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York Care Centre.

In recent years, antipsychotic medication use has been ever increasing, specifically, within the older adult (65 years and older). These medications have been given to the older population to treat behavioural symptoms occurring either at home, in hospital or in long-term care. According to the Canadian Institute of Health Information (CIHI), one in three long-term care (LTC) residents in Canada takes antipsychotic medications without diagnosis of psychosis. Although commonly prescribed to treat behavioural symptoms of dementia, research shows antipsychotic medications are: minimally effective in managing behavioral issues (Barton, 2005); associated with worsening cognitive functioning (Vigen, 2011); result in serious adverse events when used long term, especially in the elderly (Gareri, 2014) and non-pharmacological, patient-centered care approaches, should be tried first (Zuidema, 2015).

York Care Centre recognized the increase in antipsychotic medication use in our older adult population and was interested in looking further into this issue. York Care Centre came across the Canadian Foundation for Healthcare Improvement (CFHI) initiative, the objective of which is to improve care for people with dementia by reducing inappropriate prescribing of anti-psychotics in long-term care. CFHI had put a call out for various LTC organizations using the Minimum Data Set (MDS) to apply and be a part of a 14-month pan-Canadian spread collaborative reducing antipsychotic medication use in LTC. In the spring of 2014, York Care Centre was chosen to be part of this collaborative. York Care Centre is one of 15 different organizations in seven provinces and one territory to be a part of this initiative. The collaborative was to officially begin in September 2014 and be completed by November 2015.

During the implementation and rollout of this initiative, CFHI committed to support the organizations involved with training through 14 webinars and two face-to-face workshops, resources (e.g. titration tools to guide gradual reduction of medication use and funding), coaching with content and improvement experts across North America and cross-team sharing in the online learning community and through peer review. Key change strategies included team-based approach to improvement design and spread, staff education and training in person-centered care approaches (PIECES, Gentle Persuasion Approaches), improvement techniques, change management and spread practices; and to use the MDS data to inform and monitor the care planning.

York Care Centre began the initiative in September 2014 in Birch Grove, a 24 bed dementia unit. York Care Centre has a total of five units and is one of the largest LTC facilities in NB, with a total of 214 beds. This unit was chosen to begin the initiative since it is a smaller unit and the staff were well trained previously in education that helps staff understand and deal with responsive behaviours. Our aim for the improvement initiative was to reduce inappropriate medication by 25% by September 2015. Out of the 24 residents, 11 were eligible for the study. Within the first six months, six out of the 11 residents saw a successful reduction. By the third quarter of the initiative, we were able to see a 46% reduction in antipsychotic medication with the eligible population in Birch Grove. After beginning to see success in Birch Grove, we then implemented the project from unit to unit. We began moving through the "Tower" units, units 1, 2 and 3 then finally moved to our biggest unit, Dixon.

The spread was a slow and steady process. We began with discussions up front with the staff prior to beginning the spread, addressing people's concerns, discussing the process and encouraging the staff for the feedback and input along the way. We reassured staff that we would go slow with one or two residents at a time and if a reduction was not successful after a few weeks, the medication could be increased and this was not a failure, but an attempt that can potentially be revisited at a later time. Engaging staff upfront was pivotal to ensure everyone was comfortable with the initiative as the frontline staff were truly the drivers of the collaborative. Being able to contribute, provide input and give observations of the target resident's reduction process allowed the frontline staff to take charge and get all the other key players involved, such as other frontline workers, care staff and family. Meetings with the staff and continuous education huddles allowed to keep the improvement initiative moving forward.

By third quarter (April-June 2015), it was evident that there was success in the improvement of quality of life of the residents. We had residents, who prior to the initiative, no longer fed themselves and sat without interacting with others, progress to being able to feed themselves again and "awakening" to be involved in discussion and interacting with loved ones again during visits. Most residents did not see any changes in their mood or behaviour and this was a success as well. Staff were also able to see that even during the reduction, there was little to no change in the amount of care provided to the target residents during the reduction. The success stories are truly the reason why we took on such an initiative, to help better the lives of our residents. As well, seeing our staff work together, building staff capacity, and allowing each eligible resident the time to see benefits of the reduction was a wonderful benefit to this initiative.

This initiative was made possible by the tremendous effort of the staff on each of the units. It was wonderful to see all the staff involved from nursing staff, to activity, to cleaning and kitchen staff. This collaborative work was what made our Birch Unit and subsequent units see the success. Activity coordination was key in being able to help the improvement of various programs with each eligible resident to help in resident engagement and quality of life. Changes in the activity coordinator scheduling, allowed for the residents to have someone in the evening and weekends to promote therapeutic activity and engagement. This slight change was beneficial to not only the residents, but also to the care staff. Having the staff involved in the collaborative and being able to provide insight into each of the resident's involvement and response allowed for team building among each of the units.

By October 2015, York Care Centre was able to see significant results from the improvement initiative. Fifty-five residents or 26% of York Care Centre's resident population became eligible for this study. Of the fifty-five residents, 25% of the eligible resident population (14 residents) were completely discontinued from antipsychotic medication with an additional 24% of the eligible population (13 residents) reduced antipsychotic medication by 50% or greater. These numbers accounted for 13% of York Care Centre's total resident population during the September 2014- October 2015.

With the success in these numbers, York Care Centre management saw how this initiative could be beneficial to all the LTC facilities in New Brunswick. A discussion took place with our CFHI partners and they too saw the benefit this could have for our province. With CFHI coming to the Annual Symposium held by York Foundation and York Care Centre, opportunity to meet with the NB Association of Nursing Homes (NBANH) and key stakeholders to help make this provincial rollout happen were invited to the table in September 2015. After presentations and hearty discussions, the government and NBANH saw the strong need and potential for this initiative to roll out to all the NB nursing homes. Through collaboration, partnership and discussion, the provincial rollout was announced in May 2016, with the first 15 homes to be involved in the first year wave of the rollout announced. The rollout, NB Appropriate Use of Antipsychotics (NB-AUA) initiative is to be a two year rollout to the nursing homes with support from CFHI in partnership with NBANH. York Care Centre serves as resource supports for the collaborative.
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Author:Donovan, Jennifer
Publication:Info Nursing
Article Type:Report
Date:Sep 22, 2016
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