The nursing home industry will be feeling the pain of “another stick” with the Centers for Medicare & Medicaid Services’ (CMS) plan to tighten antipsychotic oversight and penalties.
At least, that’s what GAPS Health CEO Dr. Jerome Wilborn thinks. GAPS Health is a medical directorship group that aims to optimize SNF efficiency and eliminate unnecessary medications.
“Unfortunately, [the new measures] are meant to be punitive,” he said. “And that is because as an industry, we don’t do a great job with the management of antipsychotics.”
The proverbial carrot in his analogy would be more direct incentives and support to create high-level, multidisciplinary conversations about behavioral health care plans for every patient.
“Oftentimes, the attendings and the behavioral health teams are ships passing in the night,” he said. “There’s a paucity of communication and it’s become siloed. And the reality is, mental health is part of your overall health.”
On a positive note, CMS is pushing the industry toward more in-depth clinical analysis of whether residents need to be on powerful medications, he said, which is a needed measure to impact change. And greater consumer awareness will help support a larger national movement to eliminate the unnecessary use of psychotropic drugs in nursing homes, which are linked to higher mortality for people with dementia.
Still, more punitive measures may hurt operators that are struggling to manage industry setbacks, including a workforce crisis.
“Staffing is going to have a real negative impact on our ability to address behavioral health issues in the long-term care space,” he said. “There’s no question – you really need a lot of eyes and ears.”
Without an immediate solution to complex staffing and funding issues, continuing to shift the philosophy by which the long-term care system treats and prescribes medications to aging patients may be the way forward.
“A lot of our focus is centered around working with patients and families helping them understand and educating them about dementia and what the expected trajectory of the illness is, ” Dr. Sonali Wilborn, Chief Clinical Officer at GAPS Health, told SNN.
She added that her research has found that 90% of families would benefit from advanced care planning discussions, which would help them make the most informed decisions.
“It’s only about 30-plus percent of patients that actually do get robust advanced care planning,” she said. “Especially when they’re dealing with situations like advanced dementia.”
A ‘person-centered’ approach
The CMS policies announced this week target potentially erroneous schizophrenia diagnoses, which could be tied to inappropriate use of psychotropic drugs. But the issue of psychotropic — and specifically antipsychotic — reduction has long been at the forefront of discussions and efforts to improve dementia care in nursing homes.
And the two issues of schizophrenia and dementia may be intertwined. An OIG analysis found a dramatic and questionable surge in nursing home residents identified as having schizophrenia between 2015 and 2019.
“The timing of this increase coincides with CMS’s incorporation of the quality measure that tracks antipsychotic use in nursing homes in 2015 into one of its Nursing Home Five-Star Quality Rating System calculations, which impacts the nursing home’s rating on Care Compare,” the OIG report stated. “The increase in MDS reporting of schizophrenia and the number of residents who lack a corresponding diagnosis in Medicare claims is concerning as schizophrenia is a condition that is excluded from calculation in CMS’s quality measure of antipsychotic use. Therefore, any antipsychotic drug use for these residents may not be counted in their nursing homes’ quality measure of long-stay antipsychotic drug use.”
But if nursing homes are trying to obfuscate their use of psychotropic medications, it’s not for lack of dementia care models that support less reliance on medications.
Sandra Mundy is a senior administrator at The New Jewish Home-Manhattan, which was one of the first operations to adopt a dementia care model pioneered at Beatitudes, a retirement community in Phoenix, Arizona, that championed a holistic approach.
With an average resident age of 83 years, the New Jewish Home has a dedicated unit specifically for people with moderate to advanced dementia.
The percentage of residents on psychotropic drugs across the facility is only 5% – much lower than the CMS benchmark – which Mundy credits to a non-pharmacological approach to care.
“A lot of the people that we care for, even in our short-term population, do deal with cognitive deficits and different levels of dementia,” she told SNN. “So we ensure that all our staff are trained in dementia care for our entire population.”
Dementia care training for staff involves understanding that people with cognitive deficits lose the ability to communicate in the way that people without cognitive deficits can. She said that in the past, resident behaviors were interpreted as distress and mitigated with antipsychotic medications.
Pacing, wandering off, or trying to get out of a wheelchair may actually be signs of communication.
“The person is trying to tell you something, they’re just unable to use the way that we would communicate that they would say, ‘I’m hungry,’ or ‘I’m having pain,’ or ‘I need to go to the bathroom,’” she said. “We see these actions, and we try to address what that might be.”
In addition to working with residents individually to understand their needs, frequent meals, sweet snacks, music, and “person-centered” activities are a huge source of success with a non-pharmacological approach.
“If somebody was a dress designer, we might have them sewing. If somebody was an accountant, we would give them financial papers,” she said. “If you really put the effort in, usually within a few days, you can figure out what can make that person feel comfortable and calm, without any use of antipsychotics, effectively.”
Yet she said oftentimes new patients arrive after having been unnecessarily prescribed antipsychotics or psychotropic medications at an outside hospital or other health care setting.
This is a key issue industry stakeholders take with the federal plan related to antipsychotic reduction: Nursing homes aren’t the only pillar of the health care system making prescriptive decisions.
“We urge CMS to address the issue of inappropriate antipsychotic use among providers of all types,” LeadingAge CEO Katie Smith Sloan said in a statement on the new CMS provisions. “Our members often tell us of having to admit residents who’ve been prescribed these meds while under the care of other providers. Health care is a team sport; all providers in the system must be held to the same expectation.”
Mundy said her psychiatrists often call other health care providers in the community to inquire about why they prescribed the medications in the first place.
“A lot of times, hospitals will just put people on these medications just because they might be having some kind of behavior in the hospital,” she said.
After assessing their clinical needs, her team often makes the decision to take residents off of antipsychotics as quickly as possible.
“We have a very aggressive approach to getting people off of antipsychotics with dementia,” she said, adding that her team rarely prescribes them unless they’ve tried everything else.
She emphasized that there also are patients with “bonafide psychiatric diagnoses” who need such medications.
‘You don’t get rid of poison in a gradual fashion’
When a person has been on a certain medication for many years, or is on a combination of medications, more complex analysis is required. This is where more high-level clinical conversations come into play.
“Each patient needs to be individually assessed and evaluated,” GAPS Jerome Wilborn said. “For instance, a patient might be on 22 medications. What is the interaction between stopping one and discontinuing another?”
He said the word “gradual” is often a misnomer in the industry, engendering the idea that gradual reduction of dosage translates to lower risk for patients.
“You don’t get rid of poison in a gradual fashion,” he said. “You’ve got to take everything into account.”
He continued that there are rebounds that occur when patients come off certain medications, but there’s not necessarily a rebound if the patient doesn’t actually have the illness that’s being impacted by that medication.
“So even the notion of gradual dose reduction tends to stymie our progress,” he said.
Seeing as the Department of Health & Human Services (HHS) Office of the Inspector General (OIG) identified a staggering 194% increase in the number of residents reported as having schizophrenia between 2015 and 2019, many of those residents are likely misprescribed psychotropic medications intended to treat an illness that researchers estimate only impacts about 1.1% of the U.S. population.
Yet effectively “optimizing” a resident’s care and medications requires a multifaceted approach; Jerome Wilborn said antipsychotics in small doses have benefits for some individuals. The key for clinicians is understanding exactly why patients are on each medication they take, what the varied impacts of the medications are, and how they fit into the resident’s treatment plans as they age.
Sonali Wilborn echoed the sentiment that providers’ focus needs to be on patient-centered care led by physicians.
“There really should be collaboration and communication between the mental health providers and the PCP,” she said. “We need to focus on doing robust medication optimization and management, both of which would have a significant and positive impact on the quality measures in question.”
Companies featured in this article:
Centers for Medicare & Medicaid Services, GAPS Health, LeadingAge
