to have conversations with them and their families on matching the medication management cycle to their own goal of what is most important to them as individuals, she says.

“We want to match the care we are giving to the patient and not be doing things just because you can, but instead identify the patient’s own health and vision,” Petillo says.

Molly LangfordAn example, Langford says, is diabetes management. Clinicians follow evidence-based care in this area, which involves a keen focus on numbers, like glucose levels. But for some patients with multiple chronic diseases and a limited life expectancy, the numbers are not paramount.

“This is where the goal for the patient may be more about quality of life and them enjoying certain foods. The medications in this case would be more about the quality of life than about the strict adherence to a medication that may become a burden,” she says.

A Mission to Reduce Medications

When it comes to medication management, the buzz remains about implementing programs and processes to cut down on the use of antipsychotics, which are part of the larger family of drugs classified as psychotropics.

For Dinaz Bengali, director of nursing for Bartley Healthcare in Jackson, N.J., the changes in how antipsychotics are distributed has been dramatic in recent years. “Basically, we have worked on reducing antipsychotic medications. In the past we as a profession would always start the patient on meds, but now we look at this before we start them off and then review their use on a monthly basis if we keep them on,” she says.

When a nurse or related staff member sees disruptive behaviors, they are documented, but antipsychotics are only given when absolutely necessary. Beyond even the clinical issues of having someone on antipsychotics, there are practical safety concerns, too, as Bengali notes that residents on this class of drugs experience more falls, for instance, than those who are not.

Once a Cop, Always a Cop

Lauren Kessler, administrator at Bartley who works closely with Bengali, says there is also plenty of communication with the resident and their loved ones about family history, for example, and the individual’s life story, which can help facility staff figure out what may be causing behaviors or how to help remedy problems without turning to medications.

Bengali points to an example of one resident who would have awful issues with going to sleep at night. The old way of medication management would have been to dose the person to help them sleep, but the new way, the person-centered care way, involved asking questions about why the insomnia was so pronounced in this one individual.

“What we found was that this person used to be police officer and for years worked the night shift,” Bengali says. “In response to this news, we adjusted our environment and found a way to change his sleeping hours to reflect his past life.”

Other nonpharmacological methods that Bartley has found useful for its dementia residents is distraction, or ambulation. “Distraction is a big thing, such as giving a resident a task like folding towels. Ambulation, or walking them around, helps and so does food; giving a snack when they are upset can be a great way to work around behaviors, as can music.”

Results Are Positive

Kessler says the efforts to steer away from antipsychotics has reaped positive rewards. Since December 2018, Bartley has seen a 50 percent reduction in the use of such medications. The numbers fluctuate, and actually leveled at some point due to Bartley taking in some 22 new residents from a facility that had shut down. The fresh residents were receiving antipsychotics at a higher rate, but that use has gone down now that they have a new home.

Other numbers show short-term residents at Bartley with a 0 percent use of antipsychotics, compared with the state of New Jersey average of 1.5 percent and national average of 1.9 percent.

Long-term Bartley residents who are on antipsychotics had a rate of 4.1 usage percentage versus the state average of 9.5 percent and national average of 14.3 percent, Kessler says, citing statistics from the Centers for Medicare & Medicaid Services.

Bengali says the positive results are part and parcel of all new residents with a dementia diagnosis receiving a thorough psychiatric review, with the goal to reduce or eliminate medications that were possibly prescribed in the hospital setting.

Depression a Major Factor

Melissa Green
For Melissa Green, chief clinical officer, Trio Healthcare, the effort to turn residents away from antipsychotics as part of a medication management program has to consider all forms of mental health issues related to both dementia and non-dementia scenarios. 

Trio, which owns, operates, and manages 23 facilities (18 SNFs and five assisted living communities) in Ohio and Virginia, prides itself on nonpharmacological intervention, Green says. As part of the evaluation and monitoring of a resident’s health and well-being, Trio care teams have learned to recognize signs of depression.

“This is really under-evaluated in the elderly,” Green says. But it should not be, and it should not be unexpected considering the life-altering change of moving from home or a long term living arrangement to a SNF or assisted living community, she says.

“A lot of our residents come to us as their health is deteriorating, and then they have of course lost their home, and for a lot of them their properties have been sold and family members may be lost,” she says. “They move into a facility and no longer have all of that. I mean, that would depress me as well, which we don’t like to think about.”

So, to see where a new resident is at in this regard, an evaluation takes place that includes a depression screen. “Most come from the hospital where—face it—hospitals have free range to throw medications at people with dementia who may act up. They are discharged to us, and we have to figure out how to get rid of their use,” Green says.

Participation Figures in the Mix

Once a new resident is in the facility, part of the assessment keys on socialization, which helps to weigh medication use and possible alternatives. 

“Are they coming to the dining room or coffee chats or what not,” she says. “If they are isolated, we look into psychosocial history. Some folks we get are not verbal, and maybe they don’t communicate or have dementia, it can be really hard to diagnose or assess them.”

Green says even when a resident displays disruptive behaviors or acts out, the care teams convene with the goal of avoiding medications if at all possible.

“And, if we have someone who is, say, on antidepressants, we are constantly evaluating and looking at gradual dose reductions to see how they react. And, sometimes they even come to us on medications and they have no diagnosis,” she says.

Some of the methods to ease residents without deploying medications include activities or use of a quiet room, featuring sound therapy, such as hearing waterfalls and soothing lights. “When we see someone escalating, we can try these interventions,” she says.

The same holds true for those residents who may experience pain to the point they have been put on opioids.

“A lot of people come here and have been taking opioids for a long time,” Green says. In cases where opioids are the choice prescribed by a doctor, it usually comes in the form of fentanyl patches for cancer patients, for example, but the process is done on a tiered basis with attempts starting at less potent drugs all the way up to the strongest option if necessary.

“When someone is terminal, we don’t want to see them in pain, especially if there is no chance for them,” she says.

Searching for Alternatives

When it comes to medications and how to utilize them, and when to do so, Corie Sass, social services coordinator, Vetter Health Services, Elkhorn, Neb., says there are a lot of hands-on skill sets for nursing staff to deploy before that may even be necessary.

A lot of research and programming in the past five years has pinpointed ways to understand dementia and how better to communicate with residents.

“When you see a resident being combative and yelling out and challenging, this is typically treated with antipsychotics, but we are teaching our teams to interpret what the resident is trying to communicate first,” Sass says.

She points out that much of what a nurse does is highly personal, as in helping to bathe a resident or take the person to the bathroom, so much care needs to take place to ease into these situations, especially if the resident with dementia is displaying disruptive behaviors on a routine basis.

 “When you think about, like when you are undressing a resident, they may not understand what is happening, and this can provoke a response. We are telling our people, here are some ways to approach this so, for example, you don’t get kicked,” Sass says.

Eye Level Important

One of the most important things to do for a nursing staff member is to get down or below eye level of residents, Sass says. When the resident is sitting in a wheelchair, for example, it is key for the caregiver to lower herself, as towering over someone can be very threatening.

“There is also 7 and 7. This means to make all of your sentences to a resident seven words or less and give them seven seconds to respond,” she says. Simple and direct communication, done at eye level or below and with a happy and sparkling manner, is the way to go.

Does it work? Yes, she says. With the national averages of antipsychotic use near 15 to 20 percent over the years, Vetter has seen the new methods of communication help take their levels down to 6 to 8 percent.

“When you look at them trying to communicate, they may be cold, hungry, or need to use the bathroom, or be in pain as well. When they are uncomfortable it comes out in different ways,” Sass says.

One example is of a woman resident who would wander from room to room, disturbing other residents and care teams. The resident was locked into a pattern, it seemed, but it turns out she was simply trying to get to a bathroom.

“With dementia patients you cannot be task-focused, which is hard for staff to do, since it is counterintuitive to what nurses do as part of their normal routines, which is working off lists of tasks to be achieved on a daily basis,” Sass says.

Finding the Transformation

Other advice is to not send too many staffers to complete a task, since this can be overwhelming for a patient with dementia. 

“If you take two team members, one team member goes in with the eye level communications, and the other team member takes a back seat by not standing there and talking at the same time,” she says. “One team member should be the driver and say to the resident, ‘I have a helper’ so as not to make it fearful for them. It gives the resident a sense of peace and comfort.”

In the end, these approaches take time, but oftentimes result in extraordinary moments.

“It can be unbelievable. The nursing profession is a rushed profession, but over time you just have to see it work once and see the resident’s reaction, see them smile and give a hug or a kiss, and it is transformative,” Sass says.

“It gives you purpose. You took someone who was drugged up to help make them a functioning person. It makes all the difference; it is just treating them like people.”