REDUCING ANTIPSYCHOTIC PRESCRIBING IN NURSING HOMES: FACILITATORS AND BARRIERS FOR HIGH-IMPACT STATE INITIATIVES

Abstract In conjunction with the National Partnership to Improve Dementia Care in Nursing Homes initiated in 2012, states implemented initiatives to reduce antipsychotic use. All achieved substantial reductions, but improvement varied across states. By 2018, several states had achieved reductions of more than 45%, including several of the largest states. These reductions are noteworthy given the challenging nature of behavioral symptoms of dementia, and difficulties encountered historically and internationally in changing strongly-rooted clinical practices. How were these successful interventions achieved in high-performing state initiatives? What were the barriers encountered and facilitators that helped overcome these barriers? What does this experience suggest for sustainability of change? To address these questions, we draw on a mixed-methods study of antipsychotic prescribing in nursing homes incorporating analyses of prescribing data, state policy case studies, and facility case studies. Successful states integrated large-scale educational initiatives with strong regulatory action, often focusing especially on laggard facilities. Texas’ initiative was particularly noteworthy, achieving a 56.5% reduction across its far-flung network of nearly 100,000 residents and 1,200 facilities. Texas used metrics to identify facilities that achieved notable reductions in antipsychotic prescribing, and encouraged them to share their strategies with “late adopters”. The state deployed a designated Quality Monitoring Program (QMP), distinct from the survey process, to provide on-site technical assistance to laggard facilities, and provided education for all levels of staff and assistance in implementing data-driven improvement strategies. Successful state initiatives achieved considerable buy-in on the need to reduce antipsychotic use, a key factor in achieving successful system change.


EFFECTIVENESS OF HOME-AND COMMUNITY-BASED SERVICES IN DECREASING HEALTH CARE EXPENDITURE IN TAIWAN
Ya-Mei Chen, 1 Hsiao-Wei Yu, 2 and Ying-Chieh Wang 3 , 1. National Taiwan University, Taipei, Taiwan, 2. Chang Gung University of Science and Technology,Taipei,Taiwan,3. Institute of Health Policy and Management,Taipei,Taiwan Ideally, continuum of care involves wide-ranging health and long-term care (LTC) services.Taiwan's National Health Insurance scheme and 10-Year Long-term Care Plan attempts to provide universal and fundamental services of continuum care.However, the accessibility of these services for care recipients remains unclear.This study aims to examine the effectiveness of continuum care in decreasing the healthcare expenditure of LTC recipients using home-and community-based services (HCBS).Data collated from the 2010-2013 Long-Term Care Service Management System (N = 77,251) were subjected to latent class analysis to identify subgroups of recipients using HCBS.Subsequently, the 1-year primary care expenditure after receiving HCBS was compared through generalized linear modeling.Three discrete HCBS subgroups were found: home-based personal care (HP), home-based health care (HH), and communitybased care (CC).No difference in the number of visits to doctors and the average primary care expenses was observed between the HP and HH subgroups.However, considering physical and psychosocial confounders, care recipients in the CC subgroup recorded a higher number of visits to doctors (β = 3.05, SD = 0.25, p < 0.05) and lower primary care expenditure (β = -98.15,SD = 43.17,p = 0.02) than the other two subgroups.These findings suggest that LTC recipients in Taiwan may obtain better continuum care only for CC service recipients.Additionally, community-based LTC services may lower the cost of health expenditure after 1 year.In rural Ethiopia, land fragmentation, poverty, rural-urban migration, and the expansion of market forces are negatively impacting family support for older persons.This study explored an innovative community-based support system that uses its own wealth redistribution mechanism to support congregate residential care for older persons.The Awramba Community in northwest Ethiopia has different social norms and values that make it unique from surrounding communities.To explore this new approach to meeting the needs of rural elders, primary data were obtained from in-depth interviews with 8 elders who reside in the older adult center, 3 focus group discussions, and personal observations.In addition, key informant interviews were conducted with a full-time caregiver, two community leaders, and members of the Older Persons' Support Committee.Interviews explored the types of services provided to older persons, the interactions of older residents within the community, and the benefits of congregate living.Community members (N=403) must agree to 4 guiding principles relating to gender equality, respecting the rights of children, discouraging dishonesty, lying and stealing, and helping the less fortunate, ill and older persons.The Older Person's Support Committee is responsible for coordinating the provision of care for the older persons who live in the congregate center.Residing in a common residential home benefited the elders in multiple ways, including opportunities for socialization with peers and access to a full-time caregiver.As traditional family support wanes and the population of elders increases in developing nations, such alternative support strategies are critically needed.

REDUCING ANTIPSYCHOTIC PRESCRIBING IN NURSING HOMES: FACILITATORS AND BARRIERS FOR HIGH-IMPACT STATE INITIATIVES
Stephen Crystal, 1 Richard Hermida, 2 Olga F. Jarrín, 1 Sheree Neese-Todd, 1 Beth Angell, 3  These reductions are noteworthy given the challenging nature of behavioral symptoms of dementia, and difficulties encountered historically and internationally in changing strongly-rooted clinical practices.How were these successful interventions achieved in high-performing state initiatives?What were the barriers encountered and facilitators that helped overcome these barriers?What does this experience suggest for sustainability of change?To address these questions, we draw on a mixed-methods study of antipsychotic prescribing in nursing homes incorporating analyses of prescribing data, state policy case studies, and facility case studies.Successful states integrated large-scale educational initiatives with strong regulatory action, often focusing especially on laggard facilities.Texas' initiative was particularly noteworthy, achieving a 56.5% reduction across its far-flung network of nearly 100,000 residents and 1,200 facilities.Texas used metrics to identify facilities that achieved notable reductions in antipsychotic prescribing, and encouraged them to share their strategies with "late adopters".The state deployed a designated Quality Monitoring Program (QMP), distinct from the survey process, to provide on-site technical assistance to laggard facilities, and provided education for all levels of staff and assistance in implementing data-driven improvement strategies.Successful state initiatives achieved considerable buy-in on the need to reduce antipsychotic use, a key factor in achieving successful system change.

SOCIAL FUNCTIONING AS AN IMPORTANT CLINICAL TARGET DURING CARE TRANSITIONS FROM SKILLED NURSING FACILITIES
Kelsey Simons, 1 Whitney L. Mills, 2 Emily S. Bower, 1 Suzanne Gillespie, 3 and Kimberly Van Orden 4 , 1. VISN 2 Center of Excellence for Suicide Prevention, Canandaigua, New York, United States, 2. Center for Innovation in Providence VA Medical Center,Providence,Rhode Island,United States,3. Canandaigua VA Medical Center,Canandaigua,New York,United States,4. University of Rochester Medical Center,Rochester,New York,United States Care transitions from skilled nursing facilities (SNF) to home signify a period of medical risk for older adults.They also present opportunities for clinical interventions to reduce these risks and to enhance or maintain patients' quality of life.A substantial body of research has been published on improving late life care transitions (CTs), including the development of standardized CT models for acute care.However, such models typically focus on improved coordination of medical services; overlook the need to address psychosocial well-being and social connectedness; and have rarely been implemented in SNFs.This poster will present a conceptual model of social functioning in older adults that draws on constructs from the World Health Organization's World Report on Ageing and Health (2015).We propose that social functioning is a key part of overall functioning among older adults who use SNFs and is simultaneously influenced by physical, psychological, and cognitive functioning.To illustrate our model, we will present results of a qualitative study (n= 21) that describes declines in social functioning following care transitions to the community from VA SNFs.Implications for clinical practice include the need to better integrate social functioning in clinical assessments, goal setting, discharge planning, and coordination of care activities.The need for additional research on this topic will also be addressed.Our project is highly relevant to the overall conference theme "Harnessing the Power of Networks" as it presents a conceptual model and study findings related to social connectedness and social functioning in older adults who use SNFs.The Patient Health Questionnaire-9 (PHQ-9) is a depressive symptom questionnaire administered to nursing facility (NF) residents in the Minimum Data Set (MDS).Does the PHQ-9 measure mood-related aspects of quality of life (QoL)?We assessed the PHQ-9's convergent validity with negative and positive mood items from Minnesota's QoL survey, which is administered annually to a random sample of residents.We also examined if scores on both instruments were associated with various psychiatric diagnoses on the MDS.Using item response theory (IRT) models, we estimated that depressive symptoms (PHQ-9) had a correlation of 0.546 with negative mood and -0.425 with positive mood.With explanatory IRT modeling, we estimated that diagnoses of anxiety, depression, and bipolar disorder were respectively associated with 0.261, 0.339, and 0.301 (all p < 0.001) standard deviation increases in (SD) depressive symptoms, and with 0.235, 0.261, and 0.306 SD increases in negative mood (all p < 0.001), thus indicating convergent validity.For positive mood, depression and bipolar disorder had associations of similar magnitude as the other two constructs.However, anxiety disorders were not associated with lower positive mood (-0.014SD, p = 0.636).Thus, the PHQ-9 can measure mood-related aspects of QoL.However, the PHQ-9 appears to be sensitive to relatively serious depression, whereas the Minnesota items are more sensitive to lower levels of negative mood.Also, the PHQ-9 does not measure positive mood directly.Thus, the PHQ-9 is a more limited measure of mood-related QoL than the Minnesota items.

WHEN A LITTLE GOES A LONG WAY: EXPANDING HOME CARE SERVICES TO ADULTS WITH DISABILITIES
Serena Hasworth, 1 Jaclyn Winfree, 2 Ozcan Tunalilar, 2 and Diana White 2 , 1. Portland State University Institute on Aging,Portland,Oregon,United States,2. Portland State University,Portland,Oregon,United States Policy makers are increasingly interested in reducing public spending while maintaining quality of life.Since 1975, Oregon Project Independence (OPI) has supported community-based adults aged 60 and older to avoid or delay the need for residential long-term care services by increasing access to personal and home care services.The program also aims to prevent the need for Medicaid by optimizing personal resources and natural supports.In 2014, the OPI Expansion (OPI-E) pilot project began to serve adults aged 18-59 with

AWRAMBA COMMUNITY-BASED CARE FOR ELDERS LACKING FAMILY SUPPORT IN ETHIOPIA
In conjunction with the National Partnership to Improve Dementia Care in Nursing Homes initiated in 2012, states implemented initiatives to reduce antipsychotic use.All achieved substantial reductions, but improvement varied across states.By 2018, several states had achieved reductions of more than 45%, including several of the largest states.