In the last issue of the WAVE, I reported on the potential direct clinical value of an excellent AMDA Webinar on Sleep Disorders in Older Adults. In that Webinar Dr. Kitamura mentioned a number of factors which could aggravate restless leg syndrome (RLS).  One of those, the prescribing of SSRI’s directly applied to one of my older patients with RLS who was requesting Ativan, because her Ropinirole was no longer working.  A month prior, I had started her on Lexapro for depression and had recently advanced the dose to 10 mg daily. 

On January 27, 2020, the saga that began in 2013 with a lawsuit against the California Department of Public Health (then captioned CANHR v. Smith) finally concluded, although some details remain to be worked out.  The bottom line is that in skilled nursing facilities, the Epple/IDT process, sometimes referred to as an Ethics Committee or Bioethics Committee (even though the composition of such a committee in nursing homes is rarely as robust as it is for hospital Bioethics Committees), is able to make decisions for incapacitated, unrepresented nursing home residents—including all psychotropics and end-of-life decisions—but a non-facility-affiliated resident representative must be part of the process.  

As some of you know, 2019 ended with the closing of my Post-acute & Long-term Care practice.  In the process, I turned over the care of my patients to 3 other physicians and my 2 facility Medical Directorships to 2 of my colleagues.  Having been the Medical Director for over 33 years at my CCRC, I have had some time to reflect on this role, beyond the CMS expectations and AMDA guidelines ((https://paltc.org/product-store/amda-model-medical-director-agreement-and-supplemental-materials-medical-director).  

• Deaths: 54 since Sept. 29, 2019
• Outbreaks: 16 since Sept. 29, 2019
• Laboratory: 27.7% positive
• Outpatient Influenza-Like Illnesses*: Above expected levels
• Hospitalizations: Above expected levels

For more information from the CDC on this years Flu activity, go to: https://www.cdc.gov/flu/index.htm

I recently received a text message from a nurse at my Geriatric Clinic that informed me “Mrs. X, (90 y/o) is demanding a prescription for lorazepam (Ativan) for an intolerable flare of insomnia and anxiety”.  She had seen a clinic colleague 2 days prior, who had declined this request, but did prescribe an alternative medicine for her restless leg syndrome (RLS). Though my next day clinic schedule was already full, I texted back to add her to my schedule.  

I’ve recently seen a spate of reports of individuals whose “life has been saved” by the Apple Watch. Reading these articles generally reveals that it was actually the onset of atrial fibrillation that was detected. While that is very important and promptly addressing atrial fibrillation can allow treatment to prevent devastating strokes, I have yet to see true evidence of saving lives. Until they build in a defibrillator, I suspect most of the health benefits from this type of remote monitoring will be identification of bradycardia, atrial fibrillation and other cardiac arrhythmias. A large study on the value of arrhythmia monitoring with the watch, The Apple Heart Study, has had its rationale and design published but the results remain to be reported. Versions 4 and 5 of the Apple Watch can take a single lead EKG, but I have not seen any reports where changing morphology is used to detect hyperkalemia or QT prolongation or ischemia. There is a paper in preprint on using the Apple Watch to take standard and precordial leads, by placing it on the leg or changing the finger used to record. It remains to be seen if this rather cumbersome approach has practical utility in a busy medical practice.

On Saturday, October 19, the California Association of Long-Term Care Medicine (CALTCM) hosted our 2019 Fall Summit “The Best of the 2019 CALTCM Summit for Excellence,” focusing on engaging nursing home direct-care practitioners with updates on best practices, education on PDPM and immersion in expert-led discussions about ‘hot topics’ in long-term care.

Though the experience of personal trauma over a lifetime is almost ubiquitous, the possibility that trauma might be an important clinical issue to identify hasn’t been a routine part of my initial patient assessment.  I’ve seldom seen it in the work of my colleagues at an acute hospital or SNF level. 

We at the SF Jewish Home and Rehab Center on the Campus for Jewish Living were contacted by SFDPH late Friday afternoon October 25th to inquire about our current census and bed availability due to the Kincaid fire evacuations. However, it wasn’t until 9 p.m. on Monday night, October 28 that we were asked to open our doors to 3-5 frail evacuees currently at the Santa Rosa Evacuation Center. Since we did indeed have some private rooms available, we of course said yes, we would welcome them into our community. The first guest arrived at midnight, followed by two others around 3 a.m.  Internally we activated our Incident Command that met twice a day to ensure our visiting residents were adjusting well and that their care needs were being met. 

As we approach the November 28, 2019 deadline to fully implement the Phase 3 changes in the “Mega Rule,” it is important to note that some of the “changes” that were implemented in Phase 2 are expected to change in Phase 3. Specifically, under Phase 2 rules, antipsychotics could not be prescribed PRN for more than 14 days unless a resident was examined by a prescriber (every 14 days). This was ostensibly to avoid the issue of off-label overprescribing of antipsychotics in our population, especially those suffering dementia-related psychosis (DRP) or other behavioral issues that could not be attributed to an Axis 1 diagnosis of a mental condition (i.e. bipolar disorder, schizophrenia, major depression, etc.). The rule as written mentioned a tendency to “place the convenience of the caregivers above the residents’ interests.”

I recently wrote an article for the WAVE on the potential value of sharing personal pictures on your smartphone, for developing relationships and engaging patients with dementia, prior to providing medication and care plan directed care.  

Do you wonder if you are most effectively using the technology you carry in your pocket? Is your phone cluttered with medical apps that you downloaded and now you can’t even remember what they are supposed to do? Here is a guide to walk you through my approach. Caveats – this is based primarily on my own experience, and I use an iPhone not Android, so my Android info is limited. Medical apps seem to disappear from the app store with remarkable frequency, so please check availability.

In the second issue of the WAVE for June this year, I wrote about how to access “AMDA on the Go” podcasts, which are offered free to post-acute and long-term care professionals.  Over the summer, AMDA has added a number of new features including expert discussion from the Colorado Geriatric Journal Club, and now, practical clinical applications from the August issue of JAMDA.  In this podcast, Dr. Philip Sloane, the new co-Editor-in-Chief, summarized take-home lessons from: Increasing the Value of ER visits, Reducing Avoidable Transfers, Quantifying the Impact of Incomplete nursing home transfer documentation, and Measuring the Value of High-Intensity Telemedicine in Senior Living communities.  I found this podcast to whet my appetite for the details of these articles, which I can now more effectively share with my facilities and home health agency.

In recent years, I have used pictures I’ve taken on my smartphone or received from others, as part of how I relate to my patients.  Pictures are a powerful way to share common human experiences that even my advanced dementia patients can find interesting. Most of these pictures are of my dog or grandchildren or places in the area that have a story associated with them.  I commonly will then ask my patients about their experiences with similar circumstances.  

The debate and enthusiasm about telemedicine visits, as an alternative for an in person visit, are lurching in parallel tracks. Early adopters who are using it in rural areas have mainly adopted Telehealth for behavioral health and possibly dermatological consults. 

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.