Improving Opioid Safety and Quality Measures in Nursing Homes to Enhance Residents’ Quality of Life

Opioids can cause a number of negative effects, particularly in older adults, as they are more susceptible to adverse effects of pain medication. Opioids can contribute to the worsening of nursing homes’ quality measures, including, but not limited to, bladder and bowel incontinence, falls and decreased ability to perform activities of daily living, leading to a decline in the resident’s quality of life.

In 2016, Qsource launched a targeted pilot project in Tennessee, Alabama and Kentucky to help nursing homes tailor pain treatment to each resident’s needs and in turn improve incontinence among the residents. By the end of the project, the six participating homes surpassed their goals with a 12 percent decrease in the number of residents on opioids, an increase of 27 percent in the number of specific opioid indications from the prescriber, and almost a 3.5 percent decrease in residents with incontinence.

“We wanted to improve safe opioid usage for nursing homes residents because they frequently experience adverse drug events, resulting in hospital stays and readmissions,” said Amanda Ryan, PharmD, BCGP. “In addition, it allowed us to leverage efficiencies across our organization and introduce medication safety practices as a way to improve quality measures in nursing homes.”

It is not unusual for nursing home residents to report pain to their caregivers. The same residents may have one or more prescriptions for opioid medications. Opioids are commonly prescribed for pain, but, according to the Centers for Disease Control and Prevention (CDC), opioids are not indicated as first-line or routine therapy for the treatment of chronic pain.

The CDC published the CDC Guideline for Prescribing Opioids for Chronic Pain in March 2016. The Guideline focuses on the use of opioids in treating chronic pain (pain lasting longer than three months or past the time of normal tissue healing) outside of active cancer treatment, palliative care and end-of-life care. Improving the way opioids are prescribed through clinical practice guidelines can ensure patients have access to safer, more effective chronic pain treatment while reducing the number of people who misuse, abuse or overdose from these drugs.

Qsource is focused on improving medication safety for people with Medicare, including those taking opioids. Reducing adverse drug events (ADEs) due to opioids, along with hospital readmissions is a top priority. Across the Qsource five-state region, there were more than 518,000 people with Medicare taking opioids and at least two other medications in 2017. Among those people, there were nearly 345,000 hospital admissions, almost 22,000 people experienced an opioid-related ADE, and almost 74,000 people were re-admitted to the hospital within 30 days of discharge.1

Connecting the Dots

Qsource quality improvement advisors recruited nursing homes interested in medication safety for the pilot project in early 2016. Together, they identified incontinence as a top opportunity for improvement in their facilities and recognized opioids as a contributing factor.

“The nursing homes had expressed that they were interested in working on medication safety and needed a new approach to decrease bladder and bowel control issues. So we decided to look into how we could impact incontinence by improving opioid use,” said Lindsey Jett, CPhT, MALT.

Participants began to meet regularly with their Qsource advisors to assess current rates of opioid use and how the homes could implement the CDC’s new opioid guidelines. They identified opportunities in the nursing homes where there were gaps between the guidelines and current prescriptions for residents who were not receiving hospice, end of life or active cancer treatment.

“We asked for input from the participating homes on which aspect of this project they would like to address first,” said Sarah Sutherland, RT(R), MBA. “We settled on making sure that the residents had a specific indication for the use of the opioid documented in their charts.”

The specific indication helps nursing home staff apply the CDC guidelines by determining if opioids are the most appropriate therapy for treating a resident’s pain. The CDC recommends other therapies in place of or in addition to opioids for chronic pain.

Narrowing the Focus

The homes gathered data on a sample of their residents and included which opioid they were taking, how often, the indication for use and other treatments used in addition to opioids. Qsource advisors found that most residents’ indications were very vague – for example, indications like “pain”, “generalized pain” and “chronic pain” were noted in their charts.

“There was potential for some residents to have their opioids reduced or stopped. We worked with the nursing homes to manage pain with alternatives like physical therapy or over-the-counter pain relievers, in addition to or instead of opioids” said Ryan.

After baseline measures were in place, the participants set some goals for the pilot project. They aimed to reduce the number of residents on opioids by 10 percent, increase the number of specific opioid indications by 10 percent, and reduce the number of residents suffering from incontinence by 10 percent.

Taking Action

Staff in the participating homes put what they learned into action. In order to ensure every resident taking an opioid had a specific indication for use, nursing home staff reviewed all their current opioid orders and documented those indications in the residents’ charts. They consulted with the physicians, nurses, residents and family members to identify the source of a resident’s pain. Qsource advisors recommended using a checklist when a resident was transferred from the hospital to ensure that accurate information was gathered from the beginning of each admission to the nursing home.

Implementation was not always easy. There was some resistance from nursing home staff due to survey concerns.

“They were concerned that if the indication on the order was specific then the nurses might give the opioid for another reason if a patient was having pain,” said Sutherland. “If they kept the indication vague that would be a safer option.”

Qsource advisors overcame this barrier by educating them on the importance of knowing the source of the pain in order to treat it appropriately. Staff learned that the prescribed opioid may not be the best option for a resident’s other complaints. It is important to investigate new pain, so having specific indications alerts the nursing home staff quickly to changes in a resident’s condition.

One-on-one technical assistance meetings with nursing home staff were vital according to Sutherland. Sitting down with the teams and discussing specific examples helped illustrate to staff how to achieve their goals and the positive impacts the changes would have on their residents.

Advisors also battled the mindset that opioids are the only option for pain. This belief was a part of the homes’ cultures and difficult to change, according to Jett.

“We educated the staff on opioid use, that the risks are high, that evidence is lacking for opioid use in chronic pain, and that there are options for acute pain that are equally or more effective than opioids,” said Jett. “We helped them think outside the box as to what other treatments might be safer and more effective.”

Recommendations for pain treatment that did not involve opioids were shared with the nursing home staff while following the CDC guidelines and maintaining pain treatment as the number one focus.

Developing Tools

Nazareth Home Clifton in Louisville, KY worked with Qsource advisors to develop a ‘Menu of Personal Comfort Items’ to distribute to their residents. The brochure included a short pain assessment for the resident to complete and a list of ‘comfort items’ available like a visit from a therapy animal, a massage or a warm blanket. The nursing home staff used this menu as a way to promote alternatives to medication for discomfort and pain.

Using this resource, along with full participation in the pilot project, Nazareth Home Clifton decreased the number of residents on opioids from 42 percent to 30 percent. They also greatly reduced the number of residents with incontinence.

“We’ve made significant progress in our quality efforts,” said Lisa Biddle-Puffer, Administrator for Nazareth Home Clifton in Louisville. “We really appreciate our advisor’s leadership and guidance. There are more opportunities to improve, but this success has motivated us to keep at it.”

Nazareth Home will receive the Innovation in Care award from LeadingAge at the upcoming annual meeting in Kentucky based on their efforts with the Qsource Performance Improvement Project (PIP) on opioids and their use of the Comfort Menus. The mission of the LeadingAge organization is to be the trusted voice for aging in America. LeadingAge is at the forefront of innovative practices that transform how they serve the aging population, cutting-edge initiatives to develop services that meet older adults’ needs, and preferences and advocacy to advance the interest of the aging consumer.

Seeing Results

The pilot project was successful with improvement in all three of the goal measures established at the beginning. The participants achieved a 12 percent decrease in the number of residents on opioids, an increase of 27 percent in the accuracy of opioid indications from the prescriber, and almost a 3.5 percent decrease in residents with incontinence.

Looking Forward

The next phase of this project includes implementing these same strategies with another group of nursing homes across Qsource’s five states. The team is also developing an implementation guide so more providers can work to improve safe use of opioids and quality measures scores in their nursing homes on their own timeline with technical assistance provided by Qsource advisors.

“It’s great to see everyone’s hard work pay off,” said Sutherland. “We moved the needle, but most importantly we improved the lives of more than 500 seniors through this pilot project. Imagine the impact we could have as we spread what we’ve learned here.”

To learn more about the work we do to improve medication safety, visit

For more information on the Comfort Menu, email Amanda Ryan at



1 Quarterly Scorecard from the QIN NCC. 4/18/18

2The measures for the Goal 1 and 2 are expressed as a rate. For Goal 1, the numerator is defined as the number of residents on opioids. The denominator of the Goal 1 measure is the total number of residents. For Goal 2, the numerator is the number of specific indications for opioid use. The denominator for Goal 2 is the number of total indications for opioid use.