More Than a Number

How a Tennessee Nursing Home Reduced Antipsychotic Medication with Consistent Caregivers

An elderly woman sits in a wheelchair outside her nursing home room, weeping and reaching out for each person walking past her. She rocks back and forth, trying to console herself. The nurse on duty doesn’t usually work on that floor, so he is not familiar with the residents. He calms the disoriented woman, escorts her back to her room and makes a note for the attending physician to issue antipsychotics to curb the disruptive behavior.

But more medication may not be the answer.

Stephanie Sauer, assistant director of nursing at NHC in McMinnville, Tenn., believes the answer may be “consistent assignment,” the practice of ensuring nursing home residents – particularly those with dementia – are assigned the same caregivers on a regular basis. But Sauer believes consistent assignment is more than having particular staff assigned to the care of individual residents on a regular basis, it is the development of relationships between caregivers and residents — valuing residents as people and not just another check mark on a “To Do” list.

“When you have consistent caregivers, you’re able to develop relationships and trust. Patients feel safer and secure when their caregiver feels familiar,” said Sauer. “What that particular resident really needed was to get her baby doll and go lie down,” Sauer explained. “She was acting out because she was tired of sitting up.”

Had the nurse been working on his regularly assigned floor, he would have recognized the behavioral warning signs for that resident and prevented an unnecessary prescription for antipsychotic medication.

Through consistent assignment, Sauer has guided her facility to a dramatic decrease in antipsychotic medications from 33 percent to 19 percent in just two years. Nationally, the Centers for Medicare & Medicaid Services (CMS) reported that antipsychotic medication use has been cut by 28.8 percent, beating their goal of a 25 percent reduction in 2015.

Although data and reporting are critical to gauge success in antipsychotic reduction, Sauer says the most accurate information comes from dedicated, familiar healthcare providers and caregivers.

“Our patients are more than a number. They’re more than data,” explains Sauer.

To monitor improvement and determine the next steps, Sauer uses monthly reports pulled from their records on patients who are currently on antipsychotic medications. In addition to the reports, a team of providers discusses each resident, taking into account everyone’s opinion, from the prescribing physician to the certified nurse’s assistants (CNAs) that know the patients best. She says the CNAs provide very helpful information on a patient’s sleeping patterns, appetite and behavioral changes – all critical, first-hand details that physicians and pharmacists may not know about the residents.

While some residents do need antipsychotic medications for conditions like schizophrenia, Tourette’s syndrome and Huntington’s disease, others may be prescribed these powerful medications to suppress episodes of difficult behavior and aggression. These residents are not mentally ill – they are simply misunderstood.

“Every difficult behavior is really just an unmet need,” said Sauer.

When consistent caregivers get to know their patients, they learn the root cause of behaviors. They observe and pay attention to each resident and, over time, caregivers can prevent episodes of difficult behavior because they recognize the warning signs.

“Our goal is not to use antipsychotics as a way of controlling the behavior of people who have dementia, but to address the root cause of their behavior and find out their unmet needs, rather than medicating them just to calm them down,” said Sauer.

By ensuring that all staff members are on board with the facility-wide goal of reducing unnecessary antipsychotic use, Sauer believes she is setting her facility up for success.

Sauer uses continual education for both her staff and the resident’s families to achieve reductions in antipsychotic medication use. Using the CMS Hand-In-Hand training as a cornerstone, she also looks to atom Alliance, the Quality Improvement Network – Quality Improvement Organization serving Tennessee, for educational webinars, videos and resources. As a member of the Leading and Sustaining Systemic Change Collaborative (LSSCC), she participated in atom Alliance’s webinar series on reducing antipsychotic medication in long-term care facilities and consistent assignment.

“We have used many of the tools provided by atom Alliance to train and educate our team,” says Sauer. “The atom staff have been extremely helpful in giving us guidance and answering questions. The webinars are helpful and get us all on the same page,” she said.

Keeping the resident’s families involved and informed in decision-making has paid off in antipsychotic medication reduction, as well. “When you inform families and educate them about these medicines, they’re a lot more willing to accept changes in care.”

By humanizing the data and listening to her residents and staff, Sauer has found a solution to over-prescribing that works. It may not be easy, but respecting residents and treating them like people rather than numbers in a report has greatly improved their quality of life and care.


atom Alliance works hard to improve the quality of care in nursing homes throughout Alabama, Indiana, Kentucky, Mississippi and Tennessee. Learn more here.

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