On November 11, 2022, the OIG (Office of Inspector General) released a report on the Long-Term Trends of Psychotropic Drug Use in NH.  From the years 2011-2019, the use of antipsychotic medications declined from 31% to 22%, while the use of anticonvulsants increased from 28% to 40%.  In 2015, CMS began using the long-stay quality measure that tracks MDS reported antipsychotic use in the NH in its Nursing Home Five-Star Quality Rating System calculations.  Between 2015-2019, the number of NH residents reported as having schizophrenia increased 35%.  Additionally over this time, the number of residents reported as having schizophrenia but lacking a corresponding diagnosis in the Medicare claims and encounter data increased by 194%.  A small fraction of US nursing homes (99) had particularly high levels of MDS reporting of Schizophrenia (> 20% of their residents) w/o corresponding preceding diagnosis in Medicare’s database.

On January 20, 2020, CDC confirmed the first US COVID-19 case in Washington State. Over a month later, a nursing home in King County, Washington, had a COVID-19 outbreak with a devastating outcome and 34 deaths. Which nursing home in California would be next? How can we protect ourselves, our families, colleagues, and most importantly our vulnerable nursing home residents? Without enough knowledge about the virus, lack of testing supplies, and shortage of protective equipment such as masks, gowns, face shields, and even gloves, nursing homes had real challenges to face in months to come. Those questions were frightening for many of us in long-term care, especially when we did not know where to find the answers. 

In September, California’s AB 2338 (Gipson) was signed into law by Governor Newsom. This welcome new law in the probate code codifies the legal authority for medical decision-making on behalf of incapacitated patients, although it will likely have little impact on the way these decisions have traditionally been made in health care institutions. CALTCM leaders, along with other stakeholders including the California Medical Association, California Advocates for Nursing Home Reform, California Department of Public Health, and the Coalition for Compassionate Care of California collaborated to finalize the language of this law. For those who want to read the law, it is available here.

Residents and staff continue to be vulnerable to COVID-19 and other respiratory illnesses, such as influenza. Rates of COVID-19 vaccination in adults at least 65 years of age, at highest risk for hospitalization or death from COVID-19, are lower than last winter. Flu and other respiratory diseases will continue to spread this winter after an early start at high levels. 

In the PALTC space, we commonly care for patients with impaired decision making capacity either due to acute illness, delirium, depression, dementia, serious mental illness or medications. At those times, it’s wonderful to be able to identify someone who can represent them for important decisions that they currently don’t have capacity to make. When a willing representative is not available, we rely on the IDT process to discuss and decide about the use of antipsychotics, decisions to limit life sustaining care options (including DNR and POLST orders), or referral to hospice. This process has been well codified and is required for review of these interventions whether emergent or elective.

As CALTCM grows and changes, we are aligning our infrastructure to match the growing need for internal support. Dominic Lim has done a fantastic job as our Interim CEO, and we thank him for his dedicated service as he transitions into CALTCM’s Vice President position. Dominic will continue with volunteer work for CALTCM and will provide consultant services for projects best utilizing his skill set. Dominic is truly a wonderful person, and we are so honored to have him serve on our Board of Directors with his vast knowledge, skills, and volunteer work dedicated to CALTCM.

At a recent town hall meeting for a local Continuing Care Retirement Community (CCRC), I updated our residents on the state of the COVID pandemic in our community.  Compared to the prior 2 years, we are experiencing much less serious medical illness and the deaths in 2022 were about one-tenth of what we experienced in the prior 2 years.  However, the risk of dying from COVID is still about 10 times higher than that for influenza and nearly 9 in 10 COVID deaths have occurred in those over 65 years of age.   The uptake of the new bivalent booster has been disappointingly slow with only 15.4% of the eligible USA population vaccinated.  As of January 9, this booster uptake in CA has been 22.7%, which is higher in elders, but is still low.  In Sonoma County, of those over 65,  53% are boosted, but this drops to 29% of the 50-64 y/o and further drops to 8-11% for those in the 6-34 y/o age ranges.  

This law requires specified types of health care facilities (including SNF and ALF) to allow a terminally ill patient’s use of medicinal cannabis, within the health care facility, subject to certain restrictions.

There is good news regarding California's continued push to reduce unnecessary psychotropic drug use and improve dementia care.  Assemblymember Aguiar-Curry has introduced AB 48, a bill to require written informed consent for psychotropic drug prescriptions in nursing homes.  A prior version of the bill, AB 1809, was vetoed by Governor Newsom in September.  Unfortunately, there had been a mix-up about some last-minute amendments that could not be fixed after the bill was sent to the governor.  However, Assemblymember Aguiar-Curry has reintroduced the bill, with suggested amendments from the California Department of Public Health, for 2023. 

California has had an immunization registry called CAIR (CA Immunization Registry) which has been voluntary for outpatient providers.  However, as of January 1, 2023, reporting becomes mandatory for all providers of vaccines under AB 1797 (Bill Text - AB-1797 Immunization registry. (ca.gov)).  This bill also requires providers to report the Race and Ethnicity information for each patient in the registry to support assessment of health disparities in immunization coverage.

I want to thank everyone for their support, it is a privilege to serve this honorable organization as President. As Peter Drucker said, "Management people can do things right; leadership is doing the right things." As healthcare professionals we choose to do the right thing for patients each and every day. We support families while they make difficult decisions in trying to do the right thing for their beloved family member. In this, we are all leaders. 

It’s been two years since CALTCM’s nascent Public Policy Committee put forth our “Nursing Home Safety Act.”  Two of our proposals were signed into law by the Governor of California last year.  One was related to financial transparency, which ultimately became SB 650, and the other was requiring nursing home medical directors to be certified, which became AB 749, authored by the Chair of the California Assembly Committee on Aging and Long Term Care, Mr. Adrin Nazarian.  From conceptualization to today, it’s been a remarkable journey.  Last month, our President, Dr. Janice Hoffman and I had the opportunity to present Mr. Nazarian with a plaque, thanking him for his support and yeoman efforts.

This year, I became the Medical Director of a small hospice focused on caring for those living in small assisted living communities (ALs).  Because we are a small team working In family-like home settings, we chose to open hospice cases with my colleague or I present (physically or virtually) to assess the case with our RN and the patient’s family (present, or virtually available).  This structure has not only improved the clinical assessment of the health history, but also has provided a quicker understanding of the patient’s personal preferences and goals of care.  In addition, the bidirectional communication with patients and DPOA builds trust for adjusting the care plan so we provide care that matters to this patient.

I was asked to commit to writing my thoughts and impressions about my experiences as Board member President and CEO of CALTCM.  As many of you may know I served as a president for 3 years (2009-2012) and as a CEO for almost a decade.

Purpose: To evaluate the effects of evidence-based transitional care intervention and self-efficacy training for skilled nursing facility (SNF) patients and caregivers. 

I recently saw a woman for a colleague who had been one of my patients in the remote past.  Since that time, her persistent low back pain despite multiple prior back surgeries has persisted and been complicated by depression, malnutrition, frailty, polypharmacy, and recent functional decline requiring SNF care.  Fortunately for her, my colleague had begun deprescribing medicines which were potentially more burdensome than beneficial.  Though this patient didn’t recognize it, her husband said her appetite had greatly improved.  When I saw her I observed she was easily moving about the facility in her wheelchair.  When I asked if her pain was keeping her from getting about the facility, she confirmed my observation that this was a good day.  

I was so honored to present a summary of the work that my organization, Los Angeles Jewish Health is doing in Telehealth at the recent CALTCM Summit for Excellence.   Los Angeles Jewish Health is the lead program that works in partnership with the California Technology Fund in a statewide coalition. We received FCC funding to demonstrate the value of telehealth in PALTC facilities. Our purpose is to inform those who are seeking to adopt or expand telehealth in facilities, and to educate policy makers, to better understand the potential benefits and challenges of implementing telehealth in facility-based care.  

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. 

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.