PALTmed Connect is a website for Post Acute and Long-Term Care Medical Association (PALTMed) members to post questions related to the care of SNF patients. CMS has released new guidance this month to surveyors in the state operations manual regarding indications for Unnecessary Medications that update expectations for informed consent for psychotropic medications prior to their administration (CMS memo to surveyors QSO-25-07-NH).
To fully appreciate my mother’s story, I must describe it in the context of our long-term care (LTC) system. Drs. Rosalie and Robert Kane described the essence of LTC as “providing services for persons experiencing functional decline while living in their home, apartment, congregate living environments, or institutions.1 Millions of caregivers, both unpaid and paid, provide LTC services for persons identified as having dementia.2 Dementia is a general term used to describe “mental decline that is severe enough to interfere with daily living.” 3 At least half of persons with dementia in the United States are living in residential care and assisted living (RC/AL) facilities providing LTC services.4 These facilities are often components of continuing care retirement communities (CCRC), of which there are 2,000 nationally. 5
The history of tardive dyskinesia (TD) is intertwined with the development and use of antipsychotic medications. TD was first observed after the introduction of first-generation antipsychotic drugs (also known as typical antipsychotics) such as chlorpromazine (Thorazine) and haloperidol (Haldol) in the 1950s. These medications revolutionized the treatment of schizophrenia and other psychotic disorders.
Agitation is a common and challenging symptom in Alzheimer's disease, characterized by restlessness, emotional distress, and aggressive behaviors. Managing these symptoms is crucial for improving the quality of life for both patients and caregivers.
As a solo practitioner in a SNF for 40+ years, I have developed a set of decision support tools accessible on my smartphone that address many of the questions that arise while caring for increasingly complex post-acute rehabilitation patients. I have been following the evolving literature on adaptation of AI (Artificial Intelligence) to clinical medicine in medical journals and podcasts, but have not seen practical uses for clinical problem-solving in the SNF setting.
In LTC we sometimes deal with broad-stroke decisions such as “We are a no-antipsychotic facility.” What that really means is that they should only use antipsychotics for AXIS 1 disorders. Most facilities do not operate with that self-imposed restriction. They will take a Part A patient short-term with an antipsychotic onboard, as well as a long-stay patient returning with a newly prescribed antipsychotic. Many facilities allow a hospital transfer with a PRN low dose of quetiapine.
The Centers for Medicare & Medicaid Services (CMS) developed the Five-Star Quality Rating System to provide consumers with an easy way to assess the quality of care provided by nursing homes. This rating system, which can be accessed on the CMS Nursing Home Compare website (Find Healthcare Providers: Compare Care Near You | Medicare), is a key resource for families and individuals seeking long-term care options. One critical area that the CMS rating system focuses on is the use of antipsychotic medications in long-stay residents. This article will explain how the Five-Star Rating System works and why the use of antipsychotics in long-stay patients is an important quality measure.
In the midst of our daily responsibilities, of taking care of patients and our household duties or obligations to our children and family – how are we actually taking care of ourselves? Are we making sure that we are getting exercise or a few quiet minutes to reflect? Or what about that book that you have been wanting to read? Wait – did you just have a birthday and realized how you haven’t lost those 5 or 30 pounds you were planning to lose at your last birthday? Well, it should get us thinking about how do we actually use our time? We all know about the distractions of social media and we all have been a victim to being available to everyone else’s needs now that we have cell phones. Is there ever downtime?
I recently admitted a woman who was status post extensive cervical spine decompression and fusion for severe spinal stenosis. In the hospital, her urinary urgency incontinence was managed with a PureWick external urinary catheter which worked well and avoided painful transfers while she was weak, immobile, and slowly regaining muscle strength and function. She assumed we would provide the PureWick system on transfer to our facility, but we do not have wall suction in our rooms and the system is not inexpensive. The starter kit on the BD website that includes the collecting system with lithium Pump and #30 external catheters cost $608 (10% discount available). The external catheter component is available on the BD site for $209/ #30 flex external female catheters. Each catheter can be used for 8-12 hours but needs to be changed if there is blood or stool contamination.
3rd Place Poster Winner
As providers, we are often asked personal health questions from family and friends. Most providers welcome this as an opportunity to share their knowledge with people they care about. However, sometimes these interactions become tough, as we need to remember that our role is to provide information, not dictate.
CGMs (Continuous Glucose Monitors) are devices that measure blood glucose on a continuous basis using a sensor device placed in the interstitial space using an enzymatic technology which reacts with glucose molecules, generating an electric current proportional to glucose concentration. Because it takes time for blood glucose to travel from the blood stream to the interstitial fluid, there is an inherent lag time of 5-20 minutes between actual blood glucose and the level measured by the CGM.
At this years’ CALTCM Summit in Napa, Dr. Eric Widera asked us to “Dust off Our Crystal Ball” regarding the value of predicting the prognosis of a patient and use of the E-Prognosis website (https://eprognosis.ucsf.edu/ ) to improve the reliability of our predictions and recommendations.
It is understandable that there is confusion about which members of nursing services have sufficient authority and education to assess residents in California nursing homes (NHs). The confusion is a consequence of issues related to the discipline of nursing itself, California RN and LVN scopes of practice, the nature of the nursing skill mix used in NHs, and language used in the October 2024 (version 1.19.1) Resident Assessment Instrument/Minimum Data Set guidelines.1
At this year’s 50th annual CALTCM Meeting in Napa I viewed a pre-recorded session on Transinstitutionalization for Serious Mental Illness by Drs. George Woods, Glen Xiong, and Patricia Blum. Last Spring, I had a patient with a Mental Health Crisis that exposed serious gaps in crisis care not only at my facility, but within our county. At the In-The-Trench’s session on this subject, I was able to present this case to these experts and came away with very practical advice to address these gaps.
Continuing Education is a critical component of healthcare that ensures medical professionals remain current on the latest evidence-based practices, innovations, and regulatory updates. For physicians and advanced practice providers working in post-acute and long-term care (PALTC) settings, staying engaged through continuing education opportunities with peers and thought leaders is particularly important. Practicing in PALTC presents unique challenges such as managing chronic diseases, addressing end-of-life care, and ensuring seamless transitions between care settings. Earning continuing education hours alongside colleagues and thought leaders in PALTC medicine fosters not only professional growth but also ensures the delivery of high-quality patient care through collaborative learning and leadership development.
I have recently provided onsite assessments for the regulatory annual employee physicals which is a process well standardized for ensuring employees are not a contagious risk to our residents and that they are able to perform their assigned duties. Rather than breeze through the exams, I chose to ask CNAs about prior work injuries and what they were doing to not only avoid injuries at work but to prevent injuries to high-risk areas like the shoulders and back. At one exam, the CNA strained her lower back the prior shift when a patient unexpectedly latched onto her hand during a minimal assist transfer. This CNA had not used the hand over hand technique, which could have prevented that injury. I subsequently found that a few CNAs were not aware of the value of this approach to patient care. For each CNA, I thanked them for their important work on behalf of our patients. When our patients become ill, they seldom have typical symptoms of acute serious illness and instead have subtle indicators. I thanked them for being the ones who recognize and report them to licensed nurses. One CNA said this had become more difficult since the COVID pandemic with less consistent patient assignments. I couldn't agree more and thanked him for saying so. As staffing improves, we can do better for our CNAs and their patients.
This year I approved a request for a mobile FEES (Flexible Endoscopic Evaluation of Swallow) study when I was the interim medical director for PACE (Program for All-Inclusive Care for the Elderly). We had a participant with dementia who had a troublesome persistent congested cough that disturbed his sleep. We considered further modifying the diet to reduce aspiration events as a part of his cough problem, but he was already having trouble maintaining his weight despite optimal family and dietary support. Our speech therapist recommended a mobile FEES study to better assess his swallow function. We had a contract with a company to provide this service at our PACE center. This participant’s swallow was directly observed by our speech therapist by this technology during his lunch at our center. Surprisingly, his swallow was quite safe with minimal risk for aspiration. This allowed us to liberalize his diet, better meet his nutritional needs, and focus on his weak cough and expectoration capacity. This led us to try an Acapella device to create airway vibrations to improve clearance of airway secretions.
The population of adults 65 and older is growing. So is the older population living with dementia or neurocognitive disorder. The prevalence of people living with Alzheimer’s dementia as of 2020 is estimated to be over 700,000. This makes up 12% of our 65+ Californians with Alzheimer’s.
