Hard Choices at the End of Life

This year, I became the Medical Director of a small hospice focused on caring for those living in small assisted living communities (ALs).  Because we are a small team working In family-like home settings, we chose to open hospice cases with my colleague or I present (physically or virtually) to assess the case with our RN and the patient’s family (present, or virtually available).  This structure has not only improved the clinical assessment of the health history, but also has provided a quicker understanding of the patient’s personal preferences and goals of care.  In addition, the bidirectional communication with patients and DPOA builds trust for adjusting the care plan so we provide care that matters to this patient.

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Improving Care Transitions and Self-Efficacy for Skilled Nursing Facility Patients and Caregivers

First Place
CALTCM 2022 Poster Session
Presented at the 2022 CALTCM Summit for Excellence
 

Purpose: To evaluate the effects of evidence-based transitional care intervention and self-efficacy training for skilled nursing facility (SNF) patients and caregivers. 

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Reflections

I was asked to commit to writing my thoughts and impressions about my experiences as Board member President and CEO of CALTCM.  As many of you may know I served as a president for 3 years (2009-2012) and as a CEO for almost a decade.

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An In the Trenches Session Telehealth Summary

I was so honored to present a summary of the work that my organization, Los Angeles Jewish Health is doing in Telehealth at the recent CALTCM Summit for Excellence.   Los Angeles Jewish Health is the lead program that works in partnership with the California Technology Fund in a statewide coalition. We received FCC funding to demonstrate the value of telehealth in PALTC facilities. Our purpose is to inform those who are seeking to adopt or expand telehealth in facilities, and to educate policy makers, to better understand the potential benefits and challenges of implementing telehealth in facility-based care.  

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PEG Tool for Improving Persistent Pain Management

I recently saw a woman for a colleague who had been one of my patients in the remote past.  Since that time, her persistent low back pain despite multiple prior back surgeries has persisted and been complicated by depression, malnutrition, frailty, polypharmacy, and recent functional decline requiring SNF care.  Fortunately for her, my colleague had begun deprescribing medicines which were potentially more burdensome than beneficial.  Though this patient didn’t recognize it, her husband said her appetite had greatly improved.  When I saw her I observed she was easily moving about the facility in her wheelchair.  When I asked if her pain was keeping her from getting about the facility, she confirmed my observation that this was a good day.  

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“All Hands on Deck”: The New Bivalent COVID Boosters Are Here

The FDA, CDC, & Western States Scientific Safety Review Workgroup have approved the EAU for the new Pfizer and Moderna mRNA bivalent vaccines.  These vaccines target the COVID-19 spike protein, which has rapidly mutated over the course of the pandemic.  These vaccines target the original Wuhan spike protein (monovalent vaccines) and the Omicron BA.4 & BA.5 subvariants.  BA .5 has proved very contagious and still accounts for over 88% of the infections in California.  Though the numbers of COVID cases, hospitalizations, and deaths have slowly improved since the end of July, the rates are still substantial.  On 9/8/22, a large 250-hospital network study of COVID-19 hospitalizations in the USA from January 2021-April 2022 was published in JAMA IM (https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2796235).  They found the rate of hospitalization was 10.5 times greater for unvaccinated and 2.5 times higher for vaccinated, but not boosted.  We anticipate an even greater benefit of the new bivalent vaccines which better target BA .5.  This vaccine roll-out is well timed to combine with our efforts to provide the usual Flu vaccines before winter arrives.  As of 9/10, over 50 million doses have been delivered to states for distribution. 

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Liability Insurance for Practitioners Exclusively Working in the SNF Setting

As a semi-retired physician who spent the last 15 years of his career working exclusively in the SNF and CCRC (Continuing Care Retirement Community) settings of care, I was aware that some of my colleagues had trouble finding Medical Liability coverage and when they did so, the annual premium was almost twice my rate.  I believe NORCAL, my insurer, gave me favorable coverage, because I was part of a large multispecialty group. This difficulty finding affordable coverage began after California passed Elder Abuse Legislation that changed allegations from malpractice to civil tort, which has a much higher financial risk.

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Revised Long-Term Care Surveyor Guidance for October 24, 2022

As a member of the California Partnership to Improve Dementia Care, I was made aware of updated surveyor guidance issued by CMS Director of Quality, Safety, and Oversight Group (QSO-22-19-NH found at: https://www.cms.gov/files/document/qso-22-19-nh.pdf-0 ). In this update, there are significant revisions for management of abuse and neglect, managing mental health disorders, and clarifying resident readmission and visitation rights. For dementia care, surveyors have new guidance for assessing possible inaccurate diagnosis or coding of schizophrenia, which may have led to the unnecessary prescribing of antipsychotic medications. When other medications are used off label as psychotropic medications, these medications will be subject to the psychotropic medication prescribing requirements. 
Training resources are available not only for surveyors, but also for providers at: https://qsep.cms.gov/welcome.aspx

A Book Review: The Orphans' Father

The WAVE occasionally highlights recent publications by our members, but usually those are medical journal articles or medical books. Today I’d like to discuss a new book that is not medical at all. WAVE readers likely need no introduction to Dan Osterweil, MD, CMD. Dan was for many years the CEO of CALTCM and has had an outstanding career as a leader in long term care, innovator of care models for the elderly, educator, author and editor. He has been a long-time faculty member at UCLA in their Geriatric Medicine division. Now Dan has written an absolutely riveting new book, “The Orphans' Father: A Jewish Doctor’s Inspiring WW2 Historical Novel, Based on the True Story of a Holocaust Survivor

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Living in the Moment by Dr. Elizabeth Landsverk

I have benefited from Dr. Landsverk teaching on optimal dementia care by her participation in the California Partnership to Improve Dementia Care, and through her teaching presentations at CALTCM meetings.  She is a seasoned geriatrician in Northern California who has focused on the care of persons living with dementia through a house calls practice.  She has now condensed her thoughts on living with dementia in a way that our patients and caregivers can understand and support.  This is a very balanced approach that identifies the common difficulties associated with living with declining cognition, with a focus on maximizing the remaining capacities.  When this is done, the quality of life for everyone improves and there can again be joyful living.  I highly recommend this book as a very practical way for patients and caregivers to navigate the challenges associated with progressive dementias.

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Hurray! In-Person Meetings are Back

I know it’s easy and less expensive to get timely information and CME online from many sources.  I’ve appreciated the virtual-only meetings sponsored by CALTCM and AMDA during the pandemic.  Over time, they have become more user friendly and engaging. 

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What is the State of ACP In Communities in California?

How difficult is it for residents in your community to access appropriate ACP (Advance Care Planning) services?  In my experience, these conversations are often deferred until the time of a crisis, but we know these conversations are less beneficial then due to crisis related compromised cognition and emotional stress for patients, families, and providers.  Are there communities in our state where there are champions doing this good work electively in their community, particularly targeting members of their community who historically are less likely to have serious illness conversations and supported decision making?

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OLTCPR Looking for a Few Good Representatives

The new Office of the Long-Term Care Patient Representative (housed at the California Department of Aging) is getting up to speed, and they are looking to hire qualified people to work in this important capacity.  Salary range is from roughly $70-100K annually, and includes benefits.  Here is the link to the site for potential applicants: https://www.calcareers.ca.gov/CalHrPublic/Jobs/JobPosting.aspx?JobControlId=321013

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Important COVID-19 Treatment Recommendations for SNF Residents from LA County Public Health Department

As of July 27, 2022, over half of the 342 skilled nursing facilities (SNFs) in LA County are experiencing active COVID-19 outbreaks, which is the highest level of transmission since the surge last winter. All patients in SNFs are at high risk for progressing to severe COVID-19 if infected. Fortunately, there are now outpatient COVID-19 treatments such as oral antivirals that are easy to administer and can reduce the risk of poor outcomes, including hospitalization and death. Despite the wide availability of oral antivirals, they continue to be underutilized in the nursing home population. To close this crucial gap and significantly improve outcomes in this vulnerable population, Los Angeles County Department of Public Health issued an update on July 25, 2022 to the Order of the Health Officer for Control of COVID-19: Prevention of COVID-19 Transmission in Skilled Nursing Facilities requiring all SNF patients with a positive SARS-CoV-2 viral test to be immediately assessed by their healthcare provider for any symptoms of COVID-19. Oral COVID-19 antivirals should be initiated at the facility within 5 days of symptom onset if clinically appropriate, i.e., they have mild or moderate symptoms and there are no contraindications. Please do not transfer residents to hospitals solely for treatment of mild or moderate COVID-19. These residents should be treated at their SNF. Even if you are not practicing in Los Angeles County, CALTCM agrees that all PALTC medical directors, attending physicians and practitioners should evaluate every case of COVID for the potential ordering of therapeutics including Paxlovid.  Please work with SNFs where you provide care to help meet this recommendation and provide optimal care for your patients.

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Attention-Deficit Medications: Potential Use for Alzheimer’s Disease?

A recent systematic review and meta-analysis article published in the July 2022 Journal of Neurology, Neurosurgery and Psychiatry suggests noradrenergic agents may be effective in early Alzheimer’s Disease to improve cognitive function. This original research included over 1800 patients showing a small significant positive effect on the global cognition measured on the Mini-Mental State Exam (MMSE) or on Alzheimer’s Disease Assessment Scale-Cognitive Subscale (ADAS-cog). 

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“Buyer’s Remorse” and Dementia Care

How do our patients and their families define a good outcome from a surgical procedure, particularly if it is a high risk surgical procedure (defined as >1% 30-day mortality)?  What if the patient has dementia?  Have you had patients with advanced dementia with acute displaced hip fractures where the traditional best option offered has been surgical repair?  

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A Unique Opportunity to Learn about State-of-Art Geriatric Medicine

The 38th Annual UCLA Intensive Course in Geriatric Medicine and Board Review will take place September 14-17, 2022. This four-day virtual course is designed for health professionals interested in advancing their knowledge and enhancing their ability to care for older adults, as well as physicians preparing for certification or recertification examinations in Geriatric Medicine. The Intensive Course is CME and ACPE accredited and a nationally recognized premier course. 

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Bringing Back In-Person Education

The moment you have all been waiting for!

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Comments of a California Geriatrician on the Road Less Traveled

I naively assumed when I began my journey in the field of Geriatric Medicine, that I would be followed over time by hordes of other physicians, given the impending increase in aging populations.  While the population of seniors has nearly doubled, the number of physicians with Geriatric Medicine training has diminished. Less than 5% of the current California healthcare workforce is certified in geriatrics.  Moreover, the California Census Bureau projects a rate of growth of the age 65 plus population that far exceeds the other age groups, particularly among the 85 plus group, and among the non-White populations. The percentage of filled first year geriatric fellow positions dropped from 91% in 1998 to 45% in 2017. Currently, the American Geriatric Society estimates that there are 3,590 full-time practicing geriatricians, out of a total pool of less than 7,000 board-certified geriatricians. A professional colleague recently commented that if things continue to progress as they are, American geriatricians will become a historical footnote. 

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Capturing Our Patients’ and Families’ Experience of Care

CMS had AHRQ (the Agency for Healthcare Research and Quality) develop validated patient-friendly surveys that could capture the patient’s experience of care in a particular facility.  This could provide a facility with important information about their care delivery, allow comparisons with other facilities (within their system and beyond) and spark collaborative learning.  In addition, this information could incentivize facilities to improve their survey results, if they were posted on the internet.  

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