On August 17, a summit of leaders in long-term care, including officials from the California Department of Public Health and the District Office of the Centers for Medicare and Medicaid Services was convened in San Francisco to hammer out some practical strategies to reduce unnecessary antipsychotic use in skilled nursing facilities in our state. CALTCM had an important presence at this first of three meetings, entitled “California Partnership to Improve Dementia Care.” CALTCM Past President Karl Steinberg, MD, CMD presented to this stakeholders group on the importance of staff and physician education, and of engaging prescribers and medical directors (Powerpoint slides available upon request). The presentation also introduced CALTCM to some attendees who were not familiar with our organization, and emphasized our successes with Process Improvement initiatives in other areas—making us a natural choice to assist with statewide educational efforts. On October 2, the group reconvened with CALTCM President Jim Mittelberger, MD, CMD attending, and with CALTCM Board Member Flora Brahmbhatt, PharmD, presenting to the entire assembly.

Several workgroups were created at the first meeting, and specific strategies were to be devised with both short-term and long-term goals. CALTCM is participating on the Informed Consent workgroup, along with Jocelyn Montgomery of CAHF, several important CDPH officials including Acting Director Debby Rogers and Assistant Deputy Director Pam Dickfoss, as well as pharmacists Rob Menét and Debra Brown, Tony Chicotel of CANHR (California Advocates for Nursing Home Reform). One short-term goal is to remind prescribers of the importance of ensuring that informed consent is obtained for the use of antipsychotics (and all psychotropics) in our nursing home population—which this article should serve to do.

As of now, under CDPH’s latest interpretation of Title 22, only the “physician” is permitted to obtain informed consent for antipsychotics and other psychotropic medications. In fact, current interpretation is that non-physician practitioners (NPPs—including advanced practice nurses like nurse practitioners, and physician assistants) are not allowed to prescribe antipsychotics to nursing home residents, irrespective of their training, experience and scope of practice.

One suggestion that this Informed Consent workgroup has put forth is to request CDPH to reconsider the strict interpretation about the physician specifically having to obtain consent—and instead concentrate on a requirement that the necessary components of informed consent are obtained by some qualified health care provider—including nursing staff, with or without written information, as the process used to be. A concern is that under the current interpretation, there are situations where in fact the informed consent process is less effective and comprehensive than it used to be when nurses in the facilities were doing it. Now many nurses may simply tell patients and their families, “We are not allowed to give that information; only the doctor can give it.” The nurses are (not surprisingly) fearful that if they do provide information, there could be deficiencies written for performing a function that (according to CDPH’s latest interpretation) only the physician “shall” do. The general consensus of the workgroup was that it is more important to ensure that the information is provided, than who actually provides it. Certainly if a nurse provided the initial information and the resident or family had additional questions, then it would be up to the physician to clarify and explain in more detail.

At this point, it is unknown whether there will be a new policy handed down from CDPH—but in the meantime, those of us who prescribe antipsychotics should remember to be sure that nursing staff has considered non-pharmacological interventions first, and also ensure that we are indeed obtaining appropriate consent for the use of these potentially dangerous medications.

There is much more in the works, including some federal legislation that will address antipsychotics and informed consent, with respect to this important and timely topic. The Partnership’s other workgroups are also working on their areas, and these will be reported on in a subsequent issue of The Wave. It was felt that the nationally announced CMS goal of reducing (across-the-board) use of antipsychotics by 15% between May 1 and the end of this year was a reasonable one, and that probably even more impressive reductions can be obtained in the year(s) to come.

The next and final Partnership meeting is December 4. Multiple members of CALTCM’s Board of Directors will be attending this meeting, and it is hoped that we can move forward with some concrete ideas to help educate clinicians and nursing home staff, and to reduce the unnecessary use of antipsychotics. The “dashboard” of recommendations from this partnership will be made available in December, and we will share it with our readers. Stay tuned!