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. 

ALERT: Requirement for Patient Representative is delayed 12 more months for 1418.8 (Epple) decision-making.

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?

Parkinson’s Disease (PD) is a progressive neurodegenerative motor disorder with the classic triad of symptoms of bradykinesia, resting tremor, and rigidity. The prevalence for PD increases with individuals ≥ 80 years with the incidence estimated at 1903 per 100,000 population.^1,2

On May 28, the CDC updated its guidance for fully vaccinated people in non-healthcare settings.  While this is good news for healthy independent living seniors and for our staff and their families, this guidance assumes that the prevalence of COVID in your communities is low and that people with compromised immune systems are continuing to minimize their risk of COVID exposure.  The high risk settings remain indoors with poor ventilation and large gatherings of people some of whom may not be vaccinated.  Indoor activities that increase COVID transmission risk include close gatherings with:  singing, shouting, and aerobic exercise.  

Every part of medicine has seen disruption in this past year and we have all had change forced upon us. In hospice we have struggled with our patients dying alone, the family frustrations of not being able to see their loved ones at end of life which is complicating their grief process. Many of our team members have been very removed from their ability to reach patients and this has added to the Hospice Team’s stress.

CALTCM, to use a boxing term, has “punched above its weight” throughout the COVID-19 pandemic. So many of our members have put in countless hours, all in service to our mission and vision, which is always worth noting:

On May 17, CALTCM sponsored an excellent webinar on Systemic Racism and Microaggression in PALTC: A Call to Action.  This recording is available on the CALTCM website.  Some of the actions suggested by Dr. Philip Sloane were to create a universal Long-Term Care benefit, increased Medicaid rates, improved resourcing and support for low performing nursing homes, and increased pay and benefits for CNAs.  While likely to reduce racial disparities, these interventions are unlikely to occur in the near future.  We can hope MediCal rates may improve, especially if there are enhanced financial public reporting requirements for related ancillary businesses (as would occur if California’s AB 650 [Stern] were enacted). 

Crosshairs (noun); a pair of thin wires in the shape of a cross that you see when you look through a gunsight (Oxford Learners Dictionary, 2021). 

The CALTCM Wave would like to take a few moments and introduce you to CALTCM’s new CEO, David Quackenbush.  Many of you have had the pleasure of being virtually introduced to David during the April 19 webinar, and below David shares more about his background and his vision for CALTCM.

In April, a special article appeared in JAMDA (Journal of the American Medical Directors Association) titled, “Addressing Systemic Racism in Nursing Homes:  A time for Action”.  While this article is copyrighted, it may be worth purchasing if you are not already a subscriber.  Table 1 outlines the Structural/Institutional, Cultural, and Interpersonal manifestations of racism in our facilities.  Figure 2 outlines how these factors have operated at a policy and operational level.  

CALTCM’s Public Policy Committee has been quite busy over the past several months, advocating for our members and the residents we provide care for. We are the proud sponsors of AB 749, a bill that requires nursing home medical directors in California to be certified by the American Board of Post-Acute and Long Term Care Medicine. In the early days of the pandemic, some of us were faced with pressure to admit COVID patients to our facilities. CALTCM members warned that “if you send us five, we’ll send you back 20 within a week.” Sadly, we were prophetically right. Many of us also advocated testing of all staff in order to identify outbreaks early. Because of our training, we knew what to do, and we had varying levels of success in limiting outbreaks at our facilities. Our actions saved lives.

Yesterday, the CDC’s HAN (Health Alert Network) issued a detailed report regarding their recommendation to pause administration of the Janssen (J&J) vaccine (see link to this report).  The CDC has now received VAERS reports from 6 women ages 18-48 of serious clotting events after the administration of 6.85 million doses of this vaccine (as of 4/12/21).  These events appear to have been triggered by the development of platelet-activating antibodies against platelet factor 4 (PF4), which is also known as heparin-PF4 antibody.  This may trigger Vaccine-induced Immune Thrombotic Thrombocytopenia (VITTP) which can have serious CNS consequences (1 death so far).  This association is quite rare at ~ 1 case per million vaccinations.  A similar problem has been seen with the AstraZeneca vaccine, which is also a viral vector vaccine (AD26), but hasn’t been seen in the USA or internationally with the Pfizer or Moderna mRNA vaccines.  The key issue for the CDC and ACIP at this point, is the possible under-reporting of this association.  Because these events occurred 6-13 days after vaccination, the development of this rare problem may not have been linked to the vaccine.  Hopefully this HAN report will bring in more VAERS reports to allow the CDC to provide more precise information on the real risk of this event in persons receiving the Janssen vaccine.  To put this preliminary risk in perspective, the known risk of “unvaccinated persons” aged 18-48 dying of SARS-CoV2 is 125/million, which is a vastly greater than the risk of acquiring (much less of dying) of VITTP.  

Californians spent more than $11 billion on nursing home care in 2019 but low nurse staffing levels and quality of care problems have persisted in many homes over the years. The COVID-19 pandemic exacerbated these staffing and quality problems and resulted in over 61,000 resident infections, about 9,000 resident deaths, and over 50,000 staffing infections by February 2021.  While nursing homes claim that payment rates are inadequate to improve staffing and improve care, it is not clear how the current nursing home payments are being spent.  Nursing homes often use complex ownership structures to shift money to “related parties,” such as corporate home offices, property companies, and management companies and to hide profits and support facilities’ claims for increased public funding.  

Last December, I provided vacation coverage for a physician with a PA/LTC practice.  Because of the pandemic, I obtained the agreement of the facility administrative team, that our first approach to changes of condition (COC) would be a telemedicine visit, rather than the usual triage by fax or phone. 

With the remarkable efficacy of the mRNA vaccines and the newly available one shot, standard refrigeration Janssen (Johnson and Johnson) vaccine, many in long-term care are wondering if healthcare personnel (HCP) should be mandated to receive vaccines.

San Diego’s nursing home residents were early recipients of the coronavirus vaccine. In recent weeks, most nursing home seniors and staff eagerly lined up to be vaccinated at their facility by either CVS or Walgreens. Nursing home staff members also shared with me that some people felt hesitant about receiving the vaccine.

The Population Health team uses motivational interviewing skills that incorporate certain words, phrases, and motivators to engage and encourage patients to complete all needed care and immunizations. Recently the Public Health Communication Collaborative shared a national poll entitled “The Language of Vaccine Acceptance." The poll identifies the language most effective to improve confidence in COVID-19 vaccines.

Family is by far the most powerful motivator word for vaccine acceptance. Significantly, more Americans said they would be more willing to take the vaccine “for my family" as opposed to “for my country" or “for the economy." The wording and reasons demonstrated to be most convincing were: