Neuropsychiatric Symptoms Clinical Decision Education Series:The Treatment and Management of Neuropsychiatric Symptoms in

Skilled Nursing Centers

Elizabeth J. Santos, MD, MPH, DFAPA, DFAAGP

Associate Professor of Psychiatry, Neurology & Medicine

Clinical Chief, Division of Geriatric Mental Health & Memory Care

University of Rochester School of Medicine & Dentistry

Kaylee Mehlman, PharmD, RPh, BCGP, FASCP

Clinical Consultant Pharmacist

Geramed Senior Care Consulting

Moderator: Chad Worz, PharmD, BCGP

Chief Executive Officer, ASCP

Thank you!

Series Sponsor Session Partner

Meet The Speaker

Elizabeth J. Santos, MD, MPH is an Associate Professor of Psychiatry, Neurology and Medicine at the University of Rochester School of Medicine and Dentistry. Dr. Santos is the Clinical Chief of the Division of Geriatric Mental Health & Memory Care. She does nursing home consultation and is the Director or Medical Director of a number of programs including the UR Geriatric Telepsychiatry, UR Memory Care, Older Adult Services, and Project ECHO – GeMH OMH.

Meet The Speaker

Kaylee (Adams) Mehlman is a Board-Certified Geriatric Pharmacist and Fellow of ASCP with experience in Long Term Care since 2009 and an ASCP member since 2012. Currently, she is an Independent Consultant Pharmacist and owner of Geramed Senior Care Consulting and Corporate Clinical Consultant for Psych360 in Northeast Ohio.

Disclosures

• No financial relationships

• No conflicts of interest

• No promotion of commercial products or services

Follow Up: Helpful MDS Sections for CPh

• Section N:• Psychotropics received in the last 7 days

• Antipsychotic (AP) GDR history and physician documentation of CI

• Section V:• Delirium

• Cognitive loss dementia (BIMS)

• Psychosocial well-being – activities, person centered care

• Mood state (PHQ9)

• Behavioral symptoms

• Pain

Limitations of MDS Data

• BIMS (Brief interview for Mental Status) is a “snapshot” • SLUMS, MoCA, MMSE more accurate for cognitive impairment

• It has to be documented for it have happened• Ex: behaviors not charted because viewed as “baseline behavior”

Current Models

• Primary driven GDR intervals (rare) with Pharmacist oversight

• Pharmacist driven GDR intervals – addressed by Primary (no Psych involvement)

• Pharmacist driven GDR intervals – addressed by Psych• CPh to then ensure documentation of CI appropriate

• Pharmacist and Psych GDR collaboration via remote monitoring

• Pharmacist and Psych GDR collaboration as part of IDT

• Psych driven GDR intervals with Pharmacist oversight

Challenges with Current Models when No Psych

• Having primary providers address GDR recommendations – period

• If providers are not forthcoming with CI rationale, the burden can fall on the CPh and nursing staff• Do not assume the documentation in the EHR “speaks for itself”

• Psychotropics often used to target behaviors versus psychiatric conditions

Using Existing Documentation for GDR Rationale

Use to bolster documentation for – or – against GDR within recommendations. Examples:

• Newly prescribed AP?• Evaluate delirium assessments (section C)

• Ensure diagnosis is part of cumulative list (section I)

• Check for documentation of hallucinations/delusions (section E)

• Depression• Use PHQ9 score

This same documentation can be used to monitor effectiveness of psychotropic

medications

Pain and Non-pharm

• Assess pain management regardless of cognitive function• Ensure proper pain scales are used for cognitively impaired patients

• Some patients may be resistant to admit pain

• Just one aspect of considering the patient “as a whole” when treating psychiatric conditions• Always work with the interdisciplinary team for non-pharm interventions and

care planning

Other Ways to Approach Management

of Neuropsychiatric Symptomsin Skilled Nursing Facilities

Disclosures

I have no relevant financial relationships to disclose.

Salary support from the University of Rochester, NYS OMH, NIJ and HRSA.

Thanks to the UR Telepsychiatry Team for slides I have adapted.

Special thanks to:

Drs. Adam Simning & Michael Hasselberg

Senior Health Project Coordinator Mrs. Lara Press-Ellingham

Workforce Shortage▪ Only 1,596 physicians are currently

certified in geriatric psychiatry

▪ One for every 11,372 older Americans

▪ By 2030 that total is predicted to rise to only 1,659, which would then be only

one for every 20,195 older Americans (ADGAP, 2007b).

▪ Half of fellowship positions go unfilled nationwide

▪ General psychiatry is a partial solution

▪ 71% feel very prepared to dx and

treat delirium

▪ 56% to diagnose and treat

dementia.

Source: Retooling for an Aging America: Building the Health Care Workforce http://www.nap.edu/catalog/12089.htm

Overuse of Psychotropics

624 Nursing Homes

• 30% of new admissions are

among persons with mental

illness

• 50% of all residents have

cognitive impairment

• Three-fold increased risk of

hospitalization

Grabowski, et. al., 2009.; Becker, et. al., 2009; The Long Term Care Community Coalition, 2014; NYSDOH, 2017

Growing Need

• Telementoring: Project ECHO® in Geriatric Mental Health (GeMH)

• Telepsychiatry

• Psychiatric Nurse Engagement Specialist

University of Rochester Solution

Multi-level Service Approach

19

Telementoring

ECHO® HUB

University of RochesterTeam of Specialists

ECHO® SPOKE

Community-basedFront-line Clinicians

PATIENT REACH

“One to Many”

20

How Project ECHO® Works▪ Use Technology (multipoint

videoconferencing and Internet)

▪ Disease Management Model focused on reducing variation in processes of care and sharing “best practices”

▪ Case based learning through three main routes:

1. Learning Loops

2. Knowledge Networks3. Content Knowledge

Arora (2013); Supported by N.M. Dept. of Health, Agency for Health Research and Quality HIT Grant 1 UC1 HS015135-04, New Mexico Legislature, and the Robert Wood Johnson Foundation.

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Knowledge Networks

Project ECHO® GeMH for LTC

Project ECHO® GeMHGeriatric Mental Health (GEMH -LTC) in Long Term Care (12/3/2015–11/30/2019)

• 163 TeleECHO™ clinics • 5,643 total attendees

• 1756 CME credits awarded

Office of Mental Health (GEMH -OMH) (6/27/2017 – 11/30/2019)

• 55 TeleECHO™ clinics

• 2,589 total attendees

• 603 CME credits awarded

Triaging Through Project ECHO®

• Serves as a mechanism to identify residents that

might need immediate behavioral health treatment

• Used to allocate need for higher level of care

o Telepsychiatry

o Psychiatric nurse engagement specialist

o Emergency room / hospitalization

• Educates nursing homes on how to prioritize certain

patient case presentations by level of risk severity

TelepsychiatrySkilled Nursing Facilities

Staffed by:

• Geriatric Psychiatrists

• Psychiatric Nurse Practitioners

• Geropsychologists

Service is available:

Monday – Friday

830am – 5:00pm

Excluding University Holidays

Psychiatric Nurse Engagement Specialist• Provide on-site visits for training and support to nursing home treatment

teams

oCare plan development for patients with challenging behaviors

oDevelop crisis management/intervention training

oParticipate in unit rounds and case reviews

• Assists in implementing a behavior management interdisciplinary team approach to care, including medication reconciliation and reduction

• Develops Crisis Intervention Strategies

• Helps treatment team identifying appropriate case referrals for Project ECHO® GeMH and Telepsychiatry

Model Implementation in Finger Lakes Region

May 9, 2017 through October 23, 2020

38 Skilled Nursing Facilities engaged

4,925 Telepsychiatry Consults Completed

• Reasons for referralo 38% Behavior

o 31% Medication

676 Nurse Engagement visits (onsite and virtual)

• 2,228 Behavioral Care Plans created and/or reviewed

• 1,037 Residents on antipsychotics reviewed

• 269 Residents scoring 10+ on the PHQ9 reviewed

• 65 on-site Telepsych consult supports provided

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April 3, 2019 through December 5, 2019

22 Skilled Nursing Facilities engaged

(up to 38 more to be added)

291 Telepsychiatry Referrals

•Reasons for referral:

o38% Behavior

o34% Medication

Model Expansion with OMH

SNFs Served Across NYS

TELEPSYCHIATRY CONSULTS

0

500

1000

1500

2000

2500

3000

2017 2018 2019 2020 2021

291

1115

1362

2687

544

Total

As of 3/10/2021

Common Hospital Psychiatric Consult

85 yo male admitted with failure to thrive keeps getting out of bed, yelling, and resisting care.

• What did we often do as general psychiatrists? Start quetiapine or low-dose risperidone.

• This is a problem though because, once this patient is stabilized, SNFs may be reluctant to accept him.

Why the antipsychotic pushback in SNFs?

• Star ratings

• Small effect sizes with significant safety concerns (cerebrovascular events, metabolic effects, extrapyramidal symptoms, death)

• None FDA approved for dementia with behaviors

• Only three non-penalized uses of antipsychotics in NHs: Schizophrenia/Schizoaffective Disorders, Tourette Syndrome, Huntington’s Disease

** This has resulted in dementia residents being newly diagnosed with schizophrenia. **

• 15% of all NH long-stay residents receive antipsychotics

• Antipsychotics prescribing varies considerably across NHs – even by psych consultant groups (26.4% vs 12.2%)!

• Older adults admitted to NHs heavily utilizing antipsychotics have increased mortality

• NH behavioral health services in short supply – NH providers not trained to use antipsychotics.

Why the antipsychotic pushback in SNFs?

UR Medication Management ApproachTelepsychiatry Nurse

Engagement Specialist

This is rare – only 2-3x in 18 months (e.g.,

ECT, refusing medications and

medical conditions worsened)

Use antipsychotics for psychosis.

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

12/31/16 3/31/17 6/30/17 9/30/2017 12/31/2017 3/31/18 06/30/18 09/30/18 12/30/18 03/31/19 6/30/2019

Antipsychotic Use in the SNFs (12/2016 to 6/2019)

Antipsychotic Use in Long-Stay ResidentsProgram Results – Finger Lakes Region

One SNFs Success Story!Antipsychotic Use in Long-Stay Residents

Recognition of Our Work

Roundtable Discussion