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Racial Disparities, Reimbursement for Care, and Quality of Life: Factors That May Influence the Prescribing of Antipsychotics for Minority Nursing Home Residents

      Recently there has been an upsurge in published studies that have focused on the inequalities existing in the provision of care to minority residents of nursing homes. Analysis of data during COVID-19 has emphasized these disparities, reporting the increased number of deaths among Black and other minority residents during the crisis.
      As we have collectively focused on the pandemic, facilities may have shifted their attention away from the safe and appropriate prescribing of antipsychotics in the nation’s nursing homes. As a consultant pharmacist, identifying patterns and trends is paramount to what we offer facility medical directors and executive leadership. Are there any patterns or trends indicating disparities in prescribing antipsychotics to minority residents in nursing homes?

      Race and Antipsychotics in Nursing Homes

      Scant recent literature has been published about prescribing patterns of antipsychotics linked with the racial composition of the nation’s nursing homes. Several studies have analyzed data from before the introduction of federal initiatives to reduce antipsychotics in nursing homes beginning in 2012.
      One recent analysis of that data found a reduction in the use of antipsychotics in Black residents, possibly attributed to recognition that common comorbid conditions such as diabetes and hypertension can be worsened with the use of antipsychotics (J Am Geriatr Soc 2020;68:630–636). Data also exist through the federally mandated collection portals on the prevalence of the use of antipsychotics in long-stay residents (30 days or longer). The 2012 National Partnership to Improve Dementia Care in Nursing Homes initiative provided a benchmark with the goal of reducing the percentage of residents receiving these drugs.
      By 2016, Centers for Medicare & Medicaid Services reported that facilities achieved the overall goal of a 30% reduction in the use of unnecessary antipsychotics in long-stay residents; it also announced a new goal of a further 15% reduction “by the end of 2019 for long-stay residents in those homes with currently limited reduction rates” (“National Partnership to Improve Dementia Care in Nursing Homes,” updated July 29, 2022, https://go.cms.gov/3QMUIFK). The national average declined from 23.9% in the fourth quarter of 2011 to 14.5% by the fourth quarter of 2021, according to data provided by CMS via Medicare and Medicaid pharmacy claims, facility Minimum Data Set reporting, and CMS recertification surveys.

      Reimbursement and Structural Inequalities

      One recent study examining deaths of Black residents during the pandemic provides insight about racial disparities, structural biases, and financial challenges in providing care. The authors found that disparities were greatest in rural settings and that “on average, nursing homes with the highest proportions of Black residents were more likely to be for-profit organizations, report staffing shortages, have the highest percentage of Medicaid residents (∼75%), and have the least amount of [registered nurse] and aide hours per resident day” (J Am Med Dir Assoc 2021;22:P893–898.e2).
      Another study arrived at a similar conclusion: Medicaid-reliant nursing homes have a higher use of antipsychotics (J Am Geriatr Soc 2020;68:630–636). Medicaid-reliant facilities also generally do not have the resources to provide adequate staffing for enhanced support services, which could be a factor in why antipsychotics are prescribed in greater numbers as an intervention.

      Challenges for Providers

      Although we don’t have statistics reporting whether minority residents receive antipsychotics at a greater percentage than White residents after admission to a nursing home, we do know that inappropriate diagnosing, such as for schizophrenia, occurs for Black residents in greater numbers than for White residents (J Am Geriatr Soc 2021;69:3623–3630).
      Regarding the prescribing of psychotropics and specifically antipsychotics, providers are at a disadvantage when a resident is admitted because they do not know the subjective physical, emotional, and socioeconomic background of each individual. Providers caring for a new resident for the first time are unwrapping a complex package: objective reports (discharge summaries, laboratory results, ICD-10 diagnoses, medication lists), which are superseded by the unknown. Save for an obvious medication interaction or increased risk for side effects, antipsychotics are generally continued after admission.
      Although barriers occur around facility formularies and reimbursement (Medicare A stays; commercial insurances), antipsychotics generally have adequate insurance coverage in the initial short-stay admissions period and then when converting to Medicare Part D coverage for long-term stays. One challenge when assessing medications is to recognize whether the medical history provides an accurate picture of the resident, while being cognizant of the CMS mandate to eliminate unnecessary psychotropic drugs in nursing homes. For residents who convert to long-term stays or who are straight long-term admissions, additional scrutiny begins as antipsychotics are tallied in the quality measure statistics.

      Quality of Life Indictors for Minority Residents

      Do prospective residents have a choice in their selection of a facility placement, and will they be admitted to a facility that aligns with their personal life story? Most may not. When a resident converts to a long-term stay or if they are already established in the facility, there needs to be a better assessment and integration of their clinical, social, and cultural background, with an emphasis on the accuracy of medical diagnoses and any indications for use of antipsychotics. Quality of life (QOL) indicators provide insight into factors that may be underaddressed in facilities and may lead to increased use of psychotropics and antipsychotic use for all races if left unaddressed.
      One study examined 2015 QOL data in Minnesota (a state that collects validated QOL data) for minority and White residents in a representative sample of the state’s nursing homes. The authors identified disparities within these facilities, including factors such as not paying adequate attention to cultural sensitivity, discrimination, or racial bias (Innov Aging 2020;4[3]:1–9). Lack of attention to these factors may shape the culture of a facility, leading to inappropriate use of antipsychotics as an accepted solution for the care of challenging residents.
      Additionally, facilities with a higher proportion of minority residents with Medicaid as the primary source of funding have fewer resources to invest in modalities that improve QOL. Regardless of resources, it’s important to do what we can to address QOL for minority residents.

      Next Steps

      Reducing the inappropriate use of antipsychotics in nursing homes requires perseverance and is difficult work. Quality metrics will continue to measure trends, and facilities will continue to work toward reducing overall numbers. Hopefully, this article prompts medical leadership in conjunction with their consultant pharmacist to examine some of the practices within their organization or facility, to analyze the data differently, and to act on opportunities to reduce the prevalence of antipsychotics that may be overprescribed for minority residents.
      Robert Accetta is the president/owner of Rivercare Consulting, LLC, a care strategy and consulting business for post-acute rehabilitation, long-term, assisted living, group home, and community care organizations. A Board-Certified Geriatric Pharmacist, he serves as a consultant and educator in a variety of roles. Rob currently serves on the Board of Directors of the American Society of Consultant Pharmacists (ASCP). He is a graduate of St. John’s University College of Pharmacy and Health Sciences in New York.
      A number of factors directly or indirectly contribute toward patterns or trends of decreased antipsychotic prescribing among minority residents:
      • Aiming for diverse racial demographics of all medical provider staff, including medical directors, attending physicians, nurse practitioners (NPs), and physician assistants (PAs).
      • Having diverse upper management staff who are the decision makers, including those in clinical and nonclinical roles.
      • Ensuring providers are culturally educated about the residents in their care.
      • Promoting provider flexibility and medical experience, including open-mindedness regarding inappropriate prescribing of antipsychotics along racial lines.
      • Examining the medical model and ensuring providers are financially incentivized to be physically present with and to see an appropriate number of residents, with an increased proportion of time spent providing direct interactions with residents.
      • Using the services of consultant psychiatrists or specialized providers who provide both in-person and telehealth services, and are educated on the needs of minority residents.
      • Educating and mentoring all staff on diversity, equity, and inclusion; and recognizing how the ethnicity, gender, or other identities of the nursing leadership may impact education and mentoring.
      • Acknowledging the power dynamics between the “hands-on” staff who are with residents the most — certified nurse assistants, licensed practical nurses, registered nurses, social workers, housekeepers, dietary staff — and medical leadership; encouraging hands-on staff to interact with medical staff about the status of residents.
      • Educating the staff about the literacy levels and communication preferences of minority residents.