Guest Columns

Under the microscope: The ever-increasing scrutiny of antipsychotics in LTC

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Jennifer Hardesty
Jennifer Hardesty
Last year, headlines swirled as the Office of Inspector General released a blistering report focusing on the use of antipsychotics in long-term care. The report stated that a majority of Medicare claims for atypical antipsychotics were used for off-label indications  (i.e. not for schizophrenia or bipolar disorder) and 88 percent were used in residents with dementia-related psychosis, a condition for which the product labeling carries a black-box warning for increased risk of death.

A year later in April 2012, CMS released the “Initiative to Improve Behavioral Health and Reduce the Use of Antipsychotic Medications in Nursing Homes Residents” program. As part of the initiative, CMS is developing a national action plan that will use a multidimensional approach including public reporting, raising public awareness, regulatory oversight, technical assistance/training, and research. Reducing the use of antipsychotics by 15 percent was specifically mentioned as the goal for nursing facilities in 2012, with individual facility rates of usage to be reported on Nursing Home Compare.

The survey process will surely be part of the regulatory oversight by CMS, and facilities need to prepare for the increased scrutiny that surveyors will have on dementia residents taking antipsychotics. While antipsychotics may be required for some residents, a full-fledged review of all antipsychotic use in your facility may be warranted. Here are several steps for improving documentation and care process for residents with dementia on antipsychotics:

1.     Ensure basic documentation is accurate:

a.     Diagnoses are correct in the resident's medical records

b.     Problematic behaviors are documented clearly and specifically in the resident's chart

c.     Behavior monitoring forms have target behaviors identified, and are accurately filled out by staff

d.     Evidence of gradual dose reductions unless clinically contraindicated

e.     Clinical contraindications are clearly explained by the prescriber

2.     Care Plan and Therapeutic Goals are detailed, resident-specific, and should encourage documentation of:

a.     Alternative interventions prior to medications initiated

b.     Ongoing behavior modification interventions, even after antipsychotics are initiated

c.     Documentation efficacy/lack of efficacy of drug therapy

d.     Monthly observations of side effects/adverse reactions from medications

e.     Dose reduction plan

3.     Risk vs. Benefit should also be documented in the resident's chart:

a.     Risk/benefit statement should be clearly documented by prescriber

b.     Consider psychiatric evaluation, if applicable

c.     Consider obtaining verbal or written consent prior to use by resident and/or legal guardian

As a part of this overall process, engage your prescribers, psychiatric specialists, and consultant pharmacists to ensure a complete, cohesive facility plan is in place to identify, monitor and re-evaluate any dementia residents on antipsychotics.

Jennifer L. Hardesty, PharmD, FASCP is the Clinical Services Manager at Remedi SeniorCare.

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Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.

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