Dan Osterweil, MD, CMD, FACP | CALTCM President

Dear CALTCM members and friends,
It is hard to believe that another year has almost passed. Long Term Care however is an ever changing and dynamic field. We at CALTCM feel that the future may be challenging however we believe that with a collaborative effort between providers, government and the community we can overcome the hardships and deliver better service and outcomes.

As we reported in the past, CALTCM is committed to working with key stakeholders in the State on Performance Improvement Education and Training. One of our tenants has been that Performance Improvement and Quality Improvement are interlinked. We believe that it is dependent on competence to perform and on ongoing feedback that what we do is actually working to produce positive outcomes. We have set out to work with the California Association of Health Facilities (CAHF) and California Department of Public Health (CDPH) to achieve a level of trust in our approach that is hinging Performance Improvement Education, on improving knowledge, skill and competence. We are asking CDPH to include a recommendation for plan of correction that mandates training of key facility leadership members by a qualified agency such as CALTCM or one of its partners, in their survey process. We expect the CDPH to implement this as soon as possible as previously promised to us by Kathleen Bilingsley, Chief Deputy Director of Policy and Programs. This approach is consistent with the spirit of Title 22 and would help change some of the inertia related to quality improvement and make us all more accountable. This request for innovations was one of the items on the agenda of our recent meeting with the leadership of The Quality Improvement Center and Licensing at the CDPH.  In coordination with CAHF, Dr. Karl Steinberg (immediate past president and current BOD member) Rick Mendlen (CALTCM BOD member) and myself recently traveled to Sacramento and met with Pam Dickfoss, Loriann Demartini and Sue Chaban from CDPH along with Mary Jann and Jocelyn Montgomery of CAHF.

From Left to Right: Jocelyn Montgomery; Karl Steinberg, MD; Rick Mendlen; Dan Osterweil, MD; Mary Jann

Our agenda included several issues: Performance Improvement Education, enforcement activities surrounding the use of atypical antipsychotic drugs, informed consent and the role of Nurse Practitioners. We have learned that in an effort to limit use of antipsychotic medications in nursing home MediCal and CDPH have been exchanging information on potential inappropriate use of antipsychotic medications.  In order to better scrutinize use of atypical antipsychotics which cost the State of California in excess of $70 million a year, MediCal has sought assistance from CDPH licensing division.  CDPH through its licensing and survey process is able to launch a complaint investigation in each of the instances that a medication has been prescribed in a NH to a MediCal beneficiary which is "suspected" as inappropriate. In a pilot study titled "Antipsychotic Collaborative" that has been conducted in various areas. District Offices in the State they have found that in significant number of cases (62%) antipsychotic drugs use was deemed inappropriately (off label, multiple agents). They also found that in many instances (90%) these occurrences escaped the drug regimen review by the pharmacy consultant. This collaborative has also gone out to look at pharmacy consultant performance by identifying those consultants that based on their contracts and number of residents reviewed seem to provide their services below cost. That is apparently violating another Title 22 provision requiring that pharmacy consultants provide their services at fair market value. For more on this topic please see Dr. Karl Steinberg's Nov 2011 CALTCM Wave article. As part of this effort the Department of Public Health has decided to tighten enforcement using a literal interpretation of Title 22 provision that requires that a physician "shall obtain informed consent" for Atypical Antipsychotic medications. They object to the common practice involving an agent, such as another licensed professional in this process.  They have also been objecting to the common practice, involving a Nurse Practitioner or a Physician Assistant in obtaining informed consent for antipsychotics; their rationale is that prescribing antipsychotics are out the scope of their practice. According to CDPH interpretation, facilities must ensure that a physician has obtained informed consent for atypical antipsychotics before they can administer the drug. This issue has raised our concerns about potential harm to patients upon transfer from home, hospital to NH. This provision may lead to inappropriate disruption of therapies for all patients on antipsychotics as well as the logistic difficulty of obtaining informed consent upon admission since physicians are rarely present on that occasion. The department position has been that Title 22 has a provision mandating NH to accept only patients they can provide the appropriate care for, hence not being able to administer a needed medication would mean that NH cannot provide care and thus need to refuse to admit. Obviously, this position can potentially create havoc in the transition process, leaving patients in acute care setting for longer than they need to, which can potentially create a bottle neck at hospitals.

We have offered the Department of Public Health a procedure that will recognize the informed consent obtained in the acute hospital where the drug has been previously administered in the receiving Nursing Home for 72 hours until the physician's first  visit.  The department has taken this under advisement and promised to consider this after looking at the regulatory ramifications.  We have also requested that CDPH send a non binding advisory to acute care hospitals recommending transfer of documentation attesting to fact  that informed consent has  been obtained. The fact that CDPH Licensing has no statutory authority on hospitals is pointing to another gap in our "silo" system of care.

As you can see from this rreport they are many factors to consider just on these limited items. However, at the root of the dynamics between providers, the State and CMS lies the Statutory framework that guides care in California nursing homes.  The Center for Medicare and Medicaid services (CMS) has been proactive responding to the changes and dynamics of health care and changes in practice and has periodically revised and updated The State Operational Manual. The state of California needs to follow suit and develop a process to update its administrative code (Title 22) so it reflects the current standards of practice. The process the CMS have used made perfect sense. They invited stakeholder to weigh in on each of the F tags, reached consensus on the revised narrative reflecting the clinical care to date before opening it up for public comments.  From what we have learned from our brief conversation with the official in charge of this process at CDPH, it seems that CDPH is going ahead in revising Title 22 with out a formal process to seek input from stakeholders. In response to our offer to help in this process the official expressed openness to receive any comments on "any items that require change." We welcome this invitation and would like to request that the CDPH develop a transparent process to work on this monumental task. Our approach is more likely to expedite the process and keep it true to its mission. In the meantime, I am asking any CALTCM or CAHF members who have any issues related to Title 22 that bear on clinical care to make a list and forward it to our office at [email protected].  We'll forward them to the appropriate CDPH department for consideration. CALTCM is committed to work with CDPH and other stakeholders on this process.