As a semi-retired physician who spent the last 15 years of his career working exclusively in the SNF and CCRC (Continuing Care Retirement Community) settings of care, I was aware that some of my colleagues had trouble finding Medical Liability coverage and when they did so, the annual premium was almost twice my rate.  I believe NORCAL, my insurer, gave me favorable coverage, because I was part of a large multispecialty group. This difficulty finding affordable coverage began after California passed Elder Abuse Legislation that changed allegations from malpractice to civil tort, which has a much higher financial risk.

The FDA, CDC, & Western States Scientific Safety Review Workgroup have approved the EAU for the new Pfizer and Moderna mRNA bivalent vaccines.  These vaccines target the COVID-19 spike protein, which has rapidly mutated over the course of the pandemic.  These vaccines target the original Wuhan spike protein (monovalent vaccines) and the Omicron BA.4 & BA.5 subvariants.  BA .5 has proved very contagious and still accounts for over 88% of the infections in California.  Though the numbers of COVID cases, hospitalizations, and deaths have slowly improved since the end of July, the rates are still substantial.  On 9/8/22, a large 250-hospital network study of COVID-19 hospitalizations in the USA from January 2021-April 2022 was published in JAMA IM (https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2796235).  They found the rate of hospitalization was 10.5 times greater for unvaccinated and 2.5 times higher for vaccinated, but not boosted.  We anticipate an even greater benefit of the new bivalent vaccines which better target BA .5.  This vaccine roll-out is well timed to combine with our efforts to provide the usual Flu vaccines before winter arrives.  As of 9/10, over 50 million doses have been delivered to states for distribution. 

I have benefited from Dr. Landsverk teaching on optimal dementia care by her participation in the California Partnership to Improve Dementia Care, and through her teaching presentations at CALTCM meetings.  She is a seasoned geriatrician in Northern California who has focused on the care of persons living with dementia through a house calls practice.  She has now condensed her thoughts on living with dementia in a way that our patients and caregivers can understand and support.  This is a very balanced approach that identifies the common difficulties associated with living with declining cognition, with a focus on maximizing the remaining capacities.  When this is done, the quality of life for everyone improves and there can again be joyful living.  I highly recommend this book as a very practical way for patients and caregivers to navigate the challenges associated with progressive dementias.

The WAVE occasionally highlights recent publications by our members, but usually those are medical journal articles or medical books. Today I’d like to discuss a new book that is not medical at all. WAVE readers likely need no introduction to Dan Osterweil, MD, CMD. Dan was for many years the CEO of CALTCM and has had an outstanding career as a leader in long term care, innovator of care models for the elderly, educator, author and editor. He has been a long-time faculty member at UCLA in their Geriatric Medicine division. Now Dan has written an absolutely riveting new book, “The Orphans' Father: A Jewish Doctor’s Inspiring WW2 Historical Novel, Based on the True Story of a Holocaust Survivor”

I know it’s easy and less expensive to get timely information and CME online from many sources.  I’ve appreciated the virtual-only meetings sponsored by CALTCM and AMDA during the pandemic.  Over time, they have become more user friendly and engaging. 

How difficult is it for residents in your community to access appropriate ACP (Advance Care Planning) services?  In my experience, these conversations are often deferred until the time of a crisis, but we know these conversations are less beneficial then due to crisis related compromised cognition and emotional stress for patients, families, and providers.  Are there communities in our state where there are champions doing this good work electively in their community, particularly targeting members of their community who historically are less likely to have serious illness conversations and supported decision making?

The new Office of the Long-Term Care Patient Representative (housed at the California Department of Aging) is getting up to speed, and they are looking to hire qualified people to work in this important capacity.  Salary range is from roughly $70-100K annually, and includes benefits.  Here is the link to the site for potential applicants: https://www.calcareers.ca.gov/CalHrPublic/Jobs/JobPosting.aspx?JobControlId=321013

A recent systematic review and meta-analysis article published in the July 2022 Journal of Neurology, Neurosurgery and Psychiatry suggests noradrenergic agents may be effective in early Alzheimer’s Disease to improve cognitive function. This original research included over 1800 patients showing a small significant positive effect on the global cognition measured on the Mini-Mental State Exam (MMSE) or on Alzheimer’s Disease Assessment Scale-Cognitive Subscale (ADAS-cog). 

As of July 27, 2022, over half of the 342 skilled nursing facilities (SNFs) in LA County are experiencing active COVID-19 outbreaks, which is the highest level of transmission since the surge last winter. All patients in SNFs are at high risk for progressing to severe COVID-19 if infected. Fortunately, there are now outpatient COVID-19 treatments such as oral antivirals that are easy to administer and can reduce the risk of poor outcomes, including hospitalization and death. Despite the wide availability of oral antivirals, they continue to be underutilized in the nursing home population. To close this crucial gap and significantly improve outcomes in this vulnerable population, Los Angeles County Department of Public Health issued an update on July 25, 2022 to the Order of the Health Officer for Control of COVID-19: Prevention of COVID-19 Transmission in Skilled Nursing Facilities requiring all SNF patients with a positive SARS-CoV-2 viral test to be immediately assessed by their healthcare provider for any symptoms of COVID-19. Oral COVID-19 antivirals should be initiated at the facility within 5 days of symptom onset if clinically appropriate, i.e., they have mild or moderate symptoms and there are no contraindications. Please do not transfer residents to hospitals solely for treatment of mild or moderate COVID-19. These residents should be treated at their SNF. Even if you are not practicing in Los Angeles County, CALTCM agrees that all PALTC medical directors, attending physicians and practitioners should evaluate every case of COVID for the potential ordering of therapeutics including Paxlovid.  Please work with SNFs where you provide care to help meet this recommendation and provide optimal care for your patients.

The 38th Annual UCLA Intensive Course in Geriatric Medicine and Board Review will take place September 14-17, 2022. This four-day virtual course is designed for health professionals interested in advancing their knowledge and enhancing their ability to care for older adults, as well as physicians preparing for certification or recertification examinations in Geriatric Medicine. The Intensive Course is CME and ACPE accredited and a nationally recognized premier course. 

How do our patients and their families define a good outcome from a surgical procedure, particularly if it is a high risk surgical procedure (defined as >1% 30-day mortality)?  What if the patient has dementia?  Have you had patients with advanced dementia with acute displaced hip fractures where the traditional best option offered has been surgical repair?  

I naively assumed when I began my journey in the field of Geriatric Medicine, that I would be followed over time by hordes of other physicians, given the impending increase in aging populations.  While the population of seniors has nearly doubled, the number of physicians with Geriatric Medicine training has diminished. Less than 5% of the current California healthcare workforce is certified in geriatrics.  Moreover, the California Census Bureau projects a rate of growth of the age 65 plus population that far exceeds the other age groups, particularly among the 85 plus group, and among the non-White populations. The percentage of filled first year geriatric fellow positions dropped from 91% in 1998 to 45% in 2017. Currently, the American Geriatric Society estimates that there are 3,590 full-time practicing geriatricians, out of a total pool of less than 7,000 board-certified geriatricians. A professional colleague recently commented that if things continue to progress as they are, American geriatricians will become a historical footnote. 

The moment you have all been waiting for!

One year ago, CALTCM members received an alert that the Alameda County Superior Court issued a modified judgment in the 2016 CANHR v. Angell case.  That order granted another 12-month extension for the requirement for nursing homes to include a non-facility-affiliated patient representative on the interdisciplinary teams (IDTs) that are making medical decisions that require informed consent for incapacitated unrepresented residents. The extension was due to expire this month.  

CMS had AHRQ (the Agency for Healthcare Research and Quality) develop validated patient-friendly surveys that could capture the patient’s experience of care in a particular facility.  This could provide a facility with important information about their care delivery, allow comparisons with other facilities (within their system and beyond) and spark collaborative learning.  In addition, this information could incentivize facilities to improve their survey results, if they were posted on the internet.  

On April 1, AMDA - The Society for Post-Acute and Long Term-Care Medicine, sent an email recommending this resource, Geriatric Notes, at a 20% discount.  This resource was first released in 2018 and targets advanced practice providers (APP) who care for elders in our settings of care.  In this offering through AMDA, you have access to the paperback book or the E-book version available via the internet and as the eReader2 app on smartphones.  This Ebook version has updates on health maintenance, diabetes management, and the Beers list (identifies potential inappropriate medications).  I have reviewed this textbook by Jamie W Smith and Bradley J Goad, and found it to be an easy to use resource for quick point of care decisions as well as for improving understanding of common diagnosis, topics, symptoms, and guidelines encountered in the care of an aging population. 

As CALTCM’s President, I am pleased to announce that our Board of Directors has appointed Dominic Lim as CALTCM’s Interim CEO. 

Since the California Court of Appeal ruled on the CANHR v. Smith case in late 2019, and since early 2020 when the state Ombudsman’s office prohibited their ombudsman from participating in IDTs where medical decisions would be made for incapacitated unrepresented nursing home residents, California’s skilled nursing facilities have been awaiting the implementation of a brand-new office to help with these decisions.  

In recent years, seniors are voting with their feet.  We are living longer and becoming more disabled along the way.  These functional declines are often subtle in onset and progression, but eventually cause many to embrace some form of congregate living.  For many, the lower cost social model with more choices has been more attractive than the medical model of nursing homes.  Many ALFs (Assisted Living Facilities), RCFEs (Residential Care Facilities for the Elderly), and Memory Units now care for residents with similar medical complexity, polypharmacy, and functional decline as those living in SNFs.