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Deprescribing Proton Pump Inhibitors


In past communications to GLC Medical Directors and in Town Hall meetings, we have recommended our LivingCenter physicians review their patients’ orders and look for opportunities to decrease the overall medication burden on patients.

Polypharmacy is a common issue in the elderly and in the SNF in particular. Among frequently prescribed medications receiving scrutiny are the proton pump inhibitors (PPIs).  PPI usage is highly prevalent in hospitals, and while the Society for Hospital Medicine has recommended that hospitalists decrease usage for ulcer prophylaxis, the practice is still very common.  Many patients are admitted from the hospital with orders for proton pump inhibitors (PPIs)  without clear indication, as well as patients who have been on a PPI for a long enough time to have “grown” a gastroesophageal reflux  (GERD) diagnosis without being aware of it.  Often once this diagnosis gets onto a single chart, it will be replicated for the rest of the patient’s life.

Recent observational studies have demonstrated that patients on long-term PPI courses are at increased risk for C. difficile, pneumonia, and osteoporotic fractures.  There also have been links to hypomagnesemia and B12 deficiency. PPIs also can be involved in cytochrome p450 based drug-drug interactions.

What should you do?

In reviewing patients upon admission, please discontinue PPIs in patients who lack a clear indication. There are some patients who may require long-term therapy. These include patients with Barrett’s esophagus, a history of a bleeding ulcer and those on long-term NSAIDs.  If a patient has a history of peptic ulcer disease, that is still not necessarily an indication for long-term therapy. For patients with “GERD” on their chart, I encourage you to discuss this with the patient or family to see if this is actually a problem.

Even if a patient has had a history of GERD, it is not recommended to treat patients for over eight weeks. If the symptoms are controlled, a trial of discontinuation is advisable.

Is rebound acid hypersecretion a real phenomenon?

Many patients experience a worsening of acid reflux symptoms, such as nausea, reflux or heartburn upon discontinuation of their PPI. This does not necessarily mean that this will be a daily occurrence for as long as they stay off of PPIs.

Rebound hyperacidity is a real phenomenon. In a population of 120 patients without previous GI symptoms, investigators either treated them for 12 with a placebo or 8 weeks with a PPI followed by four weeks of placebo.   Of the patients receiving placebo, 44% reported gastrointestinal symptoms in the weeks following switchover to placebo compared with 15% who had never received PPI in the first place.

This development of increased symptoms in previously asymptomatic patients is consistent with the concept of the PPI itself being responsible for rebound acid hypersecretion. It is hypothesized that during the treatment phase that patients develop increased gastrin output as a bodily response to acid suppression.  The effect was seen as far out as four weeks from discontinuation.  Interestingly, this phenomenon has not been noted in patients who were positive for H. pylori.

Should doses be tapered or patients switched to H2 blockers?

There are few studies of optimal ways to discontinue PPIs. In a systematic review in 2014, investigators found that there were only 6 trials which fit their inclusion criteria and one was unpublished.  Their conclusions were that attempts to discontinue PPIs can be successful, and that there is some limited evidence that a regimen which includes either tapering the dose of PPI or switching to H2 blockade can improve success.

Because rebound hyperacidity may occur, it is appropriate to counsel the patient and family before attempting PPI withdrawal. That way they can understand that there may be a temporary period of symptoms that could be treated with less aggressive therapy (such as with antacids, sucralfate, or H2 blockade). Knowing that rebound hyperacidity can occur, it may be logical to taper the PPI dose if there is an intermediate dose available, or even to treat with an H2 blocker for a limited period of time to ease the transition. It should be noted that discontinuation of H2 blockade has also been found to result in rebound acid hypersecretion.  Since the aforementioned withdrawal study showed symptoms four weeks out after discontinuation, it makes sense to be patient and cover for that period of time. Because there is currently a paucity of guidance, you’ll have to use your discretion.


Reimer, C et al, Proton-Pump Inhibitor Therapy Induces Acid-Related Symptoms in Healthy Volunteers after Withdrawal of Therapy, Gastroenterology 2009;137;80-87.

Linsky, AL, et al Proton Pump Inhibitor Discontinuation in Long-Term Care, Journal of American Geriatric Society, Sept; 59(9), 2011.

Haastrup, P et al, Strategies for discontinuation of proton pump inhibitors: A Systematic Review, Family Practice vol 31 No 6 pp. 625-630, September 2014.

PBJ Submission Clarification

Yao Header

Dear Medical Director:

We realize that new CMS SNF Payroll-Based Journaling (PBJ) regulation has resulted in some confusion. While physicians are not legally required to log in and out of the building, there is still a contractual requirement to fill out monthly timesheets for your medical director duties.

The electronic copy of the timesheet is HERE for your convenience.  A copy also may be found in the back of the Doctor to Doctor Medical Director Handbook, Second Edition. We may modify this timesheet in the near future, but for now I ask that you continue to use this one. Please submit it to your Executive Director.

LivingCenters should be invested in encouraging and documenting Medical Director administrative participation, as this has been shown to directly benefit patient care.

Kind Regards,

Michael Yao Signature (first name)

Michael Yao, M.D.

Chief Medical Officer

Golden Living

Study Supports Non-pharmacologic Approach to Reduce Antipsychotic Usage


Last month at the Alzheimer’s Association International Conference in Toronto, researchers from Australia presented their findings from the Halting Antipsychotic use in Long Term care (HALT) project. In this study researchers trained facility nurses on non-pharmacologic management of behavioral and psychological symptoms of dementia (BPSD) in 23 long-term care facilities.  The study recruited 140 residents, all of whom had a diagnosis of dementia and were on a regular antipsychotic medication though none of them had a primary psychotic illness. They were engaged in a gradual dosage reduction program and reassessed at three, six and 12 months following initial dosage reduction.  Of these 140 residents, 132 had initiation of dosage reduction.  121 of these patients are off of medications to date,   and  75% remain off of antipsychotic medications up to six months following the date of their initial antipsychotic reduction.

A brief overview of the study may be found in the Annals of Long Term Care at:


While it is not surprising that efforts to decrease antipsychotics can work, the high percentage of patient successes in this study when a patient-centered education program for staff is involved is notable. In your LivingCenters, GLC has made the CMS-approved Hand-in-Hand education available to all staff members through the GLC electronic Learning Management System.  I encourage you to check into this yourself at :  The training videos can be downloaded to computer to burn onto DVDs.  I found that even though the training is geared toward a general caretaking staff population, and thus do not require medical expertise, I learned much about communication with demented patients from the videos.

Without culture change and a team that understands patient-centered dementia care who are comfortable handling “problem behaviors” of patients with dementia, efforts at antipsychotic reduction are not likely to be sustainable. Education and reinforcement is vital and you can play an important role here.

Golden LivingCenters has been able to reduce antipsychotic usage in our long-term patients significantly, but there is still work to be done. Please feel free to contact me if you have any questions regarding how to further antipsychotic reduction in your LivingCenter.

CMS Adds Six New Quality Measures to SNF Evaluation for 5-Star Ratings

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You may have heard that CMS  has been planning to adjust the quality measures used to calculate 5-star Quality ratings and that some of these will be used later to affect reimbursement.  As a medical director, it will be important for you to get to know these new measures, so that you may help your LivingCenter track them and if necessary, implement plans to improve performance in one or more of these areas.

The overall 5-Star rating has grown in importance since its inception in 2008.  More and more hospitals, payers, and providers are utilizing 5-star information to determine whom to include in referral networks.  Additionally, patients and their families are becoming ever more savvy regarding 5-Star ratings and are using them to help them make decisions about their post-acute choices.  Golden Living has embraced the 5-star system since it began, recognizing that although the system has been imperfect, that many of these measures do truly reflect quality of patient care and can be indicators of opportunities for improvement.

The 5-star Quality Measures (QMs) have been a key component of the overall 5-star calculation. In recent years, there has been controversy over whether the overall improvement of QMs across the nation was reflective of improved care versus SNFs learning how to report their data in the best light. In an effort to improve the accuracy of the QMs and to reflect clinical measures that have real-life impact, as well as to increase scrutiny of quality of care of short-stay patients, CMS has added new quality measures this year. Five of these QMs will be phased into calculation of the 5-star ratings between Jyly 2016 and Jan 2017.  The anxiolytic/hypnotic measure will not.

There are now six new Quality Measures.  Four pertain to short-stay residents, and two apply to long-stay residents.  Data used to calculate some of these measures now include claims data, instead of relying purely on self-reported data such as information from the Minimum Data Set (MDS).  All of these new measures, except for the anixolytic/hypnotic measure are risk-adjusted.

Fig. 1              The new CMS Quality Measures for Skilled Nursing Facilities

Short-Stay Measures* Long-Stay Measures*
% Discharged to community % patients whose independence has worsened
% patients who have had an ED visit % receiving anxiolytics or hypnotic medications
% 30 day rehospitalizations  
% who had Improvement in function by time of discharge  

*A “short-stay” patient is one who has stayed at a SNF for 100 days or less, a “long-stay” patient is one whose stay exceeds 100 days.

Short-Stay Measures

Percentage of patients discharged to the community
Right now about 54% of patients who are admitted nationally improve well enough to be discharged home or to a non-institutional setting.  This will be based on claims, so patients who are not part of a Medicare Feefor- Service program (FFS) will not be included. Discharging a patient to home is obviously considered desirable.

A patient is considered to have had a ‘successful’ discharge to community if the patient is discharged within 100 days of the nursing home admission and in the subsequent 30 days does not pass away, is not re-hospitalized, and is not admitted to another SNF.

Percentage of patients who have had an Emergency Department  visit
Understandably, CMS considers Emergency Department (ED) visits inefficient and  a suboptimal way to provide care to SNF patients.  Not only is the transport and care expensive, but the emergency physician is not likely to be familiar with the patient.  Naturally, ED visits increase risk of hospital admissions.  If a patient is admitted through the ED,  the re-hospitalization QM will be affected, but not the ED QM for that occurrence.

Percentage of patients who were re-hospitalized after a nursing home admission.
This is also claims-based.  This includes both regular and ‘observation’ admissions. This measure is going to be risk-adjusted, based upon a relatively complex system of calculation.  Factors which would affect the re-hospitalization scoring include several resident factors called “covariates.” Covariates include demographic, clinical, and functional factors and are drawn from both Medicare Claims and from MDS data.  Further adjustment of this QM is based upon a calculated “expected rate” of re-hospitalizations based on the previous 12 month covariate information from the SNF in question.

Notable resident classes excluded from this calculation include patients receiving the hospice benefit, and patients who are not in Medicare FFS plans, such as Medicare Advantage patients.  Also, patients who do not have both Medicare A and  B will be excluded.

Percentage of Patients who made improvements in function
Based on the MDS, patients will be determined to have either improved or not.  A higher percentage of patients who have improved in their level of functioning is better.

New Long-Stay Measures

Percentage of patients whose ability to move independently has worsened.

This is based on MDS data.

Percentage of residents who received an anti-anxiety or hypnotic medication
This is based on MDS data.  CMS aims to decrease the burden of psychoactive medications on patients.  The original CMS proposal included antidepressant medications, but after receiving feedback from providers, the decision was made to exclude antidepressants.  Because anxiolytic and hypnotic medications have significant potential for harm for elderly patients, with questionable long-term benefit, it is understandable that these are included in the new Quality Measures.

What you can do about it
Now that you have had a brief overview of the QMs you’ll want to learn more about what goes into their calculation, and pay attention to these measures as they begin to be discussed in your QAPI meetings. Engage in discussion with your Director of Nursing (DNS) and RN Assessment Coordinator (RNAC) about the measures.  Check out some of the resources below in order to learn more about these new measures.

Of course, the previous measures are still in place.  It is still of vital importance to track the original QMs, as antipsychotics, wounds, falls, infections and other measures continue to affect the health, safety, and quality of life of our patients.  As the Golden LivingCenters leadership also will alert you to helpful resources as they become available.

Being a medical director continues to be an ever increasing challenge.  Keeping up with clinical and regulatory developments is hard, but an informed and engaged medical director is a key factor in helping our LivingCenter leaders navigate the waters ahead.

Thanks for all you do.  If you have any questions, please don’t hesitate to contact me.

More information & References

CMS release of new quality measures:

Final Technical Specifications of the new Quality Measures:

CMS link for Quality Resources:

AlixaRx Therapeutic Interchange Program


Want a way to cut down on medication substitution calls and requests?  If your LivingCenter is served by AlixaRx, you and your associates can arrange for pre-authorized medication substitutions.*  While AlixaRx does not seek to limit drug choices through a formal formulary system, there are certain commonly used medications in several drug classes which are optimal evidence-based  for efficacy and side effects, may be  cost-effective relative to equivalently effective options, or both.

Staff and pharmacists are routinely asked to request or recommend changes to these medications when options are available.  You can save time by approving these interchanges up front.  Just ask your AlixaRx Clinical Pharmacist for this approval form.  The medications in these classes have been discussed with the AlixaRx pharmacy and therapeutics team.  Current medical evidence as well as published guidelines were considered  in the selection process.  You can review the choices and check off as many or as few of these choices which you’d like to approve as you like.  You always have the opportunity to override these substitutions at any time, but this can save you plenty of time and a few pharmacy request communications.

As attending physician, you always have the choice of what medication to order. Many of you have practice partners, so you may wish to discuss the choices briefly with your partners to make sure that you are all on the same page.  Like I mentioned before, none of the choices are mandatory, and you may still change your mind at any time.

Participation in the Therapeutic Interchange program helps to optimize patient medication regimens as well as increase the likelihood that the medication prescribed is available on-site if your LivingCenter has an Automated Drug Dispensing Unit (ADU).  This helps to avoid delays  in drug administration by improving availability.

If you have any questions regarding the automatic substitution list, please feel free to discuss them with your AlixaRx Clinical Pharmacist, GLC Pharmacy Directors Steve Hord  & Eric Stratford or myself.

Helpful contacts:
Steve Hord (404) 904-7741
Eric Stratford (919) 895-8488
Michael Yao, MD CMD (412) 551-5616

*Note:  Due to regulatory constraints, the Therapeutic Interchange program is not available in Virginia, Nebraska, or Missouri.

New Billing Code Available for Advance Care Planning


As of January 1, 2016, when you make rounds there is another billing code available to you for work that you likely already are doing.  They are billing codes for Advance Care Planning, termed the “Voluntary Advance Care Planning” also known as  “Voluntary ACP.”

How does it work?

When you or your non-physician practitioner, such as a nurse practitioner, make rounds and have a face-to-face encounter with a patient or responsible party – a family member with power of attorney – and discuss advance directives, this is a billable service.  You must document the discussion, which should include description of the patient’s wishes relative to future medical treatment.

Essentially, you’ll be discussing advance directives. An advance directive is defined as a document appointing an agent and/or recording the wishes of a patient pertaining to his or her medical treatment at a future time should he or she lack decision-making capacity at that time.  It is appropriate and necessary to discuss the options, and while appropriate associated  paperwork, such as a transfer to hospital form, POLST form or living will may be completed or discussed as part of this interaction, this is not a required part of the visit for billing purposes.  A physical examination is not even required.

The CPT code is 99497, and if the discussion and related work takes over 30 minutes, you may submit a 99498 add-on code for each additional 30 minutes taken on the same day.  This initially may seem unlikely to some, but a family conference easily could take up over an hour’s time.

Because advance care planning is often an iterative process, wherein a patient or family may not be able to make up their mind at first, this code may be used repeatedly on different dates. Naturally CMS would be on the lookout for abuse of the code, but appropriate documentation should protect you.

This “Voluntary Advance Care Planning” service as it is called also may be performed as a part of an annual wellness visit, but if you do so, you need to attach a -33 modifier to waive the patient copay.  You would be able to bill for both the annual wellness visit and the advance care planning on the same visit, but understandably the patient should not be responsible for two copays.

Why is this important?

Hopefully you already are discussing advance directives and advance care planning with your patients in the LivingCenters. Now you at least can get some reimbursement for the time spent.  At Golden Living, our philosophy and mission is patient and family centered.  Discussing a patient’s wishes empowers them and may save a patient from care that may be more aggressive or invasive than they would have wished.  Alternatively, some patients do wish for measures to be taken, as is their right, and this will reinforce their desires.  Both of these situations especially are important when family members disagree with each other.  Much strife can be circumvented when the questions are asked early in a patient’s stay, as opposed to at the moment of change in condition when everyone needs an answer quickly.

For more information:

You may find more information about this code through the following link:

A list of frequently asked questions and answers regarding this CPT code can be found at:

Please share this information with your associates and medical staff and feel free to contact me or your Regional Medical Director if you have further questions.

Meet Dr. Gerald Byers from Golden LivingCenter – Murrysville

Dr. Gerald Byers (center) with Golden Living Chief Medical Officer Dr. Michael Yao (left) and Golden Living Chief Executive Officer Dr. Neil Kurtz (right)

The 2016 Golden Living Medical Director of the Year Award recipient for Team 2 (Northeast), Dr. Gerald Byers has brought more than 25 years of experience to help care for the patients and residents at Golden LivingCenter – Murrysville in Pennsylvania.

In his nomination form, his Executive Director Melissa Sullivan said she has not seen a medical director as involved in the medical operations of the building like Dr. Byers has shown.

“Dr. Byers has distinguished himself as a promoter of our LivingCenter with our local hospitals, insurance networks and with our relationship with the Department of Health,” Sullivan continued.

Sullivan said that Dr. Byers really understands and respects the human component and has a lot of compassion for the families and staff alike.

Chief Medical Officer, Dr. Michael Yao concurs.

“Dr. Byers has for years enjoyed a reputation among the local family practice residents and attending physicians at Forbes Regional Hospital and in the community as an excellent practitioner and teacher of medicine.  Since taking over as Medical Director at Murrysville, he has been actively involved in providing medical leadership, guidance and feedback in a number of areas, including integration of a respiratory therapist into care and the deployment of nurse practitioner coverage to help to decrease avoidable hospital readmissions,”said Dr. Yao.

A Visit with Dr. Mary Evans

Mary Evans

AMDA, the Society for Post-Acute and Long-Term Care Medicine, gathers annually to discuss the hot topics in long-term care, present new research and bond around the shared experiences that make work in long-term care deeply rewarding and endlessly complex.

At this year’s conference, held last month in Orlando, Dr. Mary Evans, Golden Living’s Compliance Executive Physician, among a few other roles, was elected to AMDA’s Board of Directors as representative from the State Presidents’ Council. While this is a prestigious honor, Dr. Evans is no stranger to professional service. She just relinquished a five year run as president of the Virginia chapter of AMDA and completed her second two-year term on AMDA’s Foundation Board of Directors. If that weren’t enough, she’s currently serving her fourth term on the AMDA program committee, the committee responsible for planning the conference. She’ll be the first to tell you, “I just won’t go away.”

Dr. Evans doesn’t take on these roles to pad her resume. A quick glance at her CV will paint a picture of a driven, Mayo-trained physician with an impressive list of roles and accolades. Like an impressionist painting, you must step back to see the full picture. Dr. Evans certainly is driven and has worked for every rung on the ladder, but she finds her fulfillment working collaboratively with the team – other doctors, nurses, medical directors – to reach consensus, effect change and elevate the care physicians give. “You can’t have tunnel vision in patient care,” she cautions.

“We have to care about people,” she goes on. “What we need to do at AMDA is support the doctors trying to take care of people. We need to work together and follow AMDA’s strategic plan and reach out to the government agencies to make sure they understand the needs of our patients.”

Dr. Evans also is known for her passion helping colleagues advance and carve out their own unique path in medicine. During the AMDA conference, Dr. Evans shared a stage with five of the industry’s most respected physicians, who happen to be female, to talk about “Enhancing Leadership for Women in Post-Acute Care.” Dr. Evans used the time to tell her personal story. Fellow speaker Suzanne Gillespie, MD, RD, CMD, summed up the roundtable best with the opening to her presentation.

“Putting together this session wasn’t necessarily about women, but about the importance of the network of colleagues and having some awareness of people’s journey in their professions and how they’ve developed certain skills and roles,” said Dr. Gillespie. Leadership takes on a variety of professions. As Mary and Heidi so richly shared with us in their journeys, there are straight lines, and there are forked turns. They each have lessons for us.”

The story Dr. Evans tells is certainly forked. She didn’t take a direct path to long-term care medicine and thinks it’s beneficial for other women to know the prescribed path for physicians isn’t the only option.

“If someone had told me 20 years ago that I was going to be a corporate medical director and a compliance person in one of the largest long-term care companies in the country I would say they were out of their minds,” Dr. Evans muses. “There wasn’t that path when I got out of medical school. My point to these ladies was, ‘If you aren’t happy in your position and the schedule isn’t working out or you’re not happy then look for something else.’ There are so many possibilities within medicine that are not the traditional paths. Look for something you’re really passionate about.”

The road to Dr. Evans’ passion, long-term care, began with OB-GYN. She trained as an OB-GYN and spent eight years practicing before the daily demands of three children and long nights of patient care led her to take a two year hiatus from medical practice to focus on family. After much needed time to reflect and be a mom, she found herself longing to jump back into medicine, but the demands and rigor of a traditional practice hadn’t changed. The break begged the question that many professional women ask themselves after taking time to care for children, “What’s next?”

Providence stepped in to answer the question for Dr. Evans. She and the family packed up and moved because Dr. Evans’ husband, also a physician, accepted a position as the head of Geriatrics at the University of Virginia. He suggested that his wife to be the Associate Medical Director at his hospice. Encouraged by more predictable hours and a chance to explore new territory, Dr. Evans became certified in hospice and palliative medicine and accepted the role. Quickly she realized she loved the work and decided to open a long-term care practice. The unexpected opportunity delivered the intersection of zealous work and family flexibility.

A few years later, she was recruited by Golden Living to be a Regional Medical Director. The rest, as they say, is history. In her seven years with the company she’s maintained her long-term care practice while holding various roles and providing leadership on several special projects. As a need arises, such as wound care or compliance, Dr. Evans is thrilled to get whatever certification or training is needed to step into a new role. Today she works on the compliance team as Compliance Executive Physician, charged with complying with the corporate integrity agreement, and also oversees the wound care program for the Atlanta area facilities.

She still has one child at home and two away at college, so she is able to lean in more to her work at Golden Living. “There’s always that struggle of wanting to work, wanting to be really good at what you do without wanting to neglect your family,” Dr. Evans says.

Chief Medical Director for Golden Living, Dr. Michael Yao says, “Dr.  Evans has been a great leader in many roles for Golden Living. She has also worked on special projects for Golden Living, providing physician leadership, education, and subject matter expertise on antipsychotic reduction, cardiac and pulmonary care. She has been a key member of the Regional Medical Director team, collaborating on strategic directions for the Medical Directors while being an advisor and mentor to Medical Directors in the Southeast. Additionally, she has worked closely with our clinical team to enhance and standardize wound care.”

Dr. Yao mentions yet another passion project for Dr. Evans – Antipsychotic medication reduction. “I’ve been on the antipsychotic bandwagon for 15 years, “she says. “My husband and I have been campaigning against the use of antipsychotics and spoken to anyone who will listen.”

A project led by Dr. Yao, Dr. Evans is a champion for the campaign to reduce antipsychotic medications within the long-term care industry. She’s focused on seeing a cultural shift that encourages alternative methods to calm agitated patients. She’s an advocate for music therapy and appropriate activities, especially within dementia care. “You need to have a committed facility and create a complete culture change,” she says. “Approach people like human beings not problems to solve. Meet people where they are in their journey.” Overall, she believes changing the mindset relies on the internal collaboration.

Dr. Evans has a difficult time containing her excitement when she speaks of her “soul sister” Amy Conoly, the new Vice President of Quality of Life for Golden Living and a dementia care specialist. Dr. Evans and Connelly have found a fast friendship and mutual understanding of the steps to reduce dependence on antipsychotics on patients. They are aligned on an approach and expect to see great results in the future.

Actually, Dr. Evans feels like she has several soul sisters at Golden Living. She is fired up about the whole leadership team and is proud to see an abundance of female leadership, meaningful activities and a team approach that leads to improved quality of life for patients. “It’s the amazing teams on the ground driving change. I’m so proud of the work they’re doing.”

Key Alliances

Just recently Dr. Evans’s father passed away. She received the news the day before she had a planned trip to Atlanta for work with the wound care team. The first thing she did was message her team, including Wanda Prince, Vice President of Clinical Operations at Golden Living, to let her know she wouldn’t be able to make the trip. “She immediately called me to check and see how I was doing,” recalls Dr. Evans. “Boom, just like that she was there. I think the world of her. She’s always very supportive.”

Relationships like what she’s found at Golden Living are the kind of supportive, professional affinities between female colleagues that Dr. Evans spoke of in her AMDA presentation. She says surrounding yourself with nurturing allies is how you enhance leadership opportunities for women. “It took me many years to realize the value of those women friendships. I didn’t learn that lesson until I had the many women role models that helped bring me along. Don’t be afraid to speak up for yourself and tell your truth. Don’t limit yourself to just what you think you can do in your career.”

Dr. Evans is one of three females elected this year to the AMDA board of directors. Incidentally, all three women consider each other to be friends and colleagues in equal measure. She is optimistic about what they will be able to accomplish working together.

Dr. Yao expects great things to come from the board seat as well. “We at Golden Living have been particularly proud to hear that she has been elected to the Board of Directors of AMDA, where her combination of clinical experience and organizational leadership will be of major benefit to all LTC medical directors in the U.S.,” he says.

2016 GLC Medical Directors of the Year

Golden Living Medical Directors from Massachusetts to California converged  on Orlando Florida to attend the 2016 AMDA Society for Post-Acute and Long-Term Care Conference.  This national  conference featured renowned speakers who addressed key clinical, regulatory,  and administrative issues facing Medical Directors today.  At the Golden Living Gala, held on Friday night, GLC Medical Directors had an opportunity to hear from Sean Foster, Vice President for the West Region, as well as Wanda Prince, Vice President of Clinical Services.  The special treat was a fascinating discussion of the need of Medical Directors to be agents of change in LTC and Post-Acute Medicine, in the context of the history of skilled nursing care in the United States.

As we have been doing for the past six years, nominees and winners of the GLC Medical Director of the Year Award were announced, and attendees got to hear about their notable accomplishments in leadership in their LivingCenters.

I would like to recognize our 2016 Golden LivingCenter Medical Director of the Year award winners and thank all of our Medical Directors for their dedication to our patients and our clinical teams.

Dr. Gonzalez

In its sixth year, this award honors the important role our Medical Directors have in the quality of care Golden Living provides to its patients. They are the ones we rely on to exemplify Golden Living values of integrity, accountability, excellence and quality and practice with clinical excellence that personifies Golden Living’s long-term and post-acute care.

The winners were nominated by our Executive Directors and Directors of Nursing Services. These nominations were reviewed by Golden Living administrative, nursing and medical leaders. Our winners demonstrate clinical excellence in patient care, facility leadership, make contributions to quality of care in the LivingCenter and are involved in the community.

We announced these Medical Directors at the Golden Living Gala earlier this month in Kissimmee, Fla., where the American Medical Directors Association (AMDA) held its Long Term Care Medicine 2016 Conference. Each one of these physicians is unique but all share one distinguishing professional attribute: an unwavering dedication to our patients and their care.

My congratulations go to our 2016 GLC Medical Directors of the Year:


Dr. Sarvamitra Awasthi, GLC- Reedley, Calif.


Dr. Gerald Byers, GLC – Murrysville, Pa.


Dr. Eileen Caquias-Gonzalez, GLC- Lumberton, N.C.

The nominees this year were:

Dr. Sarvamitra Awasthi GLC-Reedley, Calif.
Dr. Priscilla Bade GLC-Bella Vista, S.D.
Dr. Joel Bolen GLC-Montgomery, Ala.
Dr. Joshua Bradford GLC-Riverside, W.Va.
Dr. Gerald Byers GLC-Murrysville, Pa.
Dr. Troy Cappleman GLC-Ripley, Mo.
Dr. Richard Chung GLC-Independence, Mo.
Dr. Brian Clonts GLC-Branson, Mo.
Dr. Catherine Cunningham GLC-Clarion, Pa.
Dr. Lowell Dale GLC-Rochester East, Minn.
Dr. Eileen Caquias-Gonzalez GLC-Lumberton, N.C.
Dr. Eric Hilgeford GLC-Camelot, Ky.
Dr. Mazen Madhoun GLC-Martinsville, Va.
Dr. Tamara McCue GLC-Wellington, Kan.
Dr. Parvez Memon GLC-Bakersfield & GLC-Shafter, Calif.
Dr. Simon Mittal GLC-Bloomington & GLC-Lynwood & GLC-Twin Rivers, Minn.
Dr. Allen Moorhead GLC-Neodesha, Kan.
Dr. Amy Muchow GLC-Beaver Dam, Wis.
Dr. John Oujiri GLC-Court Manor, Wis.
Dr. Brookes Peters GLC-Tarboro, N.C.
Dr. Frank Reusche GLC-Walnut Creek, Pa.
Dr. Chester Rogers GLC-Mishawaka, Ind.
Dr. Nancy Said GLC-Hermitage, Mass.
Dr. Aaron Shives GLC-Watertown, S.D.
Dr. Ronald Simonsen GLC-Kinzua, Pa.
Dr. Daljeet Singh GLC-New Haven, Mo.
Dr. Robert Sweeten, Jr. GLC-McDonald County, Mo.
Dr. Tarlochan Tagore GLC-Sanger, Calif.
Dr. Vincent Trapanotto GLC-South Hills, Pa.
Dr. Mark Vogt GLC-Westwood, Mo.
Dr. David Weintraub GLC-Oakhill, Mass.
Dr. Alvin Wessel, Jr. GLC-Black Hills & GLC-Meadowbrook, S.D.

Our Medical Directors are experts in long term care and are skilled in working with interdisciplinary teams. Their influence extends beyond the care of one patient; they take the initiative to lead compassionate and appropriate care of all LivingCenter patients and residents.

Their passion for caring enables them to create supportive work environments and community partnerships with the patient’s interest coming first.

A Medical Director’s work is challenging, but it is also very rewarding. Please join me in thanking and recognizing all of the physicians in our lives.

Onboarding a New Attending Physician

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Dr. James, Medical Director at GLC Northumberland was getting more irritated by the moment. Over the past three months, she had been getting calls about Dr. Atkinson, a new member of her attending medical staff who had not responded in a timely fashion to warfarin adjustment requests. Last week Dr. James had heard that Dr. Atkinson had “given a nurse the third degree” about a lab not being reported.  Now it was Friday, and she was just informed that a patient of Dr. Atkinson’s had been admitted but could not be reached for confirmation of initial admitting orders.  When Dr. James called Dr. Atkinson’s  contact number, the answering service stated that Dr. Atkinson was out of town for the next two weeks. When asked who was covering, the answering service was silent for a minute before saying…”it says here to contact Dr. James.”

What should Dr. James do?  Is there any way for Dr. James to have prevented this?

Hopefully you have never encountered this sort of situation.  If you have, you probably know that a little communication can often go a long way.  Obviously Dr. James is going to have to address a number of issues with Dr. Atkinson when he gets back in town – everything from responsiveness and coverage of patients, to interaction with staff and vacation coverage.  It also may be helpful to get Dr. Atkinson’s impression of the staff and processes in the LivingCenter to identify opportunities for improvement.

We have encountered questions at times regarding what to do regarding new attending doctors. One concept that I’d like to propose as a best practice this month has to do with the medical director helping with onboarding an attending physician.

What follows are some best practices that you could employ to help a new physician get familiar with your LivingCenter, so that he/she can hit the ground running.  Even a five minute “Hi, how are you?  I’m the medical director” type conversation can go a long way.

Meet the new doc – I’ve found that meeting the doctors helps everything work more smoothly in the future. Once a face is attached to a name, future communications are so much smoother.

Introductions – Time permitting, an introduction to the ED, DNS and daytime nursing supervisor is helpful. The ED should be more than happy to give a new doctor a tour of the Living Center.

Things to discuss if there’s time – given available time, certain topics will be particularly helpful to discuss:

Familiarity with SNF Rounds – When introducing oneself, it’s a good time to find out about the new physician’s role in their practice and his or her familiarity with SNF rounding and GLC systems.  If the doctor is new to SNF rounds, this could be crucial, as their expectations of care monitoring, labs and orders may be very different from the hospital setting.  New docs may also have a lot to learn about regulatory requirements for frequency  of visits, controlled substance prescribing, and how our medical records system works.

Coverage patterns and preferred contact information – While their office, fax, and emergency numbers should be known to the nursing staff and pharmacy, I have found that docs are willing to share personal cell phone numbers with their medical director for use in emergency. If Dr. James had had the opportunity to discuss coverage patterns, she would have been able to explain that while the medical director is required from a regulatory standpoint to provide emergency coverage, that routine coverage by the medical director as opposed to continuity coverage within is neither preferred nor ideal for patient care.  If coverage over vacation is to be arranged, advance notice is ideal.

For non-emergent, non-HIPAA restricted communication, more and more doctors prefer email.  If the attending physician would like, we will put him or her on the First Monday distribution list if you provide us with it.  Of course one should keep in mind that one should not use the address to spam the physician’s Inbox.

Availability for questions, assistance and feedback – The medical director-attending physician relationship is a two-way street, and making availability clear paves the way for future communications where you may be able to hear about concerns from your medical staff. Also, your doctors may be willing to make suggestions as to process improvements which could be extremely helpful.

Building the relationship  – I always tried to briefly interact with my other attending physicians when they were in the LC or hospital at the same time during rounds.  Usually we’re both in the middle of something, but just a minute to re-establish contact and remind them of availability can be very helpful.

If you find the time to meet with your new doctor, you may be able to save a lot of time in the future, as well as engage a partner in assuring ideal care in your LivingCenter.

Until next month,

Michael J. Yao, MD, CMD