Spreading Success: Relationships Prove Key to Low Antipsychotic Rate for Wisconsin Nursing Home

Tucked along the northern border of Wisconsin is a small town of less than 2,000 residents. Within this community, named Niagara, lies Maryhill Manor, a 75-bed skilled nursing facility (SNF) which quietly holds one of the best antipsychotic rates in the state for their long-stay residents.

In fact, Maryhill Manor has a zero percent antipsychotic rate for their long-term stay residents, which well below the average of 13 percent in Wisconsin.

Carol Bowman, Director of Nursing, and Teresa West, Admissions and Social Services Director, manage the resident’s admission and well-being at Maryhill Manor. Together, Bowman and West have developed a method of careful assessment of antipsychotic use when accepting new residents. When a hospital referral comes through, Bowman goes through the medication lists, looks at recent diagnoses and conducts an in-person visit with the potential resident to do an in-depth assessment. If an antipsychotic medication is prescribed, Bowman will talk with the doctor to clarify the reason for the prescription. West also talks with the nurses and family members to better understand the potential resident and current situation before moving the resident to Maryhill Manor.

“It’s worth the time to track the resident history because a lot of people at home are on psychoactive medications for compliance and safety,” said Bowman. “Nursing facilities have 24-hour care, so roaming, or staying up all night isn’t an issue.”

Obtaining information about the potential patient is a collaborative effort with hospital staff, and relationships have proven key. West and Bowman have worked with the local hospital for decades. The hospital three miles away provides approximately three quarters of the referrals to Maryhill Manor. Bowman and West put in the time to build and maintain strong relationships with the doctors, nurses and discharge planners. Hospital staff understand the Maryhill Manor process and recognize the questions and monitoring from Bowman is in the best interest of the resident.

“These drugs are harmful to a person,” said West. “Unless they [antipsychotics] are truly needed, we do everything possible to get the resident off [the drugs]. We really have to look at what is right for the residents. That is a priority.”

If there is concern over the need of the antipsychotic medication, Bowman will reach out the doctor who prescribed the medication and talk with the Maryhill Manor pharmacy consultant.  Together, they are very strict about the correct diagnosis for these medications. If there is no clear indicator to why the drug was prescribed, Bowman will voice her concerns to their pharmacy consultant, who can provide more knowledge and expertise on the medication, and suggest appropriate action to be taken.

“[He] really guides me,” said Bowman. “If it doesn’t sound right to him and it doesn’t sound right to me, then he’ll say ‘Let’s call the doctor and get [the antipsychotics] reduced.’”

For referrals that do not come from the nearby hospital, an in-person evaluation may not be possible. West and Bowman then rely on history and physical notes, progress notes from the hospitals, any medication lists, and talking to the family or resident representative. When meeting with the family, West gets as much information as possible by listening and watching body language. Working with the hospital discharge planner is also critical.

“It’s just important to have a good, open relationship with the discharge planners while being respectful of their time,” said Bowman. “Then they will return that respect. You just need to build that bridge and they reliability send updated progress notes and other crucial information.”

Maryhill Manor’s processes for admission were established to ensure everything is on point for each resident’s unique needs. West and Bowman focus on education to help not only staff and family, but everyone involved in the health of residents. In general, there is not enough understanding about the antipsychotic medications. Usually when families learn the medication is an antipsychotic, they are surprised and did not realize the actual indication for the use of the medication.

To keep everyone up to speed on the progress and targeted behaviors to watch for, all Certified Nurse Assistants (CNAs) and nurses get the same report sheet to record daily notes. The CNAs appreciate this involvement because it is the same form as the nurses. This allows collaborative discussion and helps the CNAs feel more involved in the resident’s care. The Maryhill Manor community is focused on making a positive and safe environment for everyone.

In addition to careful review of medications during referrals, the real goal for Maryhill Manor is to use as many non-pharmaceutical interventions as possible to ensure residents are comfortable. The culture and atmosphere for the residents and staff is designed around the happiness and ease of work for everyone. Over time, staff have started incorporating more finger foods, aromatherapy and white noise machines. Sometimes even community volunteers play instruments and family members get involved in activities. Non-pharmaceutical efforts go beyond large group settings. CNAs are encouraged to go with the flow and do what causes as little conflict during day-to-day tasks.

“If residents are up and moving, then talk and walk with to them,” said Bowman. “If they have delusions, enter their world. Don’t try to change it, go with it. It makes your job easier and they are happy.”

For example, Bowman explained, “If a resident is saying she sees things outside, lay on her bed and see what is happening. Maybe there is a light reflecting, or a curtain rod that is really the issue.”

Overall, the focus of every effort is really about the patient, and that includes reducing medications that may not be needed.

“We really do try hard. When you are in a small community like this, the residents are family,” said Bowman.

This story originally was posted by Lake Superior Quality Innovation Network in April 2017.