MDS Alert

Legislation has put an end to the RUG-II hybrid. In December, lawmakers passed the Medicare and Medicaid Extenders Act of 2010, which eliminated the RUG-III hybrid system, an interim payment system required by the healthcare reform act from Oct. 1, 2010 through Sept. 30, 2011. In anticipation that Congress might repeal the provision, CMS rolled out RUG-IV on Oct. 1, 2010, and planned to develop the hybrid system to retrospectively adjust claims, if needed.

The RUG-IV system will remain in effect, said a gleeful CMS official in the December SNF/LTC Open Door Forum. "All of the work you did to learn the MDS 3.0 and RUG-IV system won't be wasted," CMS' Sheila Lambowitz said. "I can imagine none of you looked forward to reprocessing your claims" -- and neither did CMS.

The legislation also keeps the Part B therapy cap exceptions process in place through 2011. And it maintains the 2010 Medicare physician fee schedule payment rates during that time frame. Physicians and other Part B providers had been looking at an approximate 25 percent rate cut scheduled to go into effect on Jan. 1, due to a sustainable growth factor adjustment that has accrued over the years.

Taking a look at the MDS and MAR can give you a heads up that a patient may be headed for falls and respiratory problems. How so? You may see a resident is taking medications with sedative effects and has a condition that places him at risk for respiratory depression or failure.

Combining CNS depressants produces a synergistic rather than just an additive effect, warned Thomas Lynch, PharmD, in a presentation at the March 2010 American Medical Directors Association annual meeting. Combining CNS depressants has been shown to increase falls and respiratory failure, Lynch cautioned.

The list of sedating medications includes antiepileptics, which are sometimes used for pain syndromesand biopolar disorder, Lynch noted. In addition, "antiepileptics are sometimes used for dementia-related behaviors," adds Albert Barber, PharmD, director of pharmacy for Golden Living based in Ft. Smith, Ark.

Also on the list of sedating meds: first-generation antihistamines, such as diphenhydramine and chlorepheniramine, tricyclic antidepressants, hypnotic agents (Ambien, Lunesta), benzodiazepines, and opiates, said Lynch.

Tip: "Zyrtec is not a non-sedating antihistamine," he emphasized.

Strategy: "Pharmacies and facilities should flag combinations of drugs with sedative effects," says Barber. Also flag patients at higher risk for respiratory depression before administering sedating medications. Examples include people with chronic obstructive pulmonary disease, emphysema, chronic bronchitis, and asthma, Barber says.

Tip: "Typically we encourage prescribers not to start any patient on a long-acting opioid who isn't opioid tolerant," advises Barber. "These drugs, including methadone, are drugs you go to when the shorter-acting opioids aren't working anymore. You don't start with them."

A growing number of nursing home residents with dementia are tapping the hospice benefit. That's the key finding of a new study by researchers at Brown University and Hebrew SeniorLife/Deaconess Medical Center in Boston who found that "the proportion of residents with dementia who benefited from Medicare hospice care nearly tripled -- and the duration of care more than doubled -- between 1999 and 2006," according to a press release.

"Because hospice care provides important medical benefits to patients with dementia, including more attentive assistance with feeding and medication, the increased use of the benefit is good news," said Brown University gerontologist Susan Miller, the study's lead author, in the statement.

But it could be bad news if policymakers clamp down on the benefit for nursing home residents with dementia, Miller worries.

"Initiatives focusing on reducing long hospice stays could disproportionately and adversely affect the timing of hospice referral for persons with dementia," Miller wrote in the paper along with co-authors Julie Lima of Brown and Susan Mitchell of Hebrew SeniorLife and Deaconess, as reported in the release. "It is critical that the creation of any new policy explicitly consider the challenges inherent in the timing of hospice referral for nursing home residents dying with dementia."

Read the full press release at http://news.brown.edu/pressreleases/2010/12/dementia.