The World Health Organization has recognized what experts in geriatrics and long term care medicine have known for over two months.  Unfettered COVID-19 infections are devastating to nursing homes and assisted living facilities.  Reports are finally coming out that more than half of the reported deaths have occurred in senior congregate living settings.  It is quite likely that the number of deaths is still far underreported.  Only when the epidemiologists review all of the deaths across the U.S. and the world during this pandemic will we have the true answer.  The sad truth is that the experts in our field already know the answer.  We’re just waiting for corroboration.

SNFs are now required to report patients under investigation for COVID-19 (PUIs) and actual COVID 19 cases among their residents and HCWs (Health Care Workers).  The report is updated every working day (https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/COVID-19/SNFsCOVID_19.aspx ) and indicates that over 20% of our SNFs have one or more cases associated with their facility.  

On February 29th, the first case of COVID-19 was announced, occurring in Washington state in the Kirkland nursing home.  Geriatricians around the country immediately knew what this meant. CALTCM went into action and had our first webinar on March 9.  It’s six weeks later and we’d like to give everyone direction. For anyone who has not watched our webinars, we will redirect you to the most important, in the order that they should be watched.  Keep in mind, if you’re already far along the curve, some of this might seem remedial. We can assure you, it’s not.   

The Wall Street Journal reported on April 11 that over 2100 skilled nursing and assisted living facilities in 37 states had been infected with SARS-COV2 with over 2,000 deaths occurring. In Sonoma County, we have developed 2 workgroups for coordinating, disseminating, and implementing best possible practice ideas.  One workgroup consists of Leadership from Public Health (PHD), skilled nursing facilities (SNFs), Hospitals, and Foundations. The other has leaders from the assisted living (AL), residential care facilities for the elderly (RCFE), and Senior Living Communities.  In the latter group, we were relieved to learn that our county just developed a contract with Sonoma State University to house up to 580 seniors with stable COVID disease so they can be quarantined outside their home facility, reducing the risk of COVID transmission within this high risk population. 

Our country now has the distinction of having the most COVID cases in the world.  Our response as a nation is a stress test that has exposed our lack of a coordinated system of health care in this country.  In my community, there remains a shortage of naso-pharyngeal swabs, a public expectation of easy access to testing (County Public Health Department can do 100-120 tests per day), and many facilities still don’t have real-time access to adequate PPE.  Because of the lack of PPE and nasopharyngeal swabs, testing in some facilities for influenza/RSV/Other viruses is not being done. There appears to be an over-reliance on quarantine of residents with respiratory illness as well as shelter-in-place strategy to keep their facilities COVID-naïve.

Note: This article was prepared by Mr. Horowitz and Dr. Ferrini with special thanks to Dr. Robert Gibson PhD JD, Psychologist, for his input. 

At CALTCM, we are very concerned for the welfare of our very vulnerable post-acute and long-term care (PALTC) residents, families, and staff.  Because the world in our lifetime has not experienced such a rapidly moving and serious pandemic, CALTCM presented a Webinar on the COVID-19 coronavirus last Monday which was well attended (over 900 registrants) and is currently available to the public at no charge (for a limited time only) with additional resources on the CALTCM COVID-19 webpage.  Since that time, more important tools and information have become available.  The CDC now has posters and handouts on COVID-19 available on their web page in multiple languages that could be used for staff and visitor education.

Nursing homes are always “putting out fires.”  That excuse is often used to avoid addressing critical issues.  There’s a reason that the federal Requirements of Participation recognize the need to have a person in a nursing home tasked with infection control. That person is designated as the Infection Preventionist, or IP.  Who normally does that job?  It might be an RN or an LVN.  It is often the Director of Staff Development, or DSD.  Infection control is usually one task among many for the person typically designated to be the IP.  How does that work? Is it enough?

• 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

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).  

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.”

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 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.  

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 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.

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.  

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.

“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.