In early 2026, the Centers for Medicare and Medicaid Services (CMS) introduced fundamental changes to the long-stay (LS) antipsychotic quality measure (QM) that upended long-standing facility approaches. For years, long-term care facilities focused on accurate Minimum Data Set (MDS) coding during the 7-day look-back window and gradual dose reductions. But now that approach is no longer enough.

CMS has re-specified the measure to incorporate Medicare and Medicaid claims data and Medicare Advantage encounter data, creating the first hybrid MDS and claims-based nursing home QM. This change significantly alters what the data captures and, importantly, how leaders must respond.

For facility leadership, this change is not merely a documentation adjustment. It is an operational shift.

Why CMS Changed the Measure

In its June 2025 memo, QSO-25-20-NH-Revised, CMS stated that reliance on MDS data alone has led to underreporting the use of antipsychotic medication. The agency noted concern that the measure did not capture antipsychotics prescribed outside the 7-day look-back window and that providers potentially overused exclusion diagnoses. By incorporating claims and encounter data, CMS intends to reflect medication use across the resident’s stay, not just during a single assessment window. The memo asserted that the change would result in improved accuracy of the measure.

Because this measure feeds into publicly reported data on Care Compare and contributes to the Five-Star Quality Rating System, even modest increases can directly affect a facility’s public profile and referral patterns.

What the Measure Now Captures

Under the prior measure, a resident triggered only if an antipsychotic was coded on the MDS during the 7-day look-back period. Under the revised measure, in addition to the trigger related to MDS coding, a resident will trigger if a pharmacy claim or claim for a physician-administered antipsychotic occurred during the target period (i.e., that calendar quarter).

In the past, the only exclusions were for a diagnosis coded on the MDS of schizophrenia, Tourette’s syndrome, or Huntington’s disease. Although these three conditions are still used in the revised version, the resident is only excluded if the diagnosis is supported by both MDS coding and claim data during specific exclusion periods. The revised measure has also expanded the exclusion criteria to consider Medicare and Medicaid enrollment and hospice claims data.

Leadership Strategies

Use Medication Reconciliation

High-risk times during a resident’s stay occur when medications change, especially during transitions of care. When a resident returns from a brief hospital stay or emergency department visit, a new medication may have been ordered. This scenario prompts the pharmacy to fill the medication prescription, possibly antipsychotics, before the facility has an opportunity to discontinue any unnecessary medications. Thus, the facility team needs to establish a process for medication reconciliation, either right before the resident returns to the facility or, at a minimum, immediately upon returning. This new routine requires strong coordination among nursing, providers, pharmacy, and administration.

Understand Pharmacy Workflow

Now that pharmacy dispensing activity can impact facility outcomes, it is key to understand this process. The facility clinical team must review their pharmacy refill process with a focus on how and when antipsychotics are filled. This oversight is especially important when a resident has an order for an “as needed” medication that is not routinely provided. Ensuring protocols are followed to discontinue medications that have not been used can prevent these pharmacy fills from triggering the measure.

Allow More Time

But even when a team promptly reduces or discontinues an antipsychotic, the filled prescription during that quarter will still trigger the measure. This outcome creates a greater delay in reflecting quality improvement efforts in QM reports, and an even longer time will elapse before they appear on Care Compare. Facilities must continue real-time monitoring and quality improvement strategies while at the same time recognizing the significant (and sometimes frustrating) lag in reporting.

The Bottom Line

The revised LS antipsychotic measure carries a broader expectation that facilities must manage medication use proactively across the entire stay, not reactively at assessment time. Leaders who quickly shift the team’s focus to continuous antipsychotic reduction efforts, medication reconciliation, and effective collaboration with physicians will be positioned to achieve their quality improvement goals. The data is changing, and leadership must change with it.

Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, is a senior curriculum development specialist for AAPACN (American Association of Post-Acute Care Nursing). Previously, Jessie worked as the director of clinical reimbursement for a large long-term care organization overseeing 17 clinical reimbursement consultants across 21 states including nearly 300 living centers. She has more than 20 years of long-term care experience including restorative nurse, MDS coordinator, regional clinical reimbursement specialist, clinical reimbursement trainer, and director of clinical reimbursement. She is passionate about developing the skills of nurse assessment coordinators, restorative nursing, and improving residents’ quality of life and care.

Comments or questions? Contact Patrick Connole at pconnole@parkplacelive.com.