MDS Alert

Follow these suggestions to be prepared for increased CMS scrutiny.

Get ready for CMS to be very closely monitoring the use of antipsychotic drugs in your facilities in upcoming surveys. On May 30, CMS officially unveiled its quality initiative to ensure appropriate care and use of antipsychotic medications for nursing home residents and short-stay patients. Called the Partnership to Improve Dementia Care, this new program is spurred by widespread concerns that providers are inappropriately using antipsychotic drugs in the care of their dementia patients.

"A CMS nursing home resident report found that almost 40 percent of nursing home patients with signs of dementia were receiving antipsychotic drugs at some point in 2010, even though there was no diagnosis of psychosis," notes Patrick Conway, MD, MSc, CMS' chief medical officer and director of clinical standards and quality. In addition, CMS data indicates that in 2010 more than 17 percent of nursing home residents had daily doses exceeding recommended levels.

According to the American Health Care Association (AHCA), one in three residents in skilled nursing centers receive antipsychotic drugs, mainly to manage behaviors associated with dementia. "We've learned over time that many of these medications can actually cause people to fall, be re-hospitalized and have a worse outcome," notes David Gifford, MD, MPH, AHCA's senior vice president of regulatory affairs.

"And so," adds Dave Kyllo, executive director of the National Center for Assisted Living (NCAL), "it's important that we look for alternatives, that we come up with better ways to care for the behaviors that frequently come with residents who suffer from dementia." Safely reducing the off-label use of antipsychotics by 15 percent by December 2012 is one of the goals of the AHCA/NCAL quality initiative. (More information on this initiative is available at www.ahcancal.org/quality_improvement/qualityinitiative/Pages/default.aspx).

"Managing dementia without relying on medication can help improve the quality of life for these residents," Conway emphasizes, "and the Partnership to Improve Dementia Care will equip residents, caregivers, and providers with the best tools to make the right decision."

CMS and industry advocacy partners are taking several steps to achieve this goal of improved care including:

Enhanced training: CMS has developed Hand-in-Hand, a training series for nursing homes that emphasizes person-centered care, prevention of abuse, and high-quality care for residents. According to Conway, CMS distributed a DVD and instruction guide to all nursing homes this spring. CMS is also providing training to state and federal surveyors with a focus on behavioral health and person-centered care, he added.

Increased transparency: CMS is making data on each nursing home's antipsychotic drug use available on Nursing Home Compare website starting in July of this year, and will update this data. Providers can expect to receive a preview of their new numbers and ratings about a month before they are posted on the website, Lori Grocholski, MSW, LCSW, in CMS' Office of Clinical Standards and Quality, Survey & Certification Group, Division of Nursing Homes, announced during the May 24 SNF Open Door Forum.

Alternatives to antipsychotic medication: CMS is emphasizing non-pharmacological alternatives for nursing home residents, including potential approaches such as consistent staff assignments, increased exercise or time outdoors, monitoring and managing acute and chronic pain, and planning individualized activities." (For suggestions on appropriate non-drug interventions, see the Tips for Managing Dementia Without Drugs box on pg. 64).

CMS acting administrator Marilyn Tavenner, explained, "We want our loved ones with dementia to receive the best care and the highest quality of life possible. We are partnering with nursing homes, advocates, and others to improve the quality of care these individuals receive in nursing homes. As part of this effort, our partnership has set an ambitious goal of reducing use of antipsychotics in nursing homes by 15 percent by the end of this calendar year." If this goal is met, Conway noted, this means that there should be approximately 18,000 fewer residents on antipsychotic drugs per year."

CMS is also conducting research to better understand the decision to use or not to use antipsychotic drugs in residents with dementia. A study is underway in 20 to 25 nursing homes, evaluating this decision-making process. Findings will be used to target and implement approaches to improve the overall management of residents with dementia, including reducing the use of antipsychotic drugs in this population.

Editor's note: A 50-minute video on CMS' Initiative to Improve Behavioral Health and Reduce the Use of Antipsychotic Medications in Nursing Home Residents can be viewed at http://surveyortraining.cms.hhs.gov/pubs/VideoInformation.aspx?cid=1098.

For tips from two MDs on how to steer clear of shortfalls in managing antipsychotic therapy, see the March 2012 issue of MDS Alert, pgs. 25-28.