CMS Antipsychotic QM - Part 2 - Steps For Safer Antipsychotic Use

We map a systems approach to antipsychotic use in nursing homes, from admission screening to documentation, coding, and survey readiness. Our goal is a practical stewardship model that protects residents, preserves data integrity, and withstands CMS scrutiny.

• facility assessment confirming behavioral health capacity
• pre-admission screening and verified diagnoses
• CMS exclusions and how to document them
• pharmacy reconciliation and indication clarity
• ordered vs administered tracking with exception flags
• alignment of claims, MDS, and ICD coding
• nonpharmacologic strategies and target behavior tracking
• gradual dose reduction considerations for long-stay residents
• hospice-related use and how to explain it
• education plans for nurses, providers, and billing
• antipsychotic stewardship led by the compliance committee
• escalation to psychiatric and neurocognitive specialists

Please feel free to reach out to Verity Consulting at VerityTeam.com if you'd like further assistance with your healthcare compliance needs

Chapters

• 0:00 Purpose And Scope Disclaimers
• 0:56 Systems Approach To Monitoring
• 2:46 Admissions And Diagnosis Validation
• 4:29 Exclusions And Data Alignment
• 6:30 Pharmacy And Compliance Oversight
• 9:17 Hospice Use And Measure Impact
• 11:20 Documentation, Alternatives, And Training
• 14:05 Long Stay vs Short Stay Reviews
• 16:40 New Diagnoses And DSM-5 Standards
• 18:27 Quality Measures And Star Ratings
• 21:10 Nonpsych Uses Of Antipsychotics
• 23:20 Education Gaps And Root Cause

Transcript

SPEAKER_00: 0:15

The views or opinions expressed in his podcast are for informational purposes only, not intended as legal or professional advice, and may not represent those of Verity Consulting. Although we make strong efforts to make sure our information is current, at the time the podcast episode was recorded, Verity Consulting cannot guarantee that all information in this podcast is always complete. All information in this podcast is subject to change without further notice.

SPEAKER_01: 0:48

I am a registered nurse and healthcare analyst. Let's get started. Welcome to Vital Compliance Insights. This is part two of understanding how the CMS will track antipsychotic medication use administration in nursing homes. So in part two, I want to talk a little bit more about the nuts and bolts as to what facilities can do to wrap their arms around this and feel confident and successful in monitoring use. And this is really systems level. We're looking at the whole throughput process from identifying do we have a baseline facility assessment that says we can provide this care and services to our residents? And we do have systems in place for behavioral management, behavioral health management, for effective and appropriate use of antipsychotic medications. So we are prepared to provide that service. Okay, fine. Now there's a referral made and a resident needs to be evaluated for admission, the whole pre-admission screening process. And that means that we need qualified persons, medical staff that are going to look at a potential new admission resident to find out why they are ordered an antipsychotic maybe in the hospital? What was it for? Do we still need it? We need a very clear plan of care before the resident would even come to the facility. Looking at those admission orders, once the resident is coming in, that's really critical. Is there an antipsychotic medication on the orders? Why? What's the diagnosis? Now, CMS says there are some diagnoses that are going to be excluded from the quality measure, the antipsychotic quality measure. And right now, at this time of recording this podcast, there's only a few, like schizophrenia, Huntington's Korea, Huntington's, Tourette syndrome. So we know there are only a few diagnoses right now that are listed as approved. What does that mean? That means when the CMS is looking at data, they're saying, oh, there is a diagnosis of schizophrenia. And it does correspond to, or vice versa, to that antipsychotic medication. Okay, so they will be excluded from the quality measured data. Okay. So that's that's good, but certainly that doesn't mean we have all of our documentation in place. And what I mean by that is how do we know a resident does have a diagnosis of schizophrenia? Do we have validation of that in the clinical record from a psychiatrist, a nurse practitioner, psychiatric nurse practitioner? So we need to know that that's in place to say, yes, this resident does have schizophrenia or Huntington's or TRECTS, and they need this antipsychotic. Okay. So we do need providers to be very engaged to say, I know my resident, I know this resident, and I know they need this drug. That also translates to pharmacy. The pharmacist needs to be mindful and watchful to say, uh, new admission residents coming in, and it's confusing here. I'm hearing this resident is a schizophrenic, and I'm seeing this antipsychotic medication. However, the order that was submitted to me to the pharmacy for, let's say, uh Respiridone has dementia-related psychoses. Wait a minute, there's a disconnect. So there needs to be engagement from the very beginning to make sure everybody is saying, wait, we we some there's things that are off here, and we need to understand clearly. So, and that that really reminds me to say the compliance committee needs to have individuals who are very engaged in monitoring this whole process. Are we auditing? Are we making sure our policies are followed? And if not, where are the gaps? What can we do to further understand why are there gaps? Is there a need for education, some training, just some maybe some just a couple persons need some focused education? Or do we need to do kind of facility-wide education? Now, that doesn't exclude the billing department because the billing department has a role here. They will be responsible for the ICD9 codes. So if residents admitted and they have schizophrenia as the diagnoses, is the ICD9 code correct? Okay, because CMS has indicated they're gonna pull uh claims records and they're gonna look at claims that billing for antipsychotic medications. They're gonna look at ICD9 codes too. They're gonna put all that together and say, hmm, it seems like there's some discrepancies here. So when the surveyors come in to your facility to do to conduct a review of antipsychotic medication use, they're going to be looking at all of these different elements. They're gonna come in, of course, with a lot of prior knowledge and information. So I will say you need to have excellent compliance committee involvement and very good processes in place for data integrity, and going through the whole process of how did we get to this ICD9 code? How did we get to this diagnosis? How did we get to this order for an antipsychotic? So there's going to be some more uh elements here that I'm gonna cover, but I'm gonna try to keep this moving right along here. So we do know right now that we have residents that require antipsychotics not associated with those excluded reasons, schizophrenic, schizophrenia, Huntington's, Tourette's. So what I mean by that is you may have a resident admitted who requires hospice care. And one of the medications that is used to help the resident might be an antipsychotic. Haldolperidol is commonly used to help with severe cases of agitation. And now that it depends on the provider, the hospice provider. There may be other agents that are used instead of, but there if there is use of a drug like HELDOLPERITOL, also known as HAL HELDAL, then that would trigger on the quality measure. And it doesn't mean you don't use it, it's just meaning, oh, you're gonna have to explain that. So this would be a really good time to make sure facilities have good systems in place to capture data. You know, what is the incidence of use of antipsychotic medications? But I would want to also see, is there a report that shows the ordering, how many are ordered, then another report to say, well, how many are actually administered? And I would want to pare that down to find out, well, the ones that were administered, were they as were they associated with the excluded diagnoses? Good, or you know, that's a good thing. But if they're not, then we need to definitely peel the onion and peel you peel the onion a little bit more, and we need to look at why were they used. Okay. Now, we do know that surveyors are being trained to look at some of these things to make sure there are clear signs and symptoms, there's a plan of care in place, and every effort is made to mitigate, to avoid using an antipsychotic medication. There may be other agents that are used, anziolytics, there could be antieleptics, antidepressants, there are a whole host of different drug classes other than the antipsychotic classes that may be used. But all of this needs to be managed by health care providers that have training and education in the use of antipsychotics in those other drug classes. So when your pharmacist, hopefully you have a really good pharmacist that is going to really do some inquiry into looking at the whole process of all the clinical documentation to support that this is the drug to be given and is it effective in what we're aiming to treat the resident for? Now, it goes without saying I know that we are going to do everything we can to avoid using really any of those agents, whether it's anziolytics or antipsychotics. So we're going to first, why do they require it? What have we done to avoid the use of it? Okay. So we need to really tell the story in our documentation. And the team needs to come together to look at what's being documented. Are there gaps? Is there some need for education? Do we need to help that clinician who's working caring for the resident to say, oh, I need to know this stuff. This isn't reflected in the documentation. I need more clarity on what made you give that drug. Now, we do know that we're looking at long-stay and short stay resident populations here. Now we know long-stay residents have been in the facility for greater than 101 days. And we know that there will be some residents that require long-term use, antipsychotic medications. And I'm talking about those residents that are falling into the schizophrenia, Huntington's Tourette's. We still do want to have a good understanding of has there been any kind of titration, gradual dose reduction of those agents, if appropriate, and documentation to support that. Okay. So we do know that CMS is going to be pulling claims data to look at whenever there was an antipsychotic medication ordered. Okay. They're also going to look at the MDS. They're going to look for ICD9 codes. They're going to look at all of that to say, wait, let's do some kind of more analysis on what's going on here. Residents who are admitted for short stay, less than 100 days, they will be part of this quality measure, and they will go through the same review to find out why this new admission resident now all of a sudden have a diagnosis of schizophrenia. So with that, I don't want to go into the weeds too much here, but I will say there could be occasions where a resident is admitted for some reason, and it is determined that this resident truly is has a schizophrenic diagnosis. Now that's based upon, of course, a psychiatrist or psychiatric nurse practitioner's review, because sometimes we do receive residents in our facilities that we don't know their whole history. There may not be family, they may have been homeless for a number of years and have never really had any care and certainly any diagnoses. But now we know they have some features that require the diagnoses. Now, all of this is based on the DSM five criteria guidelines. So I just want to be clear on that a little bit. Okay. All right. So we know at the end of January 2026 we are going to see the quality measures come out to show the incidence of psych antipsychotic medications administered in facilities. Now, in the previous episode, I had talked about the increase in the quality measure national average. So now we're going to be at 16.98 percent is the new national average. So it will be really interesting to see how all of this data falls out and to see what kinds of information is gathered. And if there are discrepancies or if there are things that aren't quite adding up, the facility really needs to pay close attention to all of this. So I know I have seen some disconnect in some things that just don't add up. That's why it's really, really important for the compliance committee in a facility to do some audits, gather some data. Remember, this is a systems level review. And do we have the policies and the procedures where they followed? And I always talk about gap analysis. Are there gaps that we're finding here? You know, why did uh Resident X get admitted and was ordered a couple different antipsychotics, and yet we don't have a diagnosis. What happened here? So there needs to be systems in place, especially I think it's really important because there's going this is a there's going to be a lot of anxiety associated with these quality measures, okay? And that's gonna translate down to the star rating. And we know that's very important. We know consumers look for star ratings to make decisions on whether they want to be admitted or not. So I just think really we have to make sure that we're taking the time to make sure that the full assessment period is accurate, orders are accurate, everything's matching, the interdisciplinary team is talking. And at higher levels, medical directors, directors of nursing, administrative team, corporate teams are looking at the data and doing some data integrity analysis to make sure we're doing everything correctly. So CMS is going to be auditing. They're going to be looking to see are these antipsychotic medications given? And are if they are given to residents with excluded diagnoses, okay, they'll be watching for that. Okay, so you know they're going to be auditing on a different level. And like I have already said, there's going to be some that fall some antipsychotic use that falls out of the excluded. So here's an example. And I would say, in my experience, you don't see this used a lot, but there's a drug called composine prochloroperizine. And that drug's been around a long time. It's used for nausea, typically, nausea vomiting. But certainly that could be ordered for that. And if it is, it's certainly not ordered for psychosis behavior. It's used to treat a symptom, nausea, vomiting. And so those are medications, if they are used in your facility, if they are ordered and used, it definitely needs to be clear and you need to track that. Okay. So pharmacy would maybe perhaps recommend, if appropriate, a different agent. There are other agents, anti-emetics that may be appropriate for the resident, versus composine, which can have untoward uh effects, being in the classification of an antipsychotic. So the compliance committee needs to be looking and monitoring this kind of thing all the way through the whole system, okay? And when I say that, I mean we had to give this antipsychotic medication for this, and why are we still using it? What are we doing in the treatment plan for this resident? Okay, why are we using it? And I think, you know, in my experience, sometimes there are individuals that lack they lack knowledge, they're not up to date on some behavioral health management strategies that can be used to mitigate behavior symptoms. So there's going to be a need for some training to reassess knowledge levels. I should probably say that first. Get a baseline assessment on where everybody is, and then perhaps provide some education. So the nursing staff will certainly need to be queried on. Do you have any learning needs? Do you need some updates on some things? Now I know many times pharmacists will provide in services and education, and that there may be some need for some behavioral health education, though, from, let's say, psychiatric nurse practitioner to come in and talk to the facility staff about symptoms of behavior and how to and how to figure out what kind of behavior symptoms we're seeing. And it goes without saying we always need to find out root cause. Why is this resident having what appear to be hallucinations, delusions, or very aggressive behavior? We need to query what's going on, what were some triggers, gather some information so we can make a comprehensive assessment, ask the provider for a further assessment. And if the resident has not had a full, complete, comprehensive psychiatric evaluation, that needs to be done, okay, by people who are skilled and well educated and trained to do that. Now, pharmacists. I've worked with some wonderful pharmacists who are excellent at really looking at utilization, administration of antipsychotics, and looking at the clinical notes to say, I'm not seeing it. Why did you give this dose at this day in time? What happened? And they're very good at bringing that to our attention to say, I'm not seeing it. And there's some education perhaps needed. The pharmacist certainly will be doing their own analysis and review, and that goes without saying. But they should also look at the talk to the MDS resident assessment coordinator to make sure that there's ongoing communication about correct coding. Okay, and also a connection with the billing office to make sure the ICD9 codes are correct. And overall, and I'm going to just wrap this up and say, overall, antipsychotic use, the facilities need to have an antipsychotic stewardship. I know a lot of you guys remember in the long-term care industry we talked about antibiotic stewardship to make sure we're not using antibiotics inappropriately because I've been a nurse for a long time and I know we were giving them out antibiotics out left and right. And uh and I'm being honest, we we did see that happen. So now we're much more careful about the use. And it's been wonderful to see that outcome of stewardship to say, why are we doing it? What else can we do? So with antipsychotics, I think if it's a team approach, well, it has to be a team approach. The antipsychotic stewardship, uh, I'm borrowing that phrase from Guidestar that happens to be a neurobehavioral health service that's nationwide, I believe. I'm not endorsing them, I'm just simply saying that's where I borrowed the phrase from. But I think some key elements here are a very well-engaged, interdisciplinary team about the use of antipsychotics, for which populations, and I think the compliance committee in a facility organization is going to be central to make sure all the pieces are in place so that we can maybe mitigate some things that are kind of going sideways, or really just capture to be able to carefully explain this is what we're seeing happening in our organization. I again I am a nurse and I have seen where there are times when we have residents that have some significant behavior symptoms of very aggressive behavior. And I know that there are times when the provider wants further diagnostic testing done to find out what's going on. And if all the obvious diagnostic testings are showing everything's okay, in other words, there's not a UTI, there are some other things happening, not happening that we thought maybe were, then we need to get some psychiatric neurocognitive specialists involved to help us further figure out what's going on with this resident. And so some good data collection is going to be really important. And I know there are a lot of facilities that develop good tools to capture that. So I think that's the essence of this. I don't know any healthcare provider that just wants to give out antipsychotics just because. I think people really do take this seriously already. And I think there's just going to be further clarification and review. And I think the CMS will be paying attention to that. And certainly going forward, I think if there is good antipsychotic stewardship, we're all going to win, but most importantly, the resident. So with that said, if you have any questions or any remarks, you are welcome to reach out to the VerityTeam.com. And we hope this information was helpful. Thank you for listening. Thank you for listening. Your time is appreciated. We hope you enjoyed this episode of Vital Compliance Insights and found this to be informative. Please feel free to reach out to Verity Consulting at VerityTeam.com if you'd like further assistance with your healthcare compliance needs. Stay tuned for the next episode.