Is Good Geriatric Care Affordable?

by Timothy Gieseke, MD                                                                         

As an internist trained in the ’70s, the common mantra was “the patient’s interests always come first.” This was far easier to provide at that time with no limits on work hours, very limited personal educational and start-up debt, and a low-overhead, fee-for-service system.  As I became more involved in the post-acute and long-term care sector in the ’80s & ’90s, my knowledge and expertise expanded through educational offerings of CAMD (California Medical Directors Association, the precursor to CALTCM), AMDA, and AGS. I found great fulfillment in applying this developing expertise on behalf of my patients and facilities.  However, I also found my work efficiency (# of patients seen each day) progressively declined while office overhead rapidly increased. Because of the latter, I gave up my office practice in 2005 to focus full -time on post-acute and SNF care. However, I have been able to continue servicing a geriatric clinic at my CCRC in large part due to a generous contract from this facility for my group’s provider services.   Here, my usual patient is > 85 y/o and medically complex and routine appointments are 25 min. to allow for team-based care and teaching. In this setting, I commonly bill higher-level codes for my services and have the documentation to support those codes built into my EMR notes. In fact, Blue Cross recently sent me a letter informing I was billing higher-level office based codes then most of my IM colleagues, which did not surprise me.

End of Life Option Act Update

by Timothy L. Gieseke, MD, CMD

In California, this Option (physician aid in dying) went live June 9, 2016 for persons with less than 6 months to live and intact decision-making capacity.  By law CDPH reports annually by July 1 of each year data on the previous year’s statewide experience with this option. For the year 2017, 632 persons started the process and 241 unique physicians prescribed 577 aid-in-dying drugs.  62.9% died following ingestion of these drugs, 14.9% died without ingestion of the prescribed drugs, and the outcome of the remaining 22.2% was not reported (some may have taken it in 2018). Most of the individuals taking the drugs were in the 60-89-year-old age range (77%), white (88.9%), had some college education (72.7%), and were enrolled in hospice (83.4%).  The most prevalent illnesses identified were malignancies (68.5%), followed by neurologic disorders (9.4%) like ALS and Parkinson’s. You can read the executive summary on the CDPH web site at:

The Medical Records Minefield

by Flora Bessey, Pharm.D., BCGP

What do you know about the medical records department? How often do you interact with them? Do you see them only once every three months, at the quarterly meeting? To you, are they the annoying people that are always bugging you to sign documents? Do you appreciate how vital they are?

The medical records departments of our facilities are often misunderstood and underappreciated, yet they fulfill many incredibly important needs. And having a well-functioning and highly-trained medical records staff will lead to much better resident outcomes, as well as better performance on survey.

AB 937 Gutted and Amended

by Karl Steinberg, MD, CMD, HMDC

We are happy to report that as of June 18, 2018, Assemblymember Susan Eggman has withdrawn her bill, AB 937, that would have made it very difficult to change code status if a person made a request regarding resuscitative measures, then lost decisional capacity.  The WAVE has covered AB 937 in detail previously, so we will not go over the entire history here. However, this bill passed the Assembly last year with support from the Ombudsman Association, Disability Rights California, the California Lawyers Assocation’s Trusts and Estates Section, CANHR and others. CALTCM and the Coalition for Compassionate Care of California (CCCC) were the only organizations formally opposed, and the California Medical Association issued a letter of concern but stopped short of formal opposition.

Developing Meaningful Metrics for Post-Acute Care Provider Networks

by Timothy Gieseke MD, CMD

Recently, I read with interest a report on the efforts of the Cleveland Clinic and Baystate Medical Center (Massachusetts) to develop a preferred Post-Acute Provider Network.

In my area, both of the referral hospitals have been meeting with community SNFs to better coordinate care transitions and reduce readmissions.  I have been invited to attend one of the hospitals monthly care coordination meetings where the focus has been on presenting readmission data and attempting to understand what could have gone better.  In addition, there have been brief discussions on improving palliative care, diabetes care, and other clinical topics. I’m not aware of either hospital narrowing their networks of providers as in the above article, but suspect the discharge planners do have their preferences based on similar metrics.

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