The Centers for Medicare & Medicaid Services on Tuesday will begin more closely monitoring the use of anticonvulsants in nursing homes, adding new reporting requirements to the Minimum Data Set.
The move is seen largely as a response to a critical 2022 Health and Human Services Office of Inspector General report that found nursing homes had increased their use of such drugs even as they reduced reliance on other psychotropic drugs.
Both antipsychotics and anticonvulsants often are used off-label to control agitation in patients with dementia or other cognitive diagnoses. But the changes they make to brain activity come with serious risks, and CMS previously adapted its survey processes and guidance to “specifically target inappropriate use of anticonvulsants.”
That same guidance led to increased monitoring, and then a targeted audit, of providers who had patients diagnosed with schizophrenia, which is broadly linked to the inappropriate use of antipsychotics.
“As we decreased antipsychotic medications, the overall psychotropic medication didn’t decrease because we replaced them with other psychotropic medications, including anticonvulsant medication being used for patients who didn’t have a history of previous seizure disorder,” Christine Twombly, a senior consultant with ProActive LTC Consulting, told McKnight’s Long-Term Care News Monday.
The new MDS requirement adds anticonvulsants, such as the commonly prescribed depakote, to a list of high-risk medications providers must acknowledge use of in Section N. They join antipsychotics, antidepressants, hypnotics, anticoagulants and opiates.
MDS cross-checking
The MDS must also reflect, through a yes or no response, whether there is an indication for the use of an anticoagulant in the patient’s record. The changes don’t require a diagnostic code, but facilities should be able to understand and be prepared to explain their use of a covered medication in any given patient, Twombly said.
MDS nurses also should begin routinely checking medication administration records to ensure those reflect a clinical need for the medication. If they don’t, teams need to start discussing why those indications could be missing and how to prepare for related survey activity.
“The ability for CMS to be able to look at my MDS and see that I don’t have a diagnosis in Section I related to a seizure disorder, yet I have an anticonvulsant medication, the same way they can look at my MDS and see that I have schizophrenia coded now, when I didn’t have it coded when the patient was admitted — that may give them the ability to better track and study,” Twombly said.
“I don’t know that it will necessarily result in audits,” she added, “but it will help surveyors to focus on this area.”
Inappropriate use of psychotropics, including anticonvulsants, can be cited under F-757.
ProActive Regional Director of Operations Rosanna Benbow noted in a blog earlier this month that providers could use the additional attention on anticonvulsants as an incentive to target medication improvements, “ensure compliance with clinical standards and monitor for adverse effects.”
Twombly echoed those points, urging providers to work with their interdisciplinary teams to gather insights on the use of anticonvulsants and use their monthly pharmacy reviews to prepare for changes.
While skilled nursing providers have argued that hospitals or primary care doctors often start their patients on antipsychotics, Twombly said some well-intentioned nursing homes have relied on anticonvulsants as an alternative, “thinking it’s better.”
The message from CMS, however, is that they’re now taking an equally stern approach to the anti-seizure medications.
“This may not apply to literally every nursing home in the country, but it needs to be a focus area, especially if I have been treating a lot of dementia patients with anticonvulsants,” Twombly said.
