Mark Beers created a list of PIMs (Potentially Inappropriate Medications) in older adults in the early 1990’s that became known as the Beers List. I first met Dr. Beers in about 1995 when he presented on this subject at our annual CMDA (California Medical Directors Association, the predecessor to CALTCM) CME meeting. He and his colleagues subsequently expanded this list to include potentially inappropriate meds in chronic diseases and when in combination with other drugs. These criteria unfortunately do not help the prescriber see safer or better options versus whether there may be no better option. Since Mark’s death in 2009, the American Geriatrics Society (AGS) has taken over updating the Beers Criteria with the last update in 2023. Prescribing in our SNF patient population can be difficult, as noted by the example below.

Why GDR Matters - In post-acute and long-term care, psychotropic medications such as antipsychotics, antidepressants, and benzodiazepines are common. These medications carry risks including falls, sedation, delirium, and functional decline. CMS requires us to ask regularly: Does this resident still need this medication? This is why there are several opportunities - admission, follow ups, 30-60 day visits and order reviews to re-evaluate medication appropriateness.

As a senior clinician, I am aware of the gaps in the care of older adults with serious illness. This was brought home recently when I began caring for a woman in her early 90s who was transferred to our facility for stabilization of recently decompensated heart failure, so she could have a Watchman procedure, stop her DOAC (Direct-Acting Oral Anticoagulant), and monitor a recent rectal bleeding problem. The cause of her rectal bleeding was not clear from review of the recent hospital records, and this patient and her family did not know whether her prior cancer treatment of radiation and chemotherapy was palliative or curative. She did acknowledge she was experiencing worsening incontinence with bloody diarrhea, and our nurse noticed a similar discharge from her vagina. Fortunately, I was able to reach her oncologist, who agreed this was terminal cancer. Her cardiologist agreed it was time to stop the DOAC, and she was discharged home with the support of hospice.

While nursing homes routinely review antipsychotics, opioids often receive less attention—even though they pose similar or greater risks. Oversight should be standard, especially for older adults and residents with a history of substance or alcohol use disorders.

As a healthcare provider working in post-acute and long-term care (PALTC), you are navigating one of the most rapidly evolving and challenging areas of healthcare. The 2025 CALTCM Summit for Excellence is your opportunity to step away from the daily demands of practice and reconnect with your purpose, your colleagues, and the broader vision of what excellent care can be.

In the last several years, I have seen increased requests from SNF and ALF residents and their families for more information about MAID (Medical Aid-in-Dying) in California.

In the June 2nd issue of WAVE, Dr. Geiseke wrote a thought-provoking blog titled “Are you a facilitator of agency?” Human agency is the capacity of people to have the power and resources to fulfill their potential. It reminded me of a train-the-trainer certificate I received in PHI Coaching Supervision ® ten years ago.¹ Coaching supervision is an untraditional method of supervision that emphasizes active listening, self-awareness, self-management, paraphrasing, delivering feedback, and other forms of verbal and non-verbal communication. It was specifically developed with long-term care managers and supervisors in mind. In 2021, AHCA/NCAL partnered with PHI to offer a new online training of this program for all assisted living, skilled nursing, and ID/DD staff with supervisory responsibilities.²

In 2021, the California End of Life Option Act (EOLOA) was updated with the passage of SB 380 (Blakespear), extending the sunset provision for this Act to January 1, 2031 among other revisions. The act requires healthcare facilities (including Acute Hospitals, SNFs, Hospices, and medical offices) to post a publicly visible notice on their websites and offices stating their policy with respect to the EOLOA, including if they and their employees are prohibited from participating in this Act.  All of our readers who work in skilled nursing facilities should take time to ensure that the EOLOA policy is posted on the facility’s publicly-facing website, as required by Health & Safety Code (HSC) 443.15.

Over a decade ago, Dr. Joe Ouslander and others developed the INTERACT (Interventions to Reduce Acute Care Transfers) program to help facilities recognize early clinical changes of condition that could then be managed in their facilities. 

I have often cared for people with advanced dementia syndromes or serious brain injuries, where families and staff may question if the person is still present. The GeriPal podcast, posted May 29, titled “Lucid Episodes” ( https://geripal.org/lucid-episodes-andrea-gilmore-bykovskyi-andrew-peterson/) explored the many facets of what may become of “personhood” when major cognitive impairment becomes severe and irreversible. Out of respect for the person, I have counseled families to assume the person can still appreciate their presence, touch, and verbal communication, even when no response may be evident. 

As the population of older adults continues to grow, the field of geriatric care is undergoing significant transformation. With these changes comes a pressing need for healthcare professionals—particularly pharmacists—to receive specialized training that equips them to meet the unique and complex needs of this vulnerable population.

As the model of medical care in nursing homes evolves, it’s becoming increasingly common for multiple providers to be involved in a patient’s care. Whether it’s an attending physician, one or more advanced practice providers (APPs), or a mix of both, the need for regular, effective communication is more important than ever.

“For it may safely be said, not that the habit of ready and correct observation will by itself make us useful nurses, but that without it we shall be useless with all our devotion” (Florence Nightingale, 1859/2012, p. 112)1

“Doc, I was told at the hospital that my mom has dementia. Now that she’s here, I want you to tell me; does she have Alzheimer’s disease? Can you order a scan?”

In health care, "Agency" refers to the capacity of an individual or team to make decisions and take actions that positively affect their situation or events. I recall seeing this in action in the late 1990’s when a seasoned Director of Nursing (DON), new to our area, took over this position at a skilled nursing facility (SNF) where I was the Medical Director. She had an “Open Door” policy that encouraged employees to enter and approach her with their concerns. Our employees quickly learned she was a good listener and would listen even to personal concerns that were affecting the employees’ work. She had the ability to coach an employee or a group of employees with a similar problem and then develop with them potential innovative actions that might improve the problem(s). During her time as our DON, the facility developed and sponsored scholarships for certified nursing assistants (CNAs) to go to nursing school. Our employees listened well to our patients and their families and helped them take action during the rehab process to facilitate their recovery. In a brief period, our state and federal surveys improved to the point of back-to-back deficiency-free annual surveys. Unfortunately, her husband took a job out of the area, ending her time as our model “DON.”

May’s issue of Caring for the Ages had the attached article written by Robert C. Accetto, RPh, BCGP, FASCP. The Centers for Medicare & Medicaid Services (CMS) has revised guidance to surveyors (Appendix PP, State Operations Manual) for the use of Psychotropic Medications that went live in late April 2025. This article updates us on these revisions and provides explicit guidance for adhering to the revised informed consent process and the necessary documentation that it has occurred. All boxed (“black box”) warnings must be discussed and then documented in the prescriber’s notes. 

As long-term care clinicians, we manage a complex interplay of chronic disease, cognitive decline, and frailty. But one factor consistently tied to outcomes—and often underemphasized—is nutrition. For many of our residents, poor nutrition isn't just a consequence of illness; it’s a cause of functional decline, infections, and hospitalization.

A recent PALTmed Connect recommended this website (https://qi.ipro.org/sepsis/) to assist SNFs in the early recognition and management of Sepsis. A colleague of mine recently lamented that one of her patients had done poorly because of delayed recognition of sepsis. I suspect this is a frequent problem in SNFs where we have so many new nurses and a much lower nurse-to-patient ratio than occurs in the acute hospital setting. 

I “retired” just prior to the pandemic, which flipped my script to “semi-retired.” Since 2024, I have worked maternity relief for a Program for All Inclusive Care of Elders (PACE) and since that ended, as a part time SNFist in a Continuing Care Retirement Community (CCRC) where I also will assess potential independent living residents and occasionally cover their geriatric clinic. In this capacity, I’ve reviewed medical records from Kaiser, Providence, and Sutter and am distressed by documents that are badly flawed with long lists of medical problems that aren’t accurate and misleading as well as superficial histories of the present illness that at most cover the prior 2 weeks of the patient’s illness and never document a social history. In addition, the minimalist HPI (History of Present Illness) of the ER doc is what I see cut and paste in the records of a patient’s chart by multiple providers throughout the duration of their acute hospitalization. I know that the pandemic badly stressed our health systems, but how can we provide “Care” that matters to our patients, with so little pertinent and accurate information?

Many years ago, a woman in her 80s died of a preventable upper gastrointestinal (UGI) bleed. As the facility’s Medical Director, I became involved in this case after the disaster. This resident was at our facility for rehab and a community PCP was her attending physician. The facility podiatrist diagnosed acute gouty arthritis and prescribed the nonsteroidal anti-inflammatory medication indomethacin, which at the time, was a standard treatment option. However, this woman had a history of prior peptic ulcer disease, which the PCP was aware of and would not have permitted this Rx had he been aware of it. She died about 5 days later of a massive UGI bleed. This upsetting event resulted in a policy that all new prescriptions by other providers would require the approval of an attending physician.