Dementia is one of the most common hospice diagnoses in long-term care, yet hospice referral is frequently delayed. Unlike cancer or heart failure, dementia follows a prolonged and variable trajectory, making prognosis difficult. Understanding how functional decline—not cognitive decline—determines hospice eligibility is essential for physicians and interdisciplinary teams caring for these patients.

In the 1990s, our USA immigration policy allowed skilled nursing facilities (SNFs) to sponsor healthcare workers from the Philippines and other countries. Many of these additions to our SNF team in Sonoma County rapidly advanced to leadership positions. Coming from countries whose cultures highly value older adults, the caring part of their work in SNFs enhanced our care. 

At recent Sutter meetings with SNF partners, potential transfers of patients with a first episode of Clostridioides difficile (C. diff.) with orders for the expensive antimicrobial fidaxomicin (Dificid), were sometimes slow to place for fear that insurers might only approve Vancomycin. 

The 2024 requirements for 24/7 RN coverage and minimum hours per resident day for RNs and nurse aides were officially rescinded as of February 2, 2026. Currently, thirty-six states have some type of minimum staffing requirements. Attorneys general from eighteen states are asking CMS to consider a new staffing rule for certain for-profit nursing homes (NHs)  demonstrating high-risk financial and ownership practices. 1

In December 2025 Issue 1 Wave, I introduced the subject of Ambient AI. This is a technology that has rapidly expanded across over 200 hospital systems in the USA that use EPIC as their electronic health records (EHR) platform and the Abridge Ambient AI app (see link). Those using this technology for their providers and staff report more focused time with patients and less time documenting encounters. The improved efficiency also translates into greater productivity for healthcare teams. 

PALTMed is pleased to announce the launch of a free e-learning module for medical directors and leaders of nursing homes covering the clinical trial evidence and protocols for adopting universal decolonization as a Quality Assurance and Performance Improvement (QAPI) program.

In the age of hospitalists and electronic health records (EHRs), I’ve observed a decline in comprehensive physician assessments. I commonly see the first 3-4 sentences of the ER history of present illness (HPI) reappear verbatim in multiple provider notes. I seldom see a social or functional history, and rarely see accurate personal contact information. I observe a long list of past medical diagnoses and habits that are always documented (quality indicators linked to payment).  When a palliative care consultation is conducted, the documented focus often appears to be limited to the immediate problem. I wonder if the new generation of physicians and advanced practice practitioners providing post-acute rehab services has a similar “moment in time” focus, and wonder if there are measurable differences in patient and family satisfaction metrics or in facility outcomes. 

California is a vast, progressive state that implements innovative and often more rigorous regulations regarding the role of Medical Directors and nursing home care compared to federal standards. For Medical Directors to thrive, it is essential to grasp what sets California apart, navigate existing regulations, and comprehend the implications of forthcoming regulations—many of which could profoundly affect their daily responsibilities.

“Alone we can do so little; together we can do so much.” Helen Keller

For many years, the Post-Acute and Long-Term Care Medical Association (PALTmed) has sent a contingent of leaders (officers and board members) to Washington, D.C. for Capitol Hill visits every autumn.  This year for the first time, our advocacy efforts were opened up to the general membership, and over 50 PALTmed members, representing constituents of 25 states and the District of Columbia, attended the first annual PALTmed Advocacy Summit on October 27-28, 2025.

I recently listened to a “Turn on The Lights” podcast where an expert on provider burnout favored “Moral Injury” as a more accurate way of describing a healthcare delivery system that is very inefficient and has unrealistic provider productivity expectations. As I reflect on my long career in private practice, I didn’t have to sacrifice the quality of care I provided, since my educational debt was small and most of my years of practice preceded electronic medical records (which sadly have cut my efficiency by about 60%). I have seen my cardiologist improve his efficiency using a scribe, but my billing could not justify that added expense.

As I previously reported, in the August 1 WAVE, SB 380, the End of Life Option Act (EOLOA) became a law in California in 2016 and was amended in 2021 to shorten to two days the time from the first oral request to the second one. In addition, all healthcare facilities (acute care hospitals, SNFs, hospices, and medical offices) are to post a publicly visible notice on their website and offices stating their policy with respect to the EOLOA, including if they and their employees are prohibited from participating in this Act.

In recent years, medical directors and other physicians practicing in post-acute care settings have recognized the benefits of aligning with advanced practice nurses working in these settings. Physicians benefit by having a clinical partner participating in the medical management of their patients. Academic nursing has hailed this partnership in hopes that advanced practice nurses will help to elevate the nursing practices of nursing services offered in these settings.

October was the month for employee physicals for skilled nursing facilities (SNFs) and for a Home Health Aide (HHA) and Certified Nursing Assistant (CNA) Training Academy that prepares students for certification exams. In both these situations, my job is to ensure employees are fit to perform their work and ensure they are free of serious contagious illnesses like TB. 

This mantra has been used to justify the financialization of medicine where the mission of even non-profit health systems may succumb to system decisions that maximize profit and compromise mission.  This subject was explored in great detail in a recent podcast from Turn on the Lights, “Graduate Medical Education and Social Contracts” with Dr. Tom Nasca (https://www.ihi.org/library/turn-on-the-lights-podcast).

Working as a physician and medical director in post-acute and long-term care, I’ve seen how easy it is to miss vitamin deficiencies that have real clinical impact. Many of our residents have age-related malabsorption, multiple comorbidities, and limited diets; add polypharmacy and functional decline, and the risk grows. Over the past few years, I’ve started screening vitamin D and B vitamins in residents with frailty, falls, anemia, cognitive decline, or nonspecific fatigue — and I’ve been surprised by how often this changes care. I’ve found vitamin D deficiency in the majority of residents I check, and more vitamin B6 deficiency than I expected, even in those who looked nutritionally stable on the surface.

As a physician and medical director in the post-acute and long-term care setting, I encounter dementia-related behaviors almost every day. Agitation, aggression, or resistance to care are rarely “just behaviors” — they’re often the patient communicating discomfort, fear, or confusion in the only way they can. When a nurse calls me about a resident striking out during bathing or becoming restless at night, my first instinct isn’t to reach for a prescription pad. Instead, I pause and ask: What has changed for this person? I look at recent labs, review pain control, check for constipation, infection, or dyspnea, and ask whether their usual routines — music, lighting, or sleep patterns — have been disrupted. Many times, small adjustments like restoring a familiar evening routine, dimming harsh lights, or breaking hygiene tasks into smaller steps can calm a patient without medication.

In 2012, multiple medical societies and consumer groups launched the “Choose Wisely Campaign” challenging medical specialties to identify five common tests or procedures within their field that were often overused and should be questioned by both physicians and patients. These lists were based on evidence and clinical guidelines. Since then, leaders at PALTmed have developed and just released “20 Things Prescribers and Patients Should Question in Post-Acute and Long-Term Care.

As you know, §483.20 (h) Coordination, otherwise referred to as F-tag 642, states: “A registered nurse (RN) must conduct or coordinate each assessment with the appropriate participation of health professionals.” The RN’s signature serves as the certification that the assessment is complete, but does not certify the accuracy of the assessment.¹ 

Many of us have seen the effects of hypercortisolism on diabetes control when prednisone is added to an acutely ill insulin-dependent diabetic. However, like many of you, I’ve never diagnosed Cushing’s Syndrome, which is distinctly rare. Nonetheless, most of us have cared for persons with diabetes who remain highly insulin-resistant and have suboptimal glycemic control despite using the latest diabetic glycemic control agents.