There was a time not long ago when the use of marijuana was deemed completely illegal, and judged morally reprehensible by a large proportion of the population. In fact, marijuana is even now a Schedule I controlled substance per the DEA, a category that includes heroin, LSD and mescaline!  The DEA defines Schedule I drugs as having these characteristics: The drug or other substance has a high potential for abuse, it has no currently accepted medical treatment use in the U.S., and it has a lack of accepted safety for use under medical supervision.  For comparison, methamphetamine, morphine and fentanyl are Schedule II.

Second Edition: Field Operations Guide for Nursing Homes

by Patricia Bach, PsyD, RN

 

In 2017, responding to impending Medicare and Medicaid guidelines for disaster preparedness, AARP posed the very real question, "Are nursing homes ready for the next natural disaster"? Given the recent devastating fires which ravaged northern and southern California, as well as the impact of other disasters occurring around the country, this question demands even greater attention and introspection on a systemic level at this time.  

Let’s face it: sliding scale insulin (or “rescue dose”) is still very common. This is in spite of the practice being actively discouraged for years, and being listed in the “Beers Criteria” (for years) as a treatment modality to “avoid.” The reasons for this are many, but the main reasons are:

 

1.    Prescribers want an “intervention” for high blood glucose readings (>150) that doesn’t involve a phone call.

Adverse drug reactions are the 4th leading cause of death ahead of diabetes, pulmonary disease and accidents, with 350,000 events occurring annually in nursing home residents.(1) These events are potentially preventable up to 50 percent of the time and common serious manifestations include falls, orthostatic hypotension, heart failure, and delirium. The American Geriatric Society (AGS) updated Beers Criteria is a useful toolbox for physicians in addressing medication appropriateness, identifying potentially inappropriate medications and de-prescribing to reduce avoidable adverse drug events.

The Patient Driven Payment Model, or PDPM, will go into effect on October 1, 2019.  It is far and away the biggest change to hit post acute care since Prospective Payment in the 1990’s.  Anyone who was around then should recall that most of the publicly traded nursing home chains went into bankruptcy.  That could happen again!

Dr. Wing Mar invited me to join CAMD (California Association of Medical Directors, which was CALTCM’s former name) in 1985 when we met at a California Medical Association Long Term Care Committee meeting. Dr. Mar helped to establish CAMD in 1977.  For the sake of temporal context, the American Medical Directors Association (AMDA) was formed in 1976.

As the world of post-acute care continues to evolve, and we are faced with a quickly evolving landscape of new challenges, perhaps an especially unexpected (and unwelcome) one is the increasing prevalence of opioid drug use (and abuse) in our residents. This issue is one is of keen interest in the non-LTC world, so it is no surprise that it has now become a point of contention for us.

On December 4th, 2018 our dementia partnership sponsored a webinar by Dr. Maureen Nash, a nationally recognized Gero-psychiatrist who presented the PowerPoint presentation (handout provided below) on “Helping those with Serious Mental Illness who now live in a LTC setting”. She advocated for use of best practices for persons with serious mental illness who require institutional care, most commonly because of their very high risk for cognitive impairment.  CMS’s campaign to improve dementia care by reduce antipsychotics at times may seem to compromise known best practice. She recommended following the American Psychiatric Association’s free best practice guidelines for treating: Major Depressive DO, Bipoloar DO, PTSD, OCD, Schizophrenia, and dementia persons with agitation and aggression. In these guidelines, recommendations for use of antipsychotics (many have FDA approval) represent best practice even though they may not be recognized in the excluded category by the CMS campaign.  

In the October 4, 2018 issue of Diabetes Care, the ADA and EASD (European Association for the Study of Diabetes) published their consensus report for Management of Type 2 Diabetes, 2018.  Both organizations now favor the use of Incretin Receptor Agonists or SLG2 Inhibitors for persons with established macrovascular disease (or high risk for Cardiovascular Disease), for improving glycemic control, if metformin alone isn’t adequate or not appropriate.  

CALTCM Members and Friends,  As we greet 2019 with fresh ideas and educational programs, offering you the best one can offer in professional education and training for California’s post-acute and long-term care (PALTC) arena, I am proud to share with you our accomplishments in 2018.

Recently, both poor sleep and inflamed gums have been implicated in the pathophysiology of Alzheimer’s disease. But before we discuss that, I’d like to remind you of the free resource “Alzforum” – www.alzforum.org – where the latest papers and meeting presentations are presented along with active discussion by many of the leading researchers in the field. I do not know of any other field where such a central repository has been maintained over a long period of time. It’s common for colleagues, patients and even family members to ask me about “the latest breakthrough” that they hear about on the news or read about in the lay press. I find Alzforum the best place for me to get a balanced view of the research that triggered the news report.