“I know geriatrics, because I’ve taken care of a lot of old people.” As a geriatrician, I’ve heard this refrain my whole career from other physicians who are trying to rationalize the care they deliver to older adults. The scope of this refrain is about to expand, and we shouldn’t be surprised to find nursing home administrators opining on clinical care delivery approaches.
In 2001 I co-founded Senior Care of Colorado. We were a small group of six geriatricians and a couple of physician assistants working out of two clinics who provided primary care geriatrics in local nursing homes. We immediately had offers from several local nursing homes to take positions as medical directors. Naively, we thought that these offers reflected a desire for these facilities to gain expertise in geriatrics. Realistically, they probably thought that hiring us would bring them more patients. Within a year we were under investigation from the OIG. They interviewed several nursing home administrators.
For many reasons, our education committee chose to focus this year on reducing the risk of hypoglycemia in persons with diabetes. CMS has data from April 2016-March 2017 showing this is a major reason for a higher first 30 day all-cause SNF Readmissions rate. As of Jan 1, 2019, the CMS “SNF Readmission Measure” (SNF-RM) adjusts payments to facilities based on this measure. From multiple randomized controlled studies, we know that serious hypoglycemia increases mortality. For this reason, in high risk patients, AGS and ADA have recommended higher A1C targets in those with higher hypoglycemic risk.
At the March 2019 annual AMDA meeting, Dr. Karl Steinberg (our incoming AMDA VP) and I were part of a panel debating whether the United States should adopt the Dutch policy of legalizing Advance Directives for Euthanasia. In 2014, 4.4% of deaths in the Netherlands were by euthanasia and 20% were by palliative sedation. Dr. Cees Hertogh, a Dutch physician and bioethicist, gave a wonderful presentation on the history of euthanasia in the Netherlands and the criteria for euthanasia, which have been modified to include euthanasia by advance directive (AD) for persons with dementia. In contrast, the 20-year experience of Oregon with the Death with Dignity Act (reported in the September 2017 Annals of Internal Medicine) had 0.2% of their deaths via medical aid in dying. California has had a similar frequency who died by lethal ingestion via the End of Life Option Act.
This year I planned to go to the AMDA meeting. I registered and made hotel reservations. Then something came up – I found out about a meeting that occurred at roughly the same time, but instead of emphasizing nursing home care, it specifically was organized to highlight alternative solutions to long-term care needs that allowed people to remain in their homes. I work in a PACE program, and both our mission and our financial success involve keeping people out of nursing homes whenever possible. I fully believe sometimes nursing homes are a necessary solution to meet the needs of individuals, but I also see people with dementia or other conditions requiring long-term care who end up in nursing homes because of lack of viable alternatives. The AMDA meeting was in Atlanta this year. This other meeting was in Florence, Italy. Not to denigrate Atlanta, but based on criteria of food, wine, art and gelato, Florence has advantages.
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.
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.
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.
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.
1. Prescribers want an “intervention” for high blood glucose readings (>150) that doesn’t involve a phone call.
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.
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!
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.
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.
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.
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.
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.
