Brexpiprazole (Rexulti) was recently approved by the FDA for treatment of agitation in Alzheimer Dementia based on the now published phase 3 study found in JAMA Neurology, November 6, 2023. In this 12-week study of the efficacy of this medication at the 2 and 3 mg daily dose compared to placebo, a statistically significant improvement in agitation was noted vs placebo. This medication was generally well tolerated without significant safety adverse events.  Agitation was defined as 1. excessive motor activity, 2. verbal aggression, or 3. physical aggression which caused excess distress or disability and could not be safely attributed to a suboptimal care environment or another disorder.  This is a small short-term study across multiple sites and countries.  This medication should be used for this indication with great caution until further studies confirm these results and better define those who might benefit, the degree of the benefit, and if significant long term adverse events occur with more prolonged use.   This medicine has common drug interactions that warrant dose adjustment in many circumstances.  This link has the details.

At a recent meeting of a local hospital with its SNF partners, a hospitalist made an appeal for SNFs to remove peripherally inserted central catheters (PICC) lines and Foley catheters when they were no longer necessary, since hospitalists were seeing this as a potential cause of readmissions.  After the meeting, we chatted and I discovered he was a Medical Director of a SNF, a member of CALTCM, and had signed up for the AMDA Foundation’s “Futures” program that will meet in San Antonio in March 2024.  I wish that I could have “bottled” his passion for high-quality medical care in SNFs.

At a recent Sutter Hospital meeting with their SNF partners, we were informed that our next meeting would focus on their new initiative to provide optimal transitions for patients with heart failure hospitalizations.  Many of those in attendance were perplexed by this development, since they thought they were already doing that.  

1st Place - 2023 Poster Session Winner

PALTC is a complex setting and as medical directors, clinicians, and team leaders we are often pulled in multiple directions.  The issue of antipsychotic use is just the tip of the iceberg for Behavioral Health.  Antipsychotic use continues to grab headlines due to changes in regulations and public concerns.  There were several presentations at the CALTCM Summit of Excellence, November 2-4, 2023, on Behavioral Health. For clarity, the difference between mental health vs. behavioral health is that behavioral health includes mental health and substance use disorders. 

CALTCM’s Public Policy Committee (Policy & Professional Services Committee) has been very busy!  

No, would have been my answer 20 years ago.  I had “Doctor’s” handwriting hardwired before I finished elementary school.  Writing in college was painful with so many typing errors to erase.  As a physician, I was too busy taking care of patients and attending hospital meetings. However, over time, I began writing short articles for patient education on various topics, since more of our best outcomes occur when we empower our patients to better self-care.  

Support your OWN well-being while you learn to enhance others’ at this year’s 2023 CALTCM Summit for Excellence

At a recent Town Hall meeting for a CCRC (Continuing Care Retirement Community), I encouraged the residents to read a well-done flier from Front Porch and another one from the CDC on what they could do to reduce their fall risk.  Though these documents had been posted in their facility, most were unaware of them.  At that point, I stated that falls were the greatest risk to my future health and life expectancy.  That may have seemed like an out of place comment, but it certainly got their attention.  The administrator agreed to send both documents to their mail boxes (see attached flyers).

Several years ago, the California Partnership for Improved Dementia Care concluded that the pandemic associated SNF staff shortages, would create a need for dementia education for the many new hires, as well as updates for continuing staff.

Join Us at the 2023 CALTCM Summit for Excellence! 

I recently opened a hospice case for a person with end-stage heart failure who said, “I don’t like my cardiologist.”  This person felt abandoned and left without hope.  Serious illness conversations may be difficult not only for the patient, but also for the provider.  This cardiologist didn’t avoid the conversation, but could he have more effectively communicated this bad news and the potential benefits of hospice care? 

Our state's QIO (Quality Improvement Organization) is HSAG (Health Services Advisory Group).  They have developed a series of 30-minute Webinars called Quickinars that are focused on Improving Care Transitions.  As a part of this series, they have developed a free QIIP (Quality Improvement Innovation Portal) which allows a facility and their hospital partners to share patient protected standardized readmission data that permits hospitals and their SNF partners to identify opportunities for improving care transitions. 

Happy Fall to everyone – CALTCM is moving strongly forward in amazing ways. It has been a very busy, exciting year. The grant team we formed managed to obtain a CDPH grant to educate one- and two-star nursing facilities on leadership from an infection prevention perspective. I’m very proud and want to express my sincere gratitude to all the faculty and administration for stepping up and creating a fabulous experience for these 3 cohorts, totaling 30+ facilities in need of guidance. Mike Wasserman and Barbara Hulz have gone above and beyond in preparing for these trainings. Thank you to all involved. 

As an attending physician and a Medical Director, I attended an AMDA Webinar on Resident-to-Resident Aggression in the Spring of 2022.  The presentation by a team at Cornell University in New York shared videos of persons with dementia responding to escalating resident to resident tensions during everyday meal times and social events.  The escalation was missed by the staff and resulted in reportable adverse events.  In reflecting on these videos, I became convinced that I and the staff in my facilities were missing opportunities to improve resident-to-resident relations by trainings that identify accelerating resident tensions and introduce deescalating strategies.  Another webinar attendee, KJ Page (prior CALTCM Leadership Award winner), noticed I was on the webinar, affirmed my impression, and began an implementation process in her facility.

Time and money are both limited resources. There are myriad professional meetings that we can choose to attend each year, but we usually must narrow those choices to a precious few or even only one. For many professional topics, I usually pick a national or international meeting to get the broadest exposure to important information. When it comes to long term care topics, though, I pick the state meeting – in this case, the CALTCM annual meeting. The reason is that nursing homes are predominantly regulated by the state, and assisted living (RCFE in California) is entirely regulated by the state. It is important for me to keep up to date on the latest state regulations as well as any pertinent pending legislation. The CALTCM meeting gives me the scientific and clinical content relevant to long term care that I want, while also giving me the chance to learn the latest that affects California facilities. Generally, there is a healthy attendance and participation by some of our regulators, and I find it invaluable to hear what they have to say. I also relish networking with colleagues from across the state, in a way that larger national meetings make much more difficult. Unlike some meetings that are predominantly or entirely one discipline, the CALTCM meetings are fully interdisciplinary. I truly believe that if you are working in or interested in long term care, the most important meeting for you to attend is the CALTCM annual meeting. 

The Medication Access and Training Expansion (MATE) Act went live June 27 and requires all DEA-registered providers to complete eight hours of training on opioid or other substance use disorders prior to renewal of their DEA License.  The exclusions include all practitioners graduating in good standing within the last 5 years, board-certified addiction specialists, and those with prior X-waivers.  

Last year, cases of RSV in children and adults accelerated over the summer into the fall, raising a concern about a “Triple-demic” (COVID, Flu, & RSV).  Fortunately, for unclear reasons, RSV cases declined as winter set in. 

On June 15th, the FDA asked drugmakers to update the COVID Booster to target XBB 1.5 and no longer target the Wuhan strain. This monovalent mRNA vaccine has already been field tested by Pfizer and Moderna and should be available by early September. Novavax will also have their booster available this Fall. This monovalent booster vaccine will replace the current bivalent booster.

As one of the seven virtues, gratitude is described by Cicero as “not only the greatest of virtues, but the parent of all the others”. Gratitude involves a sense of thankfulness or appreciation for the goodness, kindness, and ‘gifts’ we’ve received from others. In many ways, gratitude helps us to move forward and to connect with others on a deeper, more meaningful level, particularly in times of challenge.