Clinical success in the nursing home can be broken down into its parts – namely, performance on quality measures. And while QMs have expanded to account for a range of areas, reducing hospital readmissions and antipsychotic use remain top priorities for clinicians.
There are some throughlines here, clinical leaders told Skilled Nursing News, with interdisciplinary teams touching most, if not all, quality metrics, while leadership turnover and policy changes create compounded challenges to overcome.
Reducing antipsychotic use requires collaboration across nursing, physicians, pharmacy, therapy and activity staff, requiring all staff to manage behavioral symptoms through non-drug approaches, improving communication during a behavioral episode and avoiding medication decisions driven by panic – especially during overnight shifts, said Diversicare Healthcare Services Chief Clinical Officer Robin Mitchell. Diversicare’s corporate offices are located in Tennessee.
This collaboration and communication is paired with regular medication reviews and gradual dose reduction meetings, Mitchell said, to figure out ongoing needs while ensuring resident comfort and safety.
In fact, leadership plays a crucial role in sustaining antipsychotic reduction efforts, according to Antonio Costa, chief clinical officer at Ohio-based Saber Healthcare. The presence of a dedicated organizational champion like the chief medical officer role helps establish standardized prescribing practices and maintain consistent performance.
That’s why leadership turnover among directors of nursing and nurse managers can be so disruptive when it comes to crucial initiatives like antipsychotic use reduction. Any departure shakes up established processes while temporarily increasing antipsychotic use until new leaders become familiar with organizational expectations, Costa said.
“No matter how great they are, they don’t necessarily know your community or your organization’s practices around antipsychotic management, medication management,” said Costa. “That turnover can be a barrier. We’ll see a spike in use of antipsychotics with changes in leadership, because the team, the new team, has not yet learned our processes as an organization.”
Compounding hurdles in antipsychotic reduction
Policy hurdles add another layer of complexity too, Costa said, as the latest quality measure combines data from multiple external sources and creates documentation and coding confusion that has led to inaccurate prescribing practices.
The Centers for Medicare and Medicaid Services’ (CMS) decision to add Medicare and Medicaid claims and encounter data when factoring the percentage of residents who had such medications ordered or filled for them during their entire nursing home stay, resulted in some missteps, he said.
Still, residents who have safely benefitted from antipsychotics for years continue therapy when clinically justified, Good Samaritan Society Chief Clinical Officer DeeAndra Sandgren said, with efforts concentrated on minimizing new prescriptions. Nonprofit operator Good Samaritan is based in South Dakota.
“If that drug has worked for them for 15 years, we’re going to find a way to make sure that they can maintain that, documented properly, and do a gradual dose reduction if it’s appropriate,” said Sandgren.
If a resident comes back from a hospital stay with prescriptions started for temporary conditions like delirium, it likely shouldn’t continue once they’re back in the nursing home.
“We’re going to help regulate that circadian rhythm, we might use a lighter dose, or there could be a different drug, besides an antipsychotic, that’s appropriate,” said Sandgren. “Obviously I’m not a prescriber, and so I want to defer to my docs on what’s right, but we also work really hard at educating them, if this is what somebody needs to be on.”
Hospital readmissions
Strong operators rely on early identification of subtle changes in a resident’s condition to reduce another crucial clinical area – reducing avoidable hospital readmissions. Strong interdisciplinary communication is showing up again here, Mitchell said.
Sandgren and Mitchell discussed the “stop and watch” program, which encourages every staff member – not just nurses – to report concerns. Daily clinical meetings with people from every department helps identify risk before conditions worsen to necessitate a hospital stay.
Ongoing clinical competency training is a good supplement to “stop and watch,” and interdisciplinary teams, especially training around wound care, respiratory assessments, critical thinking and making it a practice to have nurses intervene before transferring residents to the hospital.
Sandgren touched on the intersection of technology and reducing hospital readmissions, as AI tools are increasingly used to help monitor vital signs, identify documentation patterns and alert staff when a resident needs to be watched more closely.
Virtual care programs in rural communities especially can help unlock access to more seasoned or specialized care nurses when it comes to clinical decision-making, Sandgren said. Such services have made a significant impact on reducing hospital transfers, she said, helping manage acute issues on site, when access to hospitals and healthcare providers is limited.
“We started My Care Line last year; we deployed that in South Dakota to 27 skilled nursing and assisted living locations. Four of the facilities don’t even have a hospital in their town and another four are more than 100 miles from a hospital,” said Sandgren. “It’s so important in the rural communities. You might be waking up a provider in the middle of the night … that person probably has a full day of clinic the next day as well, and they might be the only provider in the entire county.”
Another piece of the puzzle is readmission reduction programs that reflect today’s more medically complex resident, Costa said. Operators are reevaluating components of more traditional readmission reduction programs, keeping some and leaving others that create unnecessary documentation burdens.
Operators are keeping initiatives that stress streamlined workflows, updated clinical competencies and enhanced training equipment and care models that better address emerging clinical conditions like sepsis, while also preserving a nurse’s time at the bedside.
A common thread
Strong interdisciplinary teams are generally a hallmark of high-performing nursing homes altogether, Sandgren said. Such teams are mentioned over and over when it comes to improving specific quality measures and clinical performance as a whole. That includes everyone from nursing staff to therapists, dietary aides to pharmacists and physicians.
“Housekeepers on the team see themselves as a first line of defense to help keep our residents healthy,” said Sandgren. “When everybody is empowered to speak up about changes in residents, we treat those residents more proactively, that helps us reduce readmissions, that helps us avoid pressure injuries, avoid falls, and it’s all better for the bottom line, and all better for the residents in the end.”
With all of these roles working together on common care goals, residents have shorter and more predictable lengths of stay, Sandgren added, along with fewer readmissions and improved financial performance.
Companies featured in this article:
Diversicare Healthcare Services, Good Samaritan, Saber Healthcare Group
