Stemming the Rise of Psychotropics in Nursing Homes: Educational Outreach, Collaboration, Medication Management Are Key

The efforts of the federal government and nursing homes to reduce the use of psychotropics have been significant, and seem to have paid off until recently when the numbers painted a more grim picture.

Some operators believe that the alarming rise in the prescriptions of psychotropics is partly due to a lack of communication between the various entities in the healthcare system – the facilities, families and hospitals. Meanwhile, other industry stakeholders say that operators can do a better job supporting facilities in their reduction efforts. And, everyone agrees a more robust management of medications is in order.

In November 2022, a report released by the Department of Health & Human Services (HHS) Office of the Inspector General (OIG) found that the overall use of psychotropic drugs in nursing homes remained “high and unchanged” since 2011 — with 80% of nursing home residents between 2011 and 2019 prescribed a psychotropic drug, including antipsychotic drugs.

There was also a staggering 194% increase in the number of residents reported through the minimum data set (MDS) as having schizophrenia between 2015 and 2019, the OIG report stated. Erroneous schizophrenia diagnoses can lead to inappropriate prescription of antipsychotic medication.

In January, CMS began conducting targeted, off-site audits focused on whether nursing homes are accurately assessing and coding individuals diagnosed with schizophrenia. Since then, reducing the use of psychotropics at facilities has gained even more importance.

Tom Syverson, Director of Government and External Affairs at the Evangelical Lutheran Good Samaritan Society, said he remembers his days as a rural administrator and the effort it took to try to get physicians to rethink their prescribing practices when it came to psychiatric care.

“In working with rural doctors, there needs to be a partnership,” he said. “I remember going around and around with physicians trying to get them to change practice. So it’s not as if [nursing homes] are completely in control of this process. I think there needs to be just as much effort on the provider side as the facility side.”

A ‘collaborative’ effort

Syverson said that to lower the use of psychotropic medications, the industry needs a collaborative effort from all parties involved including physicians, family members, and nursing homes.

“We cannot rely solely on nursing homes to take on this task. We need everyone working together, ” he said. 

Skilled nursing operators are often finding that patients come into their care after having been prescribed a psychotropic medication in a hospital or home care setting, and their medicines haven’t been updated for years.

“We’re looking at patients that are coming to us that have been on the same drug for 10 and 15 years, and it’s like new drugs have come out since then,” said Kathy Gallin, vice president of legislative affairs and health policy at Signature HealthCARE. “Why aren’t those patients being provided the opportunity of some of the newer drugs?”

Perhaps the increase in use of antipsychotics is also related to a changing demographic for SNFs. Gallin noted that her team has seen a higher level of behavioral health patients coming into the facility, and a lot more young patients coming into facilities than ever before.

Other sector experts say the trend is also partly fed by resistance from family members to change a resident’s antipsychotic medications.

“It does seem that when we receive these residents from either the hospital or community, that they’re already on these drugs, and it was prescribed by a doctor that’s not associated with our facility … often family members don’t want them to change or take these drugs, or be removed from the drugs,” Mike Bassett, Vice President of AHCA, said at Skilled Nursing News’ CLINICAL conference in Washington, D.C. 

Bassett said there needs to be better communication between the facility, the hospital, and the community to get a larger look at the history of a patient. 

“Educational outreach is something we’ve always been working on,” he said. “We’ve been working with CMS on this for the last several years and have successfully reduced the use of these drugs,” Bassett said. “I think more education is needed. Obviously, in the broader scale of America, mental health is going to need to be a focus, it’s been lacking for a long time,” he said.

Robust medication management 

Mark Parkinson, president and CEO of the American Health Care Association, told Skilled Nursing News that there needs to be both social and medical approaches in long-term care to look at the whole person.

“As a nation, we need to be better informed and prepared to meet these needs of individuals with mental health and behavioral health issues,” he said. “In order for these residents in nursing homes to thrive, we need more support and resources to ensure we can provide them with the best environment.”  

Parkinson said to lower the use of these medications, the industry needs a collaborative effort from all parties involved including physicians, family members, and nursing homes.

“In many cases, physicians not directly affiliated with the long-term care facility are diagnosing patients and prescribing these medications prior to the admittance of a resident to a facility. Even family members can sometimes urge their use,” he said.

However, there are clinical models for reduction of psychotropics. Sandra Mundy, senior administrator at The New Jewish Home–Manhattan, told Skilled Nursing News that after taking into consideration how psychotropics may be interacting with a patient’s other medications, the clinical team often makes the decision to take them off immediately.

“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. “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.

For assuaging family concerns, Dr. Sonali Wilborn, Chief Clinical Officer at GAPs Health, said that taking the time to educate family members and explain patients’ treatment plans is key.

“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.”