I recently listened to a “Turn on The Lights” podcast where an expert on provider burnout favored “Moral Injury” as a more accurate way of describing a healthcare delivery system that is very inefficient and has unrealistic provider productivity expectations. As I reflect on my long career in private practice, I didn’t have to sacrifice the quality of care I provided, since my educational debt was small and most of my years of practice preceded electronic medical records (which sadly have cut my efficiency by about 60%). I have seen my cardiologist improve his efficiency using a scribe, but my billing could not justify that added expense.

As I previously reported, in the August 1 WAVE, SB 380, the End of Life Option Act (EOLOA) became a law in California in 2016 and was amended in 2021 to shorten to two days the time from the first oral request to the second one. In addition, all healthcare facilities (acute care hospitals, SNFs, hospices, and medical offices) are to post a publicly visible notice on their website and offices stating their policy with respect to the EOLOA, including if they and their employees are prohibited from participating in this Act.

In recent years, medical directors and other physicians practicing in post-acute care settings have recognized the benefits of aligning with advanced practice nurses working in these settings. Physicians benefit by having a clinical partner participating in the medical management of their patients. Academic nursing has hailed this partnership in hopes that advanced practice nurses will help to elevate the nursing practices of nursing services offered in these settings.

October was the month for employee physicals for skilled nursing facilities (SNFs) and for a Home Health Aide (HHA) and Certified Nursing Assistant (CNA) Training Academy that prepares students for certification exams. In both these situations, my job is to ensure employees are fit to perform their work and ensure they are free of serious contagious illnesses like TB. 

Working as a physician and medical director in post-acute and long-term care, I’ve seen how easy it is to miss vitamin deficiencies that have real clinical impact. Many of our residents have age-related malabsorption, multiple comorbidities, and limited diets; add polypharmacy and functional decline, and the risk grows. Over the past few years, I’ve started screening vitamin D and B vitamins in residents with frailty, falls, anemia, cognitive decline, or nonspecific fatigue — and I’ve been surprised by how often this changes care. I’ve found vitamin D deficiency in the majority of residents I check, and more vitamin B6 deficiency than I expected, even in those who looked nutritionally stable on the surface.

This mantra has been used to justify the financialization of medicine where the mission of even non-profit health systems may succumb to system decisions that maximize profit and compromise mission.  This subject was explored in great detail in a recent podcast from Turn on the Lights, “Graduate Medical Education and Social Contracts” with Dr. Tom Nasca (https://www.ihi.org/library/turn-on-the-lights-podcast).

As a physician and medical director in the post-acute and long-term care setting, I encounter dementia-related behaviors almost every day. Agitation, aggression, or resistance to care are rarely “just behaviors” — they’re often the patient communicating discomfort, fear, or confusion in the only way they can. When a nurse calls me about a resident striking out during bathing or becoming restless at night, my first instinct isn’t to reach for a prescription pad. Instead, I pause and ask: What has changed for this person? I look at recent labs, review pain control, check for constipation, infection, or dyspnea, and ask whether their usual routines — music, lighting, or sleep patterns — have been disrupted. Many times, small adjustments like restoring a familiar evening routine, dimming harsh lights, or breaking hygiene tasks into smaller steps can calm a patient without medication.

In 2012, multiple medical societies and consumer groups launched the “Choose Wisely Campaign” challenging medical specialties to identify five common tests or procedures within their field that were often overused and should be questioned by both physicians and patients. These lists were based on evidence and clinical guidelines. Since then, leaders at PALTmed have developed and just released “20 Things Prescribers and Patients Should Question in Post-Acute and Long-Term Care.

Many of us have seen the effects of hypercortisolism on diabetes control when prednisone is added to an acutely ill insulin-dependent diabetic. However, like many of you, I’ve never diagnosed Cushing’s Syndrome, which is distinctly rare. Nonetheless, most of us have cared for persons with diabetes who remain highly insulin-resistant and have suboptimal glycemic control despite using the latest diabetic glycemic control agents.

As you know, §483.20 (h) Coordination, otherwise referred to as F-tag 642, states: “A registered nurse (RN) must conduct or coordinate each assessment with the appropriate participation of health professionals.” The RN’s signature serves as the certification that the assessment is complete, but does not certify the accuracy of the assessment.¹ 

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.

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.

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 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. 

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.