On November 11, 2022, the OIG (Office of Inspector General) released a report on the Long-Term Trends of Psychotropic Drug Use in NH.  From the years 2011-2019, the use of antipsychotic medications declined from 31% to 22%, while the use of anticonvulsants increased from 28% to 40%.  In 2015, CMS began using the long-stay quality measure that tracks MDS reported antipsychotic use in the NH in its Nursing Home Five-Star Quality Rating System calculations.  Between 2015-2019, the number of NH residents reported as having schizophrenia increased 35%.  Additionally over this time, the number of residents reported as having schizophrenia but lacking a corresponding diagnosis in the Medicare claims and encounter data increased by 194%.  A small fraction of US nursing homes (99) had particularly high levels of MDS reporting of Schizophrenia (> 20% of their residents) w/o corresponding preceding diagnosis in Medicare’s database.

One year ago, CALTCM members received an alert that the Alameda County Superior Court issued a modified judgment in the 2016 CANHR v. Angell case.  That order granted another 12-month extension for the requirement for nursing homes to include a non-facility-affiliated patient representative on the interdisciplinary teams (IDTs) that are making medical decisions that require informed consent for incapacitated unrepresented residents. The extension was due to expire this month.  

In October 2021, palliative medicine heavyweights Drs. Sean Morrison, Diane Meier, and Bob Arnold published a Viewpoint piece in JAMA Network with the provocative title, “What’s Wrong With Advance Care Planning?” https://jamanetwork.com/journals/jama/article-abstract/2785148  Dr. Morrison has published and presented in multiple venues on this topic for the past couple of years, repeatedly ACP-bashing and comparing advance care planning to your family’s “old Pinto,” that you keep pumping money into for repairs even when it’s clear the car is all washed up and beyond repair.  The motivation for these apparent attacks on ACP seems to stem mostly from frustration that millions of dollars of research funding have been spent on ACP research, despite the somewhat disappointing results of many of these studies.  No doubt some of our WAVE readers will remember this article, and I encourage those who haven’t read it to actually read the short article, and especially read the excellent comments several people have appended to the site. 

Two years ago, I retired from an internal medicine practice in the SNF setting with emphasis on Medical Direction, Geriatrics, and Palliative Care.  Last month, I worked 3 weeks providing vacation relief and noticed how “depersonalized” the medical records have become at the acute hospital and SNF levels.  I suspect this is a reflection of our adaptation to EHRs and the perceived need for providers to become more time-efficient.  One of the things I reintroduced into these facilities was the value of the patient’s story.  This is fundamental to establishing working relationships with our patients and their families.  The story is also fundamental to the diagnostic process and leads us away from prescribing more drugs for new symptoms to a more-cost effective and better understanding of the potential causes of the patient’s symptoms.  

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).

“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. 

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.

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

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.

I wanted to start this year with a grateful word of thanks to all of our CALTCM members. Our CALTCM friends and family are leaders in medicine, nursing, administration, pharmacy, social services, ombudsman, and more who believe in quality and safety in post-acute and long-term care.  Your efforts help CALTCM serve as the medical voice of long-term care in California.  Your work through the pandemic has been heroic and the sacrifices have been many.  

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.  

Since the SARS CoV-2 virus arrived in the USA last winter, our lives have been disrupted in many ways.  We are currently in a Winter Surge that has locked down most of the state.  The latest statistics on COVID activity show a doubling or tripling of cases in most of California in the month of December, which greatly increases the risk of outbreaks in our post-acute and long-term care settings.  As of 12/10, the USA had 15.6 million confirmed cases and 294,000 deaths.  Though only 6% of the cases have been in post-acute and long-term care (PALTC), including skilled nursing facilities (SNFs) and assisted living communities (AL), our residents have had a hugely disproportionate 34% of the deaths.  As of Friday, December 11, over 100,000 persons with COVID in the USA were hospitalized and 21,000 were in ICU beds. In California, we had 33.500 new cases reported over the preceding day.  

Prior to the pandemic, most of the SNFs in Sonoma County had applied for waivers, because they weren’t able to staff CNAs at the required 2.4 FTE state standard.  I heard one administrator comment that the website “Indeed.com” had become a main source for attracting CNAs from other SNFs.  In our area, we do have a training program for CNAs through partnerships of facilities with the Red Cross and the local community college, but the number of CNAs attracted to this track has been small.  Since the COVID pandemic, our CNA shortage has been aggravated by concern for personal safety, complicated sick leave policies, inconsistent work hours, and the realization that those working in multiple facilities had a much higher risk of transmitting COVID.  

The 9 page (AFL-20-53 ) update should be studied by management in the SNF and hospital setting since it sets expectations for testing during care transitions, dialysis care, and outbreaks.  In addition, it creates a new expectation that all HCP will be tested weekly, even when in surveillance mode.  The guidance allows for routine use of Antigen testing rather than exclusive use of RT-PCR testing.  This should allow facilities to have immediate test results.  The tracking and reporting requirements for testing results in symptomatic and asymptomatic persons are also addressed.  

The Covid-19 pandemic has radically changed how providers deliver health care.  Realizing that in-office and in-facility clinical care risks transmission of SARS-CoV2, CMS has removed all restrictions on the adoption of Telemedicine.  Multiple organizations including CALTCM, AMDA, and AGS (American Geriatric Society) have provided helpful webinars and resources that have helped providers implement Telemedicine in their work flow.  Understandably, seniors have had difficulty embracing this technology.  Medical offices have enhanced their MA’s (Medical Assistant’s) training so they can contact patients prior to the telemedicine visit, to help them with technical issues and to gather pertinent information for that appointment.  

The NEJM Online June 3 edition reported a study from the University of Washington and United Health Group comparing the efficacy of COVID-19 testing in 530 subjects by nasopharyngeal swab vs. patient-collected anterior nasal swab, or mid-turbinate swab, or tongue swab.  This well-done study found similar sensitivity and specificity to that of our gold standard for RT-PCR testing, the  uncomfortable and universally detested nasopharyngeal swab.  An audio interview with Editor-in-Chief, Dr. Eric Rubin, and Deputy Editor, Dr. Lindsey Baden, endorsed these alternative collection sites.  Since that study, the public health departments of San Diego and Contra Costa Counties have approved the anterior nasal site as a collection option for SNF patients and staff.  PPE isn’t required for patient-collected swabs, and adherence to our mandated and recommended testing protocols will likely be better.  

SNFs are now required to report patients under investigation for COVID-19 (PUIs) and actual COVID 19 cases among their residents and HCWs (Health Care Workers).  The report is updated every working day (https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/COVID-19/SNFsCOVID_19.aspx ) and indicates that over 20% of our SNFs have one or more cases associated with their facility.  

The World Health Organization has recognized what experts in geriatrics and long term care medicine have known for over two months.  Unfettered COVID-19 infections are devastating to nursing homes and assisted living facilities.  Reports are finally coming out that more than half of the reported deaths have occurred in senior congregate living settings.  It is quite likely that the number of deaths is still far underreported.  Only when the epidemiologists review all of the deaths across the U.S. and the world during this pandemic will we have the true answer.  The sad truth is that the experts in our field already know the answer.  We’re just waiting for corroboration.

The Wall Street Journal reported on April 11 that over 2100 skilled nursing and assisted living facilities in 37 states had been infected with SARS-COV2 with over 2,000 deaths occurring. In Sonoma County, we have developed 2 workgroups for coordinating, disseminating, and implementing best possible practice ideas.  One workgroup consists of Leadership from Public Health (PHD), skilled nursing facilities (SNFs), Hospitals, and Foundations. The other has leaders from the assisted living (AL), residential care facilities for the elderly (RCFE), and Senior Living Communities.  In the latter group, we were relieved to learn that our county just developed a contract with Sonoma State University to house up to 580 seniors with stable COVID disease so they can be quarantined outside their home facility, reducing the risk of COVID transmission within this high risk population.