by Chris Mlot MD, CMD

It’s been so long now, I hardly remember the exact year. 1993 to 1996, I was the Medical Director for FHP’s 99 bed freestanding SNF in Westminster Ca. Truth be told, besides the nursing home in Chicago that I had visited my grandmother in once, prior to 1993, I had never stepped foot into a nursing home let alone an HMO’s skilled nursing facility which was a clever disguise for a 99 bed med-surg floor. I had never treated a decubitus ulcer or dealt with a feeding tube. Sometime prior to 1996, a persistent and remarkable doctor from LA by the name of Wing Mar called me and convinced me that I needed to join the CAMD, the California Association of Medical Directors. He said it was a group of long term care doctors working to improve the care in nursing homes. Long term care, nursing homes, nursing home doctors- my curiosity was peaked.

I was on a steep learning curve as I became immersed in the mysterious and seemingly irrational world of long term care. I didn’t understand exactly how my facility fit into Long Term Care, as we processed about 180 new admissions a month and nobody stayed longer than 100 days. But we were subject to things like Title 22 and Resident Rights and a dreaded annual event called “Survey”. I was suddenly working with nurse practitioners, speech therapists, and a person called The Administrator. So I joined CAMD.

by Jay Luxenberg, MD

As California moves forward with plans to enroll all dual-eligible (those with both Medicare and MediCal insurance) into managed care, a milestone was reached with the announcement on April 4, 2012 of the first 4 counties that will serve as the pilot for statewide implementation. Of course, since the four counties chosen (Los Angeles, Orange, San Diego and San Mateo counties) house approximately 50% of all California dual eligibles, perhaps the term “pilot” is misleading. Also announced were an additional 6 counties that may be implemented at the same starting date (January 1, 2013) if authorized by legislation - San Bernardino, Riverside, Santa Clara, Contra Costa, Alameda and Sacramento.

In October 2011, CMS indicated that it was considering mandating the separation of a facility’s consultant pharmacist from its long term care dispensing pharmacy. In April 2012, CMS reached the conclusion that this transition would be disruptive and would not solve the issue of chemical restraints.

Instead, CMS is extending the comment period and encouraging the separation but not insisting on it. CMS has restated the importance of paying “fair market” value for consulting services. Additionally, CMS is encouraging the consultant pharmacist and the facility to reach an integrity agreement to avoid any conflict in interest.

Jay S. Luxenberg, MD

It seems like every decade or so we have a new iteration of the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. The last one was in 2003, and now we have a new update with a handy, dandy pocket guide and promise of a mobile app clinical tool in the near future. I think that the impact of the new criteria will be fostered by the fact that more and more of us are using electronic health records. I used the criteria to generate some reports, and found plenty of room for improvement. The latest iteration both eliminates references to archaic drugs and adds reference to many new drugs. The criteria take into account recent studies and black box warnings. For example, for antipsychotics the criteria state, "Avoid use for behavioral problems of dementia unless non-pharmacologic options have failed and patient is threat to self or others." Note that "and" – they are really saying that unless the patient is a threat to self or others, then antipsychotics should be avoided – that is a step beyond previous advice that simply said when non-pharmacologic approaches failed to eliminate the troublesome behaviors. If you haven't had a chance to review these new recommendations, please take this opportunity to download them. I am sure there will be discussion of aspects of the new recommendations at our national meetings and at the upcoming CALTCM 38th Annual Meeting.