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).

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.

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.

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.

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.

“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

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.

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.”