The practice of psychiatry in nursing homes continues to evolve, and it’s critical that facilities and clinicians stay abreast of recent changes. While most are familiar with the need to reduce the use of antipsychotic medications prescribed to residents with dementia, all categories of psychotropic medications are now under scrutiny. The role of the psychiatric clinician now emphasizes de-prescribing of “unnecessary medications” as much as adding new ones, and there is increased demand to utilize nonpharmacological, resident-specific interventions for mood and behavioral issues.
Here are some suggestions to help guide facilities towards the goal of optimal psychotropic medication management so they can better manage the health of residents and position themselves for success during a facility survey.
- Don’t let past practice dictate current prescribing. When reviewing the medication list at admission – including medications used by the resident in the community, prescribed by the hospital, demanded by the family, or initiated by a previous nursing home – use a critical eye. Nursing homes have different goals and regulations than hospitals, which focus on the acute management of the patient’s symptoms. Many residents arrive in the SNF on a psychotropic regiment that is inappropriate and unnecessary in the nursing home setting. Additionally, heavy psychotropic medication regimens that may have been necessary in the hospital setting can actually hinder progress in the nursing home setting. Each new resident needs and deserves a thorough psychiatric evaluation that eventuates in an accurate diagnosis and the appropriate psychotropics, if indicated.
- Make sure you understand the symptoms that need attention. Many SNF residents have a litany of psychiatric diagnoses in their chart, often carried over from past providers and facilities. These can skew our perception of the resident’s current needs and conditions, leading to as many psychotropics as there are pre-existing diagnoses. The important questions, particularly at admission, are “What are the mood and behavioral symptoms being observed and documented?” and “What true psychiatric diagnoses existed prior to the hospitalization?” Having a new provider take a fresh look at the resident and focus on symptom presentation (while considering well documented history) can go a long way to effectively limiting the overprescribing of psychotropic medications.
- Highlight Gradual Dose Reduction. The regulations requiring Gradual Dosage Reductions make it imperative that psychiatric clinicians regularly evaluate every resident for GDRs and document the thought process behind changes in prescription patterns. Clinical notes should highlight the patient’s prior mental health history and their response to medications. Facilities and providers should make it easy for surveyors to recognize that every psychotropic is prescribed for a specific reason and providers are always thinking about the medical necessity and risk/benefit of each prescribed psychotropic. This shows surveyors the facility understands the need to reduce or eliminate any and all unnecessary medications.
- View regulations like a tough take-home test. CMS has clearly stated what it considers important around psychotropics and has spelled out the concrete elements that will be reviewed upon survey. Facilities should have a regular audit practice in place to identify potential issues. For example, review all residents on psychotropic medications to ensure they have diagnoses consistent with their prescribed psychotropics and there is documentation of the symptoms that support the use of the medications. Facilities should place special focus on residents who have a diagnosis of dementia and receive an antipsychotic medication. In these cases, the threshold for supporting documentation has been raised substantially, and these are charts that invite review by a surveyor.
- Document why there is no GDR in place. If a GDR is not being attempted, make sure it’s easy for surveyors to see why. Surveyors should not have to search for or interpret the clinical deliberations of the treatment team, especially if they result in an exception to GDR requirements. For example, instead of saying “No GDR at this time,” try “Resident is not a candidate for GDR as they have a longstanding psychiatric history including multiple hospitalizations, most recently in March 2018; risk of decompensation is too great” or “Resident is not a candidate for dose reduction at this time. Last reduction attempted in March 2018, which resulted in increased paranoia resulting in resident physically attacking roommate. Risk of decompensation at this time is too great.”
- Generate a GDR Report. Although facilities often rely heavily on clinicians and their pharmacy to keep track of follow-up GDR visits, ultimately the facility will be held accountable for any missteps. “When was the last time a GDR was attempted?” should be an easy question to answer. Having this information readily available, and using it as a guide to regular psychotropic medication meetings, will ensure good patient care in a way that is transparent to surveyors.
- Restrict or eliminate PRN prescribing. New regulations limit the use of PRN antipsychotic medication to 14 days and require more targeted documentation, diagnosis, evaluation and outcome measurements for the use of all PRN psychotropics for longer than 14 days. Beyond complying with these rules, the bigger issue is what your behavioral health team is doing to understand and resolve residents’ behavioral issues. The facility psychologist should be pulling your team together and developing a behavioral plan to help address underlying issues which might be triggering behavioral problems. Make sure there is clear documentation in place related to possible medical, environmental and interpersonal triggers that can be addressed to reduce the resident’s distress. Ask yourself: “What are we doing for this resident’s symptoms other than medication? How is that specific for this resident’s needs?”
- Establish a high threshold for off-label use of psychotropic medication. Recent media reports have focused on the increase in “off-label” use of medications for the management of the behavioral symptoms of dementia in nursing homes. Off-label use of medication will be a red flag for surveyors and can be interpreted as chemical sedation. If the medication being prescribed is not indicated for the diagnosis, no matter the benefit, substantial documentation should be in place explaining the reasoning and benefit to the resident.
- Support staff in their concerns around behavioral deterioration. Staff members need increased support and education to be able to manage behaviors through environmental and interpersonal strategies. When a resident’s psychotropic medication is being reduced, a behavioral plan should be in place so the staff has the tools and strategies needed to monitor and manage a resident’s mood and behavior. Without such a plan, the return of unwanted behaviors can lead to yet another “failed GDR.” Psychiatric and psychological services, working in tandem and with facility staff, is the recipe for successful GDRs.
- Examine the attitude towards psychotropics in your facility. All of these recommendations are much more likely to lead to optimal use of psychotropics if the prevailing atmosphere at the facility doesn’t promote psychotropic medication use as a knee jerk response to unwanted behavior. 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?” In many instances, residents just need support and time to adjust to the drastic changes in their lives. When residents are started too quickly on psychotropic medications, the opportunity for them to adjust to a difficult transition without a pharmacological intervention has been taken away from them.
Quality care demands residents receive every medication they need, but not one pill more. Developing a team approach with your staff, psychologist, and psychiatry provider will help achieve an integrated care model, reduce the need for pharmacological management of mood and behavior, and help your facility shine come survey time.
Robert Figlerski, PhD, is director of behavioral health services for TeamHealth
Elizabeth Borntrager, MSN, PMHNP-BC, is the national director of behavioral health operations for TeamHealth.