At this year’s 50th annual CALTCM Meeting in Napa I viewed a pre-recorded session on Transinstitutionalization for Serious Mental Illness by Drs. George Woods, Glen Xiong, and Patricia Blum. Last Spring, I had a patient with a Mental Health Crisis that exposed serious gaps in crisis care not only at my facility, but within our county. At the In-The-Trench’s session on this subject, I was able to present this case to these experts and came away with very practical advice to address these gaps. 

Continuing Education is a critical component of healthcare that ensures medical professionals remain current on the latest evidence-based practices, innovations, and regulatory updates. For physicians and advanced practice providers working in post-acute and long-term care (PALTC) settings, staying engaged through continuing education opportunities with peers and thought leaders is particularly important. Practicing in PALTC presents unique challenges such as managing chronic diseases, addressing end-of-life care, and ensuring seamless transitions between care settings. Earning continuing education hours alongside colleagues and thought leaders in PALTC medicine fosters not only professional growth but also ensures the delivery of high-quality patient care through collaborative learning and leadership development.

I have recently provided onsite assessments for the regulatory annual employee physicals which is a process well standardized for ensuring employees are not a contagious risk to our residents and that they are able to perform their assigned duties. Rather than breeze through the exams, I chose to ask CNAs about prior work injuries and what they were doing to not only avoid injuries at work but to prevent injuries to high-risk areas like the shoulders and back. At one exam, the CNA strained her lower back the prior shift when a patient unexpectedly latched onto her hand during a minimal assist transfer. This CNA had not used the hand over hand technique, which could have prevented that injury. I subsequently found that a few CNAs were not aware of the value of this approach to patient care. For each CNA, I thanked them for their important work on behalf of our patients. When our patients become ill, they seldom have typical symptoms of acute serious illness and instead have subtle indicators. I thanked them for being the ones who recognize and report them to licensed nurses. One CNA said this had become more difficult since the COVID pandemic with less consistent patient assignments. I couldn't agree more and thanked him for saying so. As staffing improves, we can do better for our CNAs and their patients.

The population of adults 65 and older is growing. So is the older population living with dementia or neurocognitive disorder. The prevalence of people living with Alzheimer’s dementia as of 2020 is estimated to be over 700,000. This makes up 12% of our 65+ Californians with Alzheimer’s.

This year I approved a request for a mobile FEES (Flexible Endoscopic Evaluation of Swallow) study when I was the interim medical director for PACE (Program for All-Inclusive Care for the Elderly). We had a participant with dementia who had a troublesome persistent congested cough that disturbed his sleep. We considered further modifying the diet to reduce aspiration events as a part of his cough problem, but he was already having trouble maintaining his weight despite optimal family and dietary support. Our speech therapist recommended a mobile FEES study to better assess his swallow function. We had a contract with a company to provide this service at our PACE center. This participant’s swallow was directly observed by our speech therapist by this technology during his lunch at our center. Surprisingly, his swallow was quite safe with minimal risk for aspiration. This allowed us to liberalize his diet, better meet his nutritional needs, and focus on his weak cough and expectoration capacity. This led us to try an Acapella device to create airway vibrations to improve clearance of airway secretions.

I am personally aware of the impact of RSV on infants with 1-3% of children in the USA hospitalized each year. The threat of RSV to older adults has become clear over the last decade as better diagnostic point of care tests have become available. The CDC reports the adverse impact of this seasonal virus to be like influenza with 60,000 to 160,000 hospitalizations and 6,000-10,000 deaths each year in those over 65. The risk is high for those over 75 and those with high-risk chronic diseases. These are the same diseases that also confer higher risk for those who acquire Influenza or Covid-19.

The Policy & Professional Services Committee remains focused on watching, reviewing, and disseminating information garnered from past, current, and upcoming State & Federal legislative efforts and partner organizations. The PPSC discusses and weighs the potential impacts from proposed and State & Federal bills  facing the long-term care industry, which includes Residential Care Facilities for the Elderly and Skilled Nursing Facilities to safeguard quality of care for residents.

As CALTCM gears up for its 50th Annual Meeting, the anticipation is palpable. Set against the picturesque backdrop of Napa Valley, this milestone event promises not only to celebrate half a century of excellence, but also to set new benchmarks in post-acute and long-term care (PALTC) education and practice.

This is an exciting time for providers caring for persons with diabetes. The first 5 months of this year, I had the opportunity to care for older adults with diabetes in a PACE (Program for All Inclusive Care for Elders) program where I was serving as the Interim Medical Director. Our participants may be homebound, fail to keep medical appointments, and may live with poor glycemic control and multiple complications of diabetes. In a brief period, I saw the benefits of comprehensive supportive healthcare using a team approach that parsed identified problems to members of our team with expertise in each area. As a provider, I was able to prescribe newer effective medications (some given subcutaneously weekly at our center) with less hypoglycemic risk than insulin or sulfonylureas. At team conferences we were able to simplify the care and help their families and caregivers provide supportive care that was beyond the capacity of the participant alone. When appropriate, we provided CGMs (Continuous Glucose Monitors) for about 2-4 weeks to better understand the effectiveness and safety of our medical interventions. In the brief time I was there, I saw safer and more effective care with hemoglobin A1c’s dropping from the 13-16 range into the 8-9 range. As that happened, I saw dramatic improvements in the participants’ cognition and quality of life.

Embodied Labs is excited to offer free access to their innovative web and VR-based trainings that enable participants to step into the shoes of those they care for through first-person experiences. 

During the Pandemic in in 2021, KJ Page and I, developed a webinar for “Best Practices in Dementia Care” as the first of a four part series for the California Partnership to Improve Dementia Care (https://www.leadingageca.org/ca-partnership-for-improved-dementia-care).  That presentation emphasized the importance of identifying and supporting what is important to the resident and introduced two evidenced based tools that improve their care, quality of life,  and reduce the need for antipsychotic medications.

Happy Summer Everyone!  Summer is hot and very busy with family and friends. As CALTCM members, we can all look forward to the end of summer and cool down with our professional friends, family, and acquaintances in Northern California at the 50th Anniversary of CALTCM Annual Meeting. The President’s Gala event will be held on Thursday September 26th and I am excited to see all of you in person at the Meritage Hotel in Napa. 

Over my career, I and other clinicians have often assumed the side effects of a medication represent a subtle new disease which commonly leads to more tests and more medications, resulting in a prescribing cascade which can be quite harmful. At a CALTCM meeting in the early 1990’s (we were then called The California Association of Medical Directors) , I had the privilege of attending a presentation by Dr. Mark Beers on “Potentially Inappropriate Medications” (PIMS) in older adults. This list became known as the Beers List. After his untimely death in 2009 the AGS (American Geriatrics Society) began updating the criteria for PIMS about every 4 years with the last update released in May 2023. A summary table can be found at: https://www.guidelinecentral.com/guideline/340784/

All mandated and aspirational goals of a nursing service in an American nursing home (NH) are only achievable through the work of individual nursing staff members working in a coordinated manner supported by the organization context or infrastructure of the NH itself and its controlling operational entity, be that a for-profit or not for profit organization.

A recent JAMDA-On-The-Go podcast (click here, with free CMD credits available) reviewed an article from Hong Kong on Staff Turnover Intention at Long Term Care Facilities: Implications of Resident Aggression, Burnout, and Fatigue. In this article, 800 nursing assistants in 70 LTC facilities were interviewed regarding the job satisfaction impact of resident aggression witnessed and experienced as well as other factors. They found resident aggression to be the greatest risk factor for a CNA to consider leaving a facility.

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The American Psychological Association defines wellness as “a dynamic state of physical, mental, and social well-being.” It then defines well-being as “a state of happiness” paired with “low levels of distress, overall good physical and mental health and outlook, or good quality of life.” Notice the use of the words “dynamic,” “low,” and “overall.” These words do not imply a need for an absence of unhappiness, or even complete optimism, but take a more holistic approach. Wellness is not synonymous with bliss, and it sure is not synonymous with fitness.

The perfect baseline care plan and comprehensive care plan in the nursing home have evolved into the holy grail of regulators, malpractice attorneys, directors of nursing, minimum data set coordinators, nurse educators, interprofessional team members, although not so much for direct care staff. In this article, I assert that we expect too much from this document because we do not properly understand its origins, evolution in policy and practice, and its historic misuse as a placeholder for the limited presence of registered nurses (RNs) in American nursing homes.

CALTCM, the California Association of Long Term Care Medicine, is set to unveil an on-demand course tailored specifically for Medical Directors in the state. Aimed at enhancing their understanding of California's intricate regulations, this program promises to be a game-changer for nursing home professionals seeking to navigate the state's unique healthcare landscape.

In the last 15 years of my career, I worked as a physician and medical director exclusively in the SNF setting. When the National Partnership to Improve Dementia Care went live in 2012, as a CALTCM board member, I joined the California Partnership to Improve Dementia Care, where I have continued to serve even after retiring from full time practice at the end of 2020. That partnership developed a model informed consent form in 2015 for use in older adults with dementia and psychosis living in SNFs (attached).  With the approval of brexipiprazole (Rexulti) in 2023, this form is out of date.  A new form is expected in 2025 when CDPH completes its informed consent tool kit for psychotropic medications in SNFs.