Good News! AB 937 Will Not Go to Senate in 2017
by Karl Steinberg MD CMD HMDC
CALTCM President-Elect 

Last week, CALTCM received good news in the form of a decision by Assembly Member Susan Eggman to convert AB 937 (covered in the Wave last month, click here to view article) to a two-year bill.  This bill, which would have created additional complexity to medical decision-making around end-of-life issues, and would undoubtedly impair decisionally incapacitated patients’ ability to receive orders for treatment concordant with their wishes based on surrogates’ representations, was supported by attorneys including Bar Association groups and California Advocates for Nursing Home Reform (CANHR).  The only organizations opposed to this legislation were the Coalition for Compassionate Care of California (CCCC) and CALTCM.

Predictors of Hospital Readmission for Patients Post-SNF discharged to Homes and Residential Care Facilities in a Post-Acute Care Setting
by Andrew Wang M.D., Alex Wang B.S., Austin Wang B.A., Parag Agnihotri M.D.
Sharp Extended Care, Sharp Health Care. Arbor Hills Skilled Nursing Rehabilitation Center, Generations Health Care

Second Place Poster Winner 


Post-SNF 30-day hospital readmissions are more likely to occur in male, cognitively impaired, lower-functioning patients.  Allen Cognitive Level placemat test is a useful tool to stratify patients of higher risk for readmission. Caregiver guides for patients at different impairment levels can facilitate home health care in various aspects of activities of daily living.  Further testing is required to validate the effect. 

Diagnosing and Treating Depression in the Elderly

by Vanessa Mandal, MD

The IOM (Institute of Medicine), now called the National Academy of Medicine, defines patient-centered care as: “Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.”1This principle can be applied to the management of depression in geriatrics. Dr. Jay Luxenberg gave a comprehensive overview of diagnosing depression and subsyndromal depression in the elderly, with focus on DSM-V criteria and applicable ICD-10 diagnostic codes.

Not all post-acute and long-term care facilities have consulting psychiatry services available on-site. It is incumbent on physicians to develop competence in diagnosing depression and differentiating from grief reactions and social isolation. The PHQ-9 is a valuable tool and is already included in all nursing homes’ Minimum Data Set information.

Pharmacist-led Antibiotic Stewardship Program at a Nursing Home
1st Place Winner - 2017 CALTCM Poster Session 
by Mariam Khachatryan, Pharm.D.
PGY-1 Pharmacy Resident

Urinary Tract Infections (UTIs) are among the most commonly treated infections in long-term care, accounting for 30-40% of all infections treated. It is important to note also, that about 50% of women and up to 40% of men have asymptomatic bacteriuria. Although challenging, it is crucial to differentiate between symptomatic UTIs and asymptomatic bacteriuria because while symptomatic UTI requires treatment with antibiotics, asymptomatic bacteriuria does not. The overuse of antibiotics in nursing homes not only increases side effects and costs, but also increases resistance to the antibiotics. As of January 2017, SB 361 has required that all nursing facilities implement an antibiotic stewardship program (ASP). Los Angeles Jewish Home for the Aging (LAJHA), the facility at which this research was conducted, has implemented ASP as of September 2016 and with the current program in place, pharmacists are able to review and make recommendations regarding the choice of antibiotic, the dose or possible discontinuation based on IDA criteria, the facility antibiogram, patient allergies, as well as culture and sensitivity results.

CALTCM Opposes AB 937 (Eggman)

by Karl Steinberg, MD, CMD, HMDC

Although CALTCM generally does not take positions on most pending legislation, our Board of Directors felt that AB 937 was sufficiently disturbing to warrant formal opposition to this bill, which if passed would make it more difficult to change a patient’s orders regarding intensity of treatment as their medical condition and prognosis changes.  The text of the bill is available online, click here.

This bill is being sponsored by the Bar Association, and the reasoning behind it is that under current law, if there is a conflict between two documents regarding resuscitative treatment, the more recent of the two takes precedence, which allows a “legally recognized healthcare decisionmaker” (LRHCDM) to change orders—which can be used to do something that might be against the patient’s own expressed wishes.  From a practical standpoint, current law makes sense, since the more current document is based on what has happened medically, and on whatever the patient may have said in the interval between the two documents—not based on whatever the patient wanted in the past when their situation was different.  In some cases, an advance directive may be executed years or even decades earlier, when a person is healthy and may desire aggressive treatments—then the document is never changed.  Unfortunately, if this law were passed, it would not allow any person not explicitly named as an agent with power of attorney for health care to make decisions on the patient’s behalf—even a spouse.  Treatment decisions would default to the last order or expression of wishes the patient made when they had decision-making capacity.

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