GLP-1 medications are becoming increasingly common among nursing home residents as their use has quickly extended beyond diabetes and weight loss to address cardiovascular health, metabolic conditions and other chronic diseases. However, weighing the risks and rewards associated with GLP-1 use among older adults is complicated by factors such as compliance and payment issues.
Clinicians see the potential to improve residents’ health and quality of life, but the new meds require changes in clinical oversight and staff education, while the big question of reimbursement remains a significant consideration, with the Centers for Medicare and Medicaid Services (CMS) delaying a more permanent coverage solution.
“We see a lot of our new admissions coming in with GLP-1s. Initially it was used solely for weight loss and diabetes, but now we’re seeing it trend in other directions as well,” said Lisa Chubb, chief nursing officer for New Jersey-based Venza Care; referring to such medication increasingly becoming a preventative for cardiovascular conditions and chronic disease, along with metabolic and organ health.
At Venza, about 30% to 40% of newly admitted residents are on GLP-1s, and that percentage is even higher for facilities with more short-stay residents, Chubb added.
Weighing the risks and benefits often means walking a fine line between resident choice and avoiding complications tied to muscle weakness and frailty. The introduction of GLP-1s in the nursing home adds an extra layer of education for interdisciplinary teams, Chubb said.
Weekly “nutrition at risk” meetings among Venza interdisciplinary teams break down resident risk; custom assessments are built in electronic health records so staff can document appropriately that they’ve reviewed the GLP-1 medications and provided education, while monitoring weight loss.
“We also have registered dietitians as part of our interdisciplinary team at Venza, and so those individuals are highly involved and focused on the patients that are taking these types of medications,” said Chubb.
Jody O’Mara, chief nursing officer for Journey Skilled Nursing, said she’s excited about the use of GLP-1s in nursing homes – the timing is right considering the operator’s discussions for a joint venture for pharmacy services among its Georgia residents.
“High-cost medications are one of those hot topics,” said O’Mara. “When you have a joint venture with a pharmacy, this becomes our cost. But the benefits outweigh the cost associated with these medications.”
Overall, the use of GLP-1s in the nursing home is expected to “change a lot of moving parts,” O’Mara said, including facility assessments, the type of residents operators are taking in, and even QAPI programs.
“CMS is realizing that if we fix the major risk factor that’s causing all of these other comorbidities then the cost is worth it, and it’s also going to drive quality,” said O’Mara.
Paying for GLP-1s
CMS started a bridge program for residents with Medicare Part D – certain GLP-1s are covered for weight loss if the resident hasn’t already been prescribed for a GLP-1 for diabetes, which is fully covered under Part D, according to Jessie McGill, senior curriculum development specialist for the American Association for Post-Acute Care Nursing (AAPACN).
In other words, GLP-1s prescribed for weight loss in residents that aren’t on the medication for diabetes can benefit from the bridge program, which adds a $50 fee per month in addition to Part D coverage. And only Wegovy, Zepbound and Foundeo are eligible for bridge program coverage, McGill said.
“That creates challenges for residents in the facility. Maybe they’re dual eligible, they have Medicaid and Medicare so they have a Part D program for medications, but they might not have the funds to cover that $50 per month fee,” said McGill. “That does help reduce the overall expense of the medication for facility residents in the facility, but it doesn’t completely remove it.”
There are different tiers of BMI and other chronic conditions to show the severity of why a resident might need to be on a GLP-1 compared to another weight loss strategy, McGill said of coverage under the bridge program.
A more permanent version of the bridge program, called BALANCE, was delayed without a future implementation date. The bridge program, meanwhile, was extended through 2027.
As for residents on Medicare Part A with a GLP-1 prescription, the nursing home would be responsible for that medication cost, said McGill.
“If they already have a GLP-1 that they’re paying for out of pocket or partially through their Part D program and they come into the facility, if it’s not one of those approved for the bridge program, that can be a high expense medication for the facility to take on. That must be part of their consideration for operational expenses,” said McGill.
To make GLP-1s more affordable, the next step would be to convince Congress to expand consolidated billing to include high-cost medications like GLP-1s, said McGill. Providers can bill Medicare Part B directly for such exclusions, which also include chemotherapy drugs and dialysis medications.
Clinical pitfalls and opportunities for GLP-1s in SNFs
From a clinical perspective, nursing home populations are different from the population typically represented in discussions about GLP-1 medications, said Lauren Stenson, curriculum development specialist with AAPACN.
Nursing home residents already have frailty or multiple chronic conditions, nutritional concerns and limitations in their functional abilities – weight loss may not be a positive outcome for every resident, she added.
“And then you also must consider the adverse effects: nausea, vomiting, constipation, dehydration,” said Stenson. “In a younger, more healthy individual, these are annoying but manageable. They wouldn’t cause complications that a frail older adult might experience.”
If GLP-1 use is accompanied by decreased muscle mass, weakness, poor nutritional intake or changes in the ability to perform activities of daily living, the care team may want further discuss pros and cons, said Stenson. This is especially true if they’re admitted to the nursing home already on a GLP-1.
“We’re going to be seeing more residents admitted into facilities who are already receiving these medications, and that creates another consideration for the nursing home teams,” said Stenson. “They need to understand why the medication was prescribed, whether it’s still appropriate, and what monitoring needs to occur.”
But there are meaningful opportunities hidden here, especially for residents with Type 2 diabetes, those with chronic cardiovascular conditions or sleep apnea, said Stenson. Long-term diabetic use, high sugar levels, affect cardiac, renal function and eye health the most, added O’Mara.
Obesity brings with it so many other comorbidities, and certain other bodily systems decline as a result, O’Mara said.
“Three of our homes are in West Virginia, and West Virginia is the number one obese state,” said O’Mara. “Having [GLP-1s] at our fingertips and at a at a decent cost, whether they’re short stay or long stay … why wouldn’t we use them?”
Increasing a resident’s protein and closely monitoring medication intake will help avoid losing too much weight too quickly, while removing insulin could help with quality of life and mobility, O’Mara said.
Still, nursing home clinicians will need to take a much more individualized approach to medication management rather than looking at GLP-1s as just another medication on their list, Stenson noted.
And if a resident is on dialysis already, the operator needs to let the dialysis center know they’re on a GLP-1, allowing them to be on the lookout for adverse side effects, Stenson said. Also, involving dietary and physical therapy staff will be crucial in ensuring a resident on a GLP-1 is functioning to the best of their ability.
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