During our annual summit, the board of directors met in person to review the past year and plan the future. It has been a huge effort by the Education Committee in bringing together the annual program. Our goal is to work together with other organizations in the state to increase collaboration and improve quality of care. We plan to continue creating programs that benefit our SNF system. We are doing great work from CALTCM SNF 2.0^® to LMG (Leadership and Management in Geriatrics) courses throughout the year.

This year, we have updated our website and continue to improve to increase utilization for all members and easier access for non-members.  The board has been doing strategic planning and met in person during the past year to work on the continued vision of the association. We continue to strive on gaining new ideas, perspectives to advance our program and participation in the state.

The two questions I can absolutely count on being asked, as the geriatrician in a crowd of healthcare providers, are “should I start statins?” and “should I continue in those who are over 80?” I usually offer the uncomfortable answer, mirroring the conclusion of this 2018 JAGS review article, which is that we still do not have enough well-designed, rigorous studies to guide definitive best practice.

That said, this particular multidisciplinary expert panel convened by The National Institute on Aging and the National Heart, Lung and Blood Institute in 2018, succinctly outlined the specific deficiencies in our current knowledge. Looking at available evidence outlining the efficacy and safety of statins in primary prevention in those aged 80 and older, the panel pointed to the current age-limited AHA/ACC guidelines as evidence of a lack of definitive data.

There was a time not long ago when the use of marijuana was deemed completely illegal, and judged morally reprehensible by a large proportion of the population. In fact, marijuana is even now a Schedule I controlled substance per the DEA, a category that includes heroin, LSD and mescaline!  The DEA defines Schedule I drugs as having these characteristics: The drug or other substance has a high potential for abuse, it has no currently accepted medical treatment use in the U.S., and it has a lack of accepted safety for use under medical supervision.  For comparison, methamphetamine, morphine and fentanyl are Schedule II.

Over the years, there has been recognition that cannabis may possess some medicinal qualities. The term “cannabis” is used to refer to marijuana (the plant that contains the drug THC, tetrahydrocannabinol, which has the stereotypical central nervous system effects associated with getting “high”) , as well as other cannabinoids, most of which have no psychoactive properties, and can be derived from marijuana or hemp.

In 2017, responding to impending Medicare and Medicaid guidelines for disaster preparedness, AARP posed the very real question, "Are nursing homes ready for the next natural disaster"? Given the recent devastating fires which ravaged northern and southern California, as well as the impact of other disasters occurring around the country, this question demands even greater attention and introspection on a systemic level at this time.  

Nursing homes provide care for some of the most vulnerable and fragile patients in any health care facility. While emergency plans for evacuation, loss of power, etc., focus on pragmatic physical issues, psychological preparation for staff, patients and providers are also critical to the success or failure of emergency responses in the face of disaster.

Let’s face it: sliding scale insulin (or “rescue dose”) is still very common. This is in spite of the practice being actively discouraged for years, and being listed in the “Beers Criteria” (for years) as a treatment modality to “avoid.” The reasons for this are many, but the main reasons are:

1.    Prescribers want an “intervention” for high blood glucose readings (>150) that doesn’t involve a phone call.

by Vanessa Mandal, MD, MS, CMD

Adverse drug reactions are the 4th leading cause of death ahead of diabetes, pulmonary disease and accidents, with 350,000 events occurring annually in nursing home residents.(1) These events are potentially preventable up to 50 percent of the time and common serious manifestations include falls, orthostatic hypotension, heart failure, and delirium. The American Geriatric Society (AGS) updated Beers Criteria is a useful toolbox for physicians in addressing medication appropriateness, identifying potentially inappropriate medications and de-prescribing to reduce avoidable adverse drug events. AGS has assumed responsibility for the criteria in 2011 with updates on the 3 year cycle since 2012, with the most recent occurring in January 2019. The interdisciplinary expert panel was comprised of 13 clinicians – physicians, pharmacists and nurses, experts with experience in ambulatory care, home care, acute hospital care, skilled nursing facility and long-term care. The Panel reviewed 1,422 articles, and abstracted 377 into evidence tables.  The abstracted evidence included 29 controlled clinical trials, 281 observational studies and 67 systematic meta-analyses and/or reviews. The primary target is practicing clinicians and the criteria are intended for use in adults age 65 and older in ambulatory, acute and institutionalized settings. The overarching goal is to improve medication selection; educate clinicians and patients; reduce adverse drug events; serve as a tool for evaluating quality of care, cost and patterns of drug use of older adults. Five types of criteria from the 2015 updates were retained in the 2019 update.

by Michael Wasserman, MD, CMD

The Patient Driven Payment Model, or PDPM, will go into effect on October 1, 2019.  It is far and away the biggest change to hit post acute care since Prospective Payment in the 1990’s.  Anyone who was around then should recall that most of the publicly traded nursing home chains went into bankruptcy.  That could happen again!

by Frank Randolph, MD, CMD and Terry Hill, MD, CMD, FACP

Dr. Wing Mar invited me to join CAMD (California Association of Medical Directors, which was CALTCM’s former name) in 1985 when we met at a California Medical Association Long Term Care Committee meeting. Dr. Mar helped to establish CAMD in 1977.  For the sake of temporal context, the American Medical Directors Association (AMDA) was formed in 1976.

by Flora Bessey, Pharm.D., BCGP

As the world of post-acute care continues to evolve, and we are faced with a quickly evolving landscape of new challenges, perhaps an especially unexpected (and unwelcome) one is the increasing prevalence of opioid drug use (and abuse) in our residents. This issue is one is of keen interest in the non-LTC world, so it is no surprise that it has now become a point of contention for us.

by Timothy Gieseke, MD, CMD

On December 4th, 2018 our dementia partnership sponsored a webinar by Dr. Maureen Nash, a nationally recognized Gero-psychiatrist who presented the PowerPoint presentation (handout provided below) on “Helping those with Serious Mental Illness who now live in a LTC setting”. She advocated for use of best practices for persons with serious mental illness who require institutional care, most commonly because of their very high risk for cognitive impairment.  CMS’s campaign to improve dementia care by reduce antipsychotics at times may seem to compromise known best practice. She recommended following the American Psychiatric Association’s free best practice guidelines for treating: Major Depressive DO, Bipoloar DO, PTSD, OCD, Schizophrenia, and dementia persons with agitation and aggression. In these guidelines, recommendations for use of antipsychotics (many have FDA approval) represent best practice even though they may not be recognized in the excluded category by the CMS campaign.  

by Timothy Gieseke, MD, CMD

In the October 4, 2018 issue of Diabetes Care, the ADA and EASD (European Association for the Study of Diabetes) published their consensus report for Management of Type 2 Diabetes, 2018.  Both organizations now favor the use of Incretin Receptor Agonists or SLG2 Inhibitors for persons with established macrovascular disease (or high risk for Cardiovascular Disease), for improving glycemic control, if metformin alone isn’t adequate or not appropriate.  

CALTCM Members and Friends,

As we greet 2019 with fresh ideas and educational programs, offering you the best one can offer in professional education and training for California’s post-acute and long-term care (PALTC) arena, I am proud to share with you our accomplishments in 2018.

by Jay Luxenberg, MD

Recently, both poor sleep and inflamed gums have been implicated in the pathophysiology of Alzheimer’s disease. But before we discuss that, I’d like to remind you of the free resource “Alzforum” – www.alzforum.org – where the latest papers and meeting presentations are presented along with active discussion by many of the leading researchers in the field. I do not know of any other field where such a central repository has been maintained over a long period of time. It’s common for colleagues, patients and even family members to ask me about “the latest breakthrough” that they hear about on the news or read about in the lay press. I find Alzforum the best place for me to get a balanced view of the research that triggered the news report.