In late July, after some four years of legal wrangling, a California Court of Appeals decision was handed down in the CANHR v. Smith (previously CANHR v. Chapman) case, which had sued the California Department of Public Health (CDPH) to challenge the constitutionality of Health & Safety Code 1418.8, also known as the Epple Law. This law, in effect for over 20 years in California, allows the interdisciplinary team (IDT) in a nursing home to make decisions—including giving informed consent for interventions that require it—on behalf of incapacitated, unrepresented residents.  

Earlier this summer, health care professionals from all over San Diego County met to learn about current trends in post-acute care and hospital readmission efforts.  Hosted by Health Services Advisory Group under the guidance of Debra Nixon and her colleagues, and with local assistance from CALTCM board members Parag Agnihotri, MD, CMD and Karl Steinberg, MD, CMD, HMDC, this half-day collaborative event drew about 150 attendees.  

In a February 2017 WAVE, I asked the question whether your facility had been stress tested (see link to this article below).  At one of my facilities, I had become aware of a serious medication error and activated a process with some of my colleagues and the administration on how to best manage the consequences of this error.  This patient and family appreciated the timely disclosure and proposed care plan adjustments, as well as our commitment to better understand what happened so that we could minimize the risk of similar future errors.  To date, there hasn’t been a lawsuit or payout with this case.

As an internist who has entered my 41^st year in private practice, I have followed our state's experience with this act hoping like many of my colleagues that those accessing this option would only do so after much thought, council, and access to good palliative care.  

Five-Star Quality Rating System (QRS) has been developed by the Centers for Medicare & Medicaid Services (CMS) to assist consumers compare nursing homes more easily based on their performance on health inspection(s), staffing and quality measures (QM) domains. Over the years, CMS has updated and enhanced the five-star QRS methodology numerous times to improve the accuracy of the rating system. The nursing facilities and medical directors need to stay up-to-date with all the changes in the 5-star QRS.  

For as long as most of us can remember, we have been subject to regulatory oversight regarding testing for tuberculosis in our residents. For most of us, this equates to a “mandatory” skin test upon admission (as well as mandatory tests for our employees!) to check for possible “exposure” to TB. The efficacy of these tests, or even the accuracy of chest x-rays, in diagnosis of the disease is tenuous at best, but we still must comply with the regulation.

In 2008, I attended the UCLA LMG (Leadership and Management in Geriatrics) course that has continued under the leadership of CALTCM.  I was paired with a nursing professor at Sacramento State who was quite helpful as a mentor for my project which was the implementation of the new POLST Form in Sonoma County.  I teamed with Susan Keller, who energetically partnered with many people and provided detailed trainings in many settings of care. Sadly, despite our efforts, I still find POLST forms initiated by frontline SNF admitting nurses that don’t have choices congruent with the ones I find on my assessments.  In addition, many of the forms fail to record basic information like care contacts, presence of AHCDs/DPOAs, and who assisted with completion of the form.  

CALTCM has partnered with CAHF to address common care processes that may interfere with our patient’s sleep preferences.  The focus of the CAHF Quality Subcommittee’s initiative has been the timing of medications and administration of beverages (see attachments below).  These model policies and procedures provide a flexible and safe way to modify incoming orders, including medication orders and timing, for both new admissions and also serve as a tool for adjusting these care plans for long-stay residents.  

CALTCM has had a busy 2019, Summer is near and the Leadership and Management in Geriatrics (LMG) course and the Fall Conference will be upon us in no time at all.  We would like to give you a quick update on our current programs and an update on two membership benefits you will not want to overlook – if you are not a member yet, take a few moments and join CALTCM today to be eligible for these opportunities.

Parables were told to alert the reader to profound truths.  This parable has been time tested as witnessed by our Good Samaritan laws and by its influence on medical ethics.  This parable (Good Samaritan Parable) was told in response to the question, “and who is my neighbor”.  In this story, the neighbor is never clearly defined, but only as someone who was robbed, beaten, and left half-dead.  His plight was deemed less important than the immediate agenda and safety of the first 2 highly respected persons who saw him from afar and passed on.  Shockingly, a despised foreigner saw the need, provided emergent care, and then paid for acute and post-hospital care.  

As an in-the-trenches clinician, I have come away from each CALTCM and AMDA annual meeting with my “batteries” recharged and with new ideas for improving patient and facility care. Going to these meetings has introduced me to many thought leaders in our setting who gladly rub shoulders with attendees and make time for curbside consults.  These are truly “family” events.

Recently, the American Geriatrics Society’s MyAGSOnline member forum posted a question about the use of weighted blankets for a dementia unit with patients who had poor judgment, impulsiveness, poor safety recall, and frequent falls.  Dr. Maureen Nash, Board Certified in Internal Medicine & Psychiatry (Portland, Oregon) wrote they can have a positive impact in some older patients offering comfort as long as they are not too heavy. They are not considered a restraint by CMS unless they are inappropriately heavy.  They provide gentle tactile stimulation to people who usually are not touched except in a clinical situation. She gave several references:

It is a pleasure to boast about the recipient of the 2019 CALTCM Leadership Award, Rebecca Ferrini, MD, MPH, CMD.  CALTCM received three separate submissions nominating Rebecca for this award – a true testament to the high regard the PALTC community holds for Rebecca.  She is full of energy and has an inspiring dedication and passion for improving the quality of care in post-acute and long-term care. She actively contributes to the CALTCM Education Committee, dedicating her time and energy to the planning of educational events, peer reviews, and selflessly assisting presenters to improve their presentations. She has five children, plays competitive soccer, her facility is 5 stars (CMS 20/20), and has been named a top nursing home in the country for seven years by US News and World Report.  

“I know geriatrics, because I’ve taken care of a lot of old people.” As a geriatrician, I’ve heard this refrain my whole career from other physicians who are trying to rationalize the care they deliver to older adults.  The scope of this refrain is about to expand, and we shouldn’t be surprised to find nursing home administrators opining on clinical care delivery approaches.

In 2001 I co-founded Senior Care of Colorado.  We were a small group of six geriatricians and a couple of physician assistants working out of two clinics who provided primary care geriatrics in local nursing homes. We immediately had offers from several local nursing homes to take positions as medical directors.  Naively, we thought that these offers reflected a desire for these facilities to gain expertise in geriatrics. Realistically, they probably thought that hiring us would bring them more patients. Within a year we were under investigation from the OIG. They interviewed several nursing home administrators.

For many reasons, our education committee chose to focus this year on reducing the risk of hypoglycemia in persons with diabetes.  CMS has data from April 2016-March 2017 showing this is a major reason for a higher first 30 day all-cause SNF Readmissions rate. As of Jan 1, 2019, the CMS “SNF Readmission Measure” (SNF-RM) adjusts payments to facilities based on this measure. From multiple randomized controlled studies, we know that serious hypoglycemia increases mortality. For this reason, in high risk patients, AGS and ADA have recommended higher A1C targets in those with higher hypoglycemic risk.  

At the March 2019 annual AMDA meeting, Dr. Karl Steinberg (our incoming AMDA VP) and I were part of a panel debating whether the United States should adopt the Dutch policy of legalizing Advance Directives for Euthanasia.  In 2014, 4.4% of deaths in the Netherlands were by euthanasia and 20% were by palliative sedation. Dr. Cees Hertogh, a Dutch physician and bioethicist, gave a wonderful presentation on the history of euthanasia in the Netherlands and the criteria for euthanasia, which have been modified to include euthanasia by advance directive (AD) for persons with dementia.  In contrast, the 20-year experience of Oregon with the Death with Dignity Act (reported in the September 2017 Annals of Internal Medicine) had 0.2% of their deaths via medical aid in dying. California has had a similar frequency who died by lethal ingestion via the End of Life Option Act.

This year I planned to go to the AMDA meeting. I registered and made hotel reservations. Then something came up – I found out about a meeting that occurred at roughly the same time, but instead of emphasizing nursing home care, it specifically was organized to highlight alternative solutions to long-term care needs that allowed people to remain in their homes. I work in a PACE program, and both our mission and our financial success involve keeping people out of nursing homes whenever possible. I fully believe sometimes nursing homes are a necessary solution to meet the needs of individuals, but I also see people with dementia or other conditions requiring long-term care who end up in nursing homes because of lack of viable alternatives. The AMDA meeting was in Atlanta this year. This other meeting was in Florence, Italy. Not to denigrate Atlanta, but based on criteria of food, wine, art and gelato, Florence has advantages.

During our annual summit, the board of directors met in person to review the past year and plan the future. It has been a huge effort by the Education Committee in bringing together the annual program. Our goal is to work together with other organizations in the state to increase collaboration and improve quality of care. We plan to continue creating programs that benefit our SNF system. We are doing great work from CALTCM SNF 2.0^® to LMG (Leadership and Management in Geriatrics) courses throughout the year.

The two questions I can absolutely count on being asked, as the geriatrician in a crowd of healthcare providers, are “should I start statins?” and “should I continue in those who are over 80?” I usually offer the uncomfortable answer, mirroring the conclusion of this 2018 JAGS review article, which is that we still do not have enough well-designed, rigorous studies to guide definitive best practice.