Opioid Use in Long-Term Care Evidence, Risks, and Management Katy - - PowerPoint PPT Presentation

▶
opioid use in long term care
SMART_READER_LITE
LIVE PREVIEW

Opioid Use in Long-Term Care Evidence, Risks, and Management Katy - - PowerPoint PPT Presentation

Sep 12, 2022 361 likes •1.05k views

Opioid Use in Long-Term Care Evidence, Risks, and Management Katy Brown PharmD Program Manager Lead, Clinical Pharmacy Specialist This material was prepared by Telligen, Medicare Quality Innovation Network Quality Improvement Organization, under

slide-1
SLIDE 1

Employee-Owned

Opioid Use in Long-Term Care

Evidence, Risks, and Management

Katy Brown PharmD

Program Manager Lead, Clinical Pharmacy Specialist

This material was prepared by Telligen, Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-QIN-C3.6- 07/17/17-2211

slide-2
SLIDE 2

2

Disclosure

  • A portion of this material was prepared by Telligen, Medicare Quality Innovation

Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

slide-3
SLIDE 3

3

Objectives

  • Explain the evidence for the use of opioids in the treatment
  • f persistent pain in older adults
  • List specific risks of chronic opioid therapy in older adults
  • Introduce the ADE Trigger Tool and review resources to assist

long term care facilities with action planning to promote resident safety and improved outcomes

  • Review a case study and actionable next steps
slide-4
SLIDE 4

4

Stats Among Institutionalized Elderly

  • persistent pain 49-84%
  • ¼ have daily pain
  • 41% moderate daily or excruciating pain

Journal of Gerentology: MEDICAL SCIENCES 2006, Vol. 61A. No2, 165-196 Long-Term Effects of Analgesics in a Population of Elderly Nursing Home Residents With Persistent Nonmalignant Pain

slide-5
SLIDE 5

5

OIG Report

Adverse and Temporary Harm

  • 1. Medication

Events

  • 2. Resident

Care Events

  • 3. Infection

events

slide-6
SLIDE 6

6

OIG Report

  • 22 percent adverse events
  • 11 percent temporary harm
  • 59 percent preventable
  • estimated cost to Medicare of $208 million in August 2011
slide-7
SLIDE 7

7

OIG Report

slide-8
SLIDE 8

8

5 Star Rating: Quality Measures & Opioid Safety

*Percentage of short-stay residents who were successfully discharged to the community *Percentage of short-stay residents who have had an

  • utpatient emergency department visit

*Percentage of short-stay residents who were re- hospitalized after a nursing home admission

Design for Nursing Home Compare Five-Star Quality Rating System: Technical Users’ Guide. January 2017 CMS

slide-9
SLIDE 9

9

5 Star Rating: Health Inspection & Opioid Safety

  • §483.75(g)

– Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements

  • How it relates to VBP (SNFPPR)

– Preventable harm!

A Resource: Office of Inspector General. Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. OEI-06-0900091. January 2012.

slide-10
SLIDE 10

10

Value Based Purchasing & Opioids

  • Preventable harm (tools)
  • QAPI plan
  • CASPER reports (pain, falls)
slide-11
SLIDE 11

11

5 Star Rating: Health Inspection & Opioid Safety

  • §483.24 -- F675

– Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care.

  • How it relates to VBP (SNFPPR)

– Preventable harm!

Resources: Report-30: LTD-Rule Job Aid, Centers for Medicare & Medicaid Services, July 14, 2017. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Centers for Medicare & Medicaid Services, Rev. 173 Issued 11/22/17.

slide-12
SLIDE 12

12

5 Star Rating: Health Inspection & Opioid Safety

  • §483.24(a) -- F676

– A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section.

  • How it relates to VBP (SNFPPR)

– Preventable harm!

Resources: Report-30: LTD-Rule Job Aid, Centers for Medicare & Medicaid Services, July 14, 2017. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Centers for Medicare & Medicaid Services, Rev. 173 Issued 11/22/17.

slide-13
SLIDE 13

13

5 Star Rating: Health Inspection & Opioid Safety

  • §483.24(b) -- F676

– The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: (1) Hygiene; (2) Mobility; (3) Elimination-toileting; (4) Dining-eating, including meals and snacks; (5) Communication

  • How it relates to VBP (SNFPPR)

– Preventable harm!

Resources: Report-30: LTD-Rule Job Aid, Centers for Medicare & Medicaid Services, July 14, 2017. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Centers for Medicare & Medicaid Services, Rev. 173 Issued 11/22/17.

slide-14
SLIDE 14

14

5 Star Rating: Health Inspection & Opioid Safety

  • §483.25(k) -- F697

– The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences.

  • How it relates to VBP (SNFPPR)

– Preventable harm!

Resources: Report-30: LTD-Rule Job Aid, Centers for Medicare & Medicaid Services, July 14, 2017. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Centers for Medicare & Medicaid Services, Rev. 173 Issued 11/22/17.

slide-15
SLIDE 15

15

5 Star Rating: Health Inspection & Opioid Safety

  • §483.45(d) -- F757

– Each resident’s drug regimen must be free from unnecessary

  • drugs. An unnecessary drug is any drug when used— (1) In

excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced

  • r discontinued; or (6) Any combinations of these reasons.
  • How it relates to VBP (SNFPPR)

– Preventable harm!

Resources: Report-30: LTD-Rule Job Aid, Centers for Medicare & Medicaid Services, July 14, 2017. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Centers for Medicare & Medicaid Services, Rev. 173 Issued 11/22/17.

slide-16
SLIDE 16

16

5 Star Rating: Health Inspection & Opioid Safety

  • §483.45(f) -- F759 and F760

– The facility must ensure that its— – (1) Medication error rates are not 5 percent or greater; and – (2) Residents are free of any significant medication errors.

  • How it relates to VBP (SNFPPR)

– Preventable harm!

Resources: Report-30: LTD-Rule Job Aid, Centers for Medicare & Medicaid Services, July 14, 2017. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Centers for Medicare & Medicaid Services, Rev. 173 Issued 11/22/17.

slide-17
SLIDE 17

17

5 Star Rating: Health Inspection & Opioid Safety

  • §483.75(d)(1) -- F867

– The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

  • How it relates to VBP (SNFPPR)

– Preventable harm!

Resources: Report-30: LTD-Rule Job Aid, Centers for Medicare & Medicaid Services, July 14, 2017. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Centers for Medicare & Medicaid Services, Rev. 173 Issued 11/22/17.

slide-18
SLIDE 18

18

5 Star Rating: Health Inspection & Opioid Safety

  • §483.75(d)(2) -- F867

– The facility will develop and implement policies addressing: (i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems; (ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and (iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

  • How it relates to VBP (SNFPPR)

– Preventable harm!

Resources: Report-30: LTD-Rule Job Aid, Centers for Medicare & Medicaid Services, July 14, 2017. State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Centers for Medicare & Medicaid Services, Rev. 173 Issued 11/22/17.

slide-19
SLIDE 19

19

Guidelines

Resource: Can Fam Physician. 2010 Jun; 56(6): 514–517.Is the WHO analgesic ladder still valid? Twenty-four years of experience.

slide-20
SLIDE 20

20

CDC Guidelines & Evidence

Determine when to initiate or continue opioids for chronic pain

  • Sustained pain relief over time not established
  • Improved function and quality of life uncertain
  • Serious risks associated with opioids
slide-21
SLIDE 21

21

Non-Pharmacological Management

  • Recognize the importance of non-pharmacologic

approaches vs. the risk

  • Recognize the importance and efficacy of patient and

caregiver education

  • Physical modalities: e.g., heat, ultrasound, cold
  • Role of physical therapy, exercise, splinting
  • Invasive procedures to manage pain: e.g. epidural

injections, nerve blocks, surgical repair/replacement

  • TENS units/ electrical stimulation

Source: AMDA Quality Prescribing of Opioid Analgesics

slide-22
SLIDE 22

22

Non-Pharmacological Alternatives

  • Osteopathic manipulative treatment
  • Psychiatry or occupational therapy
  • Acupuncture and transcutaneous electrical nerve

stimulation

  • biofeedback, massage, acupuncture
  • Spiritual connection, counseling, clergy

Source The Journal of the American Osteopathic Association, June 2007, Vol. 107, ES10-ES16. Managing Pain in Geriatric Patients.

slide-23
SLIDE 23

23

Pharmacologic Alternatives

  • Acetaminophen
  • NSAIDs
  • Anti-convulsant
  • Anti-depressants
  • Steroids
  • Topical anesthetics
  • Capsaicin
  • Topical NSAIDS

Source: AMDA Quality Prescribing of Opioid Analgesics

slide-24
SLIDE 24

24

Opioid Indication & Goals of Care

Indications

  • Acute and chronic persistent moderate to severe pain not

controlled by other strategies

  • End of life care

Goals

  • Relief of pain
  • Relief of respiratory distress
  • May improve ADLs and Quality of Life
  • Shortens recovery time after surgery

Source: AMDA Quality Prescribing of Opioid Analgesics

slide-25
SLIDE 25

25

Steps for Evaluating Chronic Pain

Medication History-Taking Severity Location Duration Factors Physical Examination Simulation test Distraction test Regional disturbances Overreaction

slide-26
SLIDE 26

26

Opioid Risks

  • Constipation/urinary retention
  • Delirium and mental status changes
  • Drug diversion
  • Falls
  • Nausea/vomiting
  • Overdose
  • Respiratory depression

Source: AMDA Quality Prescribing of Opioid Analgesics

slide-27
SLIDE 27

27

Focused Survey on Medication Safety Systems

slide-28
SLIDE 28

28

Intent of CMS ADE Trigger Tool

This tool is intended to assist surveyors to identify: 1. The extent to which facilities have identified resident-specific risk factors for adverse drug events, 2. The extent to which facilities developed and implemented systems and processes to minimize risks associated with medications that are known to be high-risk and problem-prone, and 3. When a preventable adverse event has occurred, and evaluate if the nursing home identified the issue and responded appropriately to mitigate harm to the individual and prevent recurrence

slide-29
SLIDE 29

29

Snapshot of CMS ADE Trigger Tool

slide-30
SLIDE 30

30

Assessing Adverse Drug Events & Opioids Tool

slide-31
SLIDE 31

31

Part I: Signs and Symptoms Assessment

slide-32
SLIDE 32

32

Employee-Owned

  • Utilize the second page of the document to assess

your facility’s processes

– Refining these processes can prevent harm from opioids

  • Assess residents treated with opioids based on the 11

measures

  • Use the rating scale provided:

– Rating scale: 1= never; 2 = sometimes; 3 = always

Part II: Rating Scale Assessment Questions

slide-33
SLIDE 33

33

Employee-Owned

Part II: Rating Scale

slide-34
SLIDE 34

34

Employee-Owned

  • For a change in mental status, is there evidence that the

physician conducted an evaluation of the underlying cause, including medications?

Process #1

slide-35
SLIDE 35

35

Employee-Owned

 Is the prescribed Opioid causing mental status changes ‘sedation’ in your resident?  What are the signs and symptoms the resident is exhibiting?  Has a medical provider been contacted and does the medical record support evidence of physician notification

  • f signs/symptoms?

Ask Yourself…

slide-36
SLIDE 36

36

Employee-Owned

  • Is there evidence of a system for ensuring that residents

are routinely assessed for pain – monitoring for pain relief and side effects?

Process #2

slide-37
SLIDE 37

37

Employee-Owned

 Does your facility have a best practice for pain management?  Is there a policy to support this and are all staff educated

  • n this?

 Does your facility perform routine pain audits?

Ask Yourself…

slide-38
SLIDE 38

38

Employee-Owned

Consider the following;

  • Develop a Pain Team- Increase knowledge of pain

management, assessment, and attitudes toward pain – When developing a program to improve pain management at your nursing home, you must address:

  • The needs of the residents
  • The needs of NH staff
  • The needs of primary care physicians
  • High turn-over rates for NH staff and NH leadership

positions

If the Answer is No…

slide-39
SLIDE 39

39

Employee-Owned

 Access resources provided through state and federal agencies regarding best practice  Educate staff, residents, and families with resident stories regarding pain management outcomes  Address attitudes of caregivers towards pain: physicians’ attitudes regarding reluctance to use opioid agents  Create posters about pain myths and display in facility  Provide weekly recognition of CNAs and other staff who incorporate pain assessment and management into their daily routines  Ask staff to elect a rotating Pain Champion  Directors of Nursing must provide consistency in MDS assessment data collection and reporting, along with trends in QM scores

Local Pain Management Team Strategies

slide-40
SLIDE 40

40

Employee-Owned

  • Pain is subjective and can be often overlooked and undertreated
  • One study found when pain assessments are performed more often

the use of non-pharmacological pain control methods also increase

  • Estimates for residents in nursing homes with daily pain range from

40% to 85% (Sengstaken & King, 1993; Stein & Ferrell, 1996; Won et al., 1999) AHRQ evidence based algorithm and best practice to assist facility with pain management;

https://www.guideline.gov/summaries/summary/45524

Things to consider:

slide-41
SLIDE 41

41

Employee-Owned

  • Pain is best assessed by self-reporting pain scales;
  • 2 Types of Pain Scales

– Multidimensional scales for pain measurement

  • Multidimensional scales with multiple items often provide more

stable measurement and evaluation of pain in several domains

– Unidimensional

  • Unidimensional scales consist of a single item that usually relates to

pain intensity alone.

Adopt Pain Management Policy and Assessment

slide-42
SLIDE 42

42

Employee-Owned

Process #3

  • If receiving opioid PRN and routinely, is there

consideration for the timing of administration of the PRN?

slide-43
SLIDE 43

43

Employee-Owned

 When considering timing of administration, is staff available to assess patient for the next 6 hours?

– Opioids were associated with increased risk for clinical deterioration in the 6 hours after administration

For residents who cannot verbalize pain  Assess all PRN opioid use - consider weaning trial

– Monitor behaviors with reduction of dose and frequency – Discuss finding with family or MDPOA

Ask Yourself…

slide-44
SLIDE 44

44

Employee-Owned

  • Can staff describe signs/symptoms of over sedation?

Process #4

slide-45
SLIDE 45

45

Employee-Owned

Early signs of an impending overdose

  • Sedation
  • Slowed speech
  • Confusion
  • ‘Nodding off’
  • Residents may appear relatively alert in conversation, yet

have respiratory arrest at night while asleep

Signs and Symptoms of Over Sedation

slide-46
SLIDE 46

46

Employee-Owned

 Preventing sedation and overdose

– Taper benzodiazepines – Residents should not drink alcohol – Strictly follow guidelines for initial dosing and dose titration – Warn residents not to take extra doses – Have an early warning system during initiation or titration of potent

  • pioids: Nursing family should contact the doctor or call emergency

services at the first sign of an overdose.

 CDC Pocket Guide: Tapering Opioids for Chronic Pain

https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf

Sedation and Overdose Prevention

slide-47
SLIDE 47

47

Employee-Owned

  • Is there evidence of a system for ensuring hand off

communication includes resident’s pain status and time of last dose?

Process #5

slide-48
SLIDE 48

48

Employee-Owned

Should we consider adopting communication tools?  Situation-Background-Assessment-Recommendation (SBAR)  Call-outs  Check-Backs  Handoffs

Resource for tools: https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curri culum-tools/teamstepps/longtermcare/module6/igltccommunication.pdf

Ask Yourself…

slide-49
SLIDE 49

49

Employee-Owned

  • Do resident, family, direct caregivers know signs &

symptoms of over sedation and steps to take?

Process #6

slide-50
SLIDE 50

50

Employee-Owned

 How can we incorporate education into admission procedures for residents and family members ?

– Document within medical record or include in admission paperwork attestation – Develop facility educational material for nursing to provide residents and families – Using increased opioids does not necessarily assume better pain control

 How do we provide on-going staff in-service training for facility staff?

– Conferences – Online education – Staff In-services (Multi-disciplinary)

Ask Yourself…

slide-51
SLIDE 51

51

Employee-Owned

  • Is there evidence facility implements non-

pharmacological pain management approaches?

Process #7

slide-52
SLIDE 52

52

Employee-Owned

For new LTC or Skilled admissions do we:

 Offer alternative non-opioid pain medication  Discuss opioid weaning schedule (reduce dose by 10% every 1-2 weeks)

  • Discuss alternative methods to relieve pain
  • If resident refuses weaning or alternative

treatment, document reason and educate, explain will discuss this issue again

Source: Opioid Reduction Tool: AMDA 2017

Ask Yourself…

slide-53
SLIDE 53

53

Employee-Owned

If resident fails opioid GDR trial

  • Document why GDR failed
  • Discuss GDR failures in nursing forum/ IDT to

determine better options for certain residents

Source: Opioid Reduction Tool: AMDA 2017

Reacting

slide-54
SLIDE 54

54

Employee-Owned

  • Is there a system to ensure extended-release

formulations are delivered correctly? (e.g., medications are not crushed)?

Process #8

slide-55
SLIDE 55

55

Employee-Owned

Address in pain management protocol with input from pharmacist and facility medical provider;  Only start long acting opioids after pain has been controlled with short acting  Do not use long acting opioids for acute pain

Ask Yourself…

slide-56
SLIDE 56

56

Employee-Owned

  • Does the clinical record reflect that the dietician was

made aware of an opioid being ordered so that nutritional approaches to prevent constipation could be considered?

Process #9

slide-57
SLIDE 57

57

Employee-Owned

 Best practice is to manage constipation prophylactically  Review practice of nutrition services notification and timing for any resident prescribed an opioid including documentation  Invite dietician to participate in bowel protocol development

– Consider both pharmacological and non-pharmacological approaches

React

slide-58
SLIDE 58

58

Employee-Owned

  • Are residents/families taught signs/symptoms of

constipation and the importance of reporting them?

Process #10

slide-59
SLIDE 59

59

Employee-Owned

Education in LTC  Incorporate education into admission procedures and on- going resident/family communication  Provide in-service to nursing including recent CDC opioid prescribing guidelines  Stress the importance of limited opioid use (less than 3 months) when educating residents and families

React

slide-60
SLIDE 60

60

Employee-Owned

  • Is bowel status routinely addressed by the physician?

Process #11

slide-61
SLIDE 61

61

Employee-Owned

  • Constipation problems are more frequent among elderly

in LTC facilities and common with opioid use

  • According to one source 50-74% residents use laxatives

daily

 For initial diagnosis of constipation a history and physical examination is conducted by a medical provider as evidenced by the medical record  For ongoing assessment utilize a nursing constipation assessment

  • Norgine Risk Assessment Tool

Evidence

slide-62
SLIDE 62

62

Case Study

Joe is a 90 year old man recently admitted to nursing home for rehabilitation post hospitalization for fall.

slide-63
SLIDE 63

63

Joe

Past medical history includes moderate dementia. Dependent in IADLs, able to feed and dress self if set up

  • provided. Ambulation/transfers not steady, but he is

impulsive and cannot use a walker. He keeps leaving it behind and “wall walks” using rails in halls. Requires extensive assistance of one person with toileting and bathing.

slide-64
SLIDE 64

64

Joe

He has a “new” diagnosis of prostate cancer with local invasion to bladder and distant metastases to bone. When asked, he denies pain, but he has been losing weight and is frequently seen grimacing and rubbing his upper legs. Records indicate that Joe was started on a low dose opioid prior to his fall.

slide-65
SLIDE 65

65

Joe

Does Joe have pain?

  • How would one describe it?
  • Is there anything else we can do to assess his pain?
  • Is there anything else we need to know in addition to

confirming goals of care?

slide-66
SLIDE 66

66

Employee-Owned

Use the ADE Opioid Trigger Tool to assess opioid-related processes within your facility

Next Steps: Call to ACTION

slide-67
SLIDE 67

67

References

  • http://gi.org/wp-content/uploads/2012/10/4-ajg2011349a.pdf
  • https://oig.hhs.gov/oei/reports/oei-06-11-00370.pdf
  • https://psnet.ahrq.gov/webmm/case/248/the-safety-and-quality-of-long-term-care
  • http://www.nicenet.ca/de.aspx?id=499
  • http://palliative.org/NewPC/_pdfs/management/3A11%20Bowel%20Care%20Protocol

%20for%20Constipation%20final.pdf

  • JAMDA 2017, Comprehensive Literature Review of Factors Influencing Medication

Safety in Nursing Homes: Using a Systems Model, Ali Azeez Al-Jumaili BS Pharm, MS, William R. Doucette PhD

slide-68
SLIDE 68

68

Office Hours

This material was prepared by Telligen, the Medicare Quality Improvement Organization for Colorado, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human

  • Services. The contents presented do not necessarily reflect CMS policy.