CMS medication policy creates opportunities for psychologists
The National Psychologist, Volume 24, No. 5 Sept/Oct 2015
By Paula E. Hartman-Stein, Ph.D.
A push by the Center for Medicare and Medicaid Services (CMS) to reduce the use of antipsychotic medications for nursing home residents with dementia has opened opportunities for psychologists that are being missed in many cases.
New data from the National Partnership to Improve Dementia Care in Nursing Homes, launched by the CMS in 2012, show a decrease of nearly 21.7 percent in use of antipsychotic medications in nursing home residents living with dementia.
The report released in August demonstrates the use of antipsychotic medications has been steadily dropping in nursing home patients across the country over the last four years (excluding individuals with schizophrenia, Huntington’s disease or Tourette’s Syndrome).
The American Health Care Association announced last May its goal of reducing antipsychotics in residential care by a total of 30 percent by the end of 2016.
The nudge to nursing homes became a shove in February when CMS incorporated two measures for use of antipsychotic medications (one for short stay residents and one for long stay residents) into its Five Star Rating System that evaluates quality of patient care. The public can access the ratings of residential facilities through medicare.gov/nursinghomecompare.
This movement is not limited to the United States. Similar initiatives to reduce neuroleptic use in frail nursing home residents with dementia have begun in Canada, France and Australia.
According to Cameron Camp, Ph.D., a consultant to long-term care facilities in America and abroad, “The rising number of older adults with dementia is forcing government agencies paying for psychotropic medications used with this population to examine the return on investment and to look for more cost-effective interventions.
“Once examined objectively, the case for the heavy use of psychotropic medications in long-term care falls apart like a house of cards. They do not produce the desired effects, they create problems of their own and in essence they are used as a tool to systematically deprive residents of their basic human rights and dignity while sustaining environments that helped produce these behaviors in residents in the first place. And, of course, they come with a price tag.”
Push back has occurred from the pharmaceutical industry lobbyists and industry workers who state that taking away use of these medications leaves staff helpless.
“The substitute for psychotropic medications is psychosocial treatment of dementia through person-centered care,” said Camp, “A case can, should and must be made that replacement of psychotropics by these more humane and effective interventions provides a much better return on investment.”
The door is open for institutional acceptance of psychological interventions but barriers prevent widespread changes.
Psychologist Alice Randolph, Ed.D., owner of a company providing services in long-term care facilities in Ohio, Nevada, West Virginia and Florida, said, “In many cases, when antipsychotics are reduced without behavioral health input, I am not seeing an increase in behavioral interventions by staff – just more tolerance and/or ignoring of resident behaviors that are disruptive to the peace and comfort of other residents.”
Randolph said in many facilities the titration is being managed by pharmacy rather than the clinical behavioral health professional. She advocates for CMS to expect a behavior/environmental plan concurrent with neuroleptic medication reduction.
Richard Blocker, Ph.D., (New Orleans) said he too has not seen an increase in behavioral management referrals. “The nursing homes have reacted to CMS guidelines to reduce psychotropics by possibly making more referrals for depression to psychologists,” he said.
He thinks nursing homes are reluctant to do behavioral interventions because it will require the resources of on-site staff to mediate a behavioral program.
“I suspect the most nursing care friendly entry point for psychologists would probably be a role that identifies and baselines salient target behaviors. The psychologist could develop some sort of data flow, graphs and the like to go in the chart with more ambitious interventions eventually following,” he said.
Camp said the French government now pays nursing homes to have their staff trained in non-pharmacological approaches to dementia care. “They have a list of approved trainings, with Montessori approaches to dementia treatment leading the list. The Australian government initiated a national effort to improve the quality of dementia care, with Alzheimer’s Australia being a conduit for this funding.”
Canada is also taking steps to make quality improvements in this area. Managers with the Winnipeg Regional Health Authority identified patients who may benefit from non-drug therapies to treat behavioral issues associated with dementia.
By training staff at one site to work together to provide a person-centered, non-pharmacological approach, 27 percent of a group of residents was taken off antipsychotic medication without any increase in behavioral symptoms or a rise in the use of physical restraints, yielding cost savings that translate to a potential saving of $400,000 in six months across the region, according to a report on the Canadian Foundation for Health Improvement website.
The current fee-for-service payment system under Medicare is one barrier blocking widespread changes in American nursing homes but Camp thinks psychologists can do more.
“There is an opportunity to change the environments that lead to responsive behaviors in the first place if our discipline is savvy enough to take advantage of it,” he said. “However, this will require psychologists to demonstrate their usefulness to administrators and owners via outcomes relevant to administrators and owners. Will this happen? It has not, at least thus far. If I had to hazard a guess I would predict that this will be another opportunity lost by a discipline that is too self-absorbed and egocentric to become an effective force for residential care. I would love to be proven wrong.”
Jerome Gabis, Ph.D. (Cincinnati) is one psychologist who has developed a successful clinical and business model in long-term care to change the system of residential care.
He proposed a study to the administration of an 850-bed facility in western Ohio to reduce psychoactive medications by focusing on one specific unit.
“My associate and I conducted in-service training sessions to nursing staff about non-pharmacological interventions to mood and behavior problems. By the end of the study, paid for by the facility, we had reduced psychotropic medications in more than a third of the patients without an increase in depression, anxiety, behavioral agitation or psychotic decompensation. We also found that the results of our interventions were statistically significant in reducing depression and anxiety. The study added momentum to the facility’s commitment to reduce psychoactive medication use on other units as well, and to turn to non-pharmacological interventions as a first measure to address behavioral health issues.”
According to Gabis, the level of commitment of the facility’s administrator, director of nursing and medical director impact whether a person-centered care model will be successfully implemented.
“Another factor depends on how well we have marketed ourselves and our skill set to facilities so that they utilize us to our greatest capacity. If facilities turn first to psychiatry to address mental health issues, then the likelihood of increased antipsychotic use is high. If they turn to us first, the likelihood of antipsychotic use as a first line treatment for agitation or psychosis is much lower,” he said.
Gabis has firsthand experience that psychologists can play a significant role in developing creative ways to help facilities use non-pharmacological interventions instead of turning to antipsychotics, despite the current fee-for-service system under Medicare.