Skilled Nursing
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Is Psychotropic Use Justified?
September 24, 2024If you do the right thing in the beginning, it saves a lot of time and trouble in the end. Jeffrey Herr, PharmD, manager of clinical operations at PharMerica, suggested this is one reason to determine if psychotropic use is appropriate as soon as someone is identified as taking one of these drugs – whether they come into the facility on a psychotropic or are prescribed it afterward.
Psychotropic stewardship will enable you to answer 5 questions that will help determine if the drug’s use is justified:
1. When and why was the psychotropic medication started?
By creating a stewardship program, you can ensure that medications are optimized and being used appropriately, and that all diagnostic criteria are being met. This should include a system to look for red flags and ensure that documentation and monitoring processes are in place; and the entire team should be involved in a deep dive to get as thorough a history as possible.
It also is useful to have plans for a psychotropic timeout, a formal assessment of prescribed psychotropics to establish need, continuation, and optimization. Matthew Palmer, PharmD, BCGP, director of clinical operations at PharMerica, stressed, “The most important thing is that when residents are taking these medications, they work and are effective, without adverse events.”
2. What nonpharmacologic interventions have been attempted and what was the result?
Nonpharmacologic interventions should always be strategized and attempted, if possible, before medication is started. An effective stewardship program should “call attention to nonpharmacologic parameters that need to be addressed,” said Herr. He stressed that surveyors will increasingly be paying attention to this.
For instance, Herr stated, “If a hypnotic was prescribed to help a resident sleep without trying nonpharmacologic interventions, such as changing lighting, reducing/eliminating noise, and/or limiting caffeine intake, this could be problematic and even lead to a citation.”
3. What is the plan to reassess the medication’s use and identify opportunities for dose reduction or drug discontinuation?
Essential to stewardship is a plan for and documentation of efforts to reassess psychotropic use and reduce doses or eliminate the drug altogether. “There needs to be a clear process that identifies what each team member is responsible for and ensures they have the tools, training and resources for their designated role,” said Palmer. “If after attempting appropriate nonpharmacologic interventions, we decide a psychotropic medication is appropriate and necessary, we are going to start low and go slow and make regular attempts to address dose reduction or to stop the drug,” he added.
He emphasized that it is important to determine up front how much time you’ll give the medication to achieve the desired results. Additionally, he noted, “One big misconception out there is that if we give a resident a medication and they get better, it’s because of that drug. That’s not necessarily the case, and other factors could affect how someone feels or acts.”
4. What is the goal of treatment?
This needs to consider the resident’s wishes and preferences as well as their safety and that of others. Sometimes, if residents don’t have family or anyone to represent them, pharmacists may have to take on that role and advocate for residents. Effective stewardship can help encourage and enable person-centered care
planning and make it easier for the team to share current, accurate, proven information with residents and family members.
5. Where are there opportunities for improvement?
A stewardship program is like a roadmap that helps the team set and reach realistic goals for each individual resident. By tracking outcomes and measuring them against benchmarks, a good program can help identify opportunities for improvement, such as more effective use of nonpharmacologic interventions, clinicians
who tend to prescribe more psychotropics than others, days or times when more psychotropics are used, and the need for more rigorous efforts to reduce doses or monitor outcomes. Palmer stressed, “It is important to have a program that has been proven useful and incorporates best practices. You can lean on that.”
With regulations and surveyors paying more attention to psychotropic use, stewardship increasingly is an essential component of care. It not only helps ensure the best possible outcomes and quality of life for residents; it also improves teamwork and takes burdens and stress off team members.