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Tucked into the 110-page proposed rule issued by the Centers for Medicare & Medicaid Services this week are updates governing the use of as-needed prescriptions for antipsychotics, a tool the agency had limited severely under Phase 2 regulations.

CMS now says it will allow PRN (Pro re Nata) prescriptions for antipsychotics to run more than 14 days if an attending physician or prescriber documents the rationale in a resident’s medical record. They also must indicate the expected duration. That’s a reversal, with standards adopted last year requiring a doctor’s exam to prescribe as-needed medication for more than two weeks.

Of all the elements released this week under the proposed rule, the PRN decision is the most likely to ease pain for providers, said Amy Stewart, MSN, RN, vice president of curriculum development for the American Association of Post-Acute Care Nursing.

“The regulations around this have been confusing because it was different for psychotropics than it was for antipsychotics,” she told McKnight’s. “It also had the potential to delay important medications while facility staff struggle to get a resident seen by a physician or physician extender in order for the PRN antipsychotic to be continued beyond the 14-day limit.”  

CMS acknowledged this issue in its rule.

“Many facilities, especially those that are small or in rural areas, already have difficulty with access to physicians and other healthcare providers, especially mental health practitioners,” the proposed rule said. “To avoid not being in compliance with the requirements for PRN orders, some commenters were concerned that prescribers would write routine orders that would result in residents receiving more of the drug more often than if it were given PRN or only as needed.”

CMS initially implemented the limit as part of a broader effort to cut down on the use of antipsychotic medications, citing prescribing practices that “place the convenience of the caregivers above the residents’ interests.”

But a large mental health organization told the agency the rule would interfere with psychiatrists’ ability to treat residents with mental health and substance abuse disorders.

While still concerned about potential “misuse” of antipsychotics, CMS said the proposed change will strike a better balance between patient and provider needs. The revisions to section 483.45(e) also mean all psychotropic medications can be treated the same when it comes to PRN orders.

Prescribers rarely use PRN unless they are trying to determine the appropriate dose or dealing with an acute psychotic issue, said Chad Worz, PharmD, CEO of the American Society of Consultant Pharmacists. But he applauded the switch to a more standardized approach, noting common operational difficulties in skilled nursing.

“Many SNFs specialize in advanced conditions treated more frequently with psychoactive medications, and while their use of these medications may be higher than average, it is specifically due to the type of patient admitted,” Worz told McKnight’s. “It is important that CMS continues to recognize these differences so quality measurements are reflective of appropriate and high-quality care.”