As an attending physician and a Medical Director, I attended an AMDA Webinar on Resident-to-Resident Aggression in the Spring of 2022.  The presentation by a team at Cornell University in New York shared videos of persons with dementia responding to escalating resident to resident tensions during everyday meal times and social events.  The escalation was missed by the staff and resulted in reportable adverse events.  In reflecting on these videos, I became convinced that I and the staff in my facilities were missing opportunities to improve resident-to-resident relations by trainings that identify accelerating resident tensions and introduce deescalating strategies.  Another webinar attendee, KJ Page (prior CALTCM Leadership Award winner), noticed I was on the webinar, affirmed my impression, and began an implementation process in her facility.

Time and money are both limited resources. There are myriad professional meetings that we can choose to attend each year, but we usually must narrow those choices to a precious few or even only one. For many professional topics, I usually pick a national or international meeting to get the broadest exposure to important information. When it comes to long term care topics, though, I pick the state meeting – in this case, the CALTCM annual meeting. The reason is that nursing homes are predominantly regulated by the state, and assisted living (RCFE in California) is entirely regulated by the state. It is important for me to keep up to date on the latest state regulations as well as any pertinent pending legislation. The CALTCM meeting gives me the scientific and clinical content relevant to long term care that I want, while also giving me the chance to learn the latest that affects California facilities. Generally, there is a healthy attendance and participation by some of our regulators, and I find it invaluable to hear what they have to say. I also relish networking with colleagues from across the state, in a way that larger national meetings make much more difficult. Unlike some meetings that are predominantly or entirely one discipline, the CALTCM meetings are fully interdisciplinary. I truly believe that if you are working in or interested in long term care, the most important meeting for you to attend is the CALTCM annual meeting. 

The Medication Access and Training Expansion (MATE) Act went live June 27 and requires all DEA-registered providers to complete eight hours of training on opioid or other substance use disorders prior to renewal of their DEA License.  The exclusions include all practitioners graduating in good standing within the last 5 years, board-certified addiction specialists, and those with prior X-waivers.  

Last year, cases of RSV in children and adults accelerated over the summer into the fall, raising a concern about a “Triple-demic” (COVID, Flu, & RSV).  Fortunately, for unclear reasons, RSV cases declined as winter set in. 

On June 15th, the FDA asked drugmakers to update the COVID Booster to target XBB 1.5 and no longer target the Wuhan strain. This monovalent mRNA vaccine has already been field tested by Pfizer and Moderna and should be available by early September. Novavax will also have their booster available this Fall. This monovalent booster vaccine will replace the current bivalent booster.

As one of the seven virtues, gratitude is described by Cicero as “not only the greatest of virtues, but the parent of all the others”. Gratitude involves a sense of thankfulness or appreciation for the goodness, kindness, and ‘gifts’ we’ve received from others. In many ways, gratitude helps us to move forward and to connect with others on a deeper, more meaningful level, particularly in times of challenge.

On June 15th, the FDA asked drugmakers to update the COVID Booster to target XBB 1.5 and no longer target the Wuhan strain. This monovalent mRNA vaccine has already been field tested by Pfizer and Moderna and should be available by early September. Novavax will also have their booster available this Fall. This monovalent booster vaccine will replace the current bivalent booster.

Mindfulness meditation has been popularized in mainstream culture as an opportunity to slow down and explore our experiences through natural wonder and curiosity. It has given us permission to pay attention to not only our inner workings of our own mind but also what surrounds us in a non-judgmental and non-reactive way. The following journal article discusses mindfulness as an introductory practice for psychotherapy clinicians and patients; however, the core concepts presented can be applied to other fields of practice.

JAMA Network May 9 reported on a large study linking industrial solvent in drinking water to the development of Parkinson Disease (PD) in Camp Lejeune Veterans. The 1987 Safe Drinking Water Act uncovered polluted wells at Camp Lejeune. The main contaminant was a Volatile Organic Compound (VOC) called trichloroethylene (TCE), which came from on-base sources (leaking underground storage tanks, industrial spills, and waste disposal sites) and off-base sources (dry-cleaning businesses). The study compared the prevalence of PD in Marines who had lived on this base during the high-exposure years of 1975-1985, when monthly TCE levels were 70-fold the permissible amount. This cohort was compared to Marines living at Camp Pendleton in CA, where the water had not been contaminated. The study found a 70% higher risk of PD in Camp Lejeune Marines, which may be the tip of the iceberg, since this population is only in their mid-60s.

CALTCM is proud to announce that it has received an award from CDPH's Healthcare-Associated Infections (HAI) Program. Our project, the Leadership and Management in Geriatrics Infection Prevention and Control Leadership Program (LMG-IPC Strike Team) combines the methodology from two established CALTCM programs, CALTCM SNF 2.0® and CALTCM’s Leadership and Management in Geriatrics course (LMG)®.

At CALTCM, our mission is to “promote quality patient care across the long-term care continuum through medical leadership and education.”  And our vision includes providing “excellent and individualized medical care, a team approach, and the integration of medical science with personalized care.”

I joined the boomer wave of “retirees” at the end of 2019, but for multiple reasons, have continued to work on a part time basis as a consultant and direct patient care provider. By the end of 2020, I concluded that carrying even part-time liability insurance was an excessive cost given the limited amount of direct patient care work I was doing. Subsequently, I’ve discovered Locum Tenens work minimizes my business costs while providing an opportunity to help colleagues in the PALTC space, who need coverage for vacations or acute illness. Locum Tenens is a model that allows a physician to temporarily assume the duties of a colleague’s practice during the agreed time of service. This means that when I work exclusively for a colleague on vacation, I’m covered by their medical liability insurance and use their billing system for the patients I see. At the main facility where I’ve provided this service, I’m familiar with their physician’s EHR and use that EHR for patient care documentation. At other facilities with a different physician EHR, I activate my old EHR and use that system for documenting patient care and for turning the documents into my colleague’s biller, for later reimbursement. Besides this reimbursement, I generally negotiate an incentive fee from the facility to cover the added work of picking up patients I don’t know, many of whom are medically complex. I have maintained my Medical Director Certification (CMD), so I also negotiate a fee for Medical Director services if I’m covering their Medical Director duties.

You are invited to submit a poster abstract for the 2023 Poster Session at the 2023 CALTCM Summit for Excellence. This is a unique opportunity to showcase your research findings, innovative projects, or novel ideas to a diverse audience in post-acute and long-term care (PALTC).

Dear CALTCM Medical Director Colleagues,

As a general internist, I appreciate the work of the ADA (American Diabetes Association) that identifies advances in diabetes care and adds these new developments to their comprehensive guidance called “Standards of Care''.  The SOC is published in Diabetes Care as a supplement every January.  The 2023 full version, abridged version, primary care, and other versions are all available online for free.  For providers, a free app is now available (ADA SOC) which allows real time access on your smartphone for quick guidance on specific patient care issues.  

Hooray ... Happiness is back on the horizon!

In January 2023, the requirement for prescribers to have an “X” waiver to prescribe buprenorphine (Suboxone, Subutex, others) for Opioid Use Disorder was abolished, to improve access to this important treatment modality.  This means that any prescriber who can prescribe Schedule III medications is able to prescribe it now for that indication.

This year, a good friend underwent a revision hip arthroplasty for aseptic necrosis of the femoral head after a fracture fixation several years prior.  Being 80 years old and frail, she was offered rehab in an SNF postoperatively, but instead was confident her adult children and grandchildren could properly support her in the home setting.   Both this friend and her family assumed the oxycodone would take away most of the hip pain at rest and pain triggered by movement, but they were not aware of its common side effects or how they would know if the pain was adequately managed.  

The Public Policy Committee for CALTCM continues its efforts to “make a difference.” With nursing homes continuing to be in the news in the wake of the COVID-19 pandemic, we are committed to assuring that our clinical voice is heard.  CALTCM’s Board recently approved letters to Secretary Becerra and Administrator Brooks-LaSure related to appropriate staffing and transparency. There would “appear” to be a lot of controversy related to staffing issues, but CALTCM’s position is based on the clinical experience and evidence that inadequate staffing is associated with poor care.  To minimize this in the face of staffing shortages does a disservice to the residents and the staff who care for them under less than ideal conditions.  CMS recently requested comments on a New Proposed Rule on Nursing Home Ownership Transparency, we submitted our comments, please click here to view.  These efforts continue what we started over two years ago in California that helped lead to the passage of SB 650.

I looked at my geriatric clinic schedule recently and saw the reason for the visit, “Angry Outburst.”  The clinic nurse explained that this hard-of-hearing resident in his 90s doesn’t hear our medical assistants when they knock on the door to announce their visit for medication administration, so they use their pass card to enter.  In recent times he has become very angry when he discovers them in their apartment.  The prior day, the MA was so frightened that she left and didn’t pass his medicines.  I asked the clinic nurse what she thought should happen next.  She wondered if I could prescribe a medicine that might reduce his anger so they could pass the meds and he could stay in his apartment.  In response, I asked her: if your eight-year-old child had a problem with anger management, would you ask his physician for a medicine to reduce the severity of the problem?  Of course, she said “no.”