New Frontier for Medically Complex Homebound at the Last 2 Years of Life

by Dan Osterweil MD, FACP, CMD

In an announcement on April 9, 2018, Health and Human Services Secretary Alex Azar appointed former Landmark Health CEO Adam Boehler as Director of the Centers for Medicare and Medicaid Innovation and as Deputy Administrator of the Centers for Medicare and Medicaid Services.  CMS Administrator Seema Verma made the announcement to staff by email on Friday, CMS confirmed. Boehler is founder and CEO of Landmark Health, a company that provides home-based medical care. Landmark is a medical provider group specialized in caring for complex, chronic patients. Our doctors and providers drive to patients where they live, bringing care through house calls. This home-based medical care is designed to help patients stay well and stay home. We have a multidisciplinary team and collaborate with our patient’s health plan to care for the whole patient, bringing medical care, behavioral health, palliative care and social support services to patients in the comfort of their own home—wherever and whenever they need it. This may be marking a true new direction in how HHS is viewing innovation in health delivery. Away from brick and mortar delivery systems like nursing homes, and other chronic care facilities and back to the home.

Challenges with Insulin administration: How to avoid an IJ!

by Flora Bessey, PharmD, BCGP

Those of us who have been in long-term care for awhile have seen the evolution in the treatment of diabetes, specifically insulin options. From “regular (short-acting)” to “NPH (intermediate-acting”) to “long-acting” to “analog (rapid and long-acting).” Patients with type 2 (or type 1) diabetes, and their health care providers, now have many options when choosing insulin.

Until recently, in our setting the administration of insulin was accomplished exclusively the “old-fashioned” way: with a vial and syringe. In the non-institutional world, however, patients were able to access an administration platform that is less cumbersome, and easier, for a non-clinician to utilize: insulin pens.
The Problem of Chronic Non-Cancer Pain

by Timothy Gieseke MD, CMD

Since the CDC guidelines for managing pain were published in early of 2016, state medical boards are increasingly scrutinizing physician practices to insure that we are managing acute and chronic pain in a way that minimizes the risk for opioid addiction and drug overdose death.  I have attached the CDC Summary Fact Sheet for these guidelines which unfortunately provides little guidance for the care of chronic non-cancer pain patients who are already on potentially unsafe doses of opioids.  The guidelines discourage a daily MME (morphine mg equivalents) > 50, but many of the patients I receive from the acute hospital for rehab are already on MME > 90- 100, which has an 8 times greater risk of accidental overdose. The CDC has a nice handout for Calculating Total Daily Dose of Opioids for safer opioid prescribing.  The CDC has a free new mobile app for android and apple phones called “CDC Opioid Guideline” which has a calculator within it.

Strange Bedfellows to Convene Before CALTCM Annual Meeting

by Karl Steinberg, MD, CMD, HDMC

Over the years, a perennial favorite educational activity at CALTCM’s meetings has been medicolegal and risk management sessions—often presented in a mock trial format.  This year, by popular demand, CALTCM has created an evening half-day pre-conference summit focusing on medicolegal risk management, and the nexus connecting quality of care, communication and documentation with improved outcomes and reduced exposure to civil and regulatory actions, including elder abuse lawsuits.  It will also provide information about the importance of the expert witness, including physicians, to the legal process.

Updates For Busy Physicians, Nurse Practitioners, Physician Assistants, Therapists and Other Clinicians (and Curious Administrators) On The Go!

by Albert Lam, MD

Saturday mornings at our CALTCM Annual Meeting are geared to deliver high yield updates for the clinician on the go.  Our planning committee is excited to offer six superb high yield updates separated into two back to back sessions.

The first half of the morning spotlights neurologic and rehabilitation care in post acute and long term care.  Dr. Randall Espinosa, clinical professor of geriatric psychiatry at UCLA, will be reviewing the types of dementias seen in nursing homes and connect the diagnosis with options for management and guidance for advance care planning.  After that, UCLA neurorehabilitation specialist Dr. Michael Su will update us on the latest in acute stroke management and how we should respond in nursing homes. Rounding out the 3 early talks will be physiatrist Dr. Lawrence Miller.  Dr. Miller will be reviewing common reasons for rehab in nursing facilities and we’ll learn about how to set reasonable goals in these situations.

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