Improving Dementia Care in Nursing Homes

AMDA – The Society for Post-Acute and Long-Term Care Medicine has been a strong supporter and highly involved in a number of initiatives to improve the quality of care provided to patients with dementia and Alzheimer's disease. In 2012 the Centers for Medicare & Medicaid Services (CMS) announced the creation of the Partnership to Improve Dementia Care, an initiative to ensure appropriate care and use of antipsychotic medications for nursing home patients. Read more about the partnership’s work below, and AMDA’s work with the partnership, and other work to improve the quality of care provided to those with dementia and Alzheimer’s disease.

News & Updates

Antipsychotic Drug Use In Nursing Homes: Trend Update

The Centers for Medicare & Medicaid Services (CMS) is tracking the progress of the National Partnership to Improve Dementia Care in Nursing Homes by reviewing publicly reported measures. The official measure of the Partnership is the percentage of long-stay nursing home residents who are receiving an antipsychotic medication, excluding those residents diagnosed with schizophrenia, Huntington's Disease or Tourette’s Syndrome. In fourth quarter of 2011, 23.9 percent of long-stay nursing home residents were receiving an antipsychotic medication; since then there has been a decrease of 28.8 percent, to a national prevalence of 17.0 percent in the fourth quarter of 2015. Success has varied by state and CMS region; some states and regions had a reduction greater than 25 percent. Read more here.

October 2015-Antipsychotic Drug use in Nursing Homes: Trend Update

The Centers for Medicare & Medicaid Services (CMS) is tracking the progress of the National Partnership to Improve Dementia Care in Nursing Homes by reviewing publicly reported measures. The official measure of the Partnership is the percentage of long-stay nursing home residents who are receiving an antipsychotic medication, excluding those residents diagnosed with schizophrenia, Huntington's disease or Tourette’s syndrome. In the fourth quarter of 2011, 23.9% of long-stay nursing home residents were receiving an antipsychotic medication; since then there has been a decrease of 24.8% to a national prevalence of 18.0% in the second quarter of 2015. Success varies by state and CMS region, with some states and regions seeing a reduction greater than 20%.

For More Information:

  • Visit the National Partnership web page
  • Send correspondence to

CMS Releases Focused Dementia Care Survey Tools

In response to feedback from stakeholders and partners of the National Partnership to Improve Dementia Care in Nursing Homes, CMS is sharing the revised survey materials that were developed for the 2014 Focused Dementia Care Survey Pilot and 2015 expansion effort. The intent is that facilities would use these tools to assess their own practices in providing resident care. The tools can be accessed by clicking here.

June 2015 - CMS National Partnership to Improve Dementia Care and QAPI Call

Everything from the June 16, 2015 call is posted on the CMS website including the slides presentations and audio. Click here to access all the information.

CMS Issues Update Report on Antipsychotic Use in Nursing Homes

February 12, 2015—The Centers for Medicare & Medicaid Services (CMS) recently released an update on the status of the prevalence of antipsychotic use for long-stay nursing home residents. The report shows that in the fourth quarter of 2011 23.9% of long-stay residents were receiving antipsychotic medication. Since then there has been a decrease of 19.4% bringing the overall percentage of use down to 19.2% by the third quarter of 2014. Some results have varied by state and CMS region but overall this is encouraging news for CMS and organizations such as AMDA who are involved in the Partnership to Improve Dementia Care in Nursing Homes. To read the full report and see how your state matches up to the National percentage, click here.

"Person-Centered Matters" Video to Champion Change

“Person-Centered Matters” is a beautiful and compelling 16-minute video produced by the Dementia Action Alliance and filmed by a former National Geographic filmmaker. It portrays five people living with dementia and how person-centered care helps them live more fully. AMDA’s Immediate Past-President Jonathan Evans, MD, MPH, CMD, was featured in the video and spoke about dementia patients and their continued ability to be happy even when suffering from symptoms of dementia. Click here to watch the video now.

AMDA Supports New Goals of National Partnership to Improve Dementia Care in Nursing Homes

September 9, 2014 - AMDA - The Society for Post -Acute and Long-Term Care Medicine supports the National Partnership to Improve Dementia Care’s new goals, announced today, to further reduce the use of antipsychotic medications in long-stay nursing home residents, and looks forward to working on initiatives aiming to improve the overall quality of care given to dementia patients. The new national goal is to reduce the use of antipsychotic medications in long-stay nursing home residents by 25 percent by the end of 2015 and by 30 percent by the close of 2016, using the prior baseline rate (Quarter 4, 2011). The original goal, of reducing antipsychotic use by 15 percent was met in 2013 (decreasing from 23.8 percent to 20.2 percent nationwide). Read AMDA’s full response to the goals here.

CMS Dementia Care Report Shows 15% Reduction in Antipsychotic Use

April 11, 2014 - The Centers for Medicare & Medicaid Services (CMS) recently released their Interim report on the CMS National Partnership to Improve Dementia Care in Nursing Homes: Q4 2011-Q1 2014. The report shows that in an 18 month period of time the national prevalence of antipsychotic use in long-stay residents was reduced by 15.1 percent and every CMS region showed at least some improvement. CMS has also been reviewing citations at F-329 (Unnecessary Drugs), and while this tag includes all drugs, not just antipsychotic drugs, there has also been a decrease in the number of F-329 citations at actual harm levels. In 2009, 1.91 percent of the F-329 citations were at a G or higher, and that percentage was down to .93 percent in 2013, which is a total of slightly more than 85,000 citations. Another area where CMS has seen success is in using Quality Assurance and Performance Improvement (QAPI) principles within the Partnership Initiative. It found that many nursing homes have selected gradual dose reductions as their Performance Improvement Projects (PIPs) and have seen positive results.

Since the national goal of 15 percent has been achieved for long-stay prevalence of antipsychotic drug use, CMS will be selecting a new goal as one of its next steps in 2014. They will also consider setting a target for reduction in the short-stay incidence use. Additionally, CMS will revise guidance as needed, based on surveyor feedback and enforcement trends. Specifically they will be evaluating whether Dementia Care Practices should be separated out from the surveyor guidance at F-309 and/or separate out antipsychotic drug use from F-329. The Agency had issued updated dementia care guidance in May 2013. Another next step for CMS will be to monitor outcomes from the initiatives efforts and any potential consequences, such as prescribing shifts from antipsychotics to anxiolytics or sedative/hypnotics.

An Office of Inspector General (OIG) report in 2011 spurred this dementia care initiative when it found that 83 percent of nursing home residents on antipsychotic medications did not have diagnoses that warranted the use of such medications. Since then, CMS has been working to collaborate with the States, various agencies, and stakeholder organizations to encourage nursing homes to reduce their atypical antipsychotic use.

Many AMDA members have participated in this project and some led their state-based coalitions to achieve this goal. If your facility has yet to begin to participate in this project, please contact us at to learn more about activities within your state.

World Alzheimer Report 2013 ‘Journey of Caring: An analysis of long-term care for dementia’ Now Available

The World Alzheimer Report 2013 ‘Journey of Caring: An analysis of long-term care for dementia’ is now available. The report looks at the prevalence of dependence and the contribution of dementia to dependence, and at the quality of care and evidence-based indications of how to improve it. The report also examines the cost and financing of long-term care now and in the future, including a systematic review looking at the costs of care at home versus care in care homes. Finally, the report recommends specific actions that could lead to improvements in the quality of care for people with dementia, and strategies for making long-term care more affordable.

CMS is reviewing publicly reported measures on nursing home residents who are receiving an antipsychotic medication. The official measure is a the percent of long-stay nursing home residents who are receiving an antipsychotic medication, excluding those residents diagnosed with schizophrenia, Huntington's Disease or Tourette’s Syndrome. In 2011Q4, 23.9% of long-stay nursing home residents were receiving an antipsychotic medication; since then there has been a decrease of 9.0% to 21.7% in 2013Q1. Success has varied by state and CMS region, with some states and regions having seen a reduction of greater than 10%.

A three-quarter measure is posted to the Nursing Home Compare website at www.medicare.gov/nursinghomecompare. The long-stay measure on Nursing Home Compare, is the facility’s score averaged over the last three quarters in order to give consumers information on the past history of each facility.

View the Partnership to Improve Dementia Care in Nursing Homes Antipsychotic Drug use in Nursing Homes Trend Update here. View data for individual facilities by state by clicking here.

CMS Partnership to Improve Dementia Care

AMDA is a partner in The Partnership to Improve Dementia Care, an initiative to ensure appropriate care and use of antipsychotic medications for nursing home patients. This partnership – among federal and state partners, nursing homes and other providers, advocacy groups and caregivers – has set a national goal of reducing use of antipsychotic drugs in nursing home residents by 15 percent by the end of 2012.

CMS and industry and advocacy partners are taking several steps to achieve this goal of improved care:

  • Enhanced training: CMS has developed Hand in Hand, a training series for nursing homes that emphasizes person-centered care, prevention of abuse, and high-quality care for residents. CMS is also providing training focused on behavioral health to state and federal surveyors;
  • Increased transparency: CMS is making data on each nursing home’s antipsychotic drug use available on Nursing Home Compare starting in July of this year, and will update this data;
  • CMS is emphasizing non-pharmacological alternatives for nursing home residents, including potential approaches such as consistent staff assignments, increased exercise or time outdoors, monitoring and managing acute and chronic pain, and planning individualized activities.

Watch video of the CMS Launch AMDA Board of Directors Member Susan Levy, MD, CMD, took part in the panel discussions and provided a physician/geriatric perspective on the role of physicians and medical directors specifically what factors physicians should considers when assessing a resident with dementia behavior and the importance of collecting information that might explain the behavior. She also spoke on the importance of creating a positive environment for residents and stressed the importance of staff and physician training to deal with these kinds of behaviors.

AMDA Tools & Products

Tools

  • AMDA’s Position Statement on Pharmacy Physician Relations and Appropriate Prescribing for LTC Patients can be found here.
  • AMDA’s Talking Points on Appropriate Prescribing of Antipsychotics can be found here.
  • “Dear Medical Director” Letter – this letter from AMDA President, Matthew S. Wayne, CMD, MD was sent to all Medical Directors urging them to join with AMDA and CMS, in the nationwide effort to reduce the unnecessary use of antipsychotic agents by refocusing the interdisciplinary team on a better understanding of the root cause of dementia related behaviors.

Products

Online Dementia Care Training from CMS

The Centers for Medicare & Medicaid Services (CMS) Survey and Certification Group (SCG) have provided three surveyor training programs on care of persons with dementia and unnecessary antipsychotic medication use on their website. These trainings may be viewed by providers and non-surveyors as well. A third installment in this series is in development and will be completed this spring. Content includes:

  1. How to identify whether a systematic, individualized approach was implemented for a resident with dementia
  2. How to identify that a systematic process is in place and has been followed for persons with dementia in the facility
  3. How to evaluate the role of the resident, consultant pharmacist, physician/NP/PA, medical director, direct care staff, family and other members of the interdisciplinary care team
  4. How to identify other associated tags related to care of persons with dementia and unnecessary medication use.

The third installment of the training will address how to cite severity and other aspects of deficiency citations in more detail, based on new guidance at F309, Care of Residents with Dementia, and revised guidance at F329 that is in development.

The first video program is 40 minutes in length. The second self-study may take anywhere from 45 minutes to 1 hour or somewhat longer, depending on the knowledge and experience of the individual surveyor student.

How to Access these Videos for Non-Surveyors: If you are a provider or do not wish to receive credit for viewing the program follow the instructions below.

  1. Go to http://surveyortraining.cms.hhs.gov
  2. Click on the "I am a Provider" tab
  3. Click on the "Reduction in Unnecessary Medications in Nursing Homes" at the menu at the top of the screen
  4. Click on the program that you wish to view.

For webinar technical questions contact Duva Clyburn at or Etolia Biggs at .

Legislation

AMDA has been working closely with House and Senate leaders to help address the use of antipsychotics in nursing homes. In December 2011 AMDA Vice-President Jonathan Evans, MD, CMD, testified in front of the Senate Special Committee on Aging during a hearing entitled Overprescribed: The Human and Taxpayers' Costs of Antipsychotics in Nursing Homes. The hearing, convened by Chairman Senator Herb Kohl (D-WI), examined the increased prescribing of antipsychotic medications in the nursing home setting among residents with dementia despite a Food and Drug Administration “black box” warning.

AMDA supported a bi-partisan effort to reduce use of antipsychotics in nursing homes. On May 23, 2012, AMDA sent a letter of support to a bi-partisan group of lawmakers who authored an amendment that aims to reduce the unnecessary use of antipsychotics in nursing homes. Senators Herb Kohl (D-WI), Chuck Grassley (R-IA), and Richard Blumenthal (D-CT) offered legislative language that would require the Health and Human Services Department to issue the standardized protocols “for obtaining informed consent from an older individual with dementia prior to administering an antipsychotic” off label. The requirement came in a proposed amendment to user fees legislation known as the Prescription Drug User Fee Act (PDUFA) that failed to pass.

AMDA continues to work with legislators to address this important issue.