As a physician licensed in California in 1976, I remember the strike by our state’s anesthesiologists and many other physicians protesting skyrocketing malpractice insurance costs.  This protest ended with the passage of MICRA (Medical Injury Compensation Reform Act) in September 1975, which capped awards for non-economic damages (pain and suffering) at $250,000.  This has subsequently resulted in more reasonable medical liability costs in California than in many states in our country.  At the same time, it has preserved access in our state to high risk specialty care.  As a primary care internist, my rates have remained reasonable especially at a time when costs of office based medicines dramatically increased in the late 80’s and 90’s.  These high costs drove me to close my part-time office in 2005 in favor of a full time SNF/CCRC/Teaching based practice.

Recently, the California Partnership to Improve Dementia Care vetted its mission and vision statements that reflect our direction and commitment to the care processes that better support the quality of life of our residents living with dementia. We have broadened our focus from the SNF setting to include the home and community based (ALF, RCFE, CCRC, Senior Congregate living) settings. I have found the latter social care settings to be places where antipsychotics are commonly used as chemical restraints with informed consent seldom documented. In California, we have made some progress with reducing the inappropriate use of antipsychotics for our long stay nursing home residents. The National Partnership to Improve Dementia Care on 1/14/22 reported the Q2 2021 national, regional, and state percentage use of antipsychotics in long stay residents without an approved indication. Our CMS Region 9 located in San Francisco (represents Arizona, California, Hawaii, Nevada, and Pacific Territories) performed the 3rd best of the CMS Regions at 10.87%. CMS Region 10 located in Seattle (represents Alaska, Idaho, Oregon, and Washington) performed the best at 6.89%. California was ranked the 3rd best by states at 10.4% trailing only Hawaii and the District of Columbia. While most states including California have made < then 1% improvement in the past 3-4years, how is it that CMS Region 10 in Seattle, can achieve a 6.89% antipsychotic rate? What are they doing differently to achieve these impressive results?

Palliative sedation is the use of medical therapy to induce decreased awareness to relieve severe and refractory symptoms (1). A recent case I had involved the use of antipsychotics to the point of palliative sedation for refractory symptoms in a non terminally ill patient.

CALTCM members may recall that for several years, Dr. Charlene Harrington and her team at University of California, San Francisco published a website, CalQualityCare that compared California nursing homes and other long-term care organizations on quality of care including information such as staffing, organizational characteristics, and deficiencies and fines.  In 2016 the website lost its funding and had to shut down. 

In October 2021, palliative medicine heavyweights Drs. Sean Morrison, Diane Meier, and Bob Arnold published a Viewpoint piece in JAMA Network with the provocative title, “What’s Wrong With Advance Care Planning?” https://jamanetwork.com/journals/jama/article-abstract/2785148  Dr. Morrison has published and presented in multiple venues on this topic for the past couple of years, repeatedly ACP-bashing and comparing advance care planning to your family’s “old Pinto,” that you keep pumping money into for repairs even when it’s clear the car is all washed up and beyond repair.  The motivation for these apparent attacks on ACP seems to stem mostly from frustration that millions of dollars of research funding have been spent on ACP research, despite the somewhat disappointing results of many of these studies.  No doubt some of our WAVE readers will remember this article, and I encourage those who haven’t read it to actually read the short article, and especially read the excellent comments several people have appended to the site. 

Forgiveness is a word with many emotions, definitions, and actions.  Webster defines forgiveness as “to cease to feel resentment against” – a conscious, deliberate decision to release feelings of resentment or vengeance toward a person or group who has harmed you regardless of whether they actively deserve forgiveness. 

As we move into 2022, CALTCM would like to thank its members and partners for their support for a highly successful past year. 

Those of us who care for vulnerable older adults who live in congregate settings are all 

Once it dawned on us that a pandemic was underway, those of us involved in geriatric care knew that long-term care facilities were going to be in trouble.  And yes, we knew that the usual racial and socioeconomic disparities in outcomes would appear.  But we didn’t know exactly how much trouble, nor did we know exactly how the disparities would play out.  At least for my county of Alameda, for the pre-vaccination phase of the pandemic, we now have answers.

Empathy, like dignity, can be difficult to define but its absence is felt profoundly. Residents, families and co-workers can feel when they are not being treated with empathy. Tapping into the feelings and needs of others is certainly what called many of us to the helping professions.

During the current Omicron surge, COVID-19 vaccines (primary series and boosters) are an essential way for our communities to stay healthy. We would like to share COVID-19 vaccine resources for long-term care facilities (LTCFs) and your members. 

We are in our fifth COVID surge, and my head is spinning with the rapidly evolving federal, state, and local guidance.  Wouldn’t it be nice to visit a platform that tracks all the guidance in a convenient location?  

Two years ago, I retired from an internal medicine practice in the SNF setting with emphasis on Medical Direction, Geriatrics, and Palliative Care.  Last month, I worked 3 weeks providing vacation relief and noticed how “depersonalized” the medical records have become at the acute hospital and SNF levels.  I suspect this is a reflection of our adaptation to EHRs and the perceived need for providers to become more time-efficient.  One of the things I reintroduced into these facilities was the value of the patient’s story.  This is fundamental to establishing working relationships with our patients and their families.  The story is also fundamental to the diagnostic process and leads us away from prescribing more drugs for new symptoms to a more-cost effective and better understanding of the potential causes of the patient’s symptoms.  

Assisting others who are less fortunate, emotionally, socioeconomically, or in poor health, can help change own our perspective to feel more positive.¹ There is literature that suggests, helping others can change brain chemicals leading to more happiness.^1,2 Furthermore, face-to-face volunteering, for example, lending a helping hand at a food bank or church can help reduce loneliness, isolation and can improve social and support networks.^1,3

In my community, our traditional source of providers for caring for our SNF patients has been dwindling for the past several decades as private physicians and new graduates moved into outpatient practices through hospital medical foundations.  Occasionally, older physicians have left their office practice or their foundation employer for the lower cost and flexibility of a dedicated PA/LTC practice.  However, that requires good business skills to navigate the various insurance contracts, on-call support, billing service, EHR platforms, MIPS reporting options, and triage of calls/faxes/texts from various facilities.  As I look at my community, I foresee this workforce of providers continuing to dwindle.  

Life purpose not only means different things to different people, but it also means different things to each person as we progress through the stages and events of our lives. On the formal side, Hill et al., (2010) identified four main types of life purpose as follows:

In 2018, AB 2789, the mandatory provider e-prescribing law for California, was designed to coincide with the new Medicare EPCS (Electronic Prescribing of Controlled Substances) requirement that was to go live nationally at the start of 2022.  AB 2789 goes live January 1, 2022 and extends the EPCS expectations from controlled substance to all prescriber and dispenser prescriptions with very few exemptions possible.  The CMA posted a helpful article on this subject on October 5 (link provided below).

At this year’s annual Summit in October, Dr. Steven Poser presented important information on the distinction between Neurologic and Psychiatric causes of dementia, which I highlighted in the November 1 edition of the WAVE.  

“Now is not the time for additional ‘studies’ to assess the importance of appropriate staffing levels. The combination of inadequate staffing and disparities can only lead to more tragic situations and outcomes, such as those recently seen during the latest hurricane in Louisiana.”  Thus begins CALTCM’s “White Paper on Nursing Home Staffing.”  CALTCM is the medical voice for long term care in California.  Our public policy committee developed this White Paper with the intention of making recommendations based on evidence-based literature.  It was not our intention to debate the financial impact of our recommendations or where nursing staff will come from, given the current huge workforce shortage issues.  We stand for quality care in nursing homes. We absolutely understand many of the issues that have put nursing home care in the precarious state that the COVID-19 pandemic has tragically highlighted. Those issues need to be debated and those problems addressed, but that does not change the existing evidence.  Our White Paper presents the evidence. We’re ready and willing to have a debate over the evidence, though we think it’s more important to have a vigorous discussion on how to finance these recommendations and find the nurses and nursing assistants needed to fulfill these requirements. 

As per the definition in the dictionary, gratitude is “the quality of being thankful, readiness to show appreciation and to return kindness”. Is gratitude an emotion, an attitude, a trait, a habit? It is all that, and more, depends on who you ask.