Compliance • Audits/Analysis • Reimbursement/Regulatory/Rehab • Education/Efficiency
In CMS’s latest blog, antipsychotic medications, again, are in the spotlight. In her April 15th update, CMS Administrator Seema Verma mentioned antipsychotic medications five times:
- Updating Nursing Home Compare to make it easier for consumers to identify non-compliance related to inappropriate antipsychotic medication use.
- Inappropriate use of antipsychotic medications for management of unruly or difficult behavior in residents with dementia-related psychosis.
- Enhanced oversight and enforcement of nursing homes (announced March 1st) that have not improved antipsychotic medication utilization rates for long-stay residents since 2011. These facilities are named “late adopters.”
- Plans to highlight specific quality issues on Nursing Home Care, including inappropriate use of antipsychotic medications.
- Celebration of the rewards through work with the National Partnership to Improve Dementia Care in Nursing Homes as identified by the reduction in antipsychotic medication use from a national prevalence of 38.9% (2011) to 14.6% (2018).
There can be no doubt but that reducing or eliminating inappropriate and “off-label” use of antipsychotic medication will continue to be a theme for CMS!
Keeping the CMS initiative for reducing inappropriate antipsychotic medication use; there are areas within the country where strong success has been made. A few accolades should go to:
- Hawaii (7.5%),
- California (8.3%),
- Michigan (9.1%),
- Arkansas (9.4%).
Data from the National Nursing Home Quality Improvement Campaign are presented below:
From a regulatory perspective, the RAI Users’ Manual (October 2018) notes that:
“Each aspect of antipsychotic medication uses, and management has important associations with the quality of life and quality of care of residents receiving these medications.
Antipsychotic medications are associated with increased risks for adverse outcomes that can affect health, safety and quality of life.”
As a result, the MDS captures (N0410A) the number of days an antipsychotic medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). The MDS also captures (N0450) efforts at gradual dose reduction, and physician documentation if the GDR was contraindicated.
“In addition to assuring that antipsychotic medications are being utilized to treat the resident’s condition, it is also important to assess the need to reduce these medications whenever possible.
Planning for care should include identifying residents receiving antipsychotic medications to ensure that each resident is receiving the lowest possible dose to achieve the desired therapeutic effects.”
Requirements for Gradual Dose Reduction:
- Within the first year in which a resident is admitted on an antipsychotic medication or after the facility has initiated an antipsychotic medication, the facility must attempt a GDR in two separate quarters (with at least one month between attempts), unless physician documentation is present in the medical record indicating that a GDR is clinically contraindicated. After the first year, a GDR must be attempted at least annually, unless clinically contraindicated.
PRN use of antipsychotics is particularly under scrutiny. Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;
- Residents who receive these drugs must receive gradual dose reductions and behavioral interventions, unless otherwise contraindicated, in an effort to discontinue these drugs.
- Residents are not to receive PRN orders for psychotropic drugs unless the drug is intended to treat a condition that is documented in the clinical record.
- PRN orders are limited to 14 days, unless the prescriber believes it is appropriate to extend the order beyond 14 days and documents this in the clinical record.
- PRN orders cannot be renewed beyond 14 days unless the prescriber has evaluated the resident for the appropriateness of the medication.
- If the prescriber believes the resident requires an antipsychotic drug on a PRN basis for longer than 14 days, he/she will be required to write a new PRN script every 14 days after the resident has been evaluated (details in sub-regulatory guidance).
AHCA has a nice tool kit with resources available (AHCA/NCAL Quality Initiative - Antipsychotic Management Toolkit). The following steps are suggested with review of antipsychotic medication use:
- Leadership: It is essential that the organization’s leadership set the direction and expectation that inappropriate antipsychotic medication use will be reduced. This should go beyond “making sure there is a diagnosis to support the use of the medication.” The key must be the leader’s belief that alternatives to managing behavioral dyscontrol are possible without the use of antipsychotic medications.
- Recognition/Assessment: Identifying the impact of antipsychotic medications on the resident with particular attention to sedation, fall risk and changes in level of consciousness.
- Education: Assuring that staff have “tools” for behavioral management beyond the medications. The tools should include creative ways of managing and addressing behaviors that may be dangerous to the resident or to others.
- Resident Involvement: Partnering with residents and their family members around reduction of the antipsychotic medications. Family members know the residents best and may have suggestions to address behaviors.
- Evaluation and Celebration when GDRs are successful and organizational goals to reduce antipsychotic medication use are achieved.