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Decoding the mixed messages about psychiatric care in SNFs

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Increasingly, resident populations at skilled nursing facilities (SNFs) include a large number of individuals with mental health conditions—from mood disorders and post-traumatic stress to schizophrenia and delusional disorder. When it comes to treating these residents, physicians and facility leaders face a dilemma: Though many of these individuals may benefit from antipsychotic medication, particularly when poor mental health status interferes with physical medical conditions, conflicting guidelines from Centers for Medicare and Medicaid Services (CMS) are sending mixed messages about when it’s appropriate to prescribe such drugs.

The State Operations Manual (SOM) indicates antipsychotic medication use for a range of mental health conditions. But CMS’ Five-Star Quality Rating System—which is used to assign publicly available SNF quality scores—restricts their use to just three diagnoses. In the face of this conflict, what should SNF providers do?

Understanding SOM

CMS developed the SOM specifically to guide post-acute care facilities’ clinical and operational activities to comply with standards necessary for participating in the Medicare and Medicaid programs. Though SOM is not “the law,” per se, it is widely followed and used to interpret the meaning of CMS regulations. CMS surveyors specifically rely the SOM when reviewing facilities’ CMS certification status. So, because most SNFs receive a significant share of their revenue from treating Medicare and Medicaid patients, adhering to the SOM is critical.

The good news is that following the SOM generally equates to following sound clinical practices. The document outlines reasonable guidelines and expectations, and it instructs surveyors to ensure healthcare provides are observing professional standards of care when diagnosing and treating patients.

With regard to mental health conditions, the SOM interpretative guidelines indicate antipsychotic medication use may be appropriate for a number of diagnoses, including:

  • Schizoaffective disorder
  • Schizophreniform disorder
  • Delusional disorder
  • Mood disorders
  • Psychosis in the absence of dementia
  • Medical illnesses with psychotic symptoms (e.g., delirium)
  • Tourette’s disorderHuntington’s disease
  • Hiccups (not induced by medicines)
  • Nausea/vomiting associated with cancer or chemotherapy
  • Behavioral and Psychological Symptoms of Dementia (BPSD)

The Five-Star conflict

CMS created the Five-Star Quality Rating System in 2008. The system—which is designed to help consumers, families and caregivers compare SNFs more easily—assigns a certain number of stars to each SNF that accepts Medicare and Medicaid patients, based on their performance in health inspections, staffing and quality measures.

Anyone can research a facility’s star rating by visiting CMS’s Nursing Home Compare site. The simplified message to consumers is that facilities with five stars have above-average quality and those with one star are well below average, creating inherent competition among facilities to win patients from, or at least not lose patients to, other facilities in their markets. After all, if referring physicians, patients and families can select the SNF of their choice, it stands to reason they will overlook lower-rated facilities in favor of those with four or five stars.

How do antipsychotic medications factor in to the Five-Star system? Their use is among the quality measures CMS takes into account when calculating a facility’s rating. But unlike the SOM, the Five-Star system limits diagnostic indications for antipsychotics to only three conditions: schizophrenia, Tourette’s disorder and Huntingdon’s disease.

For the full text of this article by Richard Thompson, M.D., click here to visit the I Advance Senior Care website.