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How the DNS Can Lead Risk Mitigation for Schizophrenia Diagnoses

2015—the year that the Centers for Medicare & Medicaid Services (CMS) added antipsychotic medication use quality measures (QMs) to the Five-Star Quality Rating System—marked the beginning of some difficult trends in the potentially inappropriate diagnosis of schizophrenia for long-stay nursing home residents, according to the November 2022 report Long-Term Trends of Psychotropic Drug Use in Nursing Homes from the Office of Inspector General (OIG). This report, which assessed long-stay residents aged 65 and older who were Medicare beneficiaries from 2011 – 2019, is the latest of several recent OIG reports reviewing antipsychotic drug use in nursing homes.

From 2015 – 2019, the number of long-stay residents with MDS item I6000 (Schizophrenia (e.g., Schizoaffective and Schizophreniform Disorders)) coded jumped by 35 percent, and the number of residents with that MDS coding but no corresponding schizophrenia diagnosis in Medicare claims and encounter data increased by 194 percent, according to the OIG.

“In 2015, there were 6,465 residents who were reported in the MDS as having schizophrenia but who lacked a corresponding schizophrenia diagnosis in their claims for medical visits, treatments, tests, or supplies during 2015 or in the preceding year,” explains the OIG. “By 2019, this number had almost tripled to 19,009 residents reported in the MDS as having schizophrenia but who lacked a corresponding schizophrenia diagnosis in their claims during 2019 or the preceding year.”

CMS’s own pilot audits of the MDS audit process also identified I6000 miscoding, finding that comprehensive psychiatric evaluations were often missing from the medical record and that behavior documentation, when present, was often sporadic and related to dementia behaviors, not schizophrenia behaviors. As a result, CMS will conduct offsite schizophrenia MDS audits and downgrade relevant Five-Star QM ratings, as well as conduct ongoing monitoring and possibly additional follow-up audits, when I6000 is miscoded, the agency says in Quality, Safety, and Oversight (QSO) memo QSO-23-05-NH. “Also, we plan to offer facilities the opportunity to forego the audit by admitting they have errors and committing to correct the issue.”

Note: Tips for nurse assessment coordinators (NACs) are available in the article “Schizophrenia: Keys to Coding I6000 and Supporting This Critical Diagnosis.”

However, potential schizophrenia misdiagnoses are more than an MDS issue. To mitigate the risks related to schizophrenia diagnoses, directors of nursing services (DNSs) can take the following steps:

Realize that Black residents with dementia may be at greatest risk

The issue of potentially inappropriate schizophrenia diagnoses may be most dire for Black residents with Alzheimer’s and related dementia (ADRD). From 2011 – 2015, schizophrenia diagnoses were highest among residents with ADRD, according to the study “Disproportionate Increases in Schizophrenia Diagnoses Among Black Nursing Home Residents With ADRD” in the September 2021 Journal of the American Geriatric Society.

Prior to the 2012 launch of CMS’s National Partnership to Improve Dementia Care in Nursing Homes, Black residents without ADRD had higher rates of schizophrenia compared to non-Black residents without ADRD. Following the partnership, the rate of schizophrenia diagnoses coded on the MDS went up 1.7 percent in Black residents with ADRD, while non-Black residents with ADRD saw a decrease of 1.7 percent, the study found.

Looking at 2011 – 2017 data, “The Diagnosis of Schizophrenia Among Nursing Home Residents With ADRD: Does Race Matter?” in the May 2022 American Journal of Geriatric Psychiatry similarly found that “black residents experienced a greater increase in the likelihood of having schizophrenia diagnosis than white residents” after the long-stay antipsychotic medication use QM became publicly reported.

See the potential repercussions improper diagnosis may have for the resident

An improper schizophrenia diagnosis can have multiple impacts, says Nicole Coniglio, MSN, ANCC, chief clinical officer for MindCare Solutions in Brentwood, TN; the founding member of the long-term care mental health platform Psych360 in Medina, OH; and a member of the Behavioral and Mental Health Advisory Council at AMDA, the Society for Post-Acute and Long-Term Care Medicine in Columbia, MD.

“For example, an antipsychotic medication may be prescribed for a diagnosis that doesn’t exist in the resident, and the interdisciplinary team may care plan around the wrong issues,” explains Coniglio. “The resident could have dementia, anxiety, sleep problems, or another condition that usually doesn’t need an antipsychotic medication but may require, for example, resident-specific nonpharmacological interventions developed in consultation with a mental health provider.”

Understand why inaccurate schizophrenia diagnoses may occur

The OIG report ties the rise in schizophrenia diagnoses to schizophrenia’s role as an exclusion for the antipsychotic medication QMs. “In the past, some physicians have provided schizophrenia diagnoses as a way to ‘help out’ these nursing homes,” acknowledges Coniglio. “That’s less common now, but unfortunately it still happens sometimes.”

However, nursing homes aren’t always trying to game the system, stresses Amber Givens, MSN, RN, IP, CGCP, director of nursing services at Cashmere Post-Acute in Cashmere, WA. “In nursing homes, the sheer volume of residents means that physician management may occur. Physicians, like the nursing staff, are often overwhelmed trying to figure out how to help a resident. For example, the physician may ask a nurse for an opinion. The nurse questions the physician about a schizophrenia diagnosis because they are trying to watch the facility’s antipsychotic medication use QMs, and the physician lets themselves be talked into that diagnosis. And, this often happens when neither side has a full understanding of the diagnostic criteria involved in a schizophrenia diagnosis.”

In addition, a resident who is behavioral usually needs more attention from staff, says Givens. “DNSs are often in a desperate situation with the behavioral component of resident care. When you have insanely small staffing pools and you don’t have enough staff to help manage behaviors, then the desire for medication to manage those behaviors can overtake good clinical judgment.”

So, the increase in schizophrenia diagnoses is not a situation where every clinician is going for the simplest technique, explains Givens. “The staffing crisis over the last decade has combined with the COVID-19 pandemic to create a perfect storm.”

Another issue that often contributes to improper diagnoses is residents who are poor historians, says Coniglio. “A resident may come to the nursing home and say, ‘I have been on this antipsychotic medication,’ without any supporting medical history or records. That can make it difficult for facilities when the resident or the family insists that they need that medication.”

Or, an incorrect diagnosis may follow the resident from the hospital, says Coniglio. “Sometimes, both the nursing home staff and the attending physician assume that a schizophrenia diagnosis that is carried with the resident from the hospital is true, and they are uncomfortable trying to reduce or remove an antipsychotic medication when a resident comes in with that diagnosis. Hopefully, that will start improving as clinicians look more at the diagnoses and the medications that are being used.”

Get up-to-date on the revised behavioral health guidance

Appendix PP in the State Operations Manual includes revised surveyor guidance (implemented on Oct. 24, 2022) under three behavioral health F-tags:

  • F740 (Behavioral Health Services);
  • F741 (Sufficient/Competent Staff—Behavioral Health Needs); and
  • F949 (Behavioral Health Training).

“The interdisciplinary team needs to review all of this guidance,” suggests Barbara Bates, RN, MSN, DNS-MT, DNS-CT, QCP-MT, QCP, a clinical nurse consultant based in Rochester, NY. “You want to be sure that you have policies, procedures, and processes in place that address these requirements. The survey process is an open-book test. Using this guidance will help you have effective processes to manage residents with behavioral health needs, including schizophrenia, as well as show surveyors that you are making a good faith attempt.”

Include mental health diagnoses in the admissions process

While CMS and the OIG appear to be focused primarily on new schizophrenia diagnoses that occur during the resident’s stay in a nursing home, nursing homes should try to get supporting documentation for all schizophrenia diagnoses, whether the resident was diagnosed last week or 20 years ago, says Bates. “Asking for this information is no different than asking for a history on a medical condition, and it will help the interdisciplinary team create a strong baseline care plan. That is important for residents with schizophrenia because they could destabilize just from moving into a different environment.”

The admissions team should note any information about mental health diagnoses, including schizophrenia, during the admissions process, suggests Bates. “If they identify a potential mental health diagnosis in the documentation from the acute-care hospital, they should follow up with hospital staff to see if they can get additional information. Or, for example, if the resident or family says that the resident is on a psychotropic medication, the admissions team should find out if the resident or family can tell them where the facility needs to send a records request to find out what diagnosis the medication is being used to treat.”

Mental health diagnoses that occurred prior to the resident’s acute-care hospital stay can be hard to follow up on, acknowledges Bates. “Psychiatric records can be difficult to obtain. However, if the resident has consistently been on an antipsychotic medication, that prescription is coming from somewhere. So, where is the diagnostic information? Does the resident’s primary care physician in the community have it? If the resident or family can’t help you find the records, maybe the resident has a psychiatric liaison, such as a social worker, who can help.”

The team also should check the resident’s pre-admission screening and resident review (PASARR or PASRR) status, says Bates. “Most residents who were diagnosed with schizophrenia when they were fairly young will already be covered by the Level II PASARR process due to the supports they’ve needed throughout their life. That PASARR information provides important information for the baseline care plan. And, if the resident is admitted to your facility with a schizophrenia diagnosis but no PASARR records, that’s a potential red flag that you may need to make a referral to a psychiatrist to confirm the diagnosis.”

Make sure that the IDT is educated about schizophrenia

Behavioral health education isn’t strong in healthcare, says Bates. “So, nursing home staff often aren’t aware of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) diagnostic criteria for schizophrenia.”

For example, nurses often think that hallucinations and delusions are symptoms of schizophrenia, says Coniglio. “However, hallucinations and delusions also may occur with some types of dementia, as well as with an array of other issues that aren’t psychiatric. It’s important for staff to be educated around schizophrenia and the other diagnoses that are commonly seen in your facility, such as dementia, so that they don’t automatically assume that a hallucination or a delusion is associated with schizophrenia. In addition, staff need to be educated on the process that they should use to identify which residents need a referral for psychiatric assessment to get the appropriate diagnosis.”

Note: While many types of dementia share common symptoms, some symptoms are more frequent in certain types of dementia. For example, hallucinations are more common with Lewy body dementia than with Alzheimer’s disease, according to “Assessment and Management of Behavioral and Psychological Symptoms of Dementia” in the April 2015 issue of The BMJ.

CMS has added the following description of schizophrenia under F740 (Behavioral Health Services) in Appendix PP:

Schizophrenia is a serious mental disorder that may interfere with a person’s ability to think clearly, manage emotions, make decisions and relate to others. It is uncommon for schizophrenia to be diagnosed in a person younger than 12 or older than 40. Schizophrenia must be diagnosed by a qualified practitioner, using evidence-based criteria and professional standards, such as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and documented in the resident’s medical record. Symptoms of Schizophrenia include delusions, hallucinations, disorganized speech (e.g., frequent derailment or incoherence), grossly disorganized or catatonic behavior, and diminished expression or initiative. Delusions refer to false beliefs that don’t change even when the person who holds them is presented with new ideas or facts. Hallucinations include a person hearing voices, seeing things, or smelling things others can’t perceive.  

Adapted from the:  
National Alliance on Mental Illness (NAMI). “Schizophrenia.” Accessed March 2, 2021.
• American Psychiatric Association. “Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.” 2013.

Do a diagnosis review

“Providers should have a process to review all residents who have a schizophrenia diagnosis,” says Coniglio. Questions to consider include the following:

  • Was the initial schizophrenia diagnosis made after age 65?

  • Was the initial diagnosis made after the resident was admitted to this facility?

  • Is there relevant clinical assessment and diagnostic documentation in the medical record?

    • Is there a comprehensive psychiatric evaluation?

    • Is there consistent documentation of persistent symptoms/behaviors that meet DSM-5-TR clinical criteria for schizophrenia?

  • Is the resident receiving care and/or management services from a psychiatrist or other behavioral health provider related to their schizophrenia diagnosis?

  • Does this resident need to be referred to a psychiatric provider to confirm the diagnosis?

  • If the resident is on an antipsychotic or other psychotropic medication:

    • Is gradual dose reduction (GDR) clinically contraindicated for this resident, and is that supported in the documentation?

    • Is the resident being adequately monitored for adverse consequences?

    • Is the resident receiving individualized nonpharmacological interventions, unless contraindicated?

  • If a diagnosis of schizophrenia is not confirmed, does the nurse assessment coordinator (NAC) need to do modifications on any previously submitted MDS assessments?  

Sources: Amber Givens, RN, BSN, director of nursing at Cashmere Care Center in Cashmere, WA; F758 (Free From Unnecessary Psychotropic Medications/PRN Use) from Appendix PP of the State Operations Manual; and the OIG report Long-Term Trends of Psychotropic Drug Use in Nursing Homes.

“New residents with schizophrenia who are on antipsychotics should be incorporated into this review process,” says Coniglio. “Then, as the interdisciplinary team identifies current residents who have begun exhibiting possible signs and symptoms of schizophrenia, you want to be sure that they are referred, preferably to psychiatry, for a proper diagnosis as well.”

Involve the consultant pharmacist in diagnosis reviews

Side effects of some medications can mimic symptoms of schizophrenia, says Givens. “For example, a resident who is already on a neuroleptic (i.e., an antipsychotic medication) may have tardive dyskinesia, orthostatic hypotension, or a Parkinsonian reaction. So, does this resident really have schizophrenia, or is the resident’s behaviors a reaction to a medication that they are taking? Your consultant pharmacist may need to conduct a medication regimen review to help you identify the root cause of the symptoms.”

Have a clear monitoring process/protocol

Providers should develop a policy or protocol for all residents with a schizophrenia diagnosis, says Bates. “You should have processes for how these residents are assessed and monitored, including when they are on a psychotropic medication, and you also need a process that defines who is making sure that the necessary documentation is in the medical record.”

One reason why close monitoring is so critical is that residents with schizophrenia can destabilize quickly, notes Bates. “If a resident is destabilizing despite the implementation of the comprehensive care plan, a psychiatry provider should assess the resident and work with the interdisciplinary team to revise the interventions. If the resident can’t stabilize, they may need a short-term psychiatric placement or other assistance.”

“Depression and anxiety also are common in people with schizophrenia, and they can occur at a higher rate than in the general population,” says Givens. “So, you want to make sure that the team closely monitors any resident with a schizophrenia diagnosis—or a potential schizophrenia diagnosis—for depression and anxiety. Those types of symptoms within a disorder need to be identified and treated as well.”

Start a conversation with the medical director

The DNS should open up a conversation with the medical director to discuss why a schizophrenia diagnosis would be given in a SNF or NF setting when that resident is beyond the age of standard diagnosis, says Givens. “That could lead to a deeper discussion about alternatives and interventions that could be used instead of an antipsychotic medication or other psychotropic medication.”

Loop in QAPI

Residents with a schizophrenia diagnosis should be tied into the facility’s quality assurance and performance improvement (QAPI) program, says Bates. “Is there a monitoring process that flags when a new resident suddenly gets an initial diagnosis of schizophrenia? Or, do you have a process for auditing the medical record when a new admission comes in with a schizophrenia diagnosis to determine whether any documentation is lacking? If information is lacking, should it have been picked up during the admission process, and does your admission protocol need to be revised?”

Be ready for antipsychotic QM numbers to rise

The revised Appendix PP guidance alerts surveyors to potential misdiagnoses, including the misdiagnosis of new-onset schizophrenia, in similar notes under several F-tags: F641 (Accuracy of Assessments), F658 (Services Provided Meet Professional Standards), and F757 (Drug Regimen is Free From Unnecessary Drugs) and F758 (Free From Unnecessary Psychotropic Medications/PRN Use).

“Overall, this updated survey guidance is a positive from the standpoint that it can help you and your medical director educate physicians and reduce any resistance they may have to updating diagnoses,” says Coniglio.

However, DNSs should expect to see some upward trends in their antipsychotic medication use QMs as diagnoses are updated, says Coniglio. “National and state averages likely will increase now that state surveyors have begun enforcing the updated Appendix PP guidance, and nursing homes start to see the seriousness of the issue.”

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