As of July 27, 2022, over half of the 342 skilled nursing facilities (SNFs) in LA County are experiencing active COVID-19 outbreaks, which is the highest level of transmission since the surge last winter. All patients in SNFs are at high risk for progressing to severe COVID-19 if infected. Fortunately, there are now outpatient COVID-19 treatments such as oral antivirals that are easy to administer and can reduce the risk of poor outcomes, including hospitalization and death. Despite the wide availability of oral antivirals, they continue to be underutilized in the nursing home population. To close this crucial gap and significantly improve outcomes in this vulnerable population, Los Angeles County Department of Public Health issued an update on July 25, 2022 to the Order of the Health Officer for Control of COVID-19: Prevention of COVID-19 Transmission in Skilled Nursing Facilities requiring all SNF patients with a positive SARS-CoV-2 viral test to be immediately assessed by their healthcare provider for any symptoms of COVID-19. Oral COVID-19 antivirals should be initiated at the facility within 5 days of symptom onset if clinically appropriate, i.e., they have mild or moderate symptoms and there are no contraindications. Please do not transfer residents to hospitals solely for treatment of mild or moderate COVID-19. These residents should be treated at their SNF. Even if you are not practicing in Los Angeles County, CALTCM agrees that all PALTC medical directors, attending physicians and practitioners should evaluate every case of COVID for the potential ordering of therapeutics including Paxlovid.  Please work with SNFs where you provide care to help meet this recommendation and provide optimal care for your patients.

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 recent years, seniors are voting with their feet.  We are living longer and becoming more disabled along the way.  These functional declines are often subtle in onset and progression, but eventually cause many to embrace some form of congregate living.  For many, the lower cost social model with more choices has been more attractive than the medical model of nursing homes.  Many ALFs (Assisted Living Facilities), RCFEs (Residential Care Facilities for the Elderly), and Memory Units now care for residents with similar medical complexity, polypharmacy, and functional decline as those living in SNFs. 

Since the California Court of Appeal ruled on the CANHR v. Smith case in late 2019, and since early 2020 when the state Ombudsman’s office prohibited their ombudsman from participating in IDTs where medical decisions would be made for incapacitated unrepresented nursing home residents, California’s skilled nursing facilities have been awaiting the implementation of a brand-new office to help with these decisions.  

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. 

During the current Omicron surge, COVID-19 vaccines (primary series and boosters) are an essential way for our communities to stay healthy. We would like to share COVID-19 vaccine resources for long-term care facilities (LTCFs) and your members. 

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.

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.  

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.  

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). 

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.

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.  

The NY Times research illustrates what we have known for a few years now. A nursing home’s Care Compare 5-Star rating is both a quality measure and a financial measure. And a nursing home QAPI committee that focuses on their Care Compare rating and implements performance improvement projects based on their ratings has the spillover effect of also improving their bottom line.

In the recent JAGS article- Montoya A, Jenq G, Mills J, et al. Partnering with Local Hospitals and Public Health to Manage COVID-19 Outbreaks in Nursing Homes (J Am Geriatr 2021; 69(1):30-36), a COVID-19 outbreak investigation in Michigan skilled nursing facilities was the spark for a collaboration of interest to our members. Following the outbreak, testing was performed to determine the in-house prevalence of COVID-19. Residents testing positive for the virus were then divided into cohorts in COVID-19-dedicated units. The article shows the importance of investing in stakeholder relationships and open lines of communication. California health systems should anticipate requests for help from SNFs, and should proactively reach out in response. SNF leaders and staff have experience in providing care for medically complicated elders with functional and cognitive support needs. In turn, SNFs would greatly benefit from help provided by local health systems in terms of infectious disease experts, personal protective equipment (PPE), access to testing, and clear communication protocols during transitions to and from nursing homes. In addition, the importance of integrating nursing home data with other healthcare data is emphasized. Examples of best practices to mitigate the impact of COVID-19 on SNF residents, as described in this article, should inspire healthcare stakeholders to create meaningful, mutually beneficial relationships across settings to improve patient care.