Are You Ready To Defend Your Diagnosis of Schizophrenia?
On November 11, 2022, the OIG (Office of Inspector General) released a report on the Long-Term Trends of Psychotropic Drug Use in NH. From the years 2011-2019, the use of antipsychotic medications declined from 31% to 22%, while the use of anticonvulsants increased from 28% to 40%. In 2015, CMS began using the long-stay quality measure that tracks MDS reported antipsychotic use in the NH in its Nursing Home Five-Star Quality Rating System calculations. Between 2015-2019, the number of NH residents reported as having schizophrenia increased 35%. Additionally over this time, the number of residents reported as having schizophrenia but lacking a corresponding diagnosis in the Medicare claims and encounter data increased by 194%. A small fraction of US nursing homes (99) had particularly high levels of MDS reporting of Schizophrenia (> 20% of their residents) w/o corresponding preceding diagnosis in Medicare’s database.
On January 18, 2023, CMS responded to these OIG findings in their facility QSO-23-05-NH letter (https://www.cms.gov/files/document/qso-23-05-nh.pdf ). This memorandum notifies facilities of impending audits of schizophrenia coding in the MDS and based on the results, will adjust the Nursing Home Care Compare quality measure star ratings for facilities whose audits reveal inaccurate coding. Facilities can file a request for IDR (Informal Dispute Resolution) or Independent IDR (IIDR), but this adjustment will still be posted on the website with an asterisk indicating the adjustment is under review. CMS will conduct off site audits of schizophrenia coding and based upon the results, will adjust the quality measure star ratings for facilities whose audit reveals inaccurate coding. Facilities selected for audit will receive a letter explaining the purpose of the audit, the process that will be utilized, and instructions for providing supporting documentation. Facilities will be offered the opportunity to forego the audit by admitting they have errors and by developing an acceptable POC (Plan of Correction).
This memorandum recommends that nursing homes should work with their Medical Directors and psychiatric providers to ensure the appropriate professional standards and processes are implemented related to diagnosing individuals with schizophrenia. From my perspective, facilities should review with their Medical Director their policies and procedures for ensuring the appropriate use of antipsychotics in their facilities.
By July 1, 2023, all GACHS (General Acute Hospitals) will complete a level 1 screening in the PASSR (Preadmission Screening and Resident Review) system prior to transferring an individual to a SNF per federal regulations (https://www.dhcs.ca.gov/services/MH/Pages/PASRR.aspx ). This is to ensure that an accepting nursing facility has services to accommodate a resident with serious mental illness or intellectual/developmental disability. Knowing this, facilities should work with their hospital referral sources to make sure that they not only identify persons with serious mental illness, but also identify the specific diagnosis, previous mental health providers, current medications, patient representative, and prior psychiatric hospitalizations.
For those long stay residents for whom you have diagnosed schizophrenia, this would be a good time to seek the above prior history to substantiate your diagnosis and care plan. This information might be available at a local FQHC (Federally Qualified Health Care) system or through your county mental health clinic(s). Onsite behavioral health consultation is ideal, but has become much more difficult in recent years. However, referral to a county mental health clinic is a viable option in many communities. Since schizophrenia typically presents in adolescence and late-life onset after age 45 is much less common, a new diagnosis of schizophrenia in our patient population should require well documented substantial efforts to confirm the diagnosis. For those facilities with a Psychotropic Review Committee, rapid review of those with a schizophrenia diagnosis should be done to identify those who need further diagnosis confirming efforts.
Beyond assuring the accuracy of the diagnosis of schizophrenia in your current residents, policies that reduce the risk of miss-diagnosis in the future should be considered along with policies to reduce the risk of unnecessary antipsychotics. Antipsychotic prescribing is rarely a medical emergency and when they are prescribed after hours or over the weekend by an on-call provider, the triggering event and response should be reviewed the next working day and the antipsychotic should be stopped until further review of the situation by the attending physician. For new admissions, antipsychotic medications that are newly prescribed and without a clear indication or documented informed consent, should be stopped, since most of the time, they are no longer indicated or necessary. This process is further supported by conversations on admission with the patient’s representative. In my experience, the representative(s) are usually not aware of their use or are they in favor of continuing them. When the attending does believe an antipsychotic is indicated, they must obtain informed consent and document disclosure of the black box warnings. In addition, they and nursing administration need to implement a care plan that targets potential adverse effects and anticipated benefits, which are periodically reviewed to ensure the benefit exceeds the burden. Because many of our residents with major cognitive impairment are unable to verbally express what’s bothering them, our staff needs to view problem behaviors as expressions of distress that require a more in depth assessment for preventable triggers.
This is a very difficult area of medical care. HSAG (Health Services Advisory Group) has been charged by CMS to help nursing homes provide optimal care for patients who have serious mental illness or major cognitive impairment and have serious problem behaviors. They have been the conveners of the California Partnership to Improve Dementia Care. We have developed tools and resources available at this link (https://www.leadingageca.org/ca-partnership-for-improved-dementia-care ) and in 2023 will release more educational resources that will help facilities improve the quality of life and safety of their residents living with major cognitive impairment.
Click here for the full report: https://oig.hhs.gov/oei/reports/OEI-07-20-00500.pdf
Another aspect of this is generational. For those born in the 1920s, 30s, and 40s, what we now call schizophrenia was known as dementia praecox. For those with this disorder, the lifespan was much shorter than for those without. Of course, treatment then consisted of cold water immersion, sheet-wrapping, and isolation and arguably were of little help. Today, we better understand the genetic contributors to this disorder, suggesting that its onset is rarely found past the age of 25. Lifespan for those with the disorder has lengthened, and there are possibilities that individuals with schizophrenia are in LTCs. But few, if any, would have been admitted without a prior diagnosis and treatment history for the disorder. I became a licensed psychologist in 2000. I have been fortunate to experience hands-on training from a psychiatrist who practiced BEFORE anti-pychotics became available. For any of us who entered the profession after Thorazine and Haldol had radically changed the lives of those who were actually experiencing psychosis (regardless of DSM classification) and those who had to care for them, understanding the benefits goes without question. What has to be addressed (and what is continually overlooked because it cannot be easily measured) are the behavioral challenges these disorders present. Pharmacologic interventions only address some of these issues. We remain remarkably ignorant of the actual metabolic and neurologic underpinnings of psychosis and ask much of front-line care providers to manage unruly and uncooperative residents. Without question, it takes a team to address these myriad issues. Unfortunately, CMS does not pay for teamwork.
Tim thank you for the comprehensive review about the trends in use of psychotropics in NHs. I would add a possible explanantion for this peculair trend, that might indiretly lead to clinicians change in prescribing behaviors. In my opinion based on many years of practice and management experience in this space, the trend described is a result of a gaming the system tactics. NH operator/staff convince prescribers to cut corners, helping them manage difficult behaviors. As a result describe an aberrant behavior of a demented person is labled as psychotic. From there the coding often leads to labeling it as Psychzophrenia. In my clinical experience a well run institution should have no more than 6-7\% of prescribed antipsychotics . Use of membrane stabilizers(anticonvulsives) may be justified in selected case .The suggestion you gave to review and or evise policy and procedures is wise. However this has to be coupled by engaging with competent physicians or Nurse practioners, with diagnostic and pharmacological knowledge . In an ideal world , a pharmacy consultant, assuming she or he are not hired by the local pharamcy, could serve as an advisor for the choices prescriber make.