Each year, more than one in four older adults aged 65 and older will fall. Among older Americans, falls are the number one cause of injuries and death from injury (1). This represents 29 million falls, 3 million emergency department (ED) visits, 800,000 hospitalizations, and 28,000 deaths. As the leading cause of fatal and nonfatal injuries among older adults, falls will continue to soar, as America’s baby boomers grow older (2).

As a retired internist and gerontologist, I have closely followed our government’s efforts to help us identify HCP (Health Care Personnel) with SARS-CoV-2 with the goal of reducing the risk of its transmission to residents in our homes.   Early on, we had significant difficulties obtaining the materials for molecular (RT-PCR) testing and later had difficulties obtaining the results within the desired 48-hour TAT (Turn Around Time).  However, in the past several months many facilities in our state have been able to obtain at least this TAT on their mandatory weekly screening of their HCP.

AB890: Forthcoming Changes to NP Practice 

When I was an intern, I probably learned more about medicine from nurses than anyone else.  When I was a geriatric fellow, I know I learned from the nurse practitioners in our program.  Over the last thirty years I’ve worked, hired, and supervised a multitude of nurse practitioners.  Let me start by saying that when it comes to taking care of vulnerable older adults, I’d trust many of the nurse practitioners that I’ve worked with more than many doctors.  I know that’s a pretty strong statement, and it definitely deserves some additional explanation and qualifications.

Deprescribing involves a systematic review of medications and identifying those medications with a high potential risk of harm and low benefit to the individual patient when incorporating the goals of care, safety, life expectancy, values, patient preferences, and level of functioning into the decision-making for discontinuing medications.1   According to Scott, et.al., an alternative definition of deprescribing includes: “Deprescribing is not about denying effective treatment to eligible patients. It is a positive, patient-centered intervention with inherent uncertainties, and requires shared decision-making, informed patient consent and close monitoring of effects.” 

On September 22, 2020, the California Department of Public Health posted this all-facilities letter (AFL 20-73), available at https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-78.aspx.  This letter provides guidance to nursing homes about the importance of person-centered advance care planning, including ensuring that current treatment preferences in light of COVID-19 are reflected in up-to-date treatment orders.  

This year, we must improve our vaccination program and IPC (Infection Prevention and Control) for influenza prevention.  In recognition of this necessity, CALTCM provided a free webinar on this subject on September 21, the slide handout and recording are available on CALTCM's COVID-19 Webinar Series webpage.  In that webinar, Dr. Lily Horng, CDPH Public Health Medical Officer, noted that the CDC recommends that persons with COVID should not receive the influenza vaccination until they are out of quarantine (10 days from diagnosis and 24 hrs afebrile), so as to reduce the transmission risk to HCP and other residents.  This statement can be found in the August 21 CDC Influenza Vaccination Guidance for Professionals.  If available, our seniors should receive the enhanced vaccines, which have been shown to be more effective and durable.  Immunization should start now so that our seniors and HCP are immunized prior to onset of influenza.  You should know that San Francisco has already had cases of influenza A.  The above CDC web site has a link to current influenza activity.  My county is considering an order for mandatory vaccination of all HCP unless there is an identified contraindication.  We now know that the masking rules at work do not prevent employees who have refused a flu shot from acquiring COVID outside of the facility and then spreading it within our facilities.  On a recent AMDA podcast, Dr. Barbara Resnick shared great ways to encourage your residents, families and HCP to receive flu shots.  She and AMDA were parts of work groups which created four helpful one-page fact sheets that will enhance your flu immunization program.  Please go to this free AMDA ON-THE-GO podcast where you can hear this superb educator and also download these helpful fact sheets.  

In Sonoma County since the surge of COVID-19 cases in late June, our senior congregate living homes have consistently had about 82% of the fatalities in our county.  This fact is consistently reported in our media on a weekly basis.  Early on in this outbreak, the term “die offs” was commonly used in facilities in recognition of how quickly some of our residents died after onset of COVID.  As in many other areas in our country, the initial bad outcomes were associated with the lack of PPE and timely testing, as well as staff shortages, and the need to learn and practice optimal IPC (Infection Prevention and Control).   However, with the in-facility assistance of specialists from CDPH HAI (Health Associated Infection) program, HSAG QIO (Health Services Advisory Group), and our public health department, most of our facilities have extinguished their initial outbreaks and have minimized the impact of new cases.  

The 9 page (AFL-20-53 ) update should be studied by management in the SNF and hospital setting since it sets expectations for testing during care transitions, dialysis care, and outbreaks.  In addition, it creates a new expectation that all HCP will be tested weekly, even when in surveillance mode.  The guidance allows for routine use of Antigen testing rather than exclusive use of RT-PCR testing.  This should allow facilities to have immediate test results.  The tracking and reporting requirements for testing results in symptomatic and asymptomatic persons are also addressed.  

On March 9, CALTCM produced our first webinar on COVID-19.  On August 31st we produced our 21stwebinar.  It truly has taken a village of volunteers.  Some of the webinars attracted a thousand-plus attendees.  Over 200 people participated in our most recent webinar, which is a remarkable achievement in view of the abundance of information that is available online.

Please click on the link to the ABC news video and report on the letter writing project that these sisters operationalized not only for their loved one, but also for those who need loving through pandemic spawned isolation.  Then click on their web site and take action.

July has been a discouraging time for the SNF community in Sonoma County.  Like the rest of California, we have experienced a surge of COVID-19 cases.  We now have had COVID resident cases in 10 or our 20 SNFs and have experienced a “die-off” with 30 deaths in July.  Our county experienced a 5-fold increase in deaths in July, and 67% of those deaths were in the SNF setting.  16% were in RCFE settings, including assisted living communities and dedicated dementia or “memory care” facilities, for a total of 83% of the deaths occurring in senior congregate living settings.

We are in August and it’s time to plan “back to school” for parents and students. It seems the summer flew by although it had its own challenges of limiting vacations, avoiding COVID-19 hotspots and almost cutting out social interactions unless they are on zoom!  Schools, teachers and parents have been hopeful to return to in person teaching. They have been working on setting up hand wash stations, small group classes, outdoor education, and other methods to socially distance while being on campus. It’s not even a possibility for some jurisdictions and a challenge for most public schools. With California’s COVID 19 database potentially being inaccurate – now schools have lost hope for at least another month before a waiver can even be considered for on-campus education. There are other states where schools are opening in person.

Coronaviruses are a class of enveloped viruses with a single-stranded RNA genome that infects animals and humans. There are many types of coronaviruses that cause infections exemplified by the common cold, severe acute respiratory syndrome coronavirus (SARS), Middle East respiratory syndrome-related coronavirus (MERS), and the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the pathogen associated with COVID-19. ⁽¹⁾ The clinical development of remdesivir, with a confirmed capability to inhibit SARS-CoV-2 replication, supports the evaluation for COVID-19 treatment ⁽¹⁾.

My 10 grandchildren are all in “virtual” school for the coming year, but I do remember an advance in responsible parenting, which was applied to the care of the grandkids 10 and under.  It’s a technology that has now become standard for most parents, called “baby cams.”  This has allowed “never out-of-sight or sound” parenting on a 24/7 basis as long as this device is being used.  

Our community is experiencing a surge of COVID in our Senior Living Facilities with the vast majority of cases traced to asymptomatic HCWs, particularly those working in multiple facilities.  This problem is further compounded by delays in reporting the results of mandated HCW COVID testing as long as 10 days.  Our contact tracing suggests that much of the initial infection of HCWs is occurring in the home setting where there is intergenerational living and multiple relatives living in close proximity.  We have traditional sterile hygiene measures expected of HCWs going from one facility to another, but know that transmission risk during intimate care may occur through medical masks, which may be only 45-70% effective in containing the virus, versus 95+% with certified N95 masks that have been fit tested.  

What do the above scenarios have in common?  Under the new abuse regulations, each one must be reported and investigated as potential abuse, neglect, misappropriation of resident property or mistreatment.   And if YOU hear about them, then YOU are a mandated reporter.

The Covid-19 pandemic has radically changed how providers deliver health care.  Realizing that in-office and in-facility clinical care risks transmission of SARS-CoV2, CMS has removed all restrictions on the adoption of Telemedicine.  Multiple organizations including CALTCM, AMDA, and AGS (American Geriatric Society) have provided helpful webinars and resources that have helped providers implement Telemedicine in their work flow.  Understandably, seniors have had difficulty embracing this technology.  Medical offices have enhanced their MA’s (Medical Assistant’s) training so they can contact patients prior to the telemedicine visit, to help them with technical issues and to gather pertinent information for that appointment.  

The NEJM Online June 3 edition reported a study from the University of Washington and United Health Group comparing the efficacy of COVID-19 testing in 530 subjects by nasopharyngeal swab vs. patient-collected anterior nasal swab, or mid-turbinate swab, or tongue swab.  This well-done study found similar sensitivity and specificity to that of our gold standard for RT-PCR testing, the  uncomfortable and universally detested nasopharyngeal swab.  An audio interview with Editor-in-Chief, Dr. Eric Rubin, and Deputy Editor, Dr. Lindsey Baden, endorsed these alternative collection sites.  Since that study, the public health departments of San Diego and Contra Costa Counties have approved the anterior nasal site as a collection option for SNF patients and staff.  PPE isn’t required for patient-collected swabs, and adherence to our mandated and recommended testing protocols will likely be better.