Antipsychotics in Perspective: Past, Present, and Future.

For more than half a century, there has been controversy and conflict over using psychotropic medications ("psychotropics") as strategies to modulate behavior, enhance mood, and address cognitive issues for nursing home residents. The current situation reflects a long history of investigation, reports, discussions, government and professional activity, and other attempted improvement. Although attention has focused primarily on the use of antipsychotics, particularly to manage symptoms associated with dementia, there are much broader issues. The use of all psychotropics has arguably been challenging and inconsistent. Although antipsychotic use in nursing homes has been reduced substantially, many controversies and concerns remain, such as the continuing significant use of other psychotropics. It is tempting to conclude that efforts to reduce the use of these medications might have been deliberately stymied, and that more drastic-if not coercive-measures are needed to correct these issues. However, many other compelling considerations must be defined accurately and addressed. Further improvement in the current situation requires reconsidering some current beliefs and approaches. A pause and reopening of meaningful discussion is needed. This 3-part series (in this and the next 2 issues of The Senior Care Pharmacist) will examine the history of the issues (this month), various perspectives on the issues (part 2), and lessons and recommended approaches for the future (part 3).

Smart Case Review: A Model For Successful Remote Medical Direction and Enhanced Nursing Home Quality Improvement.

This article describes how medical directors can use a strategic approach [Smart Case Review (SCR)] to perform effective and efficient clinical case reviews and key medical director oversight functions simultaneously. SCR can be done either on-site or remotely, by using existing information in the medical record for a focused clinical discussion of patient symptoms and issues while simultaneously evaluating related clinical practices and facility processes and performance. Common problem-solving and cause identification methods apply to both patient- and process-related reviews. This approach supports effective and efficient medical direction and facility quality improvement. Unlike most current approaches to quality assurance and performance improvement, SCR begins by reviewing cases and then aggregates the findings, instead of vice versa. Although the electronic medical record (EMR) facilitates the process, it can be done without an EMR. Any medical director can potentially use this approach, and it is relevant to any long-term and postacute care facility. This method could potentially transform the approach to medical direction, evaluating quality and improving care, and the nursing home survey process.

Reforming Management of Behavior Symptoms and Psychiatric Conditions in Long-Term Care Facilities: A Different Perspective.

Despite much attention including national initiatives, concerns remain about the approaches to managing behavior symptoms and psychiatric conditions across all settings, including in long-term care settings such as nursing homes and assisted living facilities. One key reason why problems persist is because most efforts to "reform" and "correct" the situation have failed to explore or address root causes and instead have promoted inadequate piecemeal "solutions." Further improvement requires jumping off the bandwagon and rethinking the entire issue, including recognizing and applying key concepts of clinical reasoning and the care delivery process to every situation. The huge negative impact of cognitive biases and rote approaches on related clinical problem solving and decision making and patient outcomes also must be addressed.

The health care decision-making process framework.

Health care decision making is a process that includes definable steps in a desirable sequence. The process is universally relevant (i.e., it applies in all settings) and enduring (i.e., it has remained applicable over time and will continue to apply in the future). Physicians play an essential role in the health care decision-making process. Learning to follow desired approaches at each step (e.g., optimal approaches to defining DMC) facilitates and improves the quality and pertinence of physician participation. Generally, diligent adherence to the steps in this process is likely to yield the best possible results--they are consistent with patient needs and values while facilitating pertinent utilization of health care resources--under often challenging and imperfect circumstances. Thus, the health care decision-making process constitutes a key component of the improvement and reform of health care, which is currently under much critical scrutiny.

The basis for improving and reforming long-term care. Part 4: identifying meaningful improvement approaches (segment 2).

While many aspects of nursing home care have improved over time, numerous issues persist. Presently, a potpourri of approaches and a push to "fix" the problem have overshadowed efforts to correctly define the problems and identify their diverse causes. This fourth and final article in the series (divided between last month's issue and this one) recommends strategies to make sense of improvement and reform efforts. This month's concluding segment covers additional proposed approaches. Despite the challenges of the current environment, all of the proposed strategies could potentially be applied with little or no delay. Despite having brought vast increases in knowledge, the research effort may be losing its traction as a formidable force for meaningful change. It is necessary to rethink the questions being asked and the scope of answers being sought. A shift to overcoming implementation challenges is needed. In addition, it is essential to address issues of jurisdiction (the apparent "ownership" of assessment and decision making over patient problems or body parts) and reductionism (the excessive management of these issues and problems without proper context) that result in fragmented and problematic care. Issues of knowledge and skill also need to be addressed, with greater emphasis on key generic and technical competencies of staff and practitioners, in addition to factual knowledge. There is a need to rethink the approach to measuring performance and trying to improve quality of care and services. There are significant limits to trying to use quality measures to improve outcomes and performance. Ultimately, vast improvement is needed in applying care principles and practices, independent of regulatory sources. Reimbursement needs to be revamped so that it helps promote care that is consistent with human biology and other key concepts. Finally, improving long-term care will require a coordinated societal effort. All social institutions and health care settings need to address their own shortcomings and contribute constructively in order to improve and reform nursing homes and health care generally. It is not helpful to scapegoat nursing homes for what are far more universal problems of care, practice, and performance.

The basis for improving and reforming long-term care. Part 4: identifying meaningful improvement approaches (segment 1).

While many aspects of nursing home care have improved over time, numerous issues persist. Presently, a potpourri of approaches and a push to "fix" the problem have overshadowed efforts to correctly define the issues and identify their diverse causes. Together, the two segments of this fourth and final article (divided between this month's issue and the next one) in the series identify strategies that should tie reform efforts together. This Segment 1 of Article 4 discusses the need to judge initiatives and proposals by how well they support and/or promote critical elements such as the care delivery process and clinical problem solving and decision making activities. It also covers the need to critically scrutinize and modify the conventional wisdom and to suppress "political correctness" thatcontinues to inhibit vital critical inquiry and dialogue that are needed to define issues correctly and make further progress. Ultimately, relatively uncomplicated and inexpensive strategies have the potential to bring dramatic progress. But there needs to be more willingness to rethink the issues and reconsider current approaches.

The basis for improving and reforming long-term care. Part 3: essential elements for quality care.

There is a pervasive effort to reform nursing homes and improve the care they provide. Many people are trying to educate and inform nursing homes and their staff, practitioners, and management about what to do and not do, and how to do it. But only some of that advice is sound. After more than 3 decades of such efforts, and despite evidence of improvement in many facets of care, there are still many issues. Despite improvements, the overall public, political, and health professional perception of nursing homes is often still negative. To date, no tactic or approach has succeeded nationwide in consistently facilitating good performance or correcting poor performance. Only some of the current efforts to try to improve nursing home quality and to measure it are on target. Many of the measures used to assess the quality of performance have limited value in guiding overall quality improvement. Before we can reform nursing homes, we must understand what needs to be reformed. This series of articles has focused on what is needed for safe, effective, efficient, and person-centered care. Ultimately, all efforts to improve nursing home care quality must be matched against the critical elements needed to provide desirable care. Based on the discussions in the previous 2 articles, this third article in this 4-part series considers 5 key elements of care processes and practices that can help attain multiple desirable quality objectives.

The basis for improving and reforming long-term care, part 2: clinical problem solving and evidence-based care.

There are intense efforts to improve the quality of long-term care. However, it is unclear whether these efforts are based on understanding root causes of the deficits in quality. This article focuses on processes of clinical problem solving and decision making as a means to enable safe, effective, efficient, and person-centered care that reflects key principles discussed in the initial article in this series. The care delivery process is the means for applying these principles to deliver care. The techniques used in clinical decision-making and problem-solving activities are not unique to health care. Whether or not it is recognized, clinical problem-solving and decision-making activities are occurring continually in all long-term care facilities. But only some staff and practitioners do them well. There is much talk about applying "evidence-based care" in all settings, including the nursing home. However, the term is widely misunderstood and only sometimes applied properly. True evidence-based care requires combining scientific evidence with sufficiently detailed evidence about the individual patient. This article applies the discussion to identify criteria for "expertise" in long-term care. We may identify characteristics of "experts" in long-term care, regardless of discipline, as well as factors that distinguish levels of expertise. Experts have the skill and judgment to apply knowledge effectively to individual patient situations. Based on these criteria, only some of the claims to expertise in caring for, advising about, or overseeing long-term care residents and patients are warranted.

The basis for improving and reforming long-term care, part 1: the foundation.

For several decades, there have been efforts to "reform" nursing homes. Despite this, the calls for such reform continue unabated. Therefore, it might lead us to ask just what has been accomplished to date, and whether it is on the right track. True reform of health care-including long-term care-requires a strategy. A key part of that strategy is that the care must conform to some universal and enduring biological and philosophical principles. Otherwise, alleged reform is likely to be a misnomer and an illusion. This article-the first in a series-identifies those key principles and their relationship to improving attributes of care quality; especially, whether care is safe, effective, and person-centered. It considers the implications for nursing homes as well as the disciplines and individuals who provide care. It then suggests broader implications for public policy-including initiatives to oversee and improve the care-and for evaluating the relevance and effectiveness of those efforts.

Understanding clinical dehydration and its treatment.

Dehydration in clinical practice, as opposed to a physiological definition, refers to the loss of body water, with or without salt, at a rate greater than the body can replace it. We argue that the clinical definition for dehydration, ie, loss of total body water, addresses the medical needs of the patient most effectively. There are 2 types of dehydration, namely water loss dehydration (hyperosmolar, due either to increased sodium or glucose) and salt and water loss dehydration (hyponatremia). The diagnosis requires an appraisal of the patient and laboratory testing, clinical assessment, and knowledge of the patient's history. Long-term care facilities are reluctant to have practitioners make a diagnosis, in part because dehydration is a sentinel event thought to reflect poor care. Facilities should have an interdisciplinary educational focus on the prevention of dehydration in view of the poor outcomes associated with its development. We also argue that dehydration is rarely due to neglect from formal or informal caregivers, but rather results from a combination of physiological and disease processes. With the availability of recombinant hyaluronidase, subcutaneous infusion of fluids (hypodermoclysis) provides a better opportunity to treat mild to moderate dehydration in the nursing home and at home.

Evidence rocks in long-term care, but does it roll?

This article reviews the problems with the implementation of evidence-based care in long-term care. It highlights the fact that many common practices are incompatible with evidence and that available evidence, including evidence about inadvisable and ineffective treatments, is often not followed. Often, there is a tendency to follow recommendations for younger persons (for example, the management of hypertension and elevated cholesterol), or to use questionable interventions (for example, choices for treating constipation). In many cases, the treatments used have only marginal efficacy and increased potential for side effects. This article makes recommendations for improving the approach to evidence-based care in long-term care and strongly urges the FDA to require drug studies in nursing homes.

The consultant pharmacist and the physician in the nursing home: roles, relationships, and a recipe for success.

Both physicians and consultant pharmacists have a longstanding role in nursing home care. The physician role was emphasized in 1974, when medical directors were required in all skilled nursing facilities. It was intensified in 1987, when the Omnibus Budget Reconciliation Act of 1987 (OBRA '87) regulations required all nursing facilities to have a medical director and reinforced that each resident should have an attending physician who visits the resident at specified intervals. In 1974, the Medicare Conditions of Participation first mandated a quarterly drug regimen review (DRR) by a consultant pharmacist in nursing facilities, which was later increased to monthly. Subsequently, the State Operations Manual (SOM) has expanded its guidance to surveyors regarding the required elements of a DRR, to help them determine if an effective DRR was occurring.