Notes from the April 12 SNF ODF

CMS covered a number of topics during the April 12 SNF Open Door Forum (ODF), leading off with an overview of the national behavioral health quality initiative, which was first introduced with a video presentation on March 29. The initiative aims to reduce the rate with which antipsychotic drugs are used unnecessarily with residents suffering from dementia, resulting in negative, unintended consequences.

The prevalence in long-staying nursing home residents is about 20-25% (national average). In addition, considerable research has revealed that these drugs, at least for the nursing home population, have very limited efficacy. These drugs also pose a risk of death in the elderly population. The initiative has set out to ensure that no one in a nursing home is receiving antipsychotic drugs unless it is deemed medically necessary based on a very detailed process that includes:

  • Identifying a clinical indication
  • Making sure that either the resident or a family member is involved in the decision-making
  • Ensuring that medical causes of cognitive changes are ruled out
  • Attempting behavioral interventions first by properly trained staff members

The initiative’s goal is to reduce the rate of antipsychotic drug use in nursing homes by 15% by the end of this year. CMS admits it is an aggressive goal, but procedures are in place to reach that goal including:

  • Educating providers, subscribers, pharmacists, and consumers on the alternatives of antipsychotic drug use
  • Public reporting (posting national and state rates of antipsychotic drug use by the summer; facilities will receive their own rates from CMS and compare their rate to other facilities in the state and across the country)

A two-day dementia care/nursing home care technical expert panel was recently held as part of the initiative, which included roughly 35 people from across the country. A range of individuals were present including:

  • Geriatric psychiatrists
  • General psychiatrists
  • Geriatricians
  • Nurses
  • Social workers
  • Policy makers
  • Advocates
  • Nursing home residents
  • Resident family members

The panel made training curriculum recommendations for providers and nursing home surveyors. The initiative aims to complete those training programs by the end of 2012.

Through the Affordable Care Act (ACA), CMS was charged with developing abuse prevention and dementia care training for nursing assistants. A DVD titled, Hand in Hand, which was filmed in nursing homes and shows interactions between residents, family members, and staff, illustrating critical principles of exemplary dementia care, is in production. Upon completion, which should be soon, the DVD and an instructor’s manual be sent out to all nursing homes nationwide over the summer. Train-the-trainer programs are also being developed by CMS as an additional resource.

Partners in the national behavioral health quality initiative include:

  • Multiple government agencies in addition to HHS and CMS (DOJ, OIG, FDA, VA, AOA)
  • The Substance Abuse and Mental Health Services Administration (SAMHSA)
  • Health Resources and Services Administration (HERSA)
  • State survey agencies
  • QIO regional offices
  • Numerous advocates, who initially pushed for this initiative in 2011

The initiative is also working with professional associations, including:

  • AHCA
  • LeadingAge
  • AMDA
  • The American Geriatrics Society
  • The American Society of Consulting Pharmacists
  • CGNO

The initiative is reviewing existing surveyor guidance such as unnecessary drugs (F329), resident rights to be free from unnecessary drugs, chemical restraints, and clinical standards for dementia care and related illnesses in order to provide surveyors with the best possible information. Currently, the initiative is conducting a qualitative study in 25 nursing homes in five different states. Researchers are asking prescribers, pharmacists, and nurses about how they decide when a resident suffering from dementia may benefit from antipsychotic medication. In understanding how these decisions get made, the initiative hopes to better determine potential alternatives that may be safer and more effective than drug use.

Any questions about the national behavioral health quality initiative can be directed to

Additional topics explained and announcements made during the ODF include:

  • The nursing home interpretive guidelines are currently being evaluated and updated. They will likely be released within the next few months.
  • The ACA initiative to reduce avoidable hospitalizations among nursing facility residents is underway. It is a collaborative effort between the CMS Medicare/Medicaid Coordination Office and the Center for Medicare and Medicaid Innovation. Currently, there are roughly nine million beneficiaries enrolled in Medicare and Medicaid. About two-thirds of nursing home residents are enrolled in both programs. It is these residents who are often susceptible to avoidable hospitalizations. Research has found that nearly 45% of hospitalizations involving dual beneficiaries were potentially avoidable. The objectives of the initiative are to reduce the frequency of avoidable hospital admissions and readmissions, to improve resident health outcome, to improve the process of transitioning between inpatient hospitals and nursing facilities, and to reduce overall healthcare spending without restricting access to care or choice of providers. Applicants must propose their own evidence-based intervention and improvement strategy. Participation is voluntary. Providers who would like to get involved must obtain letters of intent from a minimum of 15 Medicare/Medicaid-certified nursing facilities in the same state with an average resident census of 100 or more residents per facility. Providers must also obtain a letter of support from the state Medicaid agency and the state survey and certification agency. Preference will be given to proposals that are for locations where there are high Medicare costs, high hospitalization rates, and where Medicare/Medicaid beneficiaries account for a high percentage of residents within the nursing home. At least seven awards will be given involving about 150 nursing facilities. Interested parties must submit a notice of intent to apply by April 30. The complete application is due to CMS by June 14. Questions can be sent to A transcript and recording from the conference call that was hosted on April 3 are posted on CMS. An educational webinar will be hosted April 17; technical requirements (how to apply, eligibility, etc.) will not be discussed.
  • CMS has been informed that some vendors may not have updated their software prior to April 1 in conjunction with the changes to the MDS 3.0. For those providers affected, the CMS software (jRAVEN) can be used until updated software is provided by said vendors. jRAVEN can be downloaded from Click on the jRAVEN/RAVEN link in the box on the left.
  • The MDS 3.0 public frequency reports will be posted in the near future.
  • The MDS 3.0 QM reports are temporarily unavailable. CMS is working to fix this issue, and hopes to have the reports available within the next few days.
  • The March 2012 SNF clarification memo has been posted to the SNF PPS website. It is currently under the title Clarifications to March 2012 National Provider Conference Presentation (V1.1) and is listed under “FY2012 RUG-IV Education and Training”.
  • The RAI User’s Manual, effective April, has been moved from the MDS Training page and is located on the MDS 3.0 RAI Manual page. The Training page will only hold upcoming versions that are not active. Previous versions of the RAI User’s Manual are available at the MDS 3.0 Archive page.
  • Errata documents will also be posted to the MDS 3.0 RAI Manual page. CMS will be publishing V.4 of the RAI User’s Manual and will be available on the MDS 3.0 RAI Manual page once technical issues are solved with the CMS website. The most recent errata document will correct grammar issues and will address pages with updates to the RAI User’s Manual, which were presented at the MDS National Conference.
  • If you were not able to ask a question during the Q&A segment of the ODF, CMS invites you to submit your questions to the SNF ODF mailbox (

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