A cootie-covid-catcher-fortune teller (CCFT) is a homemade tool designed to boost team morale.  When envisioning this device, I wanted to make something that we could all hold physically and share virtually, that encouraged play, that invoked comforting childhood memories, and that referenced the uniquely painful-but-funny moments of our work.  On the top CCFT triangles are the On Lok site names.  Like the cootie-catcher-fortune teller of our youth, one rotates the triangles to reveal a new set of choices, each related to an aspect of PACE care.  Pick a choice, flip it open, and get a funny fortune or anecdote.  Land on “incontinence supplies”? Watch out for “Out of pull-ups, CODE BROWN.”  “Telehealth” predicts that “Grandson zoom-bombs.”

I appreciate our readers who have pointed out that the term "unbefriended" in this article may be interpreted as a demeaning term, since many of these unrepresented patients are no longer able to access their prior friendship / family network and besides that, the key issue is they no longer have decisional capacity and do not have an identifiable representative.  In this day of implicit bias, I appreciate our readers who hold us to a higher standard for our communications that address problems in the delivery of healthcare in our state.  I also did receive feedback that the California Hospital Association is aware of this problem and is working with CDPH, CALTCM, and other stakeholders to identify acceptable patient advocates.  Several physicians have suggested recruiting local retired physicians through their medical societies.  Another has suggested developing a grant proposal at a county level to develop a patient advocate program.  I hope these ideas take hold, for our facilities really do need help accessing capable patient representatives for this relatively common problem.

When COVID-19 exploded last March, my community went to work attempting to keep COVID out of our facilities.  We developed county-wide virtual learning collaboratives for Assisted Living (AL) communities and for SNFs, which met on a weekly basis.  By the end of June, we had done well with no outbreaks and only 4 deaths in the county.  Unfortunately, last summer’s surge in COVID prevalence shattered the myth that we had done enough to contain it.  Like the rest of our state, we pivoted to follow guidance focused more on infection control and early recognition of outbreaks.  By the end of October, we seemed to be back in the driver’s seat with much better facility COVID metrics.  However, with the winter surge, we are stretched thin on staff, resources, and again wondering when the bad news will end.  In my county, we have now have had 196 deaths, and 70% of them have occurred in senior congregate living facilities.  

The FDA has given EUA (Emergency Use Authorization) for bamlanivimab (Lilly) or the “cocktail” of casirivimab and imdevimab IV infusions for mild to moderate COVID-19 patients.  These monoclonal antibodies block the binding of the spike protein to the ACE2 receptor on the human cell, which blocks viral attachment.  If given early (within 10 days of symptom onset), both medicines have been shown in high-risk adults to reduce the viral load and risk of progression to severe COVID-19, and reduce the necessity for ED visits and hospitalization.  However, they didn’t help those already hospitalized and outcomes were worse in those receiving high-flow oxygen or mechanical ventilation.  Experts suspect that infusions given within the first 3 days of symptoms will be more effective than when given later.  This is similar to what we have experienced with the use of oseltamivir (Tamiflu) in Influenza or antivirals with shingles.