by: G. Allen Power, MD – Eden Mentor at St. John’s Home in Rochester, NY, and Clinical Associate Professor of Medicine at the University of Rochester. He is a board certified internist and geriatrician, and is a Fellow of the American College of Physicians / American Society for Internal Medicine.
There have been concerns raised for several years about the off-label use of antispychotic drugs in people living with various forms of dementia. But things got kicked into high gear last November 30th with HHS Inspector General Daniel Levinson’s report to Congress. CMS promptly took up the charge and has been working diligently to reduce such prescribing in nursing homes.
Over the past year, CMS has set a goal for homes to try to reduce their off-label antipsychotic use by 15% by the end of 2012. They will be releasing a new educational video series, “Hand In Hand” to all nursing homes this fall, and are working on a variety of educational initiatives for all stakeholders. Also, a National Dementia Initiative met in DC this past June to detail recommendations for a more person-centered approach to dementia, with a white paper being written for Congress as we speak.
AHCA took up the 15% reduction charge as a goal for their member homes, and last week NCAL proposed a similar goal for their assisted living communities by the end of 2013. (I’m still waiting to hear something from LeadingAge–anyone??)
Now the US Senate has raised the bar, introducing a bipartisan bill that would charge HHS to require informed consent before prescribing antipsychotic drugs to nursing home and assisted living residents. The bill would also establish monthly report cards on each home’s use of the drugs. (S. 3604)
Co-sponsor Richard Blumenthal (D-Conn) did not mince words. He called such drug prescribing “Elder abuse–plain and simple….chemical restraint as pernicious and predatory as unnecessary physical restraint.” Herb Kohl (D-Wis) added, “Despite the black box warnings and numerous multi-billion dollar settlements levied against pharmaceutical manufacturers for illegal off-label marketing, we continue to see an alarming number of dementia patients in nursing home and assisted living facilities being prescribed antipsychotics off-label…” Chuck Grassley (R-Iowa) is the third sponsor.
Strong talk, and it is laudable that the government is taking a stand on this issue, because a major barrier to medication reduction among providers is the belief that the regulators might penalize them for trying new approaches. As a member of the CMS Advisory Panel for these efforts, I can attest to the breadth and depth of their new initiatives.
Of course I will add a few comments of my own:
First, as I have mentioned previously here, the big secret is that this is not merely a problem with nursing homes, or even long-term care. The little data I have seen (including some of my own) shows that there is much, if not more, inappropriate prescribing happening in the community. Informal care partners are often ill-equipped to help their loved ones at home with minimal support. The fact that many community physicians do not have geriatric expertise is a likely factor as well.
Second, education is the key to success. Those who provide care will not be able to successfully reduce medication use unless they know how to care differently. New approaches to care are not intuitive and fly in the face of many of the common “truisms” about dementia, so both learning and “un-learning” are critical components.
Third, such re-education is not simply a “one-off” process – it requires repetition through hands-on tutelage to change patterns of care. We must all recognize that there will be a learning curve, and we need to support those who may not immediately create significant reduction in drug use, but who are working conscientiously toward that goal.
Fourth, the process of “culture change” is vital to any successful approach. While I am not particularly fond of that somewhat vague and misused term, it should be understood that in order to change our approach to care, we must transform operations to align with that new philosophy, or it is doomed to failure.
To this end, my new Eden course, “Dementia Beyond Drugs” was specially designed to link a person-centered, “experiential” approach to the transformational steps necessary to create sustainable results.
Lastly, culture change is for everyone, not just nursing homes. That means that families need to be educated, and regulators need to continue to evolve their processes to support this new philosophy. (One area of great need here is negotiating acceptable risk to enhance quality of life, which too often is regulated on the side of surplus safety.) And our reimbursement system–which incentivizes illness and invasive care, as opposed to a relationship-based, non-pharmacologic approach–needs a big overhaul.
Legislation + education + culture change = success. Unlike Meat Loaf’s claim, two out of three won’t cut it.