There are two antipsychotic quality measures, the percent of short stay residents who newly received an antipsychotic medication and the percent of long-stay residents who received an antipsychotic medication. Significantly, both of these quality measures impact the facility 5-Star rating.
Currently, 1.8% of the nation’s short stay residents are started on an antipsychotic medication after admission to a nursing facility and 14.2% of long-stay residents receive antipsychotic medications. The short stay antipsychotic measure specifically reports the number of residents who were not receiving an antipsychotic medication during the look-back period of their initial (Admission/5-day) assessment, but then are later coded as receiving an antipsychotic on a subsequent MDS assessment. So, if a resident is admitted on an antipsychotic medication and the antipsychotic is given in the look-back of the admission/5-day assessment, regardless of conditions present to support its use, the resident will not trigger for this measure. Also, if an antipsychotic is not ordered on admission, but is ordered in the facility and administered prior to the initial assessment (in the 7-day look-back period of the initial assessment), they will not trigger for the short-stay antipsychotic measure.
The long-stay antipsychotic measure reports the percentage of residents who are coded as receiving antipsychotic medications in item N0410A of the MDS who do not have an active diagnosis of Schizophrenia, Tourette’s Syndrome, or Huntington’s Disease coded in Section I of the MDS. Residents with these diagnoses will not count in the calculation of either of the antipsychotic quality measures. It is important to be sure that if any of the excluding diagnosis are active in the look-back period, that those diagnoses are coded appropriately in Section I. If for example, they are coded at I8000, versus I6000, I5350 or I5250 as required, they will not be considered as exclusions.
Follow RAI Guidelines Carefully
To ensure accuracy of these quality measures, it is important that MDS staff understand the RAI guidelines related to coding antipsychotic medications on the MDS. When coding medications at N0410, you must code based on the medication’s therapeutic category or pharmacological classification, not based on how it is used. So, if someone is receiving an antipsychotic for treatment of another medical condition, such as an antiemetic, you would still code it at N0410A. Only medications given during the 7-day look-back period are coded in item N0410. Therefore, if a resident receives a monthly injection of Haldol, but that injection wasn’t given in the 7-day look back of the MDS, you would not code it.
Best Practices for Facility Monitoring
It is important that you have good systems in place to monitor residents who are receiving antipsychotic or psychotropic medications. You must evaluate the effectiveness of the medications as well as look for potential adverse consequences. Care plans should clearly indicate the behavioral symptoms the medication is intended to treat with measurable goals for the reduction of the behavioral symptom(s) and potential adverse effects of the medication that staff must monitor for routinely. After initiating or increasing the dose of a psychotropic medication, the behavioral symptoms must be reevaluated periodically (at least during quarterly care plan review, if not more often) to determine the potential for reducing or discontinuing the dose based on therapeutic goals and any adverse effects or functional impairment.
Antipsychotic medications have serious side effects and can be especially dangerous for elderly residents. When antipsychotic medications are used without an adequate rationale, or for the sole purpose of limiting or controlling expressions or indications of distress without first identifying the root cause, there is little chance that they will be effective. In addition, antipsychotic medications commonly cause complications such as movement disorders, falls with injury, cerebrovascular adverse events and increased risk of death.
If an antipsychotic medication is identified as possibly causing or contributing to adverse consequences, you must work with the resident’s physician to determine whether the medication should be continued and document the rationale for the decision. In some cases, the benefits of treatment may outweigh the risks or burdens of treatment, so the medication may be continued.
In addition to the monthly drug regimen review conducted by your pharmacist, you should perform routine reviews of antipsychotic medications in your routine risk assessment process as part of the QAPI program. Areas of focus during the review include:
- Acceptable clinical indication for use
- Prescribed for diagnosed condition & not used for convenience or discipline
- Clinically indicated to manage symptoms where other causes have been ruled out
- Signs & symptoms clinically significant enough to warrant initiation or continuation of medication
- Benefits outweigh risks associated with use
- Monitor behavioral expressions or indications of distress
- Monitor effectiveness of medication
- Monitor for changes that may be related to the medication use
- Monitor for adverse consequences
- Appropriate dosing and duration
- Documented GDR in 2 separate quarters within first year and annually thereafter
- Non-pharmacological approaches attempted and documented
- Adherence to PRN requirements
- Care Plan for medication use, individualized approaches to care, and non-pharmacological interventions
Contact Proactive Medical Review & Consulting to request support services including training, antipsychotic program development and consultation related to reducing antipsychotic use and improving antipsychotic-related Quality Measures.