Deprescribing involves a systematic review of medications and identifying those medications with a high potential risk of harm and low benefit to the individual patient when incorporating the goals of care, safety, life expectancy, values, patient preferences, and level of functioning into the decision-making for discontinuing medications.1   According to Scott, et.al., an alternative definition of deprescribing includes: “Deprescribing is not about denying effective treatment to eligible patients. It is a positive, patient-centered intervention with inherent uncertainties, and requires shared decision-making, informed patient consent and close monitoring of effects.” 

On September 22, 2020, the California Department of Public Health posted this all-facilities letter (AFL 20-73), available at https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-78.aspx.  This letter provides guidance to nursing homes about the importance of person-centered advance care planning, including ensuring that current treatment preferences in light of COVID-19 are reflected in up-to-date treatment orders.  

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.  

On March 9, CALTCM produced our first webinar on COVID-19.  On August 31st we produced our 21stwebinar.  It truly has taken a village of volunteers.  Some of the webinars attracted a thousand-plus attendees.  Over 200 people participated in our most recent webinar, which is a remarkable achievement in view of the abundance of information that is available online.

Please click on the link to the ABC news video and report on the letter writing project that these sisters operationalized not only for their loved one, but also for those who need loving through pandemic spawned isolation.  Then click on their web site and take action.

My 10 grandchildren are all in “virtual” school for the coming year, but I do remember an advance in responsible parenting, which was applied to the care of the grandkids 10 and under.  It’s a technology that has now become standard for most parents, called “baby cams.”  This has allowed “never out-of-sight or sound” parenting on a 24/7 basis as long as this device is being used.  

Our community is experiencing a surge of COVID in our Senior Living Facilities with the vast majority of cases traced to asymptomatic HCWs, particularly those working in multiple facilities.  This problem is further compounded by delays in reporting the results of mandated HCW COVID testing as long as 10 days.  Our contact tracing suggests that much of the initial infection of HCWs is occurring in the home setting where there is intergenerational living and multiple relatives living in close proximity.  We have traditional sterile hygiene measures expected of HCWs going from one facility to another, but know that transmission risk during intimate care may occur through medical masks, which may be only 45-70% effective in containing the virus, versus 95+% with certified N95 masks that have been fit tested.  

What do the above scenarios have in common?  Under the new abuse regulations, each one must be reported and investigated as potential abuse, neglect, misappropriation of resident property or mistreatment.   And if YOU hear about them, then YOU are a mandated reporter.

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.  

One of the frustrating aspects of mitigating the impact of the COVID-19 pandemic on our post-acute and long-term care (PALTC) facilities has been the difficulty that each entity has had procuring adequate PPE to protect their health care workers (HCWs) and residents.  As I look at my community, the acute care hospitals have had sufficient PPE to meet their needs for about the last 7 weeks, but not enough PPE to share with our PALTC providers.  Our local health department (LHD) has created a real-time inventory of each facility’s PPE and has been working hard to procure sufficient PPE to direct to a facility when there is an outbreak.  

CALTCM has been advocating for a strategy involving State-led PPE procurement as part of our Quadruple Aim for combating the COVID-19 pandemic. 

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. 

On February 29th, the first case of COVID-19 was announced, occurring in Washington state in the Kirkland nursing home.  Geriatricians around the country immediately knew what this meant. CALTCM went into action and had our first webinar on March 9.  It’s six weeks later and we’d like to give everyone direction. For anyone who has not watched our webinars, we will redirect you to the most important, in the order that they should be watched.  Keep in mind, if you’re already far along the curve, some of this might seem remedial. We can assure you, it’s not.   

Note: This article was prepared by Mr. Horowitz and Dr. Ferrini with special thanks to Dr. Robert Gibson PhD JD, Psychologist, for his input. 

Our country now has the distinction of having the most COVID cases in the world.  Our response as a nation is a stress test that has exposed our lack of a coordinated system of health care in this country.  In my community, there remains a shortage of naso-pharyngeal swabs, a public expectation of easy access to testing (County Public Health Department can do 100-120 tests per day), and many facilities still don’t have real-time access to adequate PPE.  Because of the lack of PPE and nasopharyngeal swabs, testing in some facilities for influenza/RSV/Other viruses is not being done. There appears to be an over-reliance on quarantine of residents with respiratory illness as well as shelter-in-place strategy to keep their facilities COVID-naïve.

Nursing homes are always “putting out fires.”  That excuse is often used to avoid addressing critical issues.  There’s a reason that the federal Requirements of Participation recognize the need to have a person in a nursing home tasked with infection control. That person is designated as the Infection Preventionist, or IP.  Who normally does that job?  It might be an RN or an LVN.  It is often the Director of Staff Development, or DSD.  Infection control is usually one task among many for the person typically designated to be the IP.  How does that work? Is it enough?

At CALTCM, we are very concerned for the welfare of our very vulnerable post-acute and long-term care (PALTC) residents, families, and staff.  Because the world in our lifetime has not experienced such a rapidly moving and serious pandemic, CALTCM presented a Webinar on the COVID-19 coronavirus last Monday which was well attended (over 900 registrants) and is currently available to the public at no charge (for a limited time only) with additional resources on the CALTCM COVID-19 webpage.  Since that time, more important tools and information have become available.  The CDC now has posters and handouts on COVID-19 available on their web page in multiple languages that could be used for staff and visitor education.