Dementia is one of the most common hospice diagnoses in long-term care, yet hospice referral is frequently delayed. Unlike cancer or heart failure, dementia follows a prolonged and variable trajectory, making prognosis difficult. Understanding how functional decline—not cognitive decline—determines hospice eligibility is essential for physicians and interdisciplinary teams caring for these patients.

In the 1990s, our USA immigration policy allowed skilled nursing facilities (SNFs) to sponsor healthcare workers from the Philippines and other countries. Many of these additions to our SNF team in Sonoma County rapidly advanced to leadership positions. Coming from countries whose cultures highly value older adults, the caring part of their work in SNFs enhanced our care. 

The 2024 requirements for 24/7 RN coverage and minimum hours per resident day for RNs and nurse aides were officially rescinded as of February 2, 2026. Currently, thirty-six states have some type of minimum staffing requirements. Attorneys general from eighteen states are asking CMS to consider a new staffing rule for certain for-profit nursing homes (NHs)  demonstrating high-risk financial and ownership practices. 1

At recent Sutter meetings with SNF partners, potential transfers of patients with a first episode of Clostridioides difficile (C. diff.) with orders for the expensive antimicrobial fidaxomicin (Dificid), were sometimes slow to place for fear that insurers might only approve Vancomycin. 

PALTMed is pleased to announce the launch of a free e-learning module for medical directors and leaders of nursing homes covering the clinical trial evidence and protocols for adopting universal decolonization as a Quality Assurance and Performance Improvement (QAPI) program.

In December 2025 Issue 1 Wave, I introduced the subject of Ambient AI. This is a technology that has rapidly expanded across over 200 hospital systems in the USA that use EPIC as their electronic health records (EHR) platform and the Abridge Ambient AI app (see link). Those using this technology for their providers and staff report more focused time with patients and less time documenting encounters. The improved efficiency also translates into greater productivity for healthcare teams. 

In the age of hospitalists and electronic health records (EHRs), I’ve observed a decline in comprehensive physician assessments. I commonly see the first 3-4 sentences of the ER history of present illness (HPI) reappear verbatim in multiple provider notes. I seldom see a social or functional history, and rarely see accurate personal contact information. I observe a long list of past medical diagnoses and habits that are always documented (quality indicators linked to payment).  When a palliative care consultation is conducted, the documented focus often appears to be limited to the immediate problem. I wonder if the new generation of physicians and advanced practice practitioners providing post-acute rehab services has a similar “moment in time” focus, and wonder if there are measurable differences in patient and family satisfaction metrics or in facility outcomes. 

California is a vast, progressive state that implements innovative and often more rigorous regulations regarding the role of Medical Directors and nursing home care compared to federal standards. For Medical Directors to thrive, it is essential to grasp what sets California apart, navigate existing regulations, and comprehend the implications of forthcoming regulations—many of which could profoundly affect their daily responsibilities.