Richard Thompson, MD, Psychiatry Lead, Western North Carolina Region, IPC/TeamHealth

Skilled nursing facilities across the country are seeing an increasing number of patients who suffer from mental health conditions. According to a study in published in the journal Health Affairs in 2009, more than 500,000 persons with mental illness (excluding dementia) reside in U.S. nursing homes on a given day, far more than the number in all other institutions combined.

Unfortunately for the skilled nursing facilities and healthcare providers treating these patients, the Five-Star Quality Rating System for nursing homes can be directly at odds with the Centers for Medicare & Medicaid Services’ guidelines for nursing homes when it comes to diagnosing and treating patients with mental health conditions.

Background on CMS Regulations and the Five-Star System

The CMS sets the standards for healthcare facilities to participate in the Medicare and Medicaid programs. In addition, the CMS developed the State Operations Manual  specifically for long-term care facilities. The SOM is not the law, but it is widely followed in interpreting the meaning of CMS regulations, and it is used by CMS surveyors in determining whether a facility should be certified to accept Medicare and Medicaid patients. Because most nursing homes get a significant share of their revenue from treating Medicare and Medicaid patients, adhering to SOM guidelines is quite important.

In general, the SOM provides good clinical guidelines with reasonable clinical expectations. Under SOM, surveyors are focused on review of care – basically, whether healthcare practitioners are adhering to professional guidelines and standards of care when diagnosing and treating patients.

In addition to SOM, the CMS also implemented the Five-Star Quality Rating System for nursing homes. This program is designed to help consumers, families and caregivers compare nursing homes more easily.

Under the Five-Star system, each nursing home has an overall rating derived from three sources of information: health inspections, staffing and quality measures. The rating system suggests that nursing homes with five stars have well above-average quality, while those with one star have well below-average quality. Based on that framework, facilities with a poor Star rating may face negative financial repercussions relative to their higher performing peers, including the loss of residents from referral sources and the community.

The SOM vs. Five-Star dilemma

Unfortunately, the SOM and Five-Star processes are often at odds with each other when it comes to caring for patients with mental health conditions.

Most notably, the Five-Star system does not follow the SOM-approved diagnoses for antipsychotic treatment. In the SOM interpretive guidelines, indications for antipsychotic medications include the diagnoses of 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, and Behavioral and Psychological Symptoms of Dementia.

The 5-Star rating system – which includes the use of antipsychotic medications among its quality measures for determining a nursing home’s score – limits diagnostic indications for antipsychotics to only schizophrenia, Tourette’s disorder and Huntington’s disease.

In this environment, facilities striving to achieve or maintain a high Five-Star rating face a dilemma. They may have patients for whom antipsychotic medications are appropriate, based on medical judgment, standards of care for psychiatric conditions and the SOM. But if those patients’ diagnoses are “not approved” for antipsychotic medications under Five-Star, prescribing to those patients may hurt the facility’s quality rating.

Remembering our ethics

Despite the financial pressure associated with Five-Star performance, healthcare practitioners and facility leadership must remember they are ethically and medico-legally bound to adhere to professional guidelines and standards of care when diagnosing and treating patients.

For mental health practitioners, psychiatric diagnoses are defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and governed by the American Psychiatric Association and other professional organizations. However, in mental health practice it is common for a patient to not meet all DSM-5 criteria for a specific diagnosis. In these cases, the standard of care may call for “unspecified” diagnoses, despite the potential conflict it creates with the Five-Star system.

For example, an older individual with multiple medical comorbidities may develop psychotic symptoms, such as auditory or visual hallucinations and/or delusions, with no previous medical history. In this case, an “unspecified psychosis” diagnosis may be appropriate, and the use of antipsychotic medication would clearly be appropriate to reduce the thought disorder and decrease the risk to the individual and/or others. A diagnosis of “schizophrenia” would be necessary to avoid a negative impact under Five-Star, but that would yield other deleterious results.

Besides the negative impact upon the healthcare professional, for whom making an arbitrary diagnosis is unethical and considered a fraudulent act, the diagnosis may have long-lasting negative effect on the patient. Schizophrenia is a disorder which has had an unfortunate associated social stigma, and individuals may find it difficult to remove the diagnosis from their medical history, even when it has been demonstrated to have been inappropriately applied. In addition, facility finances may be impacted through higher rates for different types of insurance, etc.

Making the right call

Despite the inherent conflict between the SOM and Five-Star systems, long-term care facilities and healthcare professionals who serve them must never lost sight of the obligation to be compassionate and respectful to their patients. Yes, the healthcare environment is highly regulated and under intense financial pressures. But the most important goal must always be providing the best care to each individual, and as such, it is imperative we follow the appropriate standards of care for each patient – even when it is in conflict with Five-Star.

Richard Thompson, M.D., is a psychiatrist with IPC of Team Health.