Decoding the mixed messages about psychiatric care in SNFs

Increasingly, resident populations at skilled nursing facilities (SNFs) include a large number of individuals with mental health conditions—from mood disorders and post-traumatic stress to schizophrenia and delusional disorder. When it comes to treating these residents, physicians and facility leaders face a dilemma: Though many of these individuals may benefit from antipsychotic medication, particularly when poor mental health status interferes with physical medical conditions, conflicting guidelines from Centers for Medicare and Medicaid Services (CMS) are sending mixed messages about when it’s appropriate to prescribe such drugs.

The State Operations Manual (SOM) indicates antipsychotic medication use for a range of mental health conditions. But CMS’ Five-Star Quality Rating System—which is used to assign publicly available SNF quality scores—restricts their use to just three diagnoses. In the face of this conflict, what should SNF providers do?

Understanding SOM

CMS developed the SOM specifically to guide post-acute care facilities’ clinical and operational activities to comply with standards necessary for participating in the Medicare and Medicaid programs. Though SOM is not “the law,” per se, it is widely followed and used to interpret the meaning of CMS regulations. CMS surveyors specifically rely the SOM when reviewing facilities’ CMS certification status. So, because most SNFs receive a significant share of their revenue from treating Medicare and Medicaid patients, adhering to the SOM is critical.

The good news is that following the SOM generally equates to following sound clinical practices. The document outlines reasonable guidelines and expectations, and it instructs surveyors to ensure healthcare provides are observing professional standards of care when diagnosing and treating patients.

With regard to mental health conditions, the SOM interpretative guidelines indicate antipsychotic medication use may be appropriate for a number of diagnoses, including:

• schizoaffective disorder
• schizophreniform disorder
• delusional disorder
• mood disorders
• psychosis in the absence of dementia
• medical illnesses with psychotic symptoms (e.g., delirium)
• Tourette’s disorder
• Huntington’s disease
• hiccups (not induced by medicines)
• nausea/vomiting associated with cancer or chemotherapy
• Behavioral and Psychological Symptoms of Dementia (BPSD).

The Five-Star conflict

CMS created the Five-Star Quality Rating System in 2008. The system—which is designed to help consumers, families and caregivers compare SNFs more easily—assigns a certain number of stars to each SNF that accepts Medicare and Medicaid patients, based on their performance in health inspections, staffing and quality measures.

Anyone can research a facility’s star rating by visiting CMS’s Nursing Home Compare site. The simplified message to consumers is that facilities with five stars have above-average quality and those with one star are well below average, creating inherent competition among facilities to win patients from, or at least not lose patients to, other facilities in their markets. After all, if referring physicians, patients and families can select the SNF of their choice, it stands to reason they will overlook lower-rated facilities in favor of those with four or five stars.

How do antipsychotic medications factor in to the Five-Star system? Their use is among the quality measures CMS takes into account when calculating a facility’s rating. But unlike the SOM, the Five-Star system limits diagnostic indications for antipsychotics to only three conditions: schizophrenia, Tourette’s disorder and Huntingdon’s disease.

That means SNFs and their providers face a direct conflict. Prescribing antipsychotics in accordance with SOM guidelines (and patient needs) maintains compliance with CMS survey requirements, but if patients’ conditions are “not approved” for antipsychotic medications under Five-Star it may negatively impact the facility’s rating, and thus its financial performance. Conversely, adhering strictly to the Five-Star quality measures around antipsychotics may support efforts toward achieving and maintaining a high star rating, but it may cause patient care to suffer and the facility to run afoul of the SOM and surveyors.

Ethics matter

In the past decade, CMS has developed a number of programs that, like Five-Star, create direct or indirect financial “incentives” for healthcare providers to demonstrate quality care. In an industry where profit margins can be quite slim, it’s understandable that these programs may create a sense of urgency among facility leaders who want to perform to program standards. But in the case of the Five-Star system, medical ethics must trump financial incentives.

Healthcare providers and SNF administrators are ethically and medico-legally bound to adhere to professional guidelines and standards of care when diagnosing and treating patients. For mental health professionals, that means following the diagnoses defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and guidelines set forth by the American Psychiatric Association and other professional organizations.

Consider, for example, the hypothetical case of an SNF resident who suffers from multiple medical comorbidities. Though he has no previous medical history of mental health issues, he begins experiencing hallucinations and delusions. His physician may prescribe antipsychotic medication to reduce the thought disorder and lower any risk of harm to the individual, other residents or caregivers. The patient’s diagnosis may be best labeled as “unspecified psychosis,” given that he does not meet all DSM-5 criteria for a diagnosis of “schizophrenia.” Yet, because antipsychotic medication was prescribed, the latter diagnosis would be necessary to keep the facility from being dinged on its quality metrics under Five-Star.

This is just one example where providers and facilities must weigh the broader implications of diagnostic and treatment decisions—and err on the side of ethics and commitment to the patient. In this case, is it worth the Five-Star compliance to make an unethical, arbitrary diagnosis that may be difficult for the resident to remove from his medical history? Not in my book.

Moving forward

More than 500,000 persons with mental illness (excluding dementia) reside in U.S. nursing facilities on a given day—more than all other institutions combined, according to a 2009 study published in Health Affairs. When caring for these residents, we must always put the individual’s health and well-being above all else. Sometimes that may mean following clinical standards of care that are in conflict with programs like Five-Star. But until and unless CMS aligns the program with clinical best practices, we must reconcile ourselves to that conflict.

Richard Thompson, MD, is the Psychiatry Practice Leader for the Midsouth-West region of TeamHealth, a physician services company based in Knoxville, Tennessee. He can be reached via 800-342-2898.