The Centers for Medicare & Medicaid Services (CMS) developed the Five-Star Quality Rating System to provide consumers with an easy way to assess the quality of care provided by nursing homes. This rating system, which can be accessed on the CMS Nursing Home Compare website (Find Healthcare Providers: Compare Care Near You | Medicare), is a key resource for families and individuals seeking long-term care options. One critical area that the CMS rating system focuses on is the use of antipsychotic medications in long-stay residents.  This article will explain how the Five-Star Rating System works and why the use of antipsychotics in long-stay patients is an important quality measure.

The CMS Five-Star Quality Rating System was introduced in 2008 to help consumers, caregivers, and families compare nursing homes more effectively. It assigns each nursing home an overall star rating, ranging from 1 to 5 stars, based on three major domains:

1. Health Inspections: Ratings are derived from results of state health inspections over the past three years.  These inspections focus on several key areas, such as resident care, medication management, and facility safety.
2. Staffing Levels: This measures the amount of time nurses and other care staff spend with residents.  It is adjusted based on the needs of residents, ensuring that facilities with more medically complex residents are assessed fairly.
3. Quality Measures: This domain reflects how well nursing homes perform on specific clinical outcomes for short term and long term stays.  It includes data on factors like the prevalence of pressure ulcers, weight loss, vaccination rates, and the use of antipsychotic medications.

This overall rating is a composite of these three measures, but quality measures and staffing components can significantly influence a facility’s star rating.

One of the critical quality measures in the CMS Five-Star system is the rate of antipsychotic medication use among long-stay residents, typically those who have lived in the facility for more than 100 days.  Antipsychotic drugs are sometimes used to manage behaviors associated with conditions like schizophrenia, dementia, or other mental health issues.  However, concerns have arisen about their overuse, particularly among older adults with dementia, where these medications are often prescribed inappropriately to manage agitation, anxiety, or aggression.

The inappropriate use of antipsychotics in long-term care facilities has been linked to several risks, including:

• Increased Mortality:  Studies have shown that the use of antipsychotics in older adults, particularly those with dementia, increases the risk of death.
• Higher Incidence of Falls and Injuries:  Antipsychotics can cause drowsiness, dizziness, and confusion, making older adult patients more prone to falls.
• Negative Impact on Quality of Life: Overuse of these drugs can lead to a reduction in a patient’s ability to interact with others, reducing their overall quality of life.

Due to these risks, CMS began focusing on reducing the unnecessary use of antipsychotics as part of its broader efforts to improve the quality of care in nursing homes.  The goal is to encourage facilities to use non-pharmacological interventions first, such as behavioral therapies, before turning to medication. 

CMS collects data on the percentage of long-stay residents who receive antipsychotic medications and incorporates this measure into a nursing home’s quality rating.  Facilities with higher rates of antipsychotic use–particularly when the use is deemed inappropriate–may see a lower quality measure score, which in turn can reduce their overall star rating.  Nursing homes that are proactive in reducing antipsychotic use by adopting alternative methods of behavior management and improving resident care plans can achieve higher ratings.

Facilities are encouraged to review their use of these medications regularly, using psychiatry and/or psychology consultants as appropriate, engage in staff education on non-pharmacological treatments, and develop individualized care plans for residents to minimize the use of potentially harmful medications.

CMS has implemented several initiatives aimed at reducing the unnecessary use of antipsychotics in nursing homes.  One notable effort is the National Partnership to Improve Dementia Care in Nursing Homes, launched in 2012.  The partnership aims to decrease the use of antipsychotic medications in long-stay residents through better care planning and alternative therapies.  Since the launch of this initiative, the rates of antipsychotic use in long-stay nursing home residents have decreased significantly, though there is still room for improvement. The California Partnership for Improving Dementia Care is a part of the National Partnership and has resources and tools available on their website at: https://www.leadingageca.org/ca-partnership-for-improved-dementia-care

The CMS Five-Star Rating System plays a vital role in helping consumers make informed decisions about nursing home care, with the use of antipsychotic medications in long-stay patients serving as a key quality indicator.  By tracking and reducing the unnecessary use of these medications, nursing homes can improve their quality ratings, enhance resident well-being, and provide safer ratings, enhance resident well-being, and provide safer, more compassionate care for long-term residents.  As consumers increasingly rely on the Five-Star system to guide their choices, facilities are incentivized to adopt best practices that prioritize the health and safety of their residents.