LTC organizations support antipsychotic drug reduction goal, but some say more is needed

The majority of the professional associations representing long-term care say they support the National Partnership to Improve Dementia Care’s goal of continuing to reduce the off-label use of antipsychotic medications in long-stay nursing home residents, although some say more action is needed.

State performance

From the second quarter of 2011 to the first quarter of 2014, the national prevalence of antipsychotic medication use for long-stay nursing home residents was reduced by 17.1 percent, from 23.8 percent to 19.8 percent, according to the Centers for Medicare & Medicaid Services. All 50 states showed some improvement over the 21 months, some more than others.

States with the largest reductions in the use of antipsychotic drugs:

  • Hawaii (31.4 percent)
  • North Carolina (29.9 percent)
  • Vermont (28.2 percent)
  • Georgia (28.1 percent)

States with the smallest reductions in the use of antipsychotic drugs:

  • Nebraska (1.6 percent)
  • Wyoming (1.8 percent)
  • Nevada (6 percent)
  • Illinois (6.1 percent)

See all state rankings on the CMS website.

In a press call today, the public/private collaboration announced new goals of reducing the use of the drugs in skilled nursing facility (SNF) residents by 25 percent by the end of 2015 and by 30 percent by the end of 2016; both percentages are in relation to a baseline rate from the fourth quarter of 2011. The new goals build on an initial reduction of 15.1 percent (with total use decreasing nationwide from 23.8 percent to 20.2 percent), which occurred over time from 2011 to 2013.

‘Variety of efforts’

“CMS and all of our partners will continue to look at a variety of efforts and approaches to help meet our goals,” said Patrick Conway, MD, deputy administrator for innovation and quality and chief medical officer at the Centers for Medicare & Medicaid Services (CMS), which assembled the partnership, a group of consumers, advocacy organizations, providers and professional associations. The approaches, Conway added, will include:

  • Focused dementia care surveys,
  • Review of surveyor feedback on our new guidance and trends in enforcement,
  • Additional opportunities to measure and publicly report on improved dementia care,
  • Continuation of our national education sessions on nonpharmacologic person-centered care,
  • Ongoing work of grassroots state coalitions in all 50 states,
  • Technical assistance through quality improvement organizations or other quality improvement partners,
  • Monitoring potential consequences  and
  • Promoting research on improving systems of care in nursing homes.

In 2011, Medicare Part D spending on antipsychotic drugs was $7.6 billion, according to CMS. Antipsychotic medications were the second highest class of drugs prescribed to Medicare beneficiaries that year, accounting for 8.4 percent of Part D spending, the agency said. The primary focus of the partnership’s effort, however, Conway said, “is a quality goal around patient-centered care. We started this work and we continue to do this work because of the focus on the quality of care” rather than a cost savings, including savings related to hospital admissions and readmissions.

Shari M. Ling, MD, CMS deputy chief medical officer, said: “It is known that these medications have in and of themselves risk profiles that can be very harmful to residents and patients….By reducing antipsychotics, you actually may reduce the risk of immobility and need for hospital readmission while also encouraging that patient- and person-centered approach that would allow interpretation of difficult behaviors in a manner that can then lead to a care plan that helps keep residents comfortable…and averting a potential unnecessary transfer.”

Conway said that antipsychotic medication use would become a measure in the five-star rating system of Nursing Home Compare in 2015 and added that CMS is looking at adding other measures as well.

‘Thousands of lives…improved’

American Health Care Association/National Center for Assisted Living (AHCA/NCAL) President and CEO Mark Parkinson said that the old and new goals of the partnership mesh with those of the AHCA/NCAL Quality Initiative.

“We represent about 10,000 of the 15,000 nursing homes in the United States, and I’m really proud to say that our reduction in the use of off-label antipsychotics in those buildings has been a little bit over 17 percent,” he said. “Behind each of those percentages are literally thousands of lives that are being improved. We went and did the calculations and figured out that in just the buildings that we’re involved in, 26,200 residents who in all likelihood in the past would have received an antipsychotic intervention did not. Instead, they received…person-centered care.”

Not just for nursing homes

Larry Minnix, president and CEO of LeadingAge, said that organization’s members have seen similar results. LeadingAge member Ecumen, for instance, through its Awakenings program in Minnesota, reduced the use of antipsychotic drugs by 98 percent in 1,200 residents over three years, saving more than $200,000 per month, he said. The residents are experiencing quality-of-life benefits including increased alertness, laughter, more restful sleep, fewer falls, increased exercise and mobility, and fewer behavioral outbursts, Minnix said, and all of these benefits have implications for hospital readmissions.

The National Partnership to Improve Dementia Care also aims to reduce the use of other potentially harmful medications in SNFs and plans to expand its focus to other settings as well, a goal Minnix said LeadingAge supports. “This is not merely a nursing home issue but an opportunity for all of us to improve care and services for people with dementia in every setting in which they live, including home,” he said.

Not enough

AMDA‒The Society for Post-Acute and Long-Term Care Medicine has supported the reduction of the inappropriate use of antipsychotic medications for many years, according to its executive director, Christopher Laxton, and supports the partnership’s new goals. The group represents medical directors, attending physicians, nurse practitioners, physician assistants and others who practice medicine in LTC and PAC settings, he added.

“AMDA also wants to make it clear that reducing the inappropriate use of antipsychotics is only one of a number of strategies that should be deployed to improve dementia care for nursing home patients and residents,” however, Laxton said. “In particular, in addition to continuing a reduction in the use of antipsychotics, AMDA is committed to improving dementia care through refocusing the interprofessional team on a better understanding of the root cause of dementia-related behaviors.”

The organization offers a free training program to help identify when antipsychotic medications are appropriate, he said.

Free resources

Advancing Excellence in America’s Nursing Homes also offers free tools to improve organizational and clinical areas, with an emphasis on person-centered care, said Doug Pace, the quality-focused organization’s executive director.

Pace said that Advancing Excellence “appreciates” the partnership’s overall mission of enhancing the use of nonpharmacologic, team-based approaches and person- and family-centered dementia care practices.

“Person-centered care promotes choice and purpose and meaning in daily life,” he said. “Person-centered care means that nursing home residents are supported in achieving the level of physical, mental and psychosocial well-being that is individually practicable. This goal honors the importance of keeping the person at the center of the care-planning and decision-making process.”

The organization’s website also has free resources related to medication use.

QIOs important

Adrienne Mims, MD, MPH, president of the American Health Quality Association, noted the importance of quality improvement organizations (QIOs) in the process.

“QIOs work hand in hand with local providers, consumers and stakeholders across the continuum of care, including in nursing homes, to improve systems of healthcare delivery and ensure better, safer healthcare,” she said. “The effort to reduce the inappropriate use of antipsychotic drugs is a significant portion of QIO efforts to support quality improvements in thousands of nursing homes across the nation.”

‘Too little’

Despite overall approval for the partnership’s goals from the aforementioned organizations, some of which noted the need for additional efforts, at least one group expressed displeasure at the partnership’s goals, saying the goals do “too little to protect elderly residents.”

“More than 250,000 residents could still be administered dangerous antipsychotic medications inappropriately under targets,” the Long-Term Care Community Coalition (LTCCC) said in a press release. “The advocates fear that this signals to providers that regulators will tolerate indiscriminate use of antipsychotics in long-term care facilities.”

LTCCC, based in New York, said that the new goals also are opposed by three other organizations: the California Advocates for Nursing Home Reform, the Center for Medicare Advocacy and the National Consumer Voice for Quality Long-Term Care. These groups were part of the National Partnership to Improve Dementia Care when it launched, according to LTCCC, but maintain that “the goals, which many nursing homes ignore with impunity, will ‘not meaningfully improve current drugging practices.’ ”

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