CMS Works to Further Reduce Inappropriate Medication Use in Nursing Homes as Part of Biden Reforms

The Biden administration’s recent efforts to further reduce inappropriate medications in nursing homes has been a multi-year endeavor for industry leaders, but many in the space believe there is still a long way to go.

As part of the administration’s nursing home reforms, the Centers for Medicare & Medicaid Services (CMS) will launch a new effort to identify inappropriate use of antipsychotic medications specifically, according to a White House fact sheet published in late February detailing the reforms.

CMS pointed to its National Partnership to Improve Dementia Care in Nursing Homes in reducing the use of antipsychotics in facilities, but admitted “inappropriate diagnoses and prescribing still occur.”

The agency partnered with other federal and state organizations, nursing homes and advocacy groups to reduce antipsychotic medication by 15% by the end of 2019, with a larger mission of enhancing the use of non-pharmacological approaches for dementia care.

Its latest report shows a reduction of antipsychotic use from 23.9% in Q4 2011 to 14.4% in Q2 of 2021.

Some physician groups like Theoria Medical believe the key to medication reduction lies in holding in-house and hospital physicians accountable for prescriptions that may no longer serve a resident. Other clinicians, leery on legislation, believe real change in overprescription will heavily rely on academic research and the scientific community.

MediTelecare’s September 2020 study found a telehealth model was able to cut overall psychotropic medication use by 17% in 50 skilled nursing facilities as well. Telehealth sessions with psychiatrists and nurse practitioners focused on transitioning patients from high-risk medications to either less dangerous or non-pharmacologic options.

Still, in September a New York Times investigation found at least 21% of nursing home residents were on antipsychotic drugs.

The effects of medication optimization

GAPS Health, in its third year as a medical directorship group, has seen a 20-30% reduction in re-hospitalizations, more effective and impactful skilled therapy, and have found wounds heal better with medication management and optimization.

“There’s no one in their [sixth to tenth] decade of life who should be on 20-plus medications,” said Dr. Jerry Wilborn, co-founder and CEO of GAPS. “We’re actively managing the medication regimen, but the key word is optimizing because we make sure that the patients are on the medications they should be on based on their clinical journey.”

It’s not so much a number as it is the right medications, Wilborn told Skilled Nursing News. 

The return to hospital rate goes down, wounds heal better, patients eat better, they feel better, which is the most important thing, added Wilborn.

“In the midst of a staffing crisis in this space, we are able to easily demonstrate that we are saving literally hours of med pass time,” he said.

Med pass, or medication pass, is the process of passing out medication to residents.

Barbara Pereira, vice president of clinical pharmacy for GAPS, said the company’s heavy focus on medication management and optimization was “music” to her ears. Prior to GAPS, Pereira worked as a clinical manager for Omnicare, a CVS Health subsidiary.

The skilled space gives clinicians a unique opportunity to really examine the medications a patient is on and fundamentally change that regimen before moving on to another care setting, Wilborn and Pereira said.

A 25-day stay in a nursing home is an “eternity” compared to a higher impact hospital setting, Wilborn said. There’s more time to really look at prescribed medications and if they’re needed long term.

“That tempo changes a bit. We can watch the patients over a two- to three-week skilled stay and adjust their medications appropriately,” added Wilborn. “That’s something that typically doesn’t happen and it’s hugely beneficial in terms of reducing [hospital readmissions] in the skilled state and improving the ability for these patients to return to the community.”

Therein lies a whole other set of issues – making sure that changed regimen is maintained in a new care setting, especially with the individual’s primary care provider in the community.

Holding the right parties accountable

CMS is holding the wrong parties accountable – nurses, the administrator, the director of nursing aren’t ordering antipsychotics, according to Justin DiRezze, CEO of Theoria Medical.

That order is usually given by the nurse practitioner (NP) or physician assistant (NP) at the hospital, he added, before a patient is transferred to a long-term care setting, or the primary care doctor for a facility that might increase such medications at the nursing home.

“It’s disheartening, I think, for the industry to hear that this is the focus,” said DiRezze. “I think it’s further emphasizing the disconnect of what actually goes on at the ground level. It’s once again showing what the problem is … you have nonclinicians giving orders when they don’t fully understand the environment.”

Operators have heard this refrain before when discussing the Biden administration’s efforts to “crack down” on private equity players in the skilled nursing space.

Family members are often relieved to hear their loved ones are on less medications, Wilborn said – many suspected too many medications were in play. Staff, on the other hand, are sometimes very hesitant to change medication regimen in any way.

“By and large, optimizing medications has not been a focal point of a clinicians workflow in this space,” said Wilborn. “How do we get there? We use clinical pharmacists, and we educate on it and we talk about it and we do it and people start to see the impact of what’s happened.”

DiRezze claims a major effort on the part of their provider group is re-establishing trust because of disinterested in-house nursing home physicians.

“The counterparts that have come before me or even some of the physician organizations that came along with Theoria, they’re never held accountable,” said DiRezze. “My question to CMS is, okay, this is all fine and great, right, you’re holding nursing homes accountable, but what about the physicians and the medical directors that come into the building?”

Real change will come from the scientific community

While regulatory efforts may help with antipsychotic prescriptions for nursing home residents, overall medicine optimization and management still needs close examination by the scientific community.

Dr. Adnan Lakhani, medical director of post-acute telemedicine at Sound Physicians, told SNN that medical research will be the driving force behind lasting change to medicine management in the industry.

“I’m dubious as to the impact regulatory efforts can have,” Lakhani said.

On a national level, Lakhani did say regulations have been able to impact antibiotic stewardship and a wider focus on optimizing pain medication, but global efforts have been more difficult.

Academic papers will better inform physicians, facility owners, patients and families about this effort, added Lakhani.

The more research providers can go back to, Lakhani said, the better job they’ll do in explaining the thought process and rationale behind medication optimization to families.

“Communication and scientific focus on [medicine optimization and management] is really going to trailblaze the path. I’m not sure that from a regulatory standpoint we can really move the needle as much,” added Lakhani.