Despite federal efforts to curb inappropriate medication use in the nursing home setting, national entities say the overall use of psychotropic drugs in the space remained “high and unchanged” since 2011.
A report released Thursday by the Department of Health & Human Services (HHS) Office of the Inspector General (OIG) delved into the continued use of psychotropic drugs in nursing homes only. SNF operator associations, meanwhile, argue such findings don’t tell the whole story, and that medication reduction needs to be a continuum-wide initiative.
The report found about 80% of nursing home residents between 2011 and 2019 were prescribed a psychotropic drug, including antipsychotics, which the Centers for Medicare & Medicaid Services (CMS) has actively been trying to mitigate.
CMS has for the past decade monitored antipsychotics as part of its National Partnership to Improve Dementia Care in Nursing Homes initiative. Efforts dovetail with the Biden administration’s wider efforts to reduce inappropriate medications in nursing homes and behavioral health updates made to the requirements of participation in Medicare and Medicaid.
“I had been aware of the work that CMS was doing to reduce the use of antipsychotics. I was very surprised to see that the overall use of psychotropic drugs remained the same from 2011 to 2019,” Andrea Staples, evaluations team leader at HHS, told Skilled Nursing News. “If you’re looking at it from that lens, there was no movement on that needle.”
CMS defines psychotropic drugs as any drug that affects brain activities associated with mental processes and behavior.
Some facilities may have avoided federal monitoring of antipsychotics by indicating residents were diagnosed with schizophrenia, according to the report. These residents had no prior history of this mental health disorder.
There was a staggering 194% increase in the number of residents reported through the minimum data set (MDS) as having schizophrenia between 2015 and 2019, but these didn’t have corresponding diagnoses in Medicare claims and encounter data, the OIG report noted.
In other words, OIG researchers saw 6,400 residents reported as schizophrenic in 2015 and then 19,000 just four years later.
“That one was shocking. It put a global, national figure on something we heard anecdotally,” Brian Whitley, regional inspector general for HHS’ Office of Evaluation and Inspections in Kansas City. “194% over a four-year period, that screams to us that there’s something that we need to look at further and deeper here.”
Schizophrenia is most often diagnosed in the late teens or early twenties of someone’s life, not in the late sixties or seventies, according to Whitley.
“Schizophrenia is one of the diagnoses that can exempt a nursing home from having to report that a long-term stay beneficiary is prescribed antipsychotic medications,” said Whitley. “That’s a concern … that one floored me.”
Other findings and suggestions
Another notable finding was that skilled nursing operators continued to administer anticonvulsants, mood stabilizers and central nervous system agents as less-monitored types of psychotropic drugs.
These medications can still affect brain activity, and therefore should only be prescribed with a documented clinical indication, according to the report; they “carry risk and must be prescribed appropriately.”
OIG also found that nursing homes with lower registered nurse (RN) staff to patient ratios were linked to higher use of psychotropic drugs. Facilities with higher percentages of residents with low-income subsidies were also found to utilize psychotropic drugs more.
Researchers suggested CMS evaluate the use of all psychotropic drugs in nursing homes to see whether additional action is needed. Data could link certain nursing homes or nursing home characteristics to a higher use of psychotropic drugs to best focus federal oversight on inappropriate medication use, researchers added.
A third suggestion, which CMS did not concur with, asked the agency to expand required data elements on Medicare Part D claims to include a diagnosis code for inappropriate usage. CMS said it didn’t have statutory authority to require prescribers include diagnosis codes on prescriptions – only states can directly mandate prescription requirements.
An example OIG provided in the report to show why diagnosis codes are needed points to a nursing home with a five-star rating in Care Compare that reported 36 residents with schizophrenia in the MDS in 2019, but only three of the residents had a Medicare encounter and claim with a schizophrenia diagnosis.
“We’re not saying that this one five star is indicative of all the five stars, that’s not the case. But in this one example, it was pretty startling,” added Whitley.
Association says report is siloed
Monitoring psychotropic use through administrative data, and decisions made between physicians and patients, is “challenging and may not tell the whole story,” Dr. David Gifford, chief medical officer for the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) said in a statement.
“In many cases, physicians not directly affiliated with the long-term care facility are diagnosing patients and prescribing these medications,” Gifford added. “Many residents are already on these medications when they are admitted to the nursing home from the community or hospital, and physicians or family members are concerned about ceasing their use.”
In other words, CMS should take a less siloed approach to curbing psychotropic drugs, extending outreach and scrutiny to other parts of the care continuum, including independent physicians, hospitals, community settings and families.
“We agree with [AHCA], that CMS should look at all parts of the care continuum,” added Staples. “Although the focus of the National Partnership to Improve Dementia Care in Nursing Homes has centered on reducing the use of antipsychotic medication, the partnership has a larger mission, which is to enhance the use of nonpharmacological approaches, and person-centered practices for dementia care, and we support that mission.”
Staples also acknowledged that nursing homes are complex and require complex solutions – no one effort can solve all of the sector’s problems, she said.
GAPS Health, a medical directorship group, told SNN in an April interview 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.”
Overall, AHCA members have been “active partners” in helping reduce the amount of unnecessary psychotropic medications, Gifford noted, and the use of antipsychotics in nursing homes has decreased by 40% in 10 years.
“We continue to offer education to our member providers about how to improve dementia care through non-pharmacological interventions,” added Gifford.
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