The data released in June by the Centers for Medicare & Medicaid Services (CMS), show that nursing home residents in Connecticut, many with dementia, are still more likely to be given antipsychotics than their counterparts in 31 other states. But the state’s usage has fallen in the last 4 ½ years at a greater rate than the average drop of 27 percent, and it is now about the same as the national average — 17.4 percent. That’s down from 26 percent in 2011.

CMS has been working with states for the past five years to address the overuse of antipsychotic medications in nursing homes. While the drugs are an important treatment for patients with certain mental health conditions, such as schizophrenia, they have potentially fatal side effects when used in elderly patients with dementia. Still, some nursing homes use the drugs “off-label” to calm residents who are agitated or confused.

In Connecticut, Ann Spenard, a vice president of Qualidigm, the state’s Medicare quality improvement consultant, said a statewide effort led by Qualidigm — the Partnership to Improve Dementia Care, part of a national program – has helped to train nursing home staff in alternatives to antipsychotics, while also educating families about how to ask questions about a resident’s medications.

Two behavioral health agencies – MedOptions and Harvest Healthcare – have provided targeted help to nursing homes with high prescribing rates, she said.

In addition, some homes have put in place “music and memory” programs, funded by the Connecticut Department of Public Health, that have been found to help with agitation and other behavioral health issues related to dementia.

“There’s been a lot of work to reduce (antipsychotic prescribing), and it continues to grow,” said Spenard, who compared the state’s progress to past efforts that reduced the use of physical restraints. “It takes years of purposeful intervention. (But) there’s a real commitment by the long-term care industry to get the rates down.”

The most recent Medicare data show that 35 of the state’s 227 nursing homes, or about 15 percent overall, have antipsychotic use rates for long-stay residents at or exceeding 25 percent, meaning one in four residents is being given the drugs for unapproved reasons.

Meanwhile, 23 homes have antipsychotic use rates of less than 10 percent. Four have rates under 5 percent: Touchpoints at Bloomfield, Hughes Health & Rehabilitation in West Hartford, Pilgrim Manor in Cromwell, and Curtis Home – St. Elizabeth Center in Meriden.

At Touchpoints, administrator Jaime Faucher attributed the low rate of antipsychotic use to the home’s “evolving range of services,” especially post-acute and rehabilitative care.

“When a short-term resident comes into the facility with a prescribed antipsychotic medication, our treatment team often finds these medications are unnecessary and unsupported with a diagnosis,” Faucher said.

He said the staff of Touchpoints receives ongoing training in non-pharmacological interventions and individualized recreation activities and makes use of the “music and memory” programming.

Nursing homes were required to start publicly reporting their use of antipsychotics in 2012 – a requirement that advocates of Medicare transparency say has helped to bring down rates.

CMS, working with providers and advocacy groups, had set a goal of a 25-percent reduction in antipsychotic use among long-stay residents by the end of 2015. The new report says that goal was met, and it singles out Utah and Vermont for the most significant reductions (41.7 percent and 36.1 percent, respectively).

Hawaii, Wyoming and New Jersey now have the lowest usage rates, while Louisiana, Illinois and Mississippi have the highest.

Among New England states, Vermont has the lowest prevalence rate (16.2 percent), while Massachusetts has the highest (18.9 percent).

Other CMS data show that Connecticut has a relatively high rate nationally in terms of the number of days that nursing home residents received antipsychotics over a snapshot seven-day period. More than 20 percent of residents received the drugs for the full seven days – a higher rate than 38 other states, according to the data.

Spenard said Qualidigm, elder care providers and state officials are committed to further reducing Connecticut’s rate of antipsychotic usage – although she added, “We don’t really know what the appropriate rate is… There will always be some people who need the medications,” which are approved to treat schizophrenia, Huntington’s disease and select other illnesses.

The CMS report notes a slight increase in the percentage of nursing home residents nationally diagnosed with schizophrenia. The report says the agency is exploring potential consequences of the crackdown on antipsychotics, including “prescribing shifts… to anxiolytics or sedative/hypnotics.”

The data, released Friday by the Centers for Medicare & Medicaid Services (CMS), show that nursing home residents in Connecticut – many with dementia — are still more likely to be given antipsychotics than their counterparts in 33 other states. But the state’s usage rate has declined more than the national average drop of 17.1 percent.

“While quality improvement in the area of reducing off-label antipsychotic drug usage needs to be an ongoing effort, Connecticut’s skilled nursing facilities have achieved very positive change,” said Matt Barrett, executive vice president of the Connecticut Association of Health Care Facilities, which represents nursing homes. He said the state’s homes are making ongoing changes in “behavioral and health care practice” to further reduce reliance on antipsychotics.

Antipsychotic drugs are an important treatment for patients with certain mental health conditions, such as schizophrenia. But the Food and Drug Administration has warned that the drugs have potentially fatal side effects when used in elderly patients with dementia. Still, nursing homes use the drugs “off-label” to calm patients who are agitated or confused.

Concerned about the drugs’ overuse, federal regulators in 2012 announced a national initiative to slash their inappropriate use in nursing homes, with a goal of a 15 percent reduction by the end of 2012. That goal wasn’t met until the end of 2013.

On Friday, CMS – working with a coalition of providers and advocacy groups — set new goals of a 25 percent reduction by the end of 2015, and a 30 percent reduction by the end of 2016, compared to the baseline 2011 rate.

“We know that many of the diagnoses in nursing home residents do not merit antipsychotics, but they were being used anyway,” said Dr. Patrick Conway, CMS’ deputy administrator for innovation and quality and chief medical officer.

He said CMS has set “ ambitious goals” to reduce antipsychotic prescribing “because there are, for many people with dementia, behavioral and other approaches to provide this care more effectively and safely.”

In Connecticut, health care groups have formed a coalition — coordinated by Qualidigm, a Medicare quality-improvement organization — to improve dementia care and reduce antipsychotic use. The group is working to educate providers about the risks of using antipsychotics and the benefits of alternative, personalized interventions for dementia patients.

Ann Spenard, vice president of program operations for Qualidigm, said the state’s nursing homes are “heading in the right direction…

“Our focus is, and will continue to be, helping nursing homes to understand what drives behaviors and developing detailed care plans to help prevent or reduce the use of antipsychotic medications,” she said.

Connecticut’s rate of antipsychotic use is the second highest in New England, just after Massachusetts, the new data show. All other New England states saw higher declines than Connecticut over the last 21 months, including Maine, which cut its rate by 31.9 percent, and Rhode Island, where the rate dropped by 29.7 percent.

But nationally, some states, including Nebraska and Illinois, have seen only single-digit percentage declines.

Overall, the prevalence of antipsychotic use among long-stay nursing home residents is now 19.8 percent – down from 23.8 percent in 2011.

CMS officials said that while their focus is on antipsychotic medications, they also are reviewing prescribing rates of sedatives and anxiolytics, to make sure nursing homes do not just replace antipsychotics with other sedating drugs.

The percentage of patients receiving antipsychotics in the state’s nursing homes fell from 25.72 percent in early 2011 to 22.38 percent this year, according to new data from the Centers for Medicare & Medicaid Services (CMS). The state now ranks the 18^th highest in the country in antipsychotic use – down from 16^th highest in 2011, and no longer ranked among the top four states, as it was from 2005-10.

Antipsychotic drugs are an important treatment for patients with certain mental health conditions, such as schizophrenia. But the Food and Drug Administration has warned that the drugs have potentially fatal side effects when used in elderly patients with dementia. Still, nursing homes use the drugs “off-label” to calm patients who are agitated or confused.

Concerned about the drugs’ overuse, federal regulators last year announced a national initiative to slash their inappropriate use in nursing homes, with a goal of a 15-percent reduction by the end of 2012.

Nationally, antipsychotic use dropped 9 percent – short of the goal – to an average of 21.7 percent. But CMS touts the drop as evidence that many nursing homes are pursuing more patient-centered treatment for dementia, such as behavioral interventions.

Eleven states hit or exceeded the 15-percent target, including Maine, North Carolina, Rhode Island and Vermont. Some of those states have made antipsychotic reduction a priority.

In Connecticut, health care groups have formed a coalition — coordinated by Qualidigm, a Medicare quality-improvement organization — to improve dementia care and reduce antipsychotic use. The group is working to educate nursing home providers about the risks of using antipsychotics to treat dementia-related behaviors and to offer alternative interventions.

New data shows that some Connecticut nursing homes have made progress in reducing the drugs’ inappropriate use, while other homes remain at higher-than-average levels. In more than 10 percent of homes, at least one-third of residents are receiving antipsychotics, with usage rates as high as 67 percent.

More than half of Connecticut homes were dispensing antipsychotics at rates exceeding the national average. Only a small fraction of homes – six of 234 – had rates below 10 percent.

At Bishop Wicke Health Center in Shelton, antipsychotic prescribing has fallen below 15 percent in the last two years — due largely to training and a “team approach” to reducing use of the drugs, said the home’s administrator, Debra Samorajczyk.

Bishop Wicke began reducing reliance on antipsychotics before the federal initiative began, deeming the medications “a last resort” and training staff in alternate strategies to improve dementia care, said Faith Wajdowicz, vice president of clinical services for United Methodist Homes, which owns the nursing home.

“We’ve had the same clientele, (but) this has been one of our initiatives,” Wajdowicz said. “We do a lot of behavioral interventions and activities at the facility” to reduce residents’ distress, without medication. “It’s been a real team effort.”

At Hughes Health & Rehabilitation in West Hartford, staff members were trained using a “toolkit” of methods to care for residents with dementia. The kit was developed by University of Massachusetts Medical School researchers, in partnership with Qualidigm, and eventually will be disseminated nationally. Hughes Health singled out certain patients for antipsychotic reductions and worked with family members. Its antipsychotic rate dropped to 17.2 percent in 2012 and 6.7 percent in the most recent reporting.

Some Connecticut homes that had above-average prescribing in 2011 reported significantly lower rates. Grove Manor Nursing Home in Waterbury, for example, now has an antipsychotic use rate of 38.8 percent, down from 58.7 percent. But others have not seen a reduction: the Westside Care Center in Manchester continued to have the state’s highest percentage of residents receiving antipsychotics – 66.8 percent, down just slightly from 68 percent in 2011.

Ann Spenard, vice president of Qualidigm, said there were numerous staff training efforts underway in Connecticut to reduce antipsychotic use, and she was optimistic that the state would hit the 15-percent reduction goal by the end of the year. She noted that Connecticut nursing homes reduced the use of restraints from 12.24 percent of residents in 2002, to just 1.3 percent today.

“There’s a full-court press in the state to help all of the long-term care facilities focus on behavioral interventions,” rather than antipsychotic medications, she said. “I’m confident we will continue this trend until we bottom out. We’re really pleased that the industry has embraced this.”

Spenard said state providers have a growing understanding that antipsychotics have “minimal efficacy” in the treatment of psychological symptoms of dementia. She noted that antipsychotics were “the standard of care for a long time. Changing practice takes time.”

Other states that have made significant progress have undertaken training programs that teach nursing home workers alternatives to drugs.

In North Carolina, for example, the Carolinas Center for Medical Excellence partnered with the state ombudsman program to train 205 nursing home leaders in patient-centered care practices, such as consistent assignment of nurses’ aides, and to educate physicians about reducing antipsychotic use. A subset of facilities that received onsite training and monitoring reduced antipsychotic medications by 66 percent, according to the American Health Quality Association.

Federal regulations now mandate that nursing home residents not be started on antipsychotics unless they have specific diagnoses of psychosis or related conditions, and that facilities make gradual dose reductions for those already receiving the drugs.

For information on Connecticut’s nursing homes go to C-HIT’s updated database.

Since then, that core training has been adapted for use in other professions, including the military, firefighting and medicine.

Now, health professionals in Connecticut have taken those basic lessons and drafted a training protocol for yet another high-risk setting: Nursing homes. The authors of the program, called TeamSTEPPS for Long-Term Care, say the simple training can save lives and money. They plan to pilot the program in Connecticut in the fall and promote it nationally.

“This is the first time we have an evidence-based team training for long-term care,” said Ann Spenard, vice president of operations for Qualidigm, Connecticut’s Medicare quality improvement organization, which developed the nursing home protocol.

“We know communication is a major issue in errors – that people tend to work in silos,” she said. “We think if we can help to change that culture, there’s an opportunity to improve patient safety in nursing homes.”

The nursing home training, which emphasizes a team approach and shared responsibility for care, is a spinoff of a similar program that has been widely used in hospitals, in Connecticut and nationally. Preliminary data from evaluations of the hospital program shows that the training can lead to a reduction in errors such as adverse drug reactions, which dropped from a rate of 30 to 18 per 1,000 patient days in some hospitals studied.

Hospitals that adopted the program also saw declines in the length of patient stays in the ICU — down from a mean of 2.2 days to 1.1 days; nursing turnover in the operating room, which declined by 16 percent; and errors in medication reconciliation at patient discharge, which were reduced from 47 percent to 11 percent.

About half of the state’s hospitals have received some training in the protocol, Spenard said. At Griffin Hospital in Derby, 18 of the hospital’s units, including the operating room, the childbirth center and the ICU, have adopted TeamSTEPPS, and the new approach is paying off, said Kathleen Martin, Griffin’s vice president of patient safety and care improvement.

Many departments have morning “huddles” to discuss care plans, and operating room teams take a “time-out” before they start a procedure to verify the correct patient, correct procedure and correct site of the surgery.

In health care, “everyone tends to be on their own planes,” Martin said. “We’re trying to standardize how we communicate – to develop a common language throughout the house . . . It’s also about empowering staff to speak up when they have a concern.”

TeamSTEPPS, originally developed by the Department of Defense and the Agency for Healthcare Research and Quality (AHRQ), has been adopted in a variety of settings, including military combat-support hospitals and universities. The training clarifies roles, encourages cross-monitoring by staff, and lays out strategies to ensure that employees at every level can communicate concerns effectively.

Spenard noted that because lower-level staff shoulder considerable responsibility in nursing homes, a strictly hierarchical approach can be dangerous. Under TeamSTEPPS, a nurse’s aide who notices a lapse in care, for example, would be directed to report that problem up the chain, under a “two-challenge rule” that encourages workers to voice a concern at least twice, to make sure it is acknowledged. Employees also are empowered to “stop the line” of care if they see a safety breach.

In one case that Martin recounted, at Griffin’s childbirth center, a nurse who noticed a lapse during a delivery was reluctant to communicate the problem to the physician because the patient’s husband was in the room. So the hospital developed certain “code words” that childbirth staff can use to convey concerns without worrying patients and family members, Martin said.

“We tweak the training as we need to. It’s a strategy that can be adapted,” she said.

Besides reducing risks, the training program can save money by reducing staff turnover and clarifying responsibilities, Spenard and Qualidigm President Timothy Elwell said. Those issues are important in long-term care settings.

“The main thrust of this is to improve patient safety, but there are some clear derivative benefits, in terms of costs,” Elwell said.

TeamSTEPPS is the latest of many attempts to try to reduce medical errors in high-risk settings. The defense department’s patient safety program came up with the training in 2006, in response to a landmark report by the Institute of Medicine in 1999 that found that almost 100,000 deaths a year were caused by preventable medical errors. Qualidigm and Abt Associates, Inc., worked with AHRQ for two years on the long-term care version.

In Connecticut, nursing homes are most often cited for lapses in care that lead to patient injury, such as pressure ulcers, lack of fall-prevention strategies and mistakes in medication or treatment. At least five citations in the past year have involved residents choking to death on food, in some cases because of negligent supervision by staff.

Spenard said Qualidigm is hoping to identify a Connecticut nursing home willing to pilot the new program in the fall. The program also is available nationwide to any long-term care facilities that want to be trained. (For program details click here.)

“It’s worked in hospitals – it could be used in assisted living and other continuing care communities,” Spenard said.

“We’re going to start to beat the drum and get the word out.”

“The CNAs were so afraid they were going to get in trouble if a patient fell,” Bolella recalled. “It took us almost a year to remove 33 alarms. I eventually had to lock up the alarms, so the staff would stop using them.”

In the two years that the nursing home has stopped using both alarms and restraints, it has seen a decline in the number of falls. Bolella isn’t surprised: “I never felt the alarms were effective.”

Kimberly Hall South is among a handful of nursing homes in Connecticut that have gone “alarm-free,” meaning residents at risk of injury, usually from falls, are no longer outfitted with detectors on their mattresses, chair pads and clothing that emit a warning signal when they try to get up and move around.

Alarms became a mainstay of the nursing home industry after the federal government cracked down on the use of physical restraints in the early 1990s. While most nursing homes still use alarms, in part to protect against state and federal penalties for inadequate fall-prevention measures, the move towards alarm-free facilities is growing in Connecticut, long-term care experts say.

“I think we have to ask, ‘What is the evidence base for the use of alarms to prevent falls and injuries?’ There really is none,” said Ann Spenard, a geriatrics specialist and vice president of operations for Qualidigm, the state’s Medicare quality-improvement agency, which convened a meeting on the topic this month. “They tell us a person’s probably already on the floor, or moving . . . While we’ve gone (away) from restraints, we’ve moved to the crutch of the alarm.”

The use of physical restraints in nursing homes has dropped dramatically in the past decade, with 121 of Connecticut’s 233 homes now restraint-free, Spenard said. Qualidigm is surveying homes to try to gauge how many have eliminated alarms, but Spenard said she believes it’s only a handful, to date.

That could change, as anecdotal evidence begins to show improvements in the rate of falls after eliminating alarms, Spenard said. According to one case study, at the Jewish Rehabilitation Center for the North Shore, in Massachusetts, the number of falls dropped 32 percent below the average quarterly fall rate after alarms were removed from a 45-bed unit.

Similarly, at Cheshire House Nursing and Rehabilitation Center in Waterbury, administrator Joanne Gorenstein reported a 15-percent decrease in falls after the home eliminated alarms more than a year ago. She said her decision to go alarm-free was prompted, in part, by an incident in which multiple alarms were sounding simultaneously, and “we were all running around, colliding with each other.”

Administrators of homes where alarms have been removed said that while the move requires new ways of monitoring at-risk patients, it also lowers anxiety for residents, especially those with cognitive problems, and for staff.

At Glendale Center in Naugatuck, long-term unit manager Doreen Lloret reported that patients in a 30-bed dementia unit who were agitated and restless are “much calmer” since the alarms were removed.

At Bethel Health Care Center, administrators asked residents how they felt about alarms before deciding to remove them.

“They find them intrusive. They say there’s a loss of dignity, “said Diane Judson, director of nursing at Bethel.

Spenard said that while it’s difficult for staff to deal with the cacophony of alarms, “Can you imagine if you can’t process all this information and distill it, how agitating it can be?” She noted that alarms in nursing home settings are counterintuitive.

“Alarms in real life tell us to take action. In the nursing home, they tell the resident not to move,” she said.

A study last year in the Annals of Internal Medicine that was based at a Tennessee hospital found that alarms did not statistically reduce fall rates. Spenard said there is also some evidence indicating that alarms may contribute to falls, because they disrupt residents’ sleep, making them tired and unsteady the next day.

But other experts say alarms are an important fall-prevention measure, especially for residents with dementia or poor safety awareness who may try to get out of bed at night unsupervised. The alarms remind the residents that they should not move, while also summoning staff to assist.

According to data from the U.S. Centers for Disease Control and Prevention, about 1,800 elderly nursing home residents die each year from injuries sustained in falls. Thousands more suffer serious injuries, such as broken hips. In Connecticut, nursing homes overall report that 3.1 percent of long-stay residents experience one or more falls with major injury, slightly lower than the national average.

Spenard and home administrators stressed the need for other interventions to prevent falls, if alarms are eliminated. They include frequent rounding, or checks, on residents who are at risk of falls; detailed assessments of residents’ needs, to identify when and why they get up and try to walk, including their toileting needs; and consistent assignments of nursing staff to particular patients.

“The whole thing is being proactive, not being reactive,” said Lloret. She said consistent assignments allow caregivers to get to know a resident’s schedule and “anticipate their needs.”

Some of the alarm-free homes have CNAs stationed in hallways or checking on high-risk patients at least once an hour. Spenard said understanding the underlying reasons why a resident might become agitated and restless – boredom or pain, for example — is critical, so that a care plan can be developed that might include music, activities or exercise.

Administrators of alarm-free homes said they educated families about the change and encountered little resistance. The buy-in from staff members was harder because of fears that falls would be blamed on them. Because the state Department of Public Health cites homes for lapses in care that lead to falls, removing alarms carries the risk of penalties.

Despite those risks, “It really is a sense of relief for your staff,” said Gorenstein. While nursing staff must be more diligent in monitoring patients, they no longer have to spend time adjusting and checking alarms. She said state inspectors have been supportive of an alarm-free environment, as long as other fall-prevention strategies are in place.

Lloret said the changes in residents’ moods are worth the risk. With alarms, residents were constantly being told to stop moving – not only by workers, but by fellow patients.

“How many times have you heard your staff say, ‘Charlie, sit down!’” she recounted at the recent meeting to discuss the use of restraints and alarms.

“Now, I want them to say, ‘Charlie, why are you standing? What do you need?’”

At the same time, Westside has the state’s highest percentage of residents who receive antipsychotic drugs, even though they do not have a psychosis or related condition that regulators say warrants their use. Federal data shows 68 percent of Westside long-stay residents were receiving the drugs – more than double the state’s average of 26 percent, which already ranks in the top-third of states nationally.

A C-HIT review of federal nursing home data from December found that Westside is not alone: High antipsychotic use, considered dangerous and unnecessary in many cases, does not impact quality ratings of nursing homes, and is often unknown to consumers selecting a home. In three-dozen Connecticut homes, at least a third of long-stay residents are on antipsychotics – yet nearly half of those homes have excellent overall ratings, of 4 to 5 stars. Only three have the lowest overall rating.

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In addition, the state Department of Public Health has rarely imposed more than minimal fines on nursing homes for excessive or inappropriate use of antipsychotics, inspection records show.

Antipsychotic drugs are an important treatment for patients with certain mental health conditions, such as schizophrenia. But the Food and Drug Administration has warned that the drugs have potentially fatal side effects, including the risk of infections and cardiovascular complications, when used in elderly patients with dementia. Still, nursing homes use the drugs “off-label” to calm patients who are agitated or confused.

Concerned about the drugs’ overuse, federal regulators last year announced a national initiative to slash their inappropriate use in nursing homes, saying that nearly 40 percent of residents with dementia were receiving the powerful sedatives even though they didn’t have a condition that would warrant it. A 2011 report by the US Inspector General found that 83 percent of Medicare claims for antipsychotic drugs for nursing home patients were off-label, or for unapproved conditions.

Connecticut ranked in the top four states nationally from 2005-10 in administering antipsychotics to residents without appropriate diagnoses, and was the highest or second-highest nationwide in antipsychotic use among high-risk residents, federal data shows.

Even with recent efforts to curb the drugs’ improper use, the state’s prevalence rate of unapproved antipsychotic use remains high – 25.7 percent of long-stay nursing home residents, which is higher than 34 other states. Tennessee has the highest rate, at 30.1 percent; Alaska has the lowest rate, at 12.7 percent. The national average is 23.8 percent.

In conjunction with the federal initiative, health care advocates in Connecticut have formed a coalition — coordinated by Qualidigm, a Medicare quality-improvement organization — to reduce antipsychotic use. The group is working to educate nursing home providers about the risks of using antipsychotics to treat dementia-related behaviors and to offer alternative interventions “instead of going straight to medications,” said Ann Spenard, vice president of program operations for Qualidigm.

Antipsychotics provide, at best, “minimal benefits” for behavioral and psychological symptoms of dementia, Spenard said. But in recent years, they have become a front-line treatment for agitation, aggression and other behaviors. Alternatives include consistent assignment of caregivers to patients, and behavioral interventions to eliminate anxiety “triggers” for residents, Spenard said.

“It’s a big change,” she said, noting that the drugs were widely marketed to elderly patients for dementia, despite FDA warnings. “It’s like trying to turn the Queen Mary. It’s not going to happen overnight.” But she added, “I believe the state of Connecticut will be successful” in reducing the prevalence rate.

Toby Edelman, senior policy attorney for the Center for Medicare Advocacy, said the federal government’s encouragement of alternative treatments for dementia is important, but tougher penalties for nursing homes that overuse the drugs also are needed.

“The other piece of this is stronger enforcement,” she said. “If they misuse the drugs and have to pay a $139 fine, what do they care? It’s the cost of doing business.”

A review of three years of online inspection reports shows the Connecticut Department of Public Health (DPH) routinely addresses findings that nursing homes have administered unnecessary drugs by imposing minimal fines. In only one case contained in online reports compiled by ProPublica did state inspectors characterize the violation as serious, defined as causing “harm,” and none of the violations was found to place residents in “immediate jeopardy,” the highest level of severity.

Nationally, citations against nursing homes for unnecessarily medicating patients are relatively rare: 1,213 instances in 2012, according to data from the Centers for Medicare & Medicaid Services (CMS). Of those, only 12 were classified as posing “immediate jeopardy.”

“Almost everything is considered ‘no harm,’” Edelman said. “How can improperly medicating someone, with all the risks involved, not be considered harmful?”

U.S. Health and Human Services Inspector General Daniel Levinson has proposed stronger state and federal penalties against homes that inappropriately use antipsychotics.

Wide Swings In Prevalence

The December data shows that more than half of Connecticut homes – 128 out of 233 — were dispensing antipsychotics without appropriate diagnoses at rates exceeding the national average. In addition to Westside Care Center, three homes had rates double the national average: Grove Manor Nursing Home in Waterbury (58.7 percent), Kettle Brook Care Center in East Windsor (58.4 percent), and Silver Springs Care Center in Meriden (55.4 percent). Westside, Kettle Brook and Silver Springs are all run by iCare management.

Only one in four Connecticut homes has an antipsychotic prevalence rate below 20.3 percent, the national goal proposed by CMS.

The rate of off-label prescribing swings widely – from the high of 68 percent, to a low of about 7 percent. The lowest prevalence rates as of December were at Avalon Health Care Center at Stonebridge in Mystic (6.9 percent) and Southington Care Center (10.5 percent).

Federal standards for medication safety in nursing homes are high. Regulations mandate that residents not be started on the drugs unless antipsychotic therapy is “necessary to treat a specific condition as diagnosed and documented in the clinical record.” For patients who do require antipsychotics, facilities must make gradual dose reductions and behavioral interventions in an effort to discontinue the drugs.

Administrators of nursing homes with high rates say that regulators’ rules governing the conditions warranting antipsychotics are too narrow, and that the drugs are sometimes needed to keep residents from harming themselves or others.

Janet Aliciene, administrator of Grove Manor, said the home’s off-label antipsychotic use is high because many residents have serious mental health problems. She said no resident is placed on an antipsychotic without an order from an advanced practice registered nurse, who talks with a physician.

“We do have higher numbers, but that’s because of our population,” she said.

Darryl LeCours, administrator of Westside Care, questioned the official CMS data, saying the nursing home’s “internal data reporting” showed off-label use of antipsychotics was about half of the prevalence reported by CMS, or 32.4 percent. He said the facility had significantly reduced off-label prescribing by “aggressive alternative treatments and collaboration” among medical, mental health and pharmacy staff. Also, he said, Westside residents have “a high prevalence of chronic mental illnesses.”

At Avalon Health Care, with the lowest prevalence rate in the state, staff members actively work to find alternatives for residents with behavioral problems, said Tina Lipp, the home’s MDS coordinator.

“We’re definitely not high on antipsychotics. We don’t like them,” she said. She said Avalon’s medical staff closely tracks residents’ behavior to identify and eliminate triggers that may set off agitation or depression and works to wean residents off the drugs.

Whether staffing levels are a factor in the use of sedating medications in nursing homes is a subject of debate. The Connecticut data indicates a correlation: 75 percent of the 61 homes with the lowest prevalence of antipsychotic use reported high staffing levels — 4 or 5 stars, under CMS’ five-star rating system.

Avalon and Southington Care both provided more hours of care per resident, per day, than the statewide average of 1 hour and 35 minutes of care by licensed nursing staff, and 2 hours and 27 minutes of care by certified nursing assistants (CNAs). Avalon reported 2 hours and 17 minutes of care by nurses, and 2 hours and 30 minutes of care by CNAs.

Spenard and Michelle Pandolfi, director of consulting services for Qualidigm, said there is no evidence of a direct link between staffing levels and use of antipsychotics.

“We don’t know. No one’s done that research,” Spenard said, adding that the key to effective alternatives is not just adding staff, but training them in interventions.

But Edelman said advocates believe that overmedication is “absolutely tied to insufficient staff. If there aren’t enough people, and there’s not consistent assignment, it’s much less likely that the staff are going to know the patient and know how to care for the patient. Instead, you get cases where a patient is agitated, and the nurse calls and says, ‘We need medication.’”

In some cases, nursing homes notify families when medications are added or changed; in others, families are not informed.

Paul Caron, a children’s mental health counselor, helped to form a “family council” at the New Haven nursing home where his mother and father were residents, out of frustration over a lack of information. When he learned that both of his parents were put on antidepressants, he said his questions about side effects were rebuffed. At one meeting, he said, a nursing home clinician told him, “If you have questions about the medications, you should look them up on the Internet.”

“If they don’t involve family members, they can’t get to know the patients – which is the one way they could reduce” the reliance on psychoactive drugs, he said.

Beyond The Stars

Despite the federal crackdown on off-label use, the antipsychotic rate is not factored into CMS’ complex five-star rating system, which ranks homes on indicators that include nine quality of care measures, as well as staffing levels and inspections. That means that homes with high levels of antipsychotic use may still receive high ratings on CMS’ Nursing Home Compare website, which offers information to consumers.

Twenty-five of the 36 Connecticut homes with the highest rates of antipsychotic use had high ratings on quality measures — four or five stars, signifying above-average care. Only two had the lowest rating of one star. The nine indicators used in the quality ratings include incidences of pressure sores and urinary tract infections, but not antipsychotics.

In Connecticut, as in other states, nursing homes cited for unnecessarily medicating patients or not properly monitoring antipsychotics usually face minimal fines. For example, the DPH cited Hamden Health Care Center in 2010 for failing to identify any behaviors that justified the use of antipsychotics for three residents, including one who was simply “mad at family” and “wanting to go home.” Similarly, last March, DPH inspectors cited Ledgecrest Health Care Center of Berlin for putting a resident on antipsychotics without proper justification and monitoring.

The two homes faced state fines of less than $750 each for violations including the medication lapses.

DPH spokesman William Gerrish said the agency is concerned about “the prevalence of antipsychotic medications administered to nursing home residents with no primary psychiatric diagnosis or related conditions” and supports CMS’ reduction initiative.

The DPH reviews medication use as part of its survey process, he said, and the state’s frequency of citing homes for lapses related to unnecessary drugs is higher than the regional or national averages. In addition to fines, the state requires homes to adopt corrective action plans when it finds deficiencies.

The DPH is actively participating in the Qualidigm-led coalition and sponsored a statewide training event in December that focused on initiatives to improve dementia care, Gerrish said. The coalition also is working with Connecticut’s long-term care ombudsman program to educate nursing-home resident advocates about proper medication use.

In September, U.S. Sen. Richard Blumenthal, D-Conn., and colleagues introduced a bill that aims to reduce off-label antipsychotic prescribing in nursing homes by requiring consent from family members, training staff in alternative treatments, and tightening reporting on the use of the drugs. Blumenthal called the excessive prescribing a form of “elder abuse.”

Nursing home advocates say the extensive use of antipsychotics for elderly patients was fueled by drug companies’ improper marketing of such off-label uses – a practice that the government has cracked down on in recent years.

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