Update: California Dementia Partnership to Improve Dementia Care

by Timothy Gieseke, MD, CMD

On December 4th, 2018 our dementia partnership sponsored a webinar by Dr. Maureen Nash, a nationally recognized Gero-psychiatrist who presented the PowerPoint presentation (handout provided below) on “Helping those with Serious Mental Illness who now live in a LTC setting”. She advocated for use of best practices for persons with serious mental illness who require institutional care, most commonly because of their very high risk for cognitive impairment.  CMS’s campaign to improve dementia care by reduce antipsychotics at times may seem to compromise known best practice. She recommended following the American Psychiatric Association’s free best practice guidelines for treating: Major Depressive DO, Bipoloar DO, PTSD, OCD, Schizophrenia, and dementia persons with agitation and aggression. In these guidelines, recommendations for use of antipsychotics (many have FDA approval) represent best practice even though they may not be recognized in the excluded category by the CMS campaign.  

CMS requires consulting pharmacist in the SNF setting to recommend GDRs (gradual dose reductions) on all psychotropic meds.  They expect providers to know best practices and to not taper antipsychotics when they are not warranted. The Schizophrenia Patient Outcomes Research Team (PORT) recommendations of 2009 recommend continuous treatment of Schizophrenia since intermittent treatment has been associated with more frequent and severe relapses.  This continuous treatment should continue for at least 5 years w/o overt symptoms before even considering a lower dose.

The CMS campaign quality measure for antipsychotic use in long stay residents doesn’t exclude conditions for which there is clear evidence-based indication for the use of antipsychotics such as: Schizoaffective DO (Schizophrenia with Bipolar DO or MDD), Bipolar DO, or Major Depressive DO. This decision unfairly penalizes facilities caring for a high proportion of Medicaid patients since they are likely to have a more patients with these disorders.  To avoid being penalized by this measure (https://www.medicare.gov/nursinghomecompare/search.html), some providers may feel pressured to order inappropriate GDRs which may increase symptoms and suffering in those with serious mental illness and increase their risk for eviction.  

After this webinar, I did write to the lead facilitator of the National Partnership for Improving Dementia Care about the above concerns and was informed that CMS had no plans to expand the current exclusions (Schizophrenia, Tourette’s, and Huntington’s) or to change the necessity for consulting pharmacists to request a GDR for all conditions for which psychotropic meds are prescribed.  It truly is up to the prescriber to make informed decisions about psychotropic medications that are in the best interest of their patients while justifying reasons a GDR is not clinically indicated.

At CALTCM, we are dedicated to helping your team develop the expertise to deliver informed care for these complex patient. Our Summit is rapidly approaching and is a good place to connect with experts concerned about helping you meet your facility goals.

Powerpoint Handout

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