In my community, our traditional source of providers for caring for our SNF patients has been dwindling for the past several decades as private physicians and new graduates moved into outpatient practices through hospital medical foundations.  Occasionally, older physicians have left their office practice or their foundation employer for the lower cost and flexibility of a dedicated PA/LTC practice.  However, that requires good business skills to navigate the various insurance contracts, on-call support, billing service, EHR platforms, MIPS reporting options, and triage of calls/faxes/texts from various facilities.  As I look at my community, I foresee this workforce of providers continuing to dwindle.  

Life purpose not only means different things to different people, but it also means different things to each person as we progress through the stages and events of our lives. On the formal side, Hill et al., (2010) identified four main types of life purpose as follows:

In 2018, AB 2789, the mandatory provider e-prescribing law for California, was designed to coincide with the new Medicare EPCS (Electronic Prescribing of Controlled Substances) requirement that was to go live nationally at the start of 2022.  AB 2789 goes live January 1, 2022 and extends the EPCS expectations from controlled substance to all prescriber and dispenser prescriptions with very few exemptions possible.  The CMA posted a helpful article on this subject on October 5 (link provided below).

At this year’s annual Summit in October, Dr. Steven Poser presented important information on the distinction between Neurologic and Psychiatric causes of dementia, which I highlighted in the November 1 edition of the WAVE.  

“Now is not the time for additional ‘studies’ to assess the importance of appropriate staffing levels. The combination of inadequate staffing and disparities can only lead to more tragic situations and outcomes, such as those recently seen during the latest hurricane in Louisiana.”  Thus begins CALTCM’s “White Paper on Nursing Home Staffing.”  CALTCM is the medical voice for long term care in California.  Our public policy committee developed this White Paper with the intention of making recommendations based on evidence-based literature.  It was not our intention to debate the financial impact of our recommendations or where nursing staff will come from, given the current huge workforce shortage issues.  We stand for quality care in nursing homes. We absolutely understand many of the issues that have put nursing home care in the precarious state that the COVID-19 pandemic has tragically highlighted. Those issues need to be debated and those problems addressed, but that does not change the existing evidence.  Our White Paper presents the evidence. We’re ready and willing to have a debate over the evidence, though we think it’s more important to have a vigorous discussion on how to finance these recommendations and find the nurses and nursing assistants needed to fulfill these requirements. 

As per the definition in the dictionary, gratitude is “the quality of being thankful, readiness to show appreciation and to return kindness”. Is gratitude an emotion, an attitude, a trait, a habit? It is all that, and more, depends on who you ask.

The pandemic has made us realize two main challenges: the first is how important it is to stay in touch with each other, and the second is how important it is to organize our clinical information and networks so that we can access what we need when we need it.  For the first time in the history of our organization, CALTCM has created a free application for your mobile phone to help you meet these needs. 

At this year’s annual Summit, Dr. Steven Posar, a clinical professor of Geriatric Neuropsychiatry at St. Mary’s College in Notre Dame, Indiana, updated us on this important area of medicine.  

Dr. Dan Osterweil recently received a Lifetime Achievement Award from CALTCM.  During the same week, Governor Newsom signed AB 749, which was authored by Assembly member Adrin Nazarian (D-Van Nuys), Chair of the California State Assembly Aging and Long-Term Care Committee. That these two events occurred together was a poetic coincidence.  For many years Dr. Osterweil has championed the concept of a “medical director utility.” He regularly encouraged many of us to advocate more vociferously for medical directors.  This became the inspiration behind CALTCM’s effort to enhance the role of the nursing home medical director.

Our lives are overwhelmingly busy and it's difficult to stop to realize when and if we are experiencing a happy moment. But what is true happiness and how can you obtain it?

I admitted an older woman to a facility last summer on hospice for terminal cancer, who at that time had minimal pain, controlled with Tylenol.  I was surprised when she said she would like medical aid in dying using the End of Life Option Act.  I alerted the facility and reviewed their policy and procedure from 2017, which permitted this option but certainly didn’t facilitate it.  Since my role was vacation coverage, I subsequently asked her attending physician about his impression of what it was like to die in this facility.  He affirmed my impression of other facilities which rely on hospice to provide care that focuses on medication management of pain and suffering, rather than a comprehensive person-centered approach before and after death.  

On Thursday, August 26, the CALTCM-sponsored AB 749 (Nazarian) got off the Senate Appropriations Committee Suspense File to continue its journey through the legislative process. This was a huge moment for CALTCM and medical director certification in California.  While we have several steps to go, the Suspense File is where many bills are stopped in the process.  There will be many stories in the press about bills no longer moving forward this year and that’s due to the suspense file process in both legislative chambers.

The use of apps has become ubiquitous in society and in health care.  People use their mobile devices to communicate, learn and inform themselves, family and friends for just about all aspects of daily life.

On July 30, the MMWR (Morbidity and Mortality Weekly Report) released an early report (A) on a series of BT (breakthrough) COVID infections in fully vaccinated persons.  These cases occurred at large public summer gatherings on Cape Cod, Massachusetts.  The Delta variant was sequenced in 89% of the cases that were sequenced.  Of the 469 cases linked to these events, 74% were BT cases.  Real-time PCR cycle times (Ct) of 127 fully vaccinated persons were similar to those of 82 unvaccinated persons, suggesting the high viral load in the nose was similar and meant that fully vaccinated persons can not only acquire the Delta variant, but also can transmit it to others.  Recognizing this reality, the CDC has now again recommended universal masking in indoor public places.  

What do comedians, commuters and clinicians have in common? Their success depends on connecting with others. You’ve undoubtedly heard that people fear public speaking more than death. The antidote to this fear is connection!

My Mom was a difficult, fastidious person. Responding to her deep-seater training as a severely abused child, she brought all her coping mechanisms forward into adulthood, most of which were aimed at preserving safety that only comes from being in complete control. Child Protective Services did not exist in the 1930’s and ’40’s, and the cultural norms of the day precluded outsiders from meddling in how others chose to run their households or interact with their children. Private matters were in fact, private. I’ve heard from older relatives over the years how sad it was that Mom was not afforded a room in the family home. Because she was a bedwetter, she slept on an open back porch, something she dreaded because of the “tramps” who walked the nearby railroad tracks at night. She had no bed and slept on a pile of rags that she laundered every day. She tied the bits of fabric in knots to help them hold a shape when she lay down on them. In addition to persistent inhumane and abusive treatment, the sensational details need not be repeated here, I learned that from the age of 9, Mom supported alcoholic parents and a little brother stocking shelves at the local grocery, taking in ironing, and waitressing in a malt shop. She worked early in the morning, during school lunch hour, and after school, as well as every weekend. As a teen, she landed a great opportunity with the phone company and worked a split shift as the overseas operator. She worked as a carhop at a diner during and after the split times on the overseas board. In her junior year, her folks took her out of high school to take on more working hours. She had wanted to become a home economics teacher, and quitting school was an especially bitter pill. Fear was a constant companion. Home was especially unsafe. Work, although relentless, was a welcome respite from home, although, without a car, the 2 mile walk in the pre-dawn and late-night darkness were harrowing experiences. Thus, she ran to and from, a practice that served her well when on occasion a would-be assailant would decide to take advantage of a young, pretty girl walking alone on the highway. In true survivor fashion, Mom took respite in her mind, dreaming of a future that was calm, clean, and safe, where the things she worked so hard for were respected, and she was respected. 

I have recently become the Medical Director of a small CCRC.  During a zoom Q & A session with our residents, I was asked about my thoughts on the EOL Option Act (EOLOA).  Some vocal residents said this option should be more accessible.  They were aware that Kaiser Permanente members in my community can much more readily access it.  In fact, they said a KP member in our CCRC had recently executed this option with friends and family present and no apparent adverse events. 

Aducanumab is a monoclonal antibody targeting amyloid beta protein plaque breakdown. These plaques are a cardinal feature in Alzheimer’s Disease.  Aducanumab has raised controversy over both its safety and efficacy.¹ Safety is concerning for this monoclonal antibody as the drug can compromise the blood-brain-barrier with subsequent risk of asymptomatic intracranial hemorrhage or swelling in approximately 30-40% of patients, predominantly those patients positive for the APOE e4 allele with almost half of them discontinuing treatment .^1,3

California’s nursing facilities are anxiously awaiting any word about the requirement for a non-facility-affiliated patient representative to serve on every interdisciplinary team (IDT) convened to make decisions on behalf of an unrepresented, incapacitated resident.  It is hoped that a further delay will be granted for enforcement of this requirement (see below).  Under Health & Safety Code 1418.8 (the “Epple Law”), the IDT has been able to make decisions for such residents since the 1990s, but a 2013 lawsuit (CANHR v. Chapman and subsequent CDPH directors) resulted in a decision that brought that ability into question.  

I am part of Sonoma County’s Public Health COVID-19 learning collaborative in partnership with providers in the PA/LCT (Post Acute and Long Term Care).  We have achieved a high vaccination rate for those living in our facilities, but still have vaccine holdouts in about 10-25% of our staff.  With our state doing away with the restrictive tiers this month, the public can again go into most indoor establishments without a mask, if they are fully vaccinated.  With the increasing prevalence of Delta COVID variant (appears to be twice as transmissible as the original SARS-CoV2), is it safe for your unvaccinated staff, family, and friends to follow the new CDC guidance for public gatherings?