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LTC organizations support antipsychotic drug reduction goal, but some say more is needed

September 19, 2014
by Lois A. Bowers, Senior Editor
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The majority of the professional associations representing long-term care say they support the National Partnership to Improve Dementia Care’s goal of continuing to reduce the off-label use of antipsychotic medications in long-stay nursing home residents, although some say more action is needed.

State performance

From the second quarter of 2011 to the first quarter of 2014, the national prevalence of antipsychotic medication use for long-stay nursing home residents was reduced by 17.1 percent, from 23.8 percent to 19.8 percent, according to the Centers for Medicare & Medicaid Services. All 50 states showed some improvement over the 21 months, some more than others.

States with the largest reductions in the use of antipsychotic drugs:

  • Hawaii (31.4 percent)
  • North Carolina (29.9 percent)
  • Vermont (28.2 percent)
  • Georgia (28.1 percent)

States with the smallest reductions in the use of antipsychotic drugs:

  • Nebraska (1.6 percent)
  • Wyoming (1.8 percent)
  • Nevada (6 percent)
  • Illinois (6.1 percent)

See all state rankings on the CMS website.

In a press call today, the public/private collaboration announced new goals of reducing the use of the drugs in skilled nursing facility (SNF) residents by 25 percent by the end of 2015 and by 30 percent by the end of 2016; both percentages are in relation to a baseline rate from the fourth quarter of 2011. The new goals build on an initial reduction of 15.1 percent (with total use decreasing nationwide from 23.8 percent to 20.2 percent), which occurred over time from 2011 to 2013.

‘Variety of efforts’

“CMS and all of our partners will continue to look at a variety of efforts and approaches to help meet our goals,” said Patrick Conway, MD, deputy administrator for innovation and quality and chief medical officer at the Centers for Medicare & Medicaid Services (CMS), which assembled the partnership, a group of consumers, advocacy organizations, providers and professional associations. The approaches, Conway added, will include:

  • Focused dementia care surveys,
  • Review of surveyor feedback on our new guidance and trends in enforcement,
  • Additional opportunities to measure and publicly report on improved dementia care,
  • Continuation of our national education sessions on nonpharmacologic person-centered care,
  • Ongoing work of grassroots state coalitions in all 50 states,
  • Technical assistance through quality improvement organizations or other quality improvement partners,
  • Monitoring potential consequences  and
  • Promoting research on improving systems of care in nursing homes.

In 2011, Medicare Part D spending on antipsychotic drugs was $7.6 billion, according to CMS. Antipsychotic medications were the second highest class of drugs prescribed to Medicare beneficiaries that year, accounting for 8.4 percent of Part D spending, the agency said. The primary focus of the partnership’s effort, however, Conway said, “is a quality goal around patient-centered care. We started this work and we continue to do this work because of the focus on the quality of care” rather than a cost savings, including savings related to hospital admissions and readmissions.

Shari M. Ling, MD, CMS deputy chief medical officer, said: “It is known that these medications have in and of themselves risk profiles that can be very harmful to residents and patients….By reducing antipsychotics, you actually may reduce the risk of immobility and need for hospital readmission while also encouraging that patient- and person-centered approach that would allow interpretation of difficult behaviors in a manner that can then lead to a care plan that helps keep residents comfortable…and averting a potential unnecessary transfer.”

Conway said that antipsychotic medication use would become a measure in the five-star rating system of Nursing Home Compare in 2015 and added that CMS is looking at adding other measures as well.

‘Thousands of lives…improved’

American Health Care Association/National Center for Assisted Living (AHCA/NCAL) President and CEO Mark Parkinson said that the old and new goals of the partnership mesh with those of the AHCA/NCAL Quality Initiative.

“We represent about 10,000 of the 15,000 nursing homes in the United States, and I’m really proud to say that our reduction in the use of off-label antipsychotics in those buildings has been a little bit over 17 percent,” he said. “Behind each of those percentages are literally thousands of lives that are being improved. We went and did the calculations and figured out that in just the buildings that we’re involved in, 26,200 residents who in all likelihood in the past would have received an antipsychotic intervention did not. Instead, they received…person-centered care.”