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.

Yesterday, the CDC’s HAN (Health Alert Network) issued a detailed report regarding their recommendation to pause administration of the Janssen (J&J) vaccine (see link to this report).  The CDC has now received VAERS reports from 6 women ages 18-48 of serious clotting events after the administration of 6.85 million doses of this vaccine (as of 4/12/21).  These events appear to have been triggered by the development of platelet-activating antibodies against platelet factor 4 (PF4), which is also known as heparin-PF4 antibody.  This may trigger Vaccine-induced Immune Thrombotic Thrombocytopenia (VITTP) which can have serious CNS consequences (1 death so far).  This association is quite rare at ~ 1 case per million vaccinations.  A similar problem has been seen with the AstraZeneca vaccine, which is also a viral vector vaccine (AD26), but hasn’t been seen in the USA or internationally with the Pfizer or Moderna mRNA vaccines.  The key issue for the CDC and ACIP at this point, is the possible under-reporting of this association.  Because these events occurred 6-13 days after vaccination, the development of this rare problem may not have been linked to the vaccine.  Hopefully this HAN report will bring in more VAERS reports to allow the CDC to provide more precise information on the real risk of this event in persons receiving the Janssen vaccine.  To put this preliminary risk in perspective, the known risk of “unvaccinated persons” aged 18-48 dying of SARS-CoV2 is 125/million, which is a vastly greater than the risk of acquiring (much less of dying) of VITTP.  

Californians spent more than $11 billion on nursing home care in 2019 but low nurse staffing levels and quality of care problems have persisted in many homes over the years. The COVID-19 pandemic exacerbated these staffing and quality problems and resulted in over 61,000 resident infections, about 9,000 resident deaths, and over 50,000 staffing infections by February 2021.  While nursing homes claim that payment rates are inadequate to improve staffing and improve care, it is not clear how the current nursing home payments are being spent.  Nursing homes often use complex ownership structures to shift money to “related parties,” such as corporate home offices, property companies, and management companies and to hide profits and support facilities’ claims for increased public funding.  

Last December, I provided vacation coverage for a physician with a PA/LTC practice.  Because of the pandemic, I obtained the agreement of the facility administrative team, that our first approach to changes of condition (COC) would be a telemedicine visit, rather than the usual triage by fax or phone. 

With the remarkable efficacy of the mRNA vaccines and the newly available one shot, standard refrigeration Janssen (Johnson and Johnson) vaccine, many in long-term care are wondering if healthcare personnel (HCP) should be mandated to receive vaccines.

San Diego’s nursing home residents were early recipients of the coronavirus vaccine. In recent weeks, most nursing home seniors and staff eagerly lined up to be vaccinated at their facility by either CVS or Walgreens. Nursing home staff members also shared with me that some people felt hesitant about receiving the vaccine.

The Population Health team uses motivational interviewing skills that incorporate certain words, phrases, and motivators to engage and encourage patients to complete all needed care and immunizations. Recently the Public Health Communication Collaborative shared a national poll entitled “The Language of Vaccine Acceptance." The poll identifies the language most effective to improve confidence in COVID-19 vaccines.

Family is by far the most powerful motivator word for vaccine acceptance. Significantly, more Americans said they would be more willing to take the vaccine “for my family" as opposed to “for my country" or “for the economy." The wording and reasons demonstrated to be most convincing were:

Pantoprazole and other proton pump inhibitors (PPIs) are commonly started in the acute hospital setting and then continued in the post-acute and long-term care (PALTC) setting of care without a clear ongoing indication.  PPIs have an acid rebound withdrawal syndrome, so patients previously without GI acid symptoms may develop them, if PPIs are abruptly stopped, reinforcing the patient’s perception that they now need a PPI. 

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. 

I wanted to start this year with a grateful word of thanks to all of our CALTCM members. Our CALTCM friends and family are leaders in medicine, nursing, administration, pharmacy, social services, ombudsman, and more who believe in quality and safety in post-acute and long-term care.  Your efforts help CALTCM serve as the medical voice of long-term care in California.  Your work through the pandemic has been heroic and the sacrifices have been many.  

January was a record month for the greatest number of COVID Deaths in Sonoma County and 65% of those deaths were in senior congregate living facilities. Meanwhile, a large local continuing care retirement community (CCRC) didn't receive its first vaccinations until January 31.  Only 20 of our 176 assisted living facilities even have a date set. Crista Nelson, our head of Senior Advocacy Services, estimated that at this rate most of our residential care facilities wouldn't be vaccinated until July.  Fortunately, over the last 2 weeks, a huge collaborative effort between CDPH, Public Health, Local Pharmacies, Local hospital systems, and adjacent county providers, the situation has dramatically improved.  By the end this month, most of the residents and healthcare workers who want to be vaccinated will have received at least their first vaccine injection.  In addition, the Kaiser Team and a home care agency have been approved for making house calls on homebound persons and their caregivers.  Prisoners are also receiving vaccines.  This ramping up of the delivery of vaccines wouldn't have been possible without the heroic efforts of our public health department and the trusting relationships that have developed in this community over the course of the pandemic.  At a federal level, improving production and delivery of vaccines to the states has been huge.  We are now in the position of identifying which facilities need more help with staff vaccine hesitancy.  I've attached an excellent presentation on the subject of vaccine hesitancy provided by UCSF's Dr. Bryn Boslett, who was able to comment on the importance of the vaccine in pregnant healthcare workers by her own experience.  In Sonoma County, what once looked bleak, is now an example of what an engaged and coordinated healthcare community can achieve. 

As a clinician, we are often thanked by our patients and staff. This is such a beautiful and simple way of acknowledging and appreciating others. I have always been surprised with how wonderful I have felt when a little appreciation is shown. Gratitude in our daily lives for others is so important not only for the person receiving, but even more for the person who is saying thanks.  Actions of humility have more benefit to our well being than getting ego-boosts. When we take an active role in our lives to be thankful, it puts us in a higher frequency with the universe. 

I appreciate our readers who have pointed out that the term "unbefriended" in this article may be interpreted as a demeaning term, since many of these unrepresented patients are no longer able to access their prior friendship / family network and besides that, the key issue is they no longer have decisional capacity and do not have an identifiable representative.  In this day of implicit bias, I appreciate our readers who hold us to a higher standard for our communications that address problems in the delivery of healthcare in our state.  I also did receive feedback that the California Hospital Association is aware of this problem and is working with CDPH, CALTCM, and other stakeholders to identify acceptable patient advocates.  Several physicians have suggested recruiting local retired physicians through their medical societies.  Another has suggested developing a grant proposal at a county level to develop a patient advocate program.  I hope these ideas take hold, for our facilities really do need help accessing capable patient representatives for this relatively common problem.

A cootie-covid-catcher-fortune teller (CCFT) is a homemade tool designed to boost team morale.  When envisioning this device, I wanted to make something that we could all hold physically and share virtually, that encouraged play, that invoked comforting childhood memories, and that referenced the uniquely painful-but-funny moments of our work.  On the top CCFT triangles are the On Lok site names.  Like the cootie-catcher-fortune teller of our youth, one rotates the triangles to reveal a new set of choices, each related to an aspect of PACE care.  Pick a choice, flip it open, and get a funny fortune or anecdote.  Land on “incontinence supplies”? Watch out for “Out of pull-ups, CODE BROWN.”  “Telehealth” predicts that “Grandson zoom-bombs.”

When COVID-19 exploded last March, my community went to work attempting to keep COVID out of our facilities.  We developed county-wide virtual learning collaboratives for Assisted Living (AL) communities and for SNFs, which met on a weekly basis.  By the end of June, we had done well with no outbreaks and only 4 deaths in the county.  Unfortunately, last summer’s surge in COVID prevalence shattered the myth that we had done enough to contain it.  Like the rest of our state, we pivoted to follow guidance focused more on infection control and early recognition of outbreaks.  By the end of October, we seemed to be back in the driver’s seat with much better facility COVID metrics.  However, with the winter surge, we are stretched thin on staff, resources, and again wondering when the bad news will end.  In my county, we have now have had 196 deaths, and 70% of them have occurred in senior congregate living facilities.  

The FDA has given EUA (Emergency Use Authorization) for bamlanivimab (Lilly) or the “cocktail” of casirivimab and imdevimab IV infusions for mild to moderate COVID-19 patients.  These monoclonal antibodies block the binding of the spike protein to the ACE2 receptor on the human cell, which blocks viral attachment.  If given early (within 10 days of symptom onset), both medicines have been shown in high-risk adults to reduce the viral load and risk of progression to severe COVID-19, and reduce the necessity for ED visits and hospitalization.  However, they didn’t help those already hospitalized and outcomes were worse in those receiving high-flow oxygen or mechanical ventilation.  Experts suspect that infusions given within the first 3 days of symptoms will be more effective than when given later.  This is similar to what we have experienced with the use of oseltamivir (Tamiflu) in Influenza or antivirals with shingles.  

Since the SARS CoV-2 virus arrived in the USA last winter, our lives have been disrupted in many ways.  We are currently in a Winter Surge that has locked down most of the state.  The latest statistics on COVID activity show a doubling or tripling of cases in most of California in the month of December, which greatly increases the risk of outbreaks in our post-acute and long-term care settings.  As of 12/10, the USA had 15.6 million confirmed cases and 294,000 deaths.  Though only 6% of the cases have been in post-acute and long-term care (PALTC), including skilled nursing facilities (SNFs) and assisted living communities (AL), our residents have had a hugely disproportionate 34% of the deaths.  As of Friday, December 11, over 100,000 persons with COVID in the USA were hospitalized and 21,000 were in ICU beds. In California, we had 33.500 new cases reported over the preceding day.  

Prior to the pandemic, most of the SNFs in Sonoma County had applied for waivers, because they weren’t able to staff CNAs at the required 2.4 FTE state standard.  I heard one administrator comment that the website “Indeed.com” had become a main source for attracting CNAs from other SNFs.  In our area, we do have a training program for CNAs through partnerships of facilities with the Red Cross and the local community college, but the number of CNAs attracted to this track has been small.  Since the COVID pandemic, our CNA shortage has been aggravated by concern for personal safety, complicated sick leave policies, inconsistent work hours, and the realization that those working in multiple facilities had a much higher risk of transmitting COVID.  

On October 19, 2020, an article in the Wall Street Journal was written observing that some governors in States with surges of COVID are still insisting that masking in public settings should be a personal decision.  This conflicts with the public health guidance of CDC, CDPH, and our Governor, but is still an issue in the public domain in our state where it’s common to observe people in public without a face mask, or wearing the mask under the nose or mouth.  This may not only increase the risk of our health care providers (HCP) acquiring COVID, but data are emerging to suggest that those who acquire COVID while not wearing a mask have a greater dose exposure to COVID, and are likely to become sicker.  

Each year, more than one in four older adults aged 65 and older will fall. Among older Americans, falls are the number one cause of injuries and death from injury (1). This represents 29 million falls, 3 million emergency department (ED) visits, 800,000 hospitalizations, and 28,000 deaths. As the leading cause of fatal and nonfatal injuries among older adults, falls will continue to soar, as America’s baby boomers grow older (2).