“I Had a Dream”

by Tim Gieseke MD, CMD

Do you have a dream?  In 2007, I first became aware of an effort in California to bring the Oregon POLST Form to California.  By that time in my career, I had experienced not only the lack of palliative care in the death of my father, but I had also seen many patients and families suffer from the rampant assumption that everybody wants and benefits from aggressive medical interventions when they get sick.  At that time, I looked at the UCLA Leadership and Management course at UCLA and dreamed about implementing the POLST in Sonoma County. I attended the course in the Spring of 2008 and hit the ground running.  At the course, I further modified the project and made a crucial decision. I decided to have my mentor be Cheryl Osborne, a Professor of Nursing at Sacramento State University, rather than a physician.  She was so helpful in thinking strategically about developing a local network of key people to engage and educate the community.  I was fortunate to pair up with Susan Keller, a local community activist.  She applied for an implementation grant and together, we put together (with strong support from the Coalition for Compassionate Care of Calif) an educational curriculum for nursing homes, assisted living, and our local faith community.  This dream is still advancing today and is having an impact on care in Sonoma County and our State.

Do you have a dream?  At CALTCM, we hope you do.  We have now assumed ownership of this valuable course.  Time is running out.  Please let us help you implement your dream while advancing your leadership and management skills.

Leadership and Management in Geriatrics
by Ethan Cumbler MD, FHM, FACP
Faculty Coach, Leadership and Management in Geriatrics
Professor of Medicine from the University of Colorado, Director of the UCH ACE Unit, and founding faculty member of the Institute for Healthcare Quality, Safety, and Efficiency

Facing the challenges of a rapidly aging population, clinicians are increasingly called upon to lead and manage change.  Who better to design a better path forward in delivering high quality cost effective care that delivers exceptional outcomes than the clinicians who have been in the trenches of medicine?  Yet when the time comes to lead we often discover that the years of training in anatomy, pathology, and pharmacology that serve so well in one-on-one medicine are not enough.  Traditional education in medicine does not cover how to lead organizational transformation, analyze business opportunities, or manage in complex healthcare organizations.  To lead effectively requires a new skill set for clinicians and this calls for a new kind of training.

ASK CALTCM: August 2017


Question 1 of 3

“We have a pt. in our SNF, who came from another nursing home, who passed MBS in April 2017 while in that SNF, but S.T. evaluated pt. to still remained high risk for aspiration.

  • But pt. and family insisted on feeding pt. pureed with thickened liquids while on tube feeding, so per  their IDT only trained caregiver/family to feed pt. only.

  • When pt. was transferred to us this July, we repeated MBS which this time showed that this time he failed ALL consistencies of fluid, but family and pt. still insisting to continue feeding him.  We do not have bioethics committee in our facility. So are about to have IDT meeting with family tomorrow, to set goals and expectations.  We don't have any type of waiver form, and I was told even if we do have one, it does not release us from liability.

  • Is it then OK for trained caregiver to continue to feed him as long as they are trained (no staff member should do it since our recommendation will be NPO), while keeping the tube feeding?  If they agree for hospice care,  will that be considered as honoring pt's wishes for quality of life?

Please advise.  Will appreciate any input or advice regarding this issue, since we have a scheduled IDT meeting tomorrow with this family & pt. BTW pt. still has capacity to make his decisions.   Thanks in advance."

Update California Dementia Partnership

by Tim Gieseke MD, CMD

California has an active collaboration involving multiple stakeholders focused on improving the quality of care provided for persons with dementia living in the SNF setting.  Key stakeholders are Health Services Advisory Group (HSAG (Health Services Advisory Group), California Department of Public Health (CDPH), and the California Culture Change Coalition (CCCC), among others.  You can find helpful resources for professionals and consumers at .  The Centers for Medicare and Medicaid Services ( CMS) has provided the Hand in Hand tool kit for CNA training.  Other valuable quality improvement resources include: www.nursinghometoolkit.com ,, and  These resources emphasize non-pharmacologic approaches for improving the quality of life while minimizing or preventing problem behaviors in persons with dementia.

The Use of Renally-Dosed Medications on Beers List in Elderly Living in a SNF
Poster Winner - 3rd Place
by Meline Toutikian, Pharm.D. Candidate 1,2, Mariam Khachatryan, Pharm.D.1,2, Robert Shmaeff, RPh2,Rick Smith, MD2, Janice Hoffman, Pharm.D., CGP, FASCP1

Background: In long-term care facilities, there is often inappropriate dosing of renally-dosed medications (Sönnerstam, 2017). The Beers Criteria highlights potentially dangerous medications that require reduced dosing in renal impairment to reduce the risk of toxicities. The goal of this project was to identify residents on renally-dosed medications with doses higher than recommended in the elderly living within a Skilled Nursing Facility (SNF) and raise awareness to prescribers. Secondary outcomes include whether a dose reduction was attempted and whether medications were discontinued.

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