Schizophrenia, a long-term mental illness that interferes with a person’s ability to think clearly and manage their emotions, normally presents at adolescence. However, data from the National Institute of Health show that at least 20% of patients do not show symptoms until they are older.
And by “older,” NIH means 40 to 60 years of age.
So the likelihood that a resident in a senior care setting, especially a SNF, will develop schizophrenia after admission is extremely low. Because of the stakes of a schizophrenia diagnosis, CMS’s implementation of Phase 3 of the Mega Rule in October 2022 means greater CMS scrutiny on any diagnosis that leads to the prescription of antipsychotic medication.
A misdiagnosis can therefore lead to an “F-tag” from CMS, which indicates on the Statement of Deficiencies when a facility has failed to meet a given standard in its survey.
“An F-tag is very serious. It’s noncompliance with a guidance that has been given by CMS and Medicare and has a lot to do with funding,” says psychiatrist Richard Thompson, Jr., M.D., the National Medical Director of Behavioral Health for TeamHealth Post-Acute Care. “If a facility receives an F-tag, they typically have a limited amount of time to make corrections. And when they’re re-surveyed or audited, depending on what the issue is, if the correction is not made, they can lose their Medicare funding, which is very bad news in the nursing home world.”
Dr. Thompson details the three steps SNFs must take to avoid a misdiagnosis of schizophrenia and the potential F-tag that could follow below.
Have behavioral health providers in your building
One of the areas associated with a SNF’s star rating is antipsychotic medication usage in the building. “The higher the usage, the lower it could bring down a star rating,” Thompson says.
However, any resident on antipsychotic medication due to a diagnosis of schizophrenia is exempt from that rating reduction. That leaves residents who have either been misdiagnosed or who were admitted to the SNF with an antipsychotic medication prescription that they no longer need.
Therefore, confirming the reason a patient is on antipsychotics is important for two reasons: the wellbeing of the patient and for holding up to any CMS scrutiny, which carries the potential risk of an f-tag and impacted star rating. Having behavioral health providers in the building is paramount, as they can assign or affirm a diagnosis or identify a misdiagnosis.
“If a SNF does not have those providers in the building, for whatever reason, then their primary care provider will have to be educated about making these diagnoses because they’re probably going to be called upon to document that in the record,” Thompson says.
Stay broad with diagnoses until you can confirm
Above all, SNFs want to avoid diagnosis of schizophrenia unless they have the clinical information and patient history that can support such a diagnosis. That information can come from the patient or family, Thompson says.
“For instance, if someone was hospitalized with command auditory hallucinations and extreme paranoid delusions, and when they were in their 20s and 30s had five to seven psychotic-related psychiatric hospitalizations, and they’re still on the medication — if you document that, that would be supporting evidence for schizophrenia,” he says.
On the other hand, based on the age trends of schizophrenia, someone who has dementia and no history of psychotic illness in adulthood is likely suffering from paranoia and delusions due to dementia, not schizophrenia.
Remove any misdiagnoses — but don’t force the patient to go through abrupt withdrawal
If a behavioral health provider evaluates a SNF patient who is on antipsychotics, and the evaluation reveals that the patient does not have schizophrenia, or that an existing diagnosis of schizophrenia cannot be supported through clinical data and patient history, the SNF should either remove that diagnosis outright, or broaden it.
“Not all psychosis is schizophrenia,” Thompson says. “But the one thing I want to emphasize is don’t just stop someone abruptly from taking antipsychotic medication. First, just because we don’t early on have the clinical and historical information to support a diagnosis of schizophrenia does not mean that it’s not there. And secondly, there can be a lot of causes of psychosis and someone may need an antipsychotic. (Removing the patient from the medication) can cause a psychotic decompensation. So we don’t want to do that.”
This article is sponsored by TeamHealth. To learn more, visit TeamHealth.com.