Antipsychotic Reduction Efforts - Who Achieved the Most Success?

Nursing homes have been measured by the Centers for Medicare & Medicaid Services (CMS) for their success in reducing the use of antipsychotic drugs since 2011. Under the direction of the National Partnership to Improve Dementia Care in Nursing Homes, the national percentage of long-stay residents receiving an antipsychotic medication has been reduced through nursing home efforts from 23.9% in the 4th quarter of 2011 to a national prevalence rate of 16% effective the 4th quarter of 2016. This demonstrates a 33.2% reduction throughout the five years under review. The greatest percentages of reduction as recorded in the lastquarter of 2016 were achievedby Hawaii, Alaska, District of Columbia, New Jersey, Michigan, California, Wyoming, Delaware, Wisconsin, and Maryland. Although all states demonstrated significant improvement, those with the least reduction included Kansas, Oklahoma, Mississippi, Kentucky, Illinois, and Georgia.

The official measure used to gather prevalence rate data is the Quality Measure The percentage of long-stay nursing home residents who are receiving an antipsychotic medication, excluding those residents diagnosed with schizophrenia, Huntington's Disease, or Tourette's Syndrome. The intent of this effort is to ensure that residents only receive antipsychotic medications if there is a valid, clinical indication that includes a systematic process to evaluate each individual resident's need.

Psychotropic Medication 

Regulation Implementation

Effective November 28, 2017, CMS will implement changes to psychotropic drug regulations. The revised regulation §483.45(e) Psychotropic Drugs states that based on a comprehensive assessment of a resident, the facility must ensure that:

• Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;
• Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated;
• Residents do not receive PRN psychotropic drugs unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record;
• PRN orders for psychotropic drugs are limited to 14 days, except when the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. Then he or she should document the rationale in the resident's medical record and indicate the duration for the PRN order;
• PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

The intent of this revised requirement is that each resident's entire drug/medication regimen will be managed and monitored to ensure it helps promote or maintain the resident's highest practicable men

tal, physical, and psychosocial well-being. Collaboration should occur between the resident and/or their representative, the attending physician, and facility staff to ensure that each resident receives only those medications, doses, and duration that are clinically indicated to treat the resident's assessed condition. Non-pharmacological interventions, such as behavioral interventions, must be considered and used when appropriate, instead of, or in addition to, the medication.

The consultant pharmacist has a significant role in medication oversight through monthly completion of the Drug Regimen Review. Effective November 28, 2017, this is to include a review of the resident's full medical chart, not just portions of the chart typically accessed, such as physician orders, progress notes, and lab results. Additionally, CMS will implement the following definition of psychotropic drugs effective November 28th: any drug that affects brain activities associated with mental processes and behavior. These include, but are not limited to, drugs in the following categories: anti-psychotic, anti-depressant, anti-anxiety, and hypnotic. Include your pharmacist in preparing your staff and updating your policies and procedures to accommodate these new requirements. He or she will bring valuable information to the discussions to help you achieve compliance and improve quality of care for your residents.