Healthcare Quality Strategies Inc. Pilot Program Reduced the Use of Antipsychotic Drugs in Six New Jersey Nursing Homes by 33 Percent

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A pilot program by HQSI has helped six New Jersey nursing homes reduce the use of antipsychotic drugs by 33 percent. HQSI pharmacy and nursing experts worked to help long-term care facilities find alternate ways to engage residents without the use of sedating drugs.

The percentage of New Jersey nursing home residents who are prescribed antipsychotic drugs declined nearly 12 percent during the past two years as institutions found new ways to ease the behavioral and psychological symptoms associated with dementia and Alzheimer’s disease, according to data distributed by Health Quality Strategies Inc..

The percentage of New Jersey nursing home residents prescribed antipsychotic drugs dropped to 15.86 percent in the second quarter of this year — from 17.36 percent in the first quarter of 2011, according to the Partnership to Improve Dementia Care in Nursing Homes, a program of the Centers for Medicare & Medicaid Services (CMS). New Jersey’s rate, already below the national average of 23.5 percent in 2011, now has the nation’s fourth lowest rate and is well below the current national average of 21.14 percent.

“We are very proud of our state’s progress and we will continue to work with nursing homes to help them engage residents and find alternatives to the inappropriate use of these medications,” said Marianne Sagarese, RN, BSN, Quality Improvement Specialist at Healthcare Quality Strategies Inc. (HQSI), the Federally-designated Quality Improvement Organization (QIO) for New Jersey.

Antipsychotic drugs are approved for the treatment of psychosis, schizophrenia, and a few other disorders. However, they are frequently used off-label — prescribed for a non-approved use — to patients with Alzheimer’s disease or dementia who may be agitated, restless, confused or acting aggressively.

Data suggest the drugs are not always effective for behavioral and psychological symptoms associated with dementia or Alzheimer’s. In addition, side effects can include lethargy and sleepiness, and studies have shown the drugs increase the risk of stroke and death up to 1.7 times.

HQSI used its nursing home and pharmacy expertise to create a pilot program with six nursing homes in New Jersey to address the inappropriate use of antipsychotic medication in long term care facilities. These facilities were able to reduce the use of antipsychotic drugs by 33 percent in nine months. HQSI also supports a statewide nursing home collaborative program with similar goals.

In the pilot, HQSI quality improvement specialists - nurses and a pharmacist - worked with the facilities to create multi-disciplinary teams comprised of nursing home directors, unit managers, certified nursing assistants, therapeutic recreation specialists, physicians, and psychologists and a consultant pharmacist. The teams meet regularly to discuss medications, monitor for side effects, and assess resident needs and behaviors.

The ultimate goal is to reduce the use of antipsychotic drugs by developing non-drug interventions tailored to the individual as well as activities to engage patients. Some nursing homes created walking clubs to get patients outside more frequently and increase their level of exercise. Other facilities conducted in-depth patient histories to gain an understanding each resident’s likes and dislikes, as well as gain insight into individual sleeping and eating habits, and the times of the day a resident appeared to get most agitated.

The pilot showed how non-drug interventions can lead to remarkable improvements in residents’ quality of life, while helping to reduce or eliminate the need for some medications.

“We had one case where a woman was constantly yelling and could not be consoled,” recalled Nicole Skyer-Brandwene, a pharmacist with HQSI who led the pilot program. “The nursing staff collaborated with her family to find music from her youth, and put it on an MP3 player. When the staff played it for her, she actually stopped in the middle of a scream, looked around, and gave a thumbs-up sign. Her husband was so happy he cried.” The resident is now off all antipsychotic medication.

Brandwene also shared a story about another resident who was taking three unique antipsychotics and a sleep medication. This person was often sedated during the day, restless at night, agitated and resistant to care. At times, it was difficult to calm him down. After taking an extensive personal history, the team learned that the resident was an avid music fan and enjoyed bands such as Pink Floyd and The Who. The facility gave him a music player loaded with his favorite songs to use when he wanted. Not long afterward, the team was able to successfully remove the sleeping pill and one of the three antipsychotic medications.

The team reported that after the medication reduction, the patient was more active during the day, slept better at night, and was less likely to become agitated. “This is a great example of the importance of involving a person in his or her own care,” Brandwene said. “There were a couple of different factors at play, including possible side effects of medications. But it’s clear that getting to know a person can make a significant difference in their care and quality of life.”

The staff in the nursing home also benefited greatly when they saw the patient’s demeanor and mood improve. “It was empowering to the staff because they witnessed firsthand how they really can improve someone’s life,” Brandwene said. “It’s not about a medication; it’s about making a connection with the person.”

Active, more than passive, activities did the most to engage residents. One nursing home created a “day-at-the-beach” with sand, beach-sounds and hand massages with suntan lotion to engage the senses of residents. Other programs included crafts and activities designed for specific individuals.

Despite the efforts, not all patients can be successfully weaned from antipsychotic drugs without behavioral symptoms returning.

Sagarese said states with already-low rates, such as New Jersey, may have difficulty reducing rates further, but are still making tremendous strides.

“New Jersey has been a leader in this work and many facilities have been proactive on this topic for several years,” said Sagarese. “We are committed to continuous improvement and further advancing patient-centered care.”


About HQSI

Healthcare Quality Strategies, Inc. partners with healthcare providers, organizations, communities, and consumers to make healthcare safer, more efficient, and more effective. Working under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, HQSI is the nonprofit federally designated quality improvement organization (QIO) for New Jersey. Its methods include assessing opportunities for improvement, sharing best practices, and designing strategies with measurable and sustainable results. The goal is for consumers to receive high-quality, patient-centered care with the best possible outcomes. Learn more about HQSI at

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Carol Ann Campbell
Campbell Health Media
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