The Meaning of CMS Proposed Rule Changes for Long-Term Care
Perhaps one of the most significant outcomes from the White House Conference on Aging was the release from the Centers for Medicare and Medicaid Services (CMS) proposed rules for long-term care providers.1 CMS announced that these rules would make major changes to improve the care and safety for long-term care (LTC) residents by reducing unnecessary hospital readmissions and infections, increasing quality care, and strengthening safety. Compliance with these new rules is essential for LTC facilities because adherence to these CMS rules is a requirement for participation in Medicare and Medicaid.
The original requirements for participation were first published in the Federal Register on February 2, 1989, over a quarter of a century ago. Although these regulations have been revised and amended since that time, they have not been comprehensively reviewed and updated since September 26, 1991, despite substantial changes in service delivery in LTC over the last several decades.
The proposed rule that CMS released in July will revise the requirements that LTC facilities must meet to participate in the Medicare and Medicaid programs. CMS believes that these proposed changes are necessary to reflect the substantial advances that have been made over the past several years in the theory and practice of service delivery and safety. These proposals are also an integral part of our efforts to achieve broad-based improvements both in the quality of health care furnished through Federal programs and in patient safety while reducing procedural burdens on providers. Further, CMS believes that these changes are needed to ensure that LTC residents receive care that maintains or enhances quality of life and attains or maintains the resident’s highest practicable physical, mental, and psychosocial wellbeing.
This proposed rule would implement comprehensive changes intended to update the current requirements for long-term care facilities and create new efficiencies and flexibilities for facilities. In addition, these changes will support improved resident quality of life and quality of care. Many of the quality of life improvements we are proposing are grounded in the concepts of person-centered care and culture change. These changes result in not only improved quality of life for the resident but also improvements in the caregiver’s work satisfaction and in savings to the facility. Savings can be accrued through reduced turnover, decreased use of agency labor, and decreased worker compensation costs. CMS believes that LTC facilities may also benefit from improved bed occupancy rates.
These rules illustrate Medicare’s focus and thinking. The major areas of focus include the use of hospitalizations and of psychotropic, pain, and antibiotic medications by LTC facilities. While these areas themselves are perhaps not a surprise, the way in which Medicare is approaching them is more aggressive and intrusive than many had expected. If you have yet to read the more than 400 pages of the CMS proposed LTC facilities rule changes, the basics of what these facilities and their providers will need to do to comply are presented here.
Hospitalizations
Medicare continues its focus on reducing hospitalizations, as CMS research found that approximately 45% of hospitalizations among Medicare-Medicaid enrollees receiving either Medicare skilled nursing facility services or Medicaid nursing facility services could have been avoided. CMS believes that increased provider involvement can reduce those inappropriate hospitalizations. To this end, CMS is requesting an in-person evaluation of an LTC resident by a physician, a physician assistant, nurse practitioner, or clinical nurse specialist before an unscheduled transfer to a hospital.
Preventing potentially avoidable hospitalizations of nursing home residents is an important CMS quality-improvement initiative from the standpoint of the LTC residents and their families, and it also may yield cost reductions from the standpoint of the LTC facility. The transfer to an acute care hospital is a stressful event for a LTC resident of a skilled-nursing facility (SNF) or nursing home. As noted by the Office of the Assistant Secretary for Planning and Evaluation (ASPE) in its June 2011 report, Hospitalizations of Nursing Home Residents: Background and Options,2 such hospitalizations impose a high personal cost on nursing home residents, causing disruption, risk of complications and infections, and likelihood of reduced functioning upon return to the nursing home. LTC residents are especially vulnerable to the risks that accompany hospitalizations and transitions of care, including medication errors and hospital-acquired infections. Hospital episodes are even more difficult for LTC residents with dementia, who become disoriented in new, unfamiliar settings. As a result, CMS proposes to take a multifaceted approach to reducing unnecessary hospitalization. This approach includes:
- Requiring that a facility notify the LTC resident’s physician when there is a change in a LTC resident’s status, including any pertinent information;
- Addressing communication through a robust interdisciplinary team, comprehensive person-centered care planning process and through training requirements; and
- Requiring practitioner assessment prior to transfer to a hospital, except in an emergency situation.
It is unlikely that the requirement for a practitioner assessment prior to a hospital transfer will remain in the Proposed Rule as written, because it is impossible to implement without significant cost and risk of harm to residents. However, some version of this requirement may remain. For example, CMS could move to make this a requirement for transfers that occur during business hours while allowing virtual practitioner visits be done for transfers that occur after hours. Either way, CMS will continue to press LTC facilities to provide their residents with more access to primary care practitioners. Thus, it would serve LTC facilities to develop a plan for delivering on this new CMS demand.
Psychotropic Medications
Antipsychotic medications are frequently prescribed off-label to LTC residents with behavioral and psychological symptoms of dementia (BPSD). This has led to increased attention to the behavioral health management of nursing home LTC residents with dementia and the potentially inappropriate use of antipsychotics in this population. Evidence suggests that antipsychotics have limited benefits in this population as well as the potential to lead to adverse consequences, such as the risk of movement disorders, falls, hip fractures, cerebrovascular accidents, and death.
Previous Office of Inspector General studies3,4 found that when this population received these drugs, about half of the drugs were not given for medically accepted indications, as required for Medicare coverage, or were not recorded as being administered to the LTC resident. Furthermore, one-fifth of the drugs were not given in accordance with federal safeguards to protect nursing facility residents from unnecessary antipsychotic drug use. The potential overuse of antipsychotic agents is a symptom of a much larger problem—namely, that many nursing facilities may not have a systematic plan to provide comprehensive behavioral health care to LTC residents with diagnoses such as dementia and BPSD. In this proposed rule, CMS aims to reduce the unnecessary use of antipsychotic medications through several approaches, including:
- Requiring that each nursing home conduct a comprehensive assessment, including its physical characteristics, its LTC resident population, the competencies and knowledge of its staff, and the identification of any resources or support—including training and additional staff—that the facility would need to ensure the appropriate care and treatment for all LTC residents;
- Revising the current requirements that apply to antipsychotic drugs to also apply to any psychotropic drug (that is, any drug that affects brain activities associated with mental processes and behavior, including antidepressants being classified as psychotropic drugs); and
- Requiring that, once the facility’s consultant pharmacist has identified an irregularity (such as a drug given for an excessive duration of time or prescribed without adequate indications documented in the patient’s medical record) or has recommended a gradual dose reduction for one or more medication, the attending physician document in the patient’s medical record that he or she has reviewed the identified irregularity and what, if any, action was taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the patient’s medical record.
These proposals will extend the management difficulties LTC facilities currently have with antipsychotic use to the use of antidepressants and other medications considered in the same vein as antipsychotics. To prepare for the changes, LTC facilities should extend their current antipsychotic reduction programs to this new, broader category of psychotics. This includes improved non-pharmacologic interventions as well as clear documentation to support use of all of these medications.
Pain Management
CMS proposed to add a new requirement that facilities must ensure that LTC residents receive necessary and appropriate pain management.
Pain that impairs function affects 45–80% of nursing home residents, with half of those experiencing daily pain.5 Untreated pain is associated with multiple health consequences, including poor oral intake and weight loss, inability to sleep, depression, loss of mobility and increased risk of falls, increased risk of pressure ulcers, depression, anxiety, decreased socialization, sleep disturbance, increased emergency room transfers and increased re-hospitalization rates.6 In addition to being a medical issue, pain management also can significantly alter a LTC resident’s ability to engage in an activities program of choice, perform transfers, or ambulate; can impair quality of life; and can contribute to depression.7
In 2011, the Institute of Medicine issued a comprehensive report on pain, entitled Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research.8 This report identifies pain as a national challenge, affecting more Americans than heart disease, diabetes, and cancer combined, and as a factor that significantly increases the cost of health care across all settings, including nursing facilities. CMS believes that adequate pain management is critical to the health, safety, and quality of life of nursing home residents.
Therefore, CMS proposes to explicitly include oversight of pain management as a special concern, such that facilities must ensure that LTC residents receive treatment and care for pain management in accordance with professional standards of practice. Given the focus of CMS on reduction of pain in an environment in which the US Drug Enforcement Administration makes it increasingly difficult to access narcotics, LTC facilities will need processes for assuring appropriate assessment and access to pain treatments without delay.
Antibiotics
Antibiotic resistance has emerged as a national healthcare concern, and even the appropriate use of antibiotics can contribute to antibiotic resistance. Nursing homes are the next frontier after hospitals, where new antibiotic resistant organisms may emerge and flourish. Organisms such as Clostridium difficile and methicillin-resistant Staphylococcus aureus are known concerns. Nursing homes need to have the tools to participate in surveillance, learn and use infection control and containment practices, and adopt a proactive approach to preventing the spread of pathogens while being good stewards of antibiotics to preserve the effectiveness of the agents.
Although avoiding the inappropriate use of antibiotics is critical, one of the best mechanisms to combat the rise in antibiotic resistance is to prevent infections and, when they do occur, prevent the spread of the infection to others. In addition, the Centers for Disease Control and Prevention (CDC) have identified four core actions to prevent antibiotic resistance:9 preventing infections and the spread of those infections; tracking or monitoring; improving antibiotic prescribing and stewardship; and developing new medications and tests. The first three actions are within the control of the nursing home. Thus, CMS proposes to require that a facility’s Infection Prevention and Control Program (IPCP) incorporate practices for preventing and controlling infections and communicable diseases as well as an antibiotic stewardship program, which includes both antibiotic use protocols and a system to monitor antibiotic use.
CMS intends for these requirements to improve antibiotic use by ensuring that LTC residents who require antibiotics are prescribed the appropriate antibiotics and only for a treatment duration that is medically necessary. This should reduce unnecessary use of antibiotics and the risk posed to LTC residents by prescribing an unnecessary or inappropriate antibiotic for an inappropriate treatment duration. The surveillance and prevention aspects of the LTC facilities’ IPCP are crucial to the health of the LTC residents, as well as for individuals who work at or visit the facility.
On the basis of its research, CMS proposes to revise the regulatory description of the infection control program to: include infection prevention, identification, surveillance, and antibiotic stewardship; require each facility to periodically review and update its program; require performance of an analysis of their LTC resident population and facility; designate an infection prevention and control officer(s) (IPCO); integrate the IPCO with the facility’s quality assurance and performance improvement (QAPI) program; establish written policies and procedures for the IPCP; and provide the IPCO and facility staff with education or training related to the IPCP.
To comply with this requirement, LTC facilities will need to fill or assign this new position for some of IPCO. The IPCO will be charged with a host of infectious disease prevention and control processes including vaccination and antibiotic stewardship programs as CMS under the CDCs watchful eye work to reduce the spread of antibiotic resistant infections.
More Changes Coming from Washington
In addition to CMS’ Proposed Rule change, another significant change to LTC is coming through is the introduction of the Medicare Post-Acute Care Value-Based Purchasing Act of 2015 (H.R. 3928) by the US House of Representatives Ways and Means Committee.10 This bill will establish a competitive program for home health agencies, skilled nursing facilities, rehabilitation hospitals and long-term acute care hospitals to earn value-based payments beginning in October 2019. The only measure included in this proposed legislation is Medicare spending per beneficiary, which is the measure included in the IMPACT Act of 2014.
Initially, the bill would establish a 3% withholding in Fiscal Year 2019; each year until 2025, the withhold percentage would increase by 1 percentage point, up to 8%. CMS would keep a portion of the withheld amount as savings and use the rest to establish a post-acute incentive pool for high performers. Performance would be based on both improvement and attainment in terms of lowering spending and would be a blend of both the individual provider’s performance and the score for their entire service area as defined in the legislation. LTC providers (home health aides, skilled-nursing facilities, inpatient rehabilitation facilities and LTC homes) would compete for these bonus payments. This will force LTC providers to focus on delivery of cost-effective care outcomes.
Conclusions
In the end, these rules and legislative changes deserve careful analysis by LTCs so that they can respond accordingly in order to assure their success. As a result, LTCs would be well served to prepare for a world in which a greater portion of hospital-level care is provided outside the walls of the hospital in settings like nursing homes. This higher level of care in nursing homes will require increased primary care practitioner access and other services required to deliver efficient and effective outcomes. In addition, medication use in the areas of pain, antibiotic, and psychotropic use will require processes, and in some cases staff, to assure that all medications are used appropriately. All of these steps are needed in order to take care of an growing population of aging individuals that had previously been cared for in acute care hospitals but now increasingly is being cared for in LTC facilities.
References
1. Center for Medicare and Medicaid Services. Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities. Federal Register 2015;80(136):42168–42269. https://www.gpo.gov. Accessed August 12, 2015.
2. Office of the Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services. Hospitalizations of Nursing Home Residents: Background and Options. 2011. https://aspe.hhs.gov/pdf-report/hospitalizations-nursing-home-residents-background-and-options. Accessed August 12, 2015.
3. Office of Inspector General, US Department of Health and Human Services. Prescription Drug Use in Nursing Homes. Report 3: A Pharmaceutical Review and Inspection Recommendations. 1997. https://oig.hhs.gov/oei/reports/oei-06-96-00082.pdf Accessed August 12, 2015.
4. Office of Inspector General, US Department of Health and Human Services. Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents. 2011. https://oig.hhs.gov/oei/reports/oei-07-08-00150.pdf. Accessed August 12, 2015.
5. AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50(suppl 6):S205–S224.
6. Ferrell BA, Ferrell BR, Osterweil D. Pain in the nursing home. J Am Geriatr Soc. 1990;38:409–414.
7. Ferrell BA. Pain management in elderly people. J Am Geriatr Soc. 1991;39(1):64–73.
8. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. 2011. https://iom.nationalacademies.org/reports/2011/relieving-pain-in-america-a-blueprint-for-transforming-prevention-care-education-research.aspx. Accessed August 12, 2015.
9. Centers for Disease Control and Prevention, US Department of Health and Human Services. Antibiotic Resistance Threats in the United States, 2013. 2013. https://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf. Accessed August 12, 2015.
10. Committee on Ways and Means, US House of Representatives. The Medicare Post-Acute Care Value-Based Purchasing Act of 2015. 2015. https://waysandmeans.house.gov/. Accessed August 12, 2015.
