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Kansas Nursing Home A Model For Cutting Antipsychotic Use Among Dementia Patients

Andy Marso
Kansas News Service
Janell Wohler, the administrator of Linn Community Nursing Home, speaks at a conference of fellow administrators about reducing use of antipsychotics among patients. At right is Kate Rieth, director of nursing at the facility.

Kansas continues to rank among the worst states when it comes to sedating nursing home residents with powerful antipsychotic drugs.

Janell Wohler and Kate Rieth of the Linn Community Nursing Home told their colleagues Tuesday that it doesn’t have to be that way.

Wohler is the administrator and Rieth is the director of nursing at the facility, which has eliminated off-label use of antipsychotics for residents over the last five years.

Rieth said it’s a matter of educating staff to look for the underlying reasons behind residents’ non-compliant behavior and addressing those, rather than reaching for a phone to call a doctor who can prescribe a “chemical restraint.”

“Doctors are fixers,” Rieth said. “And how do they fix things? With medicine.”

But Rieth and Wohler said that when it comes to antipsychotics, the fix can do more harm than good, with side effects that include increased risk of infections, blood clots, stroke and death.

The two led a presentation on “Antipsychotic Reduction in Action” at a conference of Kansas nursing home administrators in Manhattan. In addition to meeting basic needs like hunger and thirst, they said their facility focuses on keeping residents with dementia busy with activities, including a “Music and Memory” program.

Their message was well-timed, as new research shows that progress on reducing antipsychotic use has stalled in Kansas and the state is slipping behind others.

Antipsychotic medications are commonly used to treat mental illness, but they’re not approved for treating dementia. The U.S. Food and Drug Administration has issued a “black box” warning outlining the significant side effects the medications can have if used improperly.

The federal Centers for Medicare and Medicaid Services launched an initiative to reduce their use in nursing homes in 2011, when nearly 24 percent of long-stay nursing home residents nationwide were on the drugs.

At the time, Kansas ranked 41st with 26.1 percent of nursing home residents receiving antipsychotics. New information from CMS shows that at the end of 2016 Kansas had reduced that rate to 20.3 percent but now ranks 50th, ahead of only Oklahoma.

Download the CMS report on antipsychotic use in nursing homes

“Have we had some reduction? Yes,” said Mitzi McFatrich, executive director of Kansas Advocates for Better Care, a group that works on behalf of nursing home residents. “But in comparison to what other states have done, pretty much none.”

McFatrich said her organization continues to get reports of improper use of antipsychotics to sedate residents who may be uncooperative but aren’t mentally ill.

She cited examples like a woman who walked the halls of her nursing facility shutting doors and a man who refused to go back in his room while a nurse was trying to do paperwork. She said the reports sometimes come from doctors who are asked to write the antipsychotic prescriptions.

The solution in these situations, McFatrich said, is more staffing and better training, not medications.

Other States Improving

The use of antipsychotics in Kansas nursing homes has dropped about 6 percent since the federal initiative started. Meanwhile, states like Tennessee (13 percent), Louisiana (11 percent) and Texas (11 percent) have surpassed Kansas by showing much more improvement.

Missouri started with the same rate as Kansas in 2011 but has reduced it to 18.8 percent. It ranks 44th in the nation.

Kansas had its rate down to 20.4 percent by the third quarter of 2015, but progress has since stalled. McFatrich pointed to that as evidence that the state’s KanCare companies have not followed through on promises to lower rates of antipsychotic use.

The state signed contracts with the three private insurance companies to administer Medicaid starting in 2013. About half of the residents in Kansas nursing homes fall under KanCare.

Kansas has always ranked high in the use of the antipsychotic drugs, in part because the state has 11 nursing facilities for mental health that other states don’t have.

McFatrich said some states have used regulatory enforcement — inspections and deficiency reports that can lead to fines — to crack down on inappropriate antipsychotic use, but that doesn’t appear to be the case in Kansas.

Instead, she said the Kansas Department for Aging and Disability Services has ceded leadership on the issue to the Kansas Partnership for Improving Dementia Care, a coalition led by Linda Farrar, a nurse and former nursing home administrator who is now a consultant.

“She has no standing or authority,” McFatrich said. “She has a lot of passion. She’s done work to try and get movement, she’s done trainings around the state, but she has no standing.”

Angela de Rocha, a spokeswoman for KDADS, said the agency has not ceded leadership on reducing improper antipsychotic use but cannot interfere with doctors’ prescribing orders for nursing home residents.

Nor can KDADS cite nursing homes as deficient just because their rates of antipsychotic use outstrip the national average.

“With that said, it is an important part of our mission for the agency to educate facilities on how they can lower their antipsychotic rate,” de Rocha said.

Worth The Effort

Farrar said Kansas has always ranked high in the use of the antipsychotic drugs, in part because the state has 11 nursing facilities for mental health that other states don’t have.

But the CMS report accounts for some proper use of antipsychotics in those settings and others by excluding residents diagnosed with schizophrenia, Huntington’s disease and Tourette syndrome.

Farrar said even when those facilities are taken out, Kansas still ranks 36th in the nation — and that’s too high.  

But she said Linn Community Nursing Home provides a good model and if more homes follow its lead, the state’s overall ranking will improve.

“They bought into the initiative early on and have been very successful with it,” Farrar said.

Rieth and Wohler said it had not been an easy process to wean staff from the quick fix of calling a doctor, but it’s worth it.

Wohler said the state’s near-bottom ranking should spur more change.

“It’s bad in Kansas,” Wohler said. “It’s not a laughing matter here anymore. It’s bad.”

Andy Marso is a reporter for KCUR’s Kansas News Service, a collaboration of KCUR, Kansas Public Radio and KMUW covering health, education and politics in Kansas. You can reach him on Twitter @andymarso. Kansas News Service stories and photos may be republished at no cost with proper attribution and a link back to kcur.org.

Andy Marso is a reporter for KCUR 89.3 and the Kansas News Service based in Topeka.
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