New to CALTCM or the annual meeting?  Nursing home and PALTC medicine can be lonely. We don't always have a chance to meet others to share our problems and best practices while getting interesting continuing education credits - especially during the last 18 months. This meeting was created for a virtual setting and is set up for busy professionals. We ask our speakers to distill two hours of content to 15 minutes, and this process assures you get the most critical information.

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. 

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.