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CMS Launches Partnership to
Improve Dementia Care in Nursing Homes

Updated 04/09/2014

On March 29, 2012, CMS launched a national partnership with the mission to improve quality of care provided to individuals with dementia living in nursing homes. This partnership focuses on the delivery of health care that is person-centered, comprehensive and interdisciplinary, in addition to protecting residents from being prescribed antipsychotic medications unless there is a valid, clinical indication and a systematic process to evaluate each individual. The partnership promotes rethinking approaches that are utilized in dementia care, reconnecting with people using person-centered care approaches and restoring good health and quality of life in nursing homes. CMS is partnering with federal and state agencies, nursing homes, other providers, advocacy groups, and caregivers to improve dementia care. The partnership promotes a multidimensional approach that includes public reporting, national partnerships and state-based coalitions, research, training for providers and surveyors and revised surveyor guidance.

The Advancing Excellence in America’s Nursing Homes Campaign has offered to make available a variety of resources and clinical tools to assist nursing homes achieve the goals of this partnership. Nursing homes are encouraged to review the resources and tools and select those that will be most useful. This site will be updated regularly as new tools become available.

Resources and Tools

Physician Resources

This document was compiled by the National Partnership to Improve Dementia Care in Nursing Homes to provide links to resources and tools for physicians on clinical practice guides, non-pharmacological interventions for dementia, information for physicians to provide to families, data, and evidence-based research.

Background

The national prevalence of antipsychotic use in long stay nursing home residents has been reduced by 9.1 percent by the first quarter of 2013, compared to the last quarter of 2011.

(Press release) LeadingAge, March 2012.

Video (50 minutes) that describes the national initiative to reduce the use of antipsychotic drug usage by 15% by December 31, 2012.
Centers for Medicare and Medicaid Services

Recorded Webcast (58 minutes) describes the national initiative to reduce the use of antipsychotic drug usage, and provides in-depth discussion about the symptoms and various management/intervention strategies to help nursing homes work toward the national goal.
Dr. Cheryl Phillips and Tena Alonzo LeadingAge

A PowerPoint presentation that describes the state of research and effort to improve dementia care in the UK.
Dr. Clive Ballard | King’s College London & Director of Research, Alzheimer’s Society (UK)

A two-part PowerPoint presentation describing the background and current state of knowledge about unsafe prescribing of antipsychotics among people with dementia.
From Alliant | Georgia Medical Care Foundation

This presentation provides an overview of the magnitude of the risks and benefits of antipsychotics for individuals with dementia residing in nursing homes; information on interpreting CMS’ quality measures on antipsychotic use; and strategies to safely reduce these medications in the long term care setting.
Dr. Dave Gifford | American Health Care Association

Initiatives and Presentations

Shared by Michael Preston, Director of Professional Relations, Preston Pharmacy

Call hosted by CMS Partnership to Improve Dementia Care in Nursing Homes

Call hosted by CMS Partnership to Improve Dementia Care in Nursing Homes

37-minute WebEx presentation from Great Plains Quality Care Collaborative from CIMRO of Nebraska. An excellent resource to communicate with Medical Directors about the effort to reduce inappropriate antipsychotics among residents with dementia. George Voigtlander, MD provides informations information about F-tag 329, person-centered approaches to dementia care, a useful environmental changes that can assist in caring for residents with dementia.

Provided by the Centers for Medicare and Medicaid Services. Six-slide walk-through of how nursing homes can access their Nursing Home Compare data, as well as other data sources.

Call hosted by CMS Partnership to Improve Dementia Care in Nursing Homes

Presentation to LeadingAge by Lisa M. O’Hara (PharmD, CGP), Corporate Director of Clinical Services GrandView Pharmacy

Slides from presentation about alternative approaches to dementia care through the creative arts
The Alzheimer’s Association

Recording of live event presented March 28, 2013. This is the first in the Mental Health and Aging Training Initiative, Series II, presented by the Geriatric Mental Health Planning Partnership, in collaboration with the VCU Department of Gerontology and the Riverside Center for Excellence in Aging and Lifelong Health

Recording of live event presented April 22, 2013. This is the second in the Mental Health and Aging Training Initiative, Series II, presented by the Geriatric Mental Health Planning Partnership, in collaboration with the VCU Department of Gerontology and the Riverside Center for Excellence in Aging and Lifelong Health

Call hosted by CMS Partnership to Improve Dementia Care in Nursing Homes

Call hosted by CMS Partnership to Improve Dementia Care in Nursing Homes

From Centers for Medicare and Medicaid Services

Continuing Care Leadership Coalition

LEADER (Louisiana Enhancing Aging with Dignity Through Empowerment and Respect)

Call hosted by CMS Partnership to Improve Dementia Care in Nursing Homes

The Hand in Hand training was created by CMS to provide nursing homes with a high-quality training program that emphasizes person-centered care in the care of persons with dementia and the prevention of abuse.

PowerPoint presentation providing background and examples for work on inappropriate use of antipsychotic medications.
Kathie J. Gately, BSW

Handouts

Sixth in a series of monthly tips from Primaris(Missouri QIO) on working to reduce inappropriate antipsychotics.
Primaris

A list of trainings for dementia care compiled by the National Partnership to Improve Dementia Care in Nursing Homes.

Fifth in a series of monthly tips from Primaris(Missouri QIO) on working to reduce inappropriate antipsychotics.
Primaris

This brochure, provides facts about memory problems and dementia, when to seek help, questions to ask your doctor and advice for family members. Available in English, Spanish, and as a poster.
Developed by the Joint Commission

Fourth in a series of monthly tips from Primaris(Missouri QIO) on working to reduce inappropriate antipsychotics.
Primaris

Third in a series of monthly tips from Primaris(Missouri QIO) on working to reduce inappropriate antipsychotics.
Primaris

Second in a series of monthly tips from Primaris(Missouri QIO) on working to reduce inappropriate antipsychotics.
Primaris

First of a series of monthly tips from Primaris (Missouri QIO) on working to reduce inappropriate antipsychotics

The Centers for Medicare & Medicaid Services (CMS) and Advancing Excellence in America’s Nursing Homes national campaign coordination group developed a set of common questions and answers below, for nursing homes, in order to clarify how some of the many initiatives relate to and are aligned with each other. The purpose is to help nursing homes better understand how to participate in and benefit from various initiatives.

Oklahoma Foundation for Medical Quality and Stratis Health, the National Coordinating Center (NCC) for Improving Individual Patient Care (IIPC) Aim.

The document shows how each of the distinct nursing home initiatives are connected and to simplify the information in the most understandable format possible.
Health Services Advisory Group, Inc.

Steve Levenson

Brochure on antipsychotic medication and dementia developed by the Georgia Medical Care Foundation in collaboration with the Advisory Board on the Partnership to Improve Dementia Care team

American Geriatrics Society

American Geriatrics Society

Item #2 of this campaign form the American Board of Internal Medicine is " Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia" and includes several physician education and public education resources.

Long Term Care Community Coalition (LTCCC)

A useful resource as a reference for long-term care teams focused on antipsychotic drugs
Co-developed by the Delmarva Foundation for Medical Care (Maryland/DC QIO) and Healthcare Quality Strategies, Inc. (NJ QIO)

Centers for Medicare and Medicaid Services

Trainings

Available through the American Therapeutic Recreation Association. Working as a recreational therapist with individuals who have dementia and Alzheimer's Disease can be challenging, especially when you encounter behavioral problems. This all-day intensive course will provide you with ATRA's exclusive training for utilizing Dementia Practice Guideline for Recreational Therapy: Treatment of Disturbing Behaviors, authored by Linda Buettner, Ph.D., CTRS and Suzanne Fitzsimmons, MS, RN.

Training and resource materials for nursing home leadership and staff. Created by University of Massachusetts and Qualidigm, made possible by funding from the Agency for Healthcare Research Quality.

This course is a 5-hour professional development experience that focuses on the recognition, assessment, treatment and monitoring of dementia in the long term care facility. Once the course and all three surveys are complete, three-month access will be provided free-of-charge to AMDA’s electronic version of their Clinical Practice Guideline Subscription.

Individual Tools and How-To's

Shared by TMF Health Quality Institute

Behavioral Assessment and Treatment Tools

This program from the University of Illinois at Chicago was developed as a collaborative effort of a multidisciplinary team consisting of advanced practice nurses, neurologists, geriatricians, gero-pharmacists, and clinical researchers in dementia care. Relevant research findings were used to identify and support the steps in the assessment and treatment of behavioral symptoms associated with dementia, providing an evidence-based treatment algorithm. This algorithm is intended to be used by all levels of care providers (MDs, PAs, Advanced Practice Nurses, and Registered Nurses) and across care settings, including community and institutional settings, to improve quality of care and treatment outcomes. This algorithm may also be useful to allied health professionals, such as social workers and physical, occupational, and recreational therapists. Also available as an app for Android or Mac devices (search for Behavioral Symptoms of Dementia in the App store for iPod, iPad, iPhone).

The BCAT Approach is a unique applied concept for assessing and working with people who have memory and other cognitive impairments. It is designed for any clinical and residential setting in which cognitive functioning and cognitive impairment is a central issue. The BCAT Approach integrates three distinct systems: The BCAT Test System, the BCAT Brain Rehabilitation Program, and the BCAT Recreation Program. All three are person-centered programs that are used by healthcare professionals, facilities, and other stakeholders. The Test System rapidly, yet comprehensively, assesses current cognitive functioning. Test scores can be used to determine specific Brain Rehabilitation interventions and Recreation approaches. The BCAT Approach is interactive and online. Information about training and costs for licensure to administer and use the assessment is available here.

Geriatric Pain Assessment and Education

From the www.geriatricpain.org website, this section provides core principles of pain assessment, recommendations for effective pain management and is organized with tools for assessing, documenting and monitoring pain in cognitively intact and cognitively impaired older adults. Resources for training staff on screening and assessment procedures are provided, including best practice tools for assessing pain behavior in nonverbal adults. Suggestions for using an analgesic trial as part of the assessment process in cognitively impaired older adults are also provided.

From the www.geriatricpain.org website, resources in this section include terminology, key principles for pain management, and tools for documenting and communicating pain treatments and response to treatment; communicating with prescribers; and monitoring analgesic therapy.

From the www.geriatricpain.org website, section provides resources to support education for providers, education for staff and resources to be shared with the older adults and their families.

Sample Nursing Home Readiness and Preparedness Assessment

A list of questions for direct caregivers and nursing home leadership to assist facilities in assessing their approach to dementia care.
Partnership to Improve Dementia Care in Nursing Homes

Suggested list of questions for provider to use to assess their approach to dementia care.
Partnership to Improve Dementia Care in Nursing Homes

A flow chart with suggested steps for implementing quality improvement efforts to reduce inappropriate use of antipsychotics.
Partnership to Improve Dementia Care in Nursing Homes

Resident Assessment Tools

The PAR (Patient-at-Risk) form from Alliant GMCF (Georgia QIO) provides a tool to document antipsychotic usage, side effects, and communication with families.
Alliant GMCF

Christine M. Waszynski, MSN, APRN, BC, Hartford Hospital

The Confusion Assessment Method (CAM) was intended to provide a new standardized method to enable nonpsychiatrically trained clinicians to identify delirium quickly and accurately in both clinical and research settings.

Partnership to Improve Dementia Care in Nursing Homes

Dr. Karyn Leible

American Geriatrics Association (AGS)

Sample Medication Policy
Shared Decision Making

Substance Abuse and Mental Health Services Administration (SAMHSA)

Practice Guidelines
Comprehensive Tool Kits

Kathy Gately, BSW, designed this Home Thermostat (HT) to assist nursing homes, resi­dential care and assisted living facilities with a tangible tool to evalu­ate and discover behavioral “hot spots” throughout their perspective homes. This tool will guide you to objectively listen, look and discuss what root causes within the facility may be promoting behaviors, and what alternatives and rearrangements you may utilize to decrease behaviors and differentiate between abnormal and normal behavior.

California Advocates for Nursing Home Reform (CANHR)

Iowa Geriatric Education Center

The Pioneer Network’s comprehensive list of tools to assist nursing homes in various aspects of staffing, culture change, and quality improvement activities that are important to improving care for residents with dementia.

Developed by Planetree in partnership with Picker Institute, the Long-Term Care Improvement Guide was created in 2010 to propel long-term care communities in their improvement efforts.

Using Data

Provided by the Centers for Medicare and Medicaid Services. Six-slide walk-through of how nursing homes can access their Nursing Home Compare data, as well as other data sources.

Consumer Information

Shared by the National Partnership to Improve Dementia Care in Nursing Homes

The consumer fact sheet provides family members and others involved in a resident’s care background on the off-label use of antipsychotics, as well as frequently asked questions regarding loved ones living with dementia. It also gives family members suggestions on how they can partner with providers to get the best possible care for their loved one. Click here for Spanish version.
American Health Care Association

The national prevalence of antipsychotic use in long stay nursing home residents has been reduced by 9.1 percent by the first quarter of 2013, compared to the last quarter of 2011.

Brochure on antipsychotic medication and dementia developed by the Georgia Medical Care Foundation in collaboration with the Advisory Board on the Partnership to Improve Dementia Care team

HealthinAging.org

Arthur D. Hayward, M.D. writing for HealthinAging.org

National Consumer Voice for Quality Long-Term Care

The National Consumer Voice for Quality Long-Term Care

The National Consumer Voice for Quality Long-Term Care

Alzheimer’s Association

Substance Abuse and Mental Health Services Administration (SAMHSA)

Evidence-Based Research

The National Plan to Address Alzheimer’s Disease, released in 2012, directed the federal government to partner with private organizations to convene a meeting of leading researchers, health care and social service professionals, and community service providers to conduct  a review of the state of the art of non-pharmacological treatments and care practices for people with Alzheimer’s or other dementias and their family caregivers. This white paper presents the findings and recommendations from the meeting. It is intended to support deliberations about how to make effective non-pharmacological treatments and care practices available to people who will benefit from them.
Katie Maslow, MSW, supported by the United States Administration on Aging, the Alliance for Aging Research, and the MetLife Foundation.

Agency for Healthcare Research and Quality

Preface, Chapter 1: Diagnosis & Chapter 2: History Taking and the Medical Record from: LeBlond, RF; DeGowin, RL; Brown, DD. DeGowin’s Diagnostic Examination 9th Edition. McGraw Medical; 2009.

From the American Psychological Association, a comprehensive list of articles and other resources for non-pharmacologic approaches to dementia care.

(Book) Department of Veterans Affairs. Washington, D.C.; 2011.

Innovations

Training series developed by Karen Stobbe using theater games with creativity exercises. In The Moment provides caregivers with the methods to become better at what they do.

Leadership and care providers at the Villages of Southern Hills in Tulsa, OK support a national and state initiative to reduce unnecessary antipsychotic medication. In this video, you'll meet Bill, and hear how his providers engaged him in the decision to reduce and ultimately eliminate the antipsychotics he had been on for years.

The SAIDO method involves a caregiver (called a “Supporter”) trained to work with two older adults (called “Learners”) by engaging them in simple arithmetic, writing and reading exercises for 30 minutes. Eliza Jennings is the first location in the United States to offer SAIDO Learning for improving the quality of life for older adults suffering from Alzheimer’s disease and other symptoms of dementia. SAIDO has been practiced in Japan for more than 11 years with impressive results, and empirical data have proven its effectiveness.

National Public Radio story on the use of music with nursing home residents with dementia. Click here for YouTube clip of documentary.

Developed by psychologist Kelly O’Shea Carney, PhD, CMC, the Eldercare Method is a systematic process of behavioral health consultation designed for use within long term care settings. It is based upon a clinical model of geriatric behavioral health care.

A nursing home in California has built a fully-accessible community garden for residents to grow and harvest their own produce and donate it to citizens in need. This shift in culture has allowed residents to find new purpose and engage in daily activities, and has helped improve the care and quality of life among residents with dementia. Click here for a short YouTube documentary of this amazing program.

Mission View Health Center’s most recent community project is making “Helping Hands Hand Soap,” a glycerin-based soap in a variety of shapes, colors and scents. By allowing residents to become “givers” instead of just “care receivers”, Mission View has reintroduced meaning and a feeling of purpose to residents who showed significant signs of depression and withdrawal. Residents fully run this non-profit business, which sells the soaps and then donates the proceeds to various causes, including buying food which the residents prepare and serve to people at a local homeless shelter. All proceeds go to local charities which are be chosen by our residents. Click here and here for a two-part YouTube presentation of this great program.

A few years ago, staff members at Ecumen in Minnosota became concerned about the number of people with Alzheimer’s and other dementia-related diseases being admitted who were on antipsychotic drugs. They started exploring alternative treatments that could provide these residents with a better quality of life. These treatments emphasize human relationships and non-pharmaceutical remedies. In 2009, Ecumen piloted these alternative treatments in one of their nursing homes in Two Harbors, Minnesota. This initiative is called Awakenings because it re-awakens residents to physical and cognitive vitality that’s often been severely diminished by an inappropriate use of antipsychotic drugs. We can’t cure Alzheimer’s, but we have learned much more about how to control the aggressive and sometimes violent behaviors that accompany it without using drugs that rob residents of their personalities and energy.

Books, Articles, and DVDs

Perspective of Kathleen Lynch Scherer, Director of Nursing at Genesis Lebanon Center in New Hampshire, about their experiences with antipsychotic reduction efforts.

Preface, Chapter 1: Diagnosis & Chapter 2: History Taking and the Medical Record from: LeBlond, RF; DeGowin, RL; Brown, DD. DeGowin’s Diagnostic Examination 9th Edition. McGraw Medical; 2009.

The Medical Letter: On Drugs and Therapeutics. Volume 50 Issue 1301/1302. December 2008.

Caring For the Ages editorial by Jeffrey Nichols, MD

(Article) Raia, P. Massachusetts Alzheimer’s Association Chapter Newsletter; Spring 2005.

(Book chapter) Raia, P. In: Volicer L, Bloom-Charette L, editors. Enhancing the Quality of Life in Advanced Dementia. Philadelphia: Taylor & Francis; 1999. pp. 21–37.

(Book) Power, G. A. Health Professions Press; 2010.

(Article) American Geriatrics Society. JAGS; 2012.

Independent Drug Information Service (IDIS)

(Article) Maher, A. et al: JAMA, Vol. 306, No. 12, September 28, 2011.

(Book) Scogin, F. & Shah, A., editors. American Psychological Association; 2012.

CD ROM/DVD for purchase from Pioneer Network

(Book) Brackey, J. Purdue University Press; 2008

Feil, N. & de Klerk-Rubin, V. Health Professionals Press; 2012.

Useful Websites

The BCAT Approach is a unique applied concept for assessing and working with people who have memory and other cognitive impairments. It is designed for any clinical and residential setting in which cognitive functioning and cognitive impairment is a central issue. The BCAT Approach integrates three distinct systems: The BCAT Test System, the BCAT Brain Rehabilitation Program, and the BCAT Recreation Program. All three are person-centered programs that are used by healthcare professionals, facilities, and other stakeholders. The Test System rapidly, yet comprehensively, assesses current cognitive functioning. Test scores can be used to determine specific Brain Rehabilitation interventions and Recreation approaches. The BCAT Approach is interactive and online. Information about training and costs for licensure to administer and use the assessment is available here.

The Geriatric Pain web site content was developed for STTI by representatives from five of the nine John A. Hartford Centers of Geriatric Nursing Excellence: The University of Iowa, Oregon Health & Science University, the University of Arkansas for Medical Sciences, the University of California at San Francisco and the University of Pennsylvania. The Geriatric Pain website was created to provide nurses who work in long-term care environments with access to free best-practice pain assessment tools and resources to help manage pain in older adults, including quality improvement processes focused on pain management.

This Toolkit was prepared for the Commonwealth Fund in collaboration with the Hartford Foundation. Ann Kolanowski, RN, Ph.D., and Kimberly Van Haitsma, Ph.D., served as the coordinators of the expert panel who compiled much of the information contained in the toolkit.

Music & Memory is a non-profit organization that brings personalized music into the lives of the elderly or infirm through digital music technology, vastly improving quality of life.

Provided through the Geriatric Mental Health Foundation, Find-A-Geriatric-Psychiatrist lists doctors who are members of the American Association for Geriatric Psychiatry (AAGP). Membership in the AAGP does not constitute certification of a member doctor's competence, qualifications, or expertise.

Psychologists In Long Term Care, Inc. (PLTC) is a network of psychologists and other professionals dedicated to providing high quality mental health services in long-term care settings, including skilled nursing homes, rehabilitation centers, assisted living facilities, and congregate housing.

The Office on Aging is a coordination point for APA activities pertaining to aging and geropsychology (the field within psychology devoted to older adult issues). The Office on Aging also supports the work of the APA Committee on Aging.

This website is a collaborative effort between the American Psychological Association’s (APA) Divisions of Society of Clinical Geropsychology and Adult Development & Aging, along with the Council of Professional Geropsychology Training Programs (CoPGTP), Psychologists in Long Term Care (PLTC), and the APA Committee ON Aging (CONA) to bring together available resources for geropsychology training, service provision, policy, and research, including online assessment of geropsychology competencies, in a central internet location.

Connecting to Combat Alzheimer’s brings together National Institutes of Health (NIH)-funded Alzheimer’s Disease Centers (ADCs) that conduct research with the Administration for Community Living’s (ACL) aging services agencies, which annually reach over 10 million older people and family caregivers.

Information about the Certified Dementia Practitioner credentialing through NCCDP

Scroll halfway down the page to “Item 2: Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia”. A variety of professional education and public information resources available.

The APA Office of Aging provides links to articles and postings on issues of aging and geropsychology, including links to dementia care guidelines, Alzheimer’s, and psychological care of older people.

This site provides information on the vital role consultant pharmacists play in improving dementia care for residents of nursing homes.

This website provides a free public repository of a growing collection of geriatric educational materials. Visitors to the site can search for key words such as “antipsychotics” to get a variety of links to podcasts, presentations, peer reviewed articles, and more.

The Eden Alternative is a small not-for-profit organization based on the core belief that aging should be a continued stage of development and growth, rather than a period of decline. This website includes a list of trainings on Reducing the Use of Antipsychotic Medications for People Living in Long Term Care Settings.

Pines of Sarasota is a nursing facility in Florida that has developed excellent resources, trainings, and presentations about compassionate and effective person-centered care of persons with Alzheimer’s and dementia. The Pines Education Institute was established as a regional training center for medical professionals, paraprofessionals and at home caregivers in order to provide cutting edge education and training for a broad range of medical interests, which will improve the quality of care for seniors in residential and home based settings. Additionally, there is a freely accessible Pines of Sarasota YouTube Channel that has many English and Spanish videos about person-centered care.