Article Archive
March/April 2019

Medication Monitor: Psychotropic Medication: Best Practices to Avoid Survey Problems
By Elizabeth Borntrager, MSN, PMHNP-BC, and Robert Figlerski, PhD
Today’s Geriatric Medicine
Vol. 12 No. 2 P. 8

In a push to enhance the quality of life for postacute care residents, the Centers for Medicare & Medicaid Services (CMS) in recent years has adopted a series of new regulatory guidelines that target the use of psychotropic medications. Specifically, regulators want clinicians to minimize the use of “unnecessary medications” in postacute care settings and, whenever possible, rely on nonpharmacological interventions to treat mood and behavioral issues.

Meeting these expectations can be challenging for postacute facilities—especially those with limited access to mental health professionals—and that can lead to survey problems. To help clinical leaders better navigate these issues and avoid survey trouble, here’s an overview of recent CMS guidance and some tips to help clinical teams better manage the health of residents.

CMS Guidance
In 2012, the National Partnership to Improve Dementia Care in Nursing Homes brought CMS together with federal and state agencies, nursing homes, and other providers, advocacy groups, and caregivers to improve comprehensive dementia care. The goal of the partnership was to reduce the use of antipsychotic medications and promote nonpharmacological approaches and person-centered care practices. The partnership is credited with helping reduce the rate of antipsychotic medication use from nearly 24% in the fourth quarter of 2011 to less than 16% in the first quarter of 2018.

Additionally, the 2016 Mega Rule, also referred to as the “final rule,” revised the requirements for long term care facilities to participate in Medicare and Medicaid. Among the rule’s provisions were requirements to develop a person-centered care plan for every new resident and to provide necessary behavioral health services for any resident exhibiting behavioral symptoms or with a history of psychiatric diagnosis. It also revised the prior guidance concerning the use of antipsychotic medications, broadening its scope to include all “psychotropic” medications and adding several provisions related to reducing or eliminating the need for those drugs.

The result is an expectation that postacute providers deliver physical and behavioral health care that’s specific to each patient and minimizes the use of psychotropic drugs, including antidepressants, antianxiety medications, antipsychotics, hypnotics, and mood stabilizers.

New Perspective
For some facilities, these guidelines represent a new approach to managing residents with behavioral health issues. CMS wants to see facilities, instead of turning to the medication cart, considering and implementing other interventions that can enhance quality of care and quality of life for residents. That requires both tactical practice adjustments, which are discussed in more detail below, as well as a broader cultural shift to promote a new way of thinking.

In an environment that strives to create a nonpharmacological culture, the first question staff should ask is, “What are the medical, environmental, and interpersonal factors that can be addressed before we resort to a pharmacological intervention?”

Those interventions will likely look dramatically different from patient to patient, but that’s what makes them person centered. For example, consider the case of a nursing home resident who routinely becomes angry in the midafternoon. A nurse remembers the resident’s wife saying that he likes ice cream, and she discovers that giving the resident some ice cream at about 3 pm prevents him from becoming agitated for the rest of the day. When documented and performed consistently, this kind of patient-specific, nonpharmacological intervention is what CMS is looking for—and the kind of intervention that facilities can promote by creating a culture that encourages all staff members to take ownership of residents’ care planning.

Update Practice Patterns
Under the umbrella of a nonpharmacological culture, there are a number of specific steps clinical teams can take to better adhere to CMS guidelines and promote quality care.

1. Take a fresh look at each admission.

Some clinicians fall into a habit of relying heavily on residents’ past clinical information—prior diagnoses, current medication lists, demands of the residents or families—to determine a treatment approach. Instead, it’s important to take a fresh look at each new resident. Use a critical eye when reviewing the medication list at admission. Many residents arrive in a postacute setting on a psychotropic medication regimen that’s unnecessary and inappropriate for that setting. Taking a new look at the resident and focusing on symptom presentation (while considering well-documented history) can go a long way to effectively limiting the overprescribing of psychotropic medications.

2. Ensure any psychotropic use is justified.

When a resident needs a psychotropic drug, it’s critical to make sure there’s an appropriate, documented justification for its use. That means looking at the medication and whether there’s both a behavioral justification, such as agitation, and a diagnosis that’s FDA approved or considered the standard of care for that medication, such as bipolar disorder.

As part of this process, consider the risk/benefit of the drug and whether other approaches might be equally or more effective than medication. Consider, too, what might happen if you don’t provide medication therapy. If a resident with dementia won’t let staff change her because she thinks they’re trying to hurt her, medication may be necessary to avoid the risk of a skin breakdown and sepsis. But if a patient is hallucinating that her mother is speaking to her, and it’s not bothering her, there may be no reason to employ an antipsychotic.

Also consider whether a change in any environmental factors might provide symptom relief or whether there are other nonmedication interventions to try prior to, or in conjunction with, medication therapy.

When making the decision to write the prescription, consider the following questions:

• Were medical causes ruled out, or are they being addressed?

• If the underlying case was identified, was treatment initiated in a timely manner?

• If a medical cause was ruled out, was a root cause analysis conducted?

• Were family members/caregivers contacted for information?

• Was the medication prescribed consistent with the diagnosis, or was it an off-label use?

• Were nonpharmacological, person-centered interventions such as a behavior management plan, quarterbacked by the facility psychologist, attempted first?

• Were family and/or legal guardians’ representatives contacted about use of psychotropic medication, and was contact documented?

• Does the drug use have a defined timeframe?

• Is there appropriate monitoring in place for improvement of target behaviors?

• Are staff aware of potential side effects?

• Is there interdisciplinary team documentation and an ongoing discussion about the resident?

3. Understand gradual dose reduction (GDR).

CMS requires postacute providers to evaluate for a GDR on any psychotropic medication in residents’ first year in the facility or within the first year they’re started on the medication. Unless clinically contraindicated, facilities must attempt a GDR twice within the first year, with at least one month between attempts and at least annually thereafter unless contraindicated.

Examples of good opportunities for GDR include pharmacists’ monthly medication reviews, practitioners’ reviews of orders and care plans, care plan updates, quarterly Minimum Data Set reviews, or as clinically indicated during a medically necessary visit. It’s important to focus on GDR early so you don’t fall behind and miss an evaluation window.

There are cases of clinical contraindication recognized by CMS in which a GDR does not need to be performed. For the severe and persistent mentally ill, being on a psychotropic medication is the current standard of practice. You are not required to do a GDR in such cases, though you are required to evaluate the need for it and document the rationale for not attempting one. Consider someone with schizophrenia, diagnosed at age 20. You must evaluate the need for a GDR, but it would be wrong to do one. Much like type 1 diabetes, there is nothing in the scientific literature to suggest that schizophrenia clears up. It’s a lifelong illness that requires lifelong treatment. Another clinical contraindication is if you attempt a GDR and symptoms return or persist. Document that, too, as justification for not attempting a GDR in the future.

4. Limit use of PRNs.

Under the Mega Rule, CMS limits the prescription of antipsychotic medications on an as-needed basis (ie, pro re nata [PRN]) to 14 days. These medications should be used only in very specific circumstances, such as in the case of a resident being sent to the hospital who is acutely dangerous to others. Otherwise, it could be viewed by CMS as a chemical restraint. All other PRN psychotropics may be written for longer than 14 days if the diagnosis, target symptoms, rationale, and timeframe are clearly documented. Note that complying with this rule may have the unintended consequence of keeping residents on a psychotropic longer than necessary. Always be vigilant in examining all prescribed psychotropics to look for opportunities to discontinue or reduce their use.

5. Educate and engage staff.

To support a nonpharmacological culture, all clinical staff, not just the attending psychiatrist or psychologist, need to understand these regulations and tactics and how they affect daily responsibilities. You want nurses and certified nursing assistants to know the guidelines, what symptoms to look for in particular diagnoses, and what behaviors might be problematic.

The goal is to have the entire interdisciplinary team working together toward the common goal of optimizing the resident’s functioning. Provide training on nonpharmacological interventions, care planning, and documentation. Educate staff on common symptoms of psychiatric diagnoses such as schizophrenia, depression, and dementia, while also establishing realistic expectations for how much improvement or symptom relief can be expected.

Survey Success
Delivering quality care means residents receive the medication they need, but not one pill more. CMS is paying ever-closer attention to how postacute facilities are prescribing and managing psychotropic medications. With these guidelines and tips, interdisciplinary clinical teams can be more prepared to meet care and documentation expectations to ensure compliance with all CMS requirements on their next survey.

— Elizabeth Borntrager, MSN, PMHNP-BC, is the national director of behavioral health operations for TeamHealth.

— Robert Figlerski, PhD, is the director of behavioral health services for TeamHealth.