When the Centers for Medicare & Medicaid Services (CMS) revised its Five-Star Quality Rating System last year, it added two new Quality Measures: 1.) percent of long-stay residents who received an antipsychotic medication and 2.) percent of short-stay residents who newly received an antipsychotic medication.

Both measures pertain to residents who are prescribed the so-called “off-label” use of these medications; that is, without a diagnosis of schizophrenia, Huntington’s disease, or Tourette syndrome.

Getting A Head Start

But NHC HealthCare, Fort Sanders, in Knoxville, Tenn., had already started to tackle the problem. In 2014 the skilled nursing care center teamed up with Statcare Medical Group, an acute and post-acute care hospitalist group, to address antipsychotic reduction through the use of CMS’ Quality Assurance Performance Improvement (QAPI) process.

Statcare uses a model of health care delivery in five skilled nursing facilities in the Knoxville market in which primary care and behavioral health are integrated into one team.
CMS has encouraged skilled nursing centers to use the QAPI process in their quality improvement efforts. QAPI is defined as “a thorough approach to ensure high-quality, proactive, patient-centered care using evidence-based practices to escalate knowledge for planning, implementing, and sustaining measureable improvement.”

During 2014, the center began to work on systems to address reducing antipsychotic medications. From the second quarter through the fourth quarter of 2014, leaders’ focused attention resulted in a decline from 21.6 percent, to 20.8 percent, to 18.4 percent on the “long-stay” resident medications. While the center maintained a Five-Star Quality rating, its three-quarter average of 20.3 percent was still above the national average of 19.3 percent.

Following QAPI’s Lead

The first element of QAPI is Design and Scope. In this step, the center focused on the patient’s clinical care and quality of life, emphasizing these objectives to the team as they worked toward achieving their quality objectives.

In the Governance and Leadership step, the primary stakeholders included the administrator, director of nursing (DON), assistant DON, pharmacist, nursing personnel, and a Statcare Medical Group medical director. This group decided that Kimberly Quigley, MD, a psychiatrist from the Statcare post-acute care medical staff, should be added to implement the program and provide clinical care in an integrated manner with the hospitalists and nursing center staff.

In the Feedback, Data Systems, and Monitoring step, the center employed several tools to gauge and monitor progress. While the Nursing Home Compare Five-Star Rating data were somewhat helpful, they were not broken down to the needed levels. For that the center turned to the CASPER (Certification and Survey Provider Enhanced Report) and MDS 3.0 Facility Level Quality Measure Reports.

CASPER uses a more current six-month reporting period and also provides specific patient data, by name, on each of the 11 Quality Measures, allowing for a more detailed review of patient data.

Making Progress

In the Performance Improvement Projects section of the QAPI process, the center used another quality improvement tool called Rapid Cycle. In this process the psychotropic medication monitoring care plans were implemented with specific documentation regarding gradual dose reduction of current medications. New medication substitutions and supporting diagnoses were monitored as alternative interventions.

During the Systematic Analysis and Systematic Action phase, which gained momentum in January 2015, the center developed a communication board for integrating care with the psychiatrist. In February, Assistant DON Amy Morgan developed an Excel spreadsheet to monitor gradual dose reduction results, diagnosis, and follow-up visits. The primary antipsychotic targets were Abilify, Geodon, Haldol, Risperdal, Seroquel, and Zyprexa.

In March the team noticed an increase in short-stay resident antipsychotics, so the psychiatrist began a review of all new admissions and reviewed the center’s readmission screening processes. The close communication that the psychiatrist has with the primary medical team, and knowledge of the local acute care medical community, were integral in lowering psychotropic medication rates among the newly admitted residents. The center’s pharmacist also provided a list of other medications for review such as hypnotics, antidepressants, and anxiolytics.

Seeing Results

In December 2014 the center had 19 residents on antipsychotics with 32 orders. By April 2015 they were down to 10 residents with 16 orders. From the fourth quarter 2014 to the first quarter 2015 the average had dropped from 18.4 percent (long-stay) to 10.5 percent. In the short-stay group the average had dropped from 3.4 percent to 2.1 percent.

The three-quarter average for short-stay was now below the national average, while the long-stay average was well below the national average. The data from the Jan. 1 to June 30, 2015, CASPER report showed even greater results, with long-stay at 6.8 percent and short-stay at 1.2 percent. Throughout this process, employing QAPI and Rapid Cycle, the center also made reports to its Quality Assurance Committee, which is made up of two additional physicians along with the medical director. The involvement of the entire health care team and the systematic and structured approach to the problem enabled the center to reduce the long-stay percentage from 21.6 percent to less than 6.8 percent within a nine- to 12-month span of time.
Kimberly Quigley, MD, is medical director of behavioral health integration for Statcare Medical Group, a division of Summit Medical Group in Knoxville, Tenn. Douglas Ford, MS, NHA, FACHCA, is administrator of NHC HealthCare, Fort Sanders, in Knoxville, Tenn. He has served with National HealthCare Corp. for more than 28 years.