Dear CALTCM Medical Director Colleagues,

As a general internist, I appreciate the work of the ADA (American Diabetes Association) that identifies advances in diabetes care and adds these new developments to their comprehensive guidance called “Standards of Care''.  The SOC is published in Diabetes Care as a supplement every January.  The 2023 full version, abridged version, primary care, and other versions are all available online for free.  For providers, a free app is now available (ADA SOC) which allows real time access on your smartphone for quick guidance on specific patient care issues.  

Hooray ... Happiness is back on the horizon!

This year, a good friend underwent a revision hip arthroplasty for aseptic necrosis of the femoral head after a fracture fixation several years prior.  Being 80 years old and frail, she was offered rehab in an SNF postoperatively, but instead was confident her adult children and grandchildren could properly support her in the home setting.   Both this friend and her family assumed the oxycodone would take away most of the hip pain at rest and pain triggered by movement, but they were not aware of its common side effects or how they would know if the pain was adequately managed.  

In January 2023, the requirement for prescribers to have an “X” waiver to prescribe buprenorphine (Suboxone, Subutex, others) for Opioid Use Disorder was abolished, to improve access to this important treatment modality.  This means that any prescriber who can prescribe Schedule III medications is able to prescribe it now for that indication.

The Public Policy Committee for CALTCM continues its efforts to “make a difference.” With nursing homes continuing to be in the news in the wake of the COVID-19 pandemic, we are committed to assuring that our clinical voice is heard.  CALTCM’s Board recently approved letters to Secretary Becerra and Administrator Brooks-LaSure related to appropriate staffing and transparency. There would “appear” to be a lot of controversy related to staffing issues, but CALTCM’s position is based on the clinical experience and evidence that inadequate staffing is associated with poor care.  To minimize this in the face of staffing shortages does a disservice to the residents and the staff who care for them under less than ideal conditions.  CMS recently requested comments on a New Proposed Rule on Nursing Home Ownership Transparency, we submitted our comments, please click here to view.  These efforts continue what we started over two years ago in California that helped lead to the passage of SB 650.

I looked at my geriatric clinic schedule recently and saw the reason for the visit, “Angry Outburst.”  The clinic nurse explained that this hard-of-hearing resident in his 90s doesn’t hear our medical assistants when they knock on the door to announce their visit for medication administration, so they use their pass card to enter.  In recent times he has become very angry when he discovers them in their apartment.  The prior day, the MA was so frightened that she left and didn’t pass his medicines.  I asked the clinic nurse what she thought should happen next.  She wondered if I could prescribe a medicine that might reduce his anger so they could pass the meds and he could stay in his apartment.  In response, I asked her: if your eight-year-old child had a problem with anger management, would you ask his physician for a medicine to reduce the severity of the problem?  Of course, she said “no.”  

In the past few years, our attention has been necessarily focused on the COVID-19 pandemic. Although COVID-19 is still with us, it is time to catch up with progress in other aspects of managing our patients that impacts our long-term care population.

Last Fall, we were anticipating the triple threat and another significant surge of COVID complications, but fortunately, both threats proved much less than anticipated.  In my county, we have improved from highly prevalent status to low prevalence of COVID.  Our hospital and ICU cases with COVID have also significantly improved.  This good news is tempered by the reality that in the USA we still have about 7,000-8,000 deaths each month attributed to COVID.  Nine out of 10 of those dying are > 60 y/o and some of these are up to date on their COVID vaccine.  

We are now 3 years into the COVID-19 Pandemic. We have lived through unprecedented times where millions of people have become infected with the SARS-CoV-2 virus and, sadly, over 1.1 million people in the USA, and 6.86 million in the world, have died from this infection.  We have found that some of the initial recommendations for prevention of COVID-19 acquisition and transmission have changed. This has fostered some distrust and skepticism in the general public. In my opinion, Public Health experts have been building this COVID-19 prevention plane as they were flying it. In other words, we all have been learning as we go.

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.

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. 

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.

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.

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.

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.