The perfect baseline care plan and comprehensive care plan in the nursing home have evolved into the holy grail of regulators, malpractice attorneys, directors of nursing, minimum data set coordinators, nurse educators, interprofessional team members, although not so much for direct care staff. In this article, I assert that we expect too much from this document because we do not properly understand its origins, evolution in policy and practice, and its historic misuse as a placeholder for the limited presence of registered nurses (RNs) in American nursing homes.

CALTCM, the California Association of Long Term Care Medicine, is set to unveil an on-demand course tailored specifically for Medical Directors in the state. Aimed at enhancing their understanding of California's intricate regulations, this program promises to be a game-changer for nursing home professionals seeking to navigate the state's unique healthcare landscape.

In the last 15 years of my career, I worked as a physician and medical director exclusively in the SNF setting. When the National Partnership to Improve Dementia Care went live in 2012, as a CALTCM board member, I joined the California Partnership to Improve Dementia Care, where I have continued to serve even after retiring from full time practice at the end of 2020. That partnership developed a model informed consent form in 2015 for use in older adults with dementia and psychosis living in SNFs (attached).  With the approval of brexipiprazole (Rexulti) in 2023, this form is out of date.  A new form is expected in 2025 when CDPH completes its informed consent tool kit for psychotropic medications in SNFs.  

In today's dynamic and competitive world, effective leadership skills are essential for success in any professional field, even post-acute and long-term care. Investing in a leadership skills course can be incredibly beneficial:

There have been a lot of questions about AB 1417 (Wood), the bill that revised the mandated reporting system in long-term care facilities in California, since it was passed in 2023 and went into effect on January 1, 2024. The California Long-Term Care Ombudsman Association (CLTCOA) has provided monthly trainings since December 2023 educating mandated reporters on the new system, which was sponsored by the Association and included feedback from CALTCM, the California Association of Health Facilities (CAHF), the California Assisted Living Association (CALA), and many other stakeholders. As someone who was intimately involved in the drafting of AB-1417 and has led the Association’s trainings on its implementation since then, I’m happy to provide more context to alleviate some of the confusion around the new law and why it was passed. 

Pay-for-Performance financially penalizes facilities that have excessive hospital readmission rates. To some extent, though, this depends on the intrinsic readmission risk of the patients accepted for admission. When you admit sicker, higher-risk patients, you should be able to capture the added cost through your PDPM reports. However, even with higher-risk patients, systems that identify potential changes of conditions before they become serious may allow effective onsite care.

During PALTC24, AMDA’s annual conference, the House of Delegates voted unanimously to change the organization's name to the Post-Acute and Long-Term Care Medical Association (PALTMed). This name is inclusive and representative of all clinicians working in PALTC. 

In March, CALTCM launched an alliance to bring together organizations who share a commitment to improving the quality of care, and quality of life, for older adults through collaborative efforts, innovative solutions, and advocacy. By pooling our unique perspectives, expertise, and passion, we can address the diverse needs of older adults more effectively and create positive change in the post-acute and long-term care (PALTC) community.

Heart Failure syndrome has a 50% five-year mortality even for patients in stage B, presymptomatic phase. Over the last 35 years, many studies have demonstrated classes of medications that can not only reduce the mortality of heart failure, but also improve quality of life and reduce the risk of hospitalization. Major advances have occurred in the last 10 years with sacubitril/valsartan (Entresto) replacing ACEs and ARBs as a more protective agent. In addition, SGL2 Inhibitors (Empagliflozin, Dapagliflozin) have now become standard care for all heart failure patients, even in those without diabetes. 

I believe that many of our staff and families are hoping this is true. We are now living in the post-pandemic era and have seen the benefits of natural and vaccine immunity with people still acquiring COVID, but for the most part not getting as sick, with most self-managing their illness and often not reporting it, or not even testing. We know that both are transmitted by the aerosolized modality and that new cases occur without an obvious source. The vaccine for both flu and COVID has waning illness prevention protection after about 6 months. The protection of both vaccines from infection in elders is imperfect and may only be in the 40-70% range. Flu has been most prevalent in the winter months in part due to people living in more crowded indoor conditions at that time of the year, but this is not true for COVID. Outbreaks have occurred in the Spring, Summer, and Fall and seem to correlate with the prevalence of a new variant of concern. The mortality this past flu season has also been quite different with COVID having almost 10 times the mortality of influenza with most of the mortality occurring in those aged over 60 or in younger persons who are high-risk for serious illness. 

About 5 years ago, I wrote an article for the WAVE on this subject based on a patient of mine who experienced a serious medical error while under my care at a SNF.  As I reflect on that case, I  recall that I immediately sought advice from the referring colleague and from a trusted colleague.  I then reported the error to the administration and was relieved that they supported full disclosure.  I disclosed the serious medication error to the patient and his wife with sensitivity, but the experience was emotionally traumatic for them and those involved with their care.  In retrospect, our response was reactive and done without the support of HR, clinical psychologist, risk management, or the counsel of our liability carriers.  

Steve Levenson never had any qualms telling things as they were. It’s what I loved the most about him. Remarkably, his analysis of all things related to geriatrics and long-term care medicine were almost always spot on.  He was an encyclopedia of knowledge and a laser focused repository of institutional memory. What I will miss the most about Steve is that I no longer have someone to call to get an unvarnished and incredibly well-informed answer to almost any question related to the art, science and policies surrounding nursing home care.  We have lost a once in a lifetime voice that I worry might be impossible to replace.

California’s End of Life Option Act began in June of 2016 and was modified in 2022 to allow a shorter minimum interval (48 hours rather than 15 days) between the two verbal requests and required providers to make clear to their patients whether they participate—and for those who do not participate, they are required to record the timing of an initial request so that the time from request to receiving MAID (Medical Aid in Dying) was not delayed. Since this change, there has been a slight uptick in requests for MAID (Medical Aid In Dying) in 2022 as opposed to prior years. The required data are reported by CDPH every July with the most recent report of July 2023 available online, click here.

CALTCM has a robust public policy committee (officially the Policy & Professional Services Committee [PPSC]) with interdisciplinary members who have more than a century of combined post-acute and long-term care experience.  The group meets once a month on a zoom call to discuss major concerns and outline steps to address serious issues.

In a recent IDT meeting for a Program for All Inclusive Care for the Elderly (PACE), we discussed the advantages of self-monitoring of BP in the home setting. We now have guidelines from multiple organizations that recommend home BP measurements as superior to those done in clinics or institutional settings. The SPRINT trial of 2014 and now multiple other studies have confirmed that reliable BP measurements require:

What makes a good life? This age-old question has many facets depending on who you ask. For some, happiness and joy come from having a successful career. For others, it means having financial wealth and security. And for some, it means having loving family and friends. According to the Harvard Study of Adult Development, the longest running study of 75 years, led by psychiatrist Dr. Robert Waldinger, the answer to having a good life is about having good relationships.
 
He posits three life lessons from his ongoing research:

Brexpiprazole (Rexulti) was recently approved by the FDA for treatment of agitation in Alzheimer Dementia based on the now published phase 3 study found in JAMA Neurology, November 6, 2023. In this 12-week study of the efficacy of this medication at the 2 and 3 mg daily dose compared to placebo, a statistically significant improvement in agitation was noted vs placebo. This medication was generally well tolerated without significant safety adverse events.  Agitation was defined as 1. excessive motor activity, 2. verbal aggression, or 3. physical aggression which caused excess distress or disability and could not be safely attributed to a suboptimal care environment or another disorder.  This is a small short-term study across multiple sites and countries.  This medication should be used for this indication with great caution until further studies confirm these results and better define those who might benefit, the degree of the benefit, and if significant long term adverse events occur with more prolonged use.   This medicine has common drug interactions that warrant dose adjustment in many circumstances.  This link has the details.

At a recent meeting of a local hospital with its SNF partners, a hospitalist made an appeal for SNFs to remove peripherally inserted central catheters (PICC) lines and Foley catheters when they were no longer necessary, since hospitalists were seeing this as a potential cause of readmissions.  After the meeting, we chatted and I discovered he was a Medical Director of a SNF, a member of CALTCM, and had signed up for the AMDA Foundation’s “Futures” program that will meet in San Antonio in March 2024.  I wish that I could have “bottled” his passion for high-quality medical care in SNFs.

At a recent Sutter Hospital meeting with their SNF partners, we were informed that our next meeting would focus on their new initiative to provide optimal transitions for patients with heart failure hospitalizations.  Many of those in attendance were perplexed by this development, since they thought they were already doing that.  

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