JAMDA On-The-Go | January 2024

Music. This is JAMDA on the go, your review of the content featured in JAMDA,

the research-focused monthly journal of AMDA, the Society for Post-Acute and Long-Term Care Medicine. Statements made by guests on this podcast are their own opinions and are not necessarily the positions of the Society. A speaker's appearance on the program does not imply an endorsement of them, their views, or any entity they represent. This podcast is eligible for a a BPLM, pre-approved certified medical director credits. Details will be provided at the end of this podcast.

And now here's our host for JAMDA on the Go, Dr. Carl Steinberg. Hello, and welcome to the kickoff session of JAMDA on the Go for January 2024. Happy New Year to all our listeners. I'm Dr. Carl Steinberg, your host for this podcast. JAMDA on the Go discusses selected articles in the current issue of JAMDA, the Journal of Post-Acute and Long-Term Care, also sometimes referred to as the Journal of the American Medical Directors Association.

Today, it's my pleasure to welcome JAMDA co-editor-in-chief, Dr. Paul Katz. This afternoon, we're also delighted to have the opportunity to interview the authors of two JAMDA articles in the January issue, We hope our listeners are continuing to enjoy our podcast's interactive style, including some of the content experts who actually did the research.

Dr. Katz is a professor of geriatrics at Florida State University and also serves as medical director for Westminster Communities of Florida and Presbyterian Senior Living based in Pennsylvania. Paul is a past president of AMDA with a research focus on medical staff organization and its relationship to quality. He's a certified medical director with over 40 years of clinical experience in nursing homes, assisted living, and outpatient geriatric care.

So today, your editors have chosen three articles we'll be highlighting from the January issue that we think will be of particular interest to our listeners. These topics include a paper discussing a survey of technology abandonment in U.S. Nursing homes, a paper reporting on the outcomes for long-stay nursing facility residents following on-site acute care under a CMS initiative.

And finally, we'll discuss a study examining the use of psychotropic, anticonvulsant, and opioid medications in assisted living residents before and during the COVID-19 pandemic. So it's an honor to start our discussion with Gregory Alexander, PhD, RN, FAAN, FACMI, FIAHSI. Dr. Alexander is a professor at Columbia in New New York City, and has a broad background in human factors, informatics, gerontology. Patient safety, and quality measures.

Dr. Alexander is a Fulbright Scholar Ambassador. He's a fellow in the American Academy of Nursing, American College of Medical Informatics, and the International Academy of Health Sciences Informatics. He's currently completing a third national study assessing the impact of information system maturity on nursing home quality measurements. Dr. Alexander's third study is also evaluating care environments where nurse practitioners work.

He's also serving as a co-chair of the HIT Committee on the National Moving Forward Coalition, which has been established to ensure that the quality of nursing home life improves in the U.S., and I'm sure many of our listeners are familiar with the work that Moving Forward is doing. Dr. Alexander is senior author on the JAMDA article we'll be discussing today,

a survey of technology abandonment in U.S. nursing homes. Now, Dr. Micah Siegelman, PhD, is a health policy researcher at RTI International who utilizes health services research methods to inform health care policy for older adults.

Dr. Siegelman has studied the quality of nursing home care, nursing home staffing, potentially avoidable hospitalizations of nursing home residents and other community-dwelling older adults, the Program of All-Inclusive Care for the Elderly, or PACE, programs, Medicaid, home and community-based services, and hospice care. Micah's work has been published in a number of journals, including Health Affairs, Milbank Quarterly, JAGS, JAMDA, and the Journal of Aging and social policy.

Dr. Siegelman is the lead author of the article we'll discuss today, Outcomes for Lawn Stay Nursing Facility Residents Following On-Site Acute Care Under a CMS Initiative. So welcome, Drs. Katz, Alexander, and Siegelman. Thank you. Thank you so much. All right. So Greg, can you start out by telling us a little bit about yourself and your team? Sure. Hello, and thank you for asking me to participate today in this On the Go podcast.

Like you said, I'm the Columbia University of Presbyterian Hospital School of Nursing Alumni Association professor, and I would consider myself to be an expert in informatics applications in long-term care settings, with an emphasis on how quality and and safety of care are impacted by IT systems. I have to acknowledge my recruitment team, Keeley Wise and Brooke Shrimp, who were so viable in conducting this research.

I also want to acknowledge the first, second, and third authors on this paper, including Dr. Kim Powell, who was a postdoctoral student of mine, and Matthew Farmer, who's a PhD student. Both work at the University of Missouri Sinclair School of Nursing. And the third author, Dr. Junfeng Liu, Lou is a biostatistician who works on my team at Columbia University.

This particular research was developed from a larger national HRQ, or Agency for Healthcare Research and Quality, funded R01 study, where we were examining information technology, or IT, maturity over seven years. IT maturity is a measure of IT capabilities, the extent of IT use, and IT integration in resident care clinical support, which includes pharmacy, radiology, and laboratory services, and administration activities.

We noticed during other analysis over the seven years that we've been conducting IT maturity that IT maturity was quite variable from one year to the next. For instance, when we examined 306 facilities', patterns of total IT maturity from nursing homes that had completed three surveys in consecutive years from 2014 to 2017 in our first R01 study, Just over 71% of those more than 300 facilities exhibited a net positive increase in their IT maturity, or they were adopting IT maturity.

However, nearly 19% had a net negative decrease or technology abandonment in total IT maturity, while 10% had a consistently negative pattern of adoption or technology abandonment over three years. So this led our team to ask if this pattern of technology abandonment was consistent in our most recent national study, which is occurring from 2019 to 2023. Two thousand and twenty three. Yep, that's right. Our second R01 study, which examines IT maturity in nursing homes for a second time.

Wow, that's a it's shocking, right? I mean, first of all, nursing homes were really late to the table. Well, CMS incentivized doctors' offices and hospitals to get into the IT bandwagon early on. That didn't happen in nursing homes, so we're already really behind. And it shocks me to hear that facilities were actually going in the wrong direction on that.

So, well, let me ask, I think the impetus for exploring the issue is obvious because there are so many ways in which good IT helps improve care. But did you encounter any challenges in conducting this study? Yeah, we definitely encountered challenges in conducting the study. For example, the first year of recruitment of this particular study, that was when COVID occurred and regulations were modified to increase IT adoption.

So, for example, rules on the use of telehealth and video conferencing systems by the authorizing HIPAA organization were softened to support healthcare delivery for isolated residents in nursing homes. So, nursing homes were actually incentivized, or there was no penalties for HIPAA violations in relationship to the use of telehealth, which were a barrier prior to COVID for nursing homes to utilize telehealth.

Also, nursing homes aren't really reimbursed for telehealth use like other systems are. So what happened was we were concerned that this may have increased IT maturity over the first year, which is a good thing, we think. But we were interested in finding out if these IT systems were sustained in the second year, even though regulations still supported ITs during that time.

And it was imperative for our study to recruit facilities that had participated in both years of the study to explore how much technology abandonment was occurring, because each facility that participated needed a year one survey and a year two survey to be able to tell the differences and changes in their IT maturity. And COVID created some obstacles, obviously, and time constraints for many facilities and administrators to participate in ongoing research about this sector.

But we were really pleased to have over 300 homes that did participate in the work during this time. Yeah, well, that's because things were mighty, mighty busy and pretty awful during that time. So, what would you say your take-home messages are for our listeners and any ways that you think your findings might change clinical practice beyond to the extent any of us can encourage increased adoption of good technology?

What are your recommendations? Yeah, so we had just about 300 nursing homes that completed both years of our study, and about 28% experienced a reduction in their IT maturity or technology abandonment, compared to about 44%, which experienced an increase in IT maturity or technology growth. So on one hand, you've got a part of the sector that's doing really well. And on the other hand, you've got part of the sector that is not doing so well.

So when we examined where abandonment was occurring, we found most abandonment occurred in IT systems used in resident care and clinical support or lab pharmacy and radiology, like I mentioned.

Although, I'm sorry. Yeah. Yeah, that's just kind of shocking, right? Right. I'm just shaking our heads here. Yeah. And although uncovering reasons for these facilities technology abandonment was not really within the scope of our project, our prior work on similar issues has shown that poor workflow alignment was a big factor, a lack of available IT resources or knowledgeable IT staff on the site, Right. Low IT integration levels and poor interoperability are all contributing factors.

In other words, we've shown that hit disintegration or abandonment could impact quality, such as the ability of staff to monitor use of antibiotics and treatments for urinary tract infections and antibiotics. And thereby lowering quality of care. In other words, what we found in prior research was that as IT maturity increased, the ability of an administrator to monitor the use of antibiotics and treatments for urinary tract infection was much improved.

So we believe that abandonment has the reverse effect, that it decreases their ability to really improve quality of care, which is not good. Yeah, that makes sense intuitively, right? And I'm just curious, did you happen to look at, you know, for-profit versus non-profit status or any pearls about what facilities, what kinds of facilities are in this technology abandonment arena? So interestingly, large facilities tended to have more change in their administrative activity areas.

So they tended to have more abandonment in their specific areas where they utilize technology for administrative activities and oversight of clinical areas. We also found that for-profit facilities tended to have a degree, a higher degree of change. When you're looking at facilities that have that kind of ownership. So rural facilities tend to have a lower IT maturity, we find in most studies that we've done. And of course, they're impacted by the change as well.

Yeah. Yeah. Paul, any questions for Dr. Alexander?

Yeah. Hold on one second. Second, Greg, your findings are particularly disturbing, as Carl was mentioning, particularly because you had mentioned that the abandonment occurred in resident care capabilities and clinical support. And although I think you've already answered this, I'm going to ask the question a little bit differently.

When you think of the solution to this trend, is it merely more financial resources or I'm sensing there may be a need for a culture change around technology for these facilities? What are your thoughts about that? Yes, I think it's both financial resources and culture change, among other factors.

For example, one of the things that we're doing in the Moving Forward Coalition, which we've mentioned, is trying to understand how value-based payment models are impacting IT adoption across the healthcare sector. We know that there's been incentives integrated into regulation where the health care facilities, including nursing homes, are being required to exchange data through interoperable means to make data seamless and to make it be effortlessly exchanged between different systems.

But because nursing homes have not been incentivized to do this in the past, they're not... Many of them are not at a level that many other settings are. So there's a lot of disparity in how nursing homes have adopted IT compared to acute or ambulatory care services. So these incentives that can be used to promote use of IT to promote better quality of care and higher value should be made readily available to all sectors of healthcare, including nursing homes.

Data exchange is particularly important in nursing homes, especially in clinical

support areas like lab, pharmacy, and radiology, because most nursing homes don't have these departments on site like hospitals do. Unless the nursing home is part of a larger healthcare system corporation that operates hospitals and nursing homes concurrently. And oftentimes in our studies, we do not include those types of facilities because we feel their incentives, they receive some benefit out of the incentives by being part of that corporation.

Additionally, the design of IT innovations, I think, are really important as I'm thinking about this question, especially in the care of older adults like patient portals and telehealth. Those things need to be explored to maximize the interventions to improve workflow and communication. some of the abandonment occurs as a result of poor design and poor workflows. So we need to understand how these systems work to support care in a seamless way.

And finally, the workforce, I don't think I could really go without mentioning the workforce is experiencing the brunt of the system change, either in IT adoption or abandonment, which impacts their work.

And expectations should should be that the workforce should be adequately trained and supported to manage and use the clinical technologies that are required, which could improve their work satisfaction and potentially reduce the high turnover rates that we see as a result of the dissatisfaction with those environments that are out there. Oh, thank you for that extensive answer. Clearly multifactorial, but thank you very much. Carl?

Yeah, yeah. All right. Well, that's been some great discussion and perspective.

Dr. Alexander, many thanks for taking the time to chat with us today on Jammed On The Go. And for our listeners, let's please encourage our facilities to the extent we have any decision-making power to embrace and continually improve our capacity in the IT arena. This episode will return after this special message. Join your professional community at PLTC24.

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Probably a lot of our listeners are familiar with this type of work and so much more attention on sort of, you know, hospital at home and those types of things. And we clinicians are well aware that a transition from a stable long-term care in a nursing home to an acute care hospital often results in disasters of various types. So we welcome this kind of work. So Dr. Siegelman was the first author on this study. And Micah, can you tell us a little bit about yourself and your team?

Yes. Thank you so much, Carl, for inviting me and Paul. And I really appreciate being here. We worked at RTI International with a large evaluation team. This study was part of a much larger study evaluating the CMS, the CMMI initiative to reduce avoidable hospitalizations for long-term residents of nursing homes. The leadership team at RTI included Mel Ingber, Jean-Lien Feng, Galina Katusky, Lauren Burka, and myself.

We worked closely with some terrific staff at CNMI and with a large team at RTI. For this present paper, that included Duany Hariharan, Doug Fletcher, and Angela Kostaska, but a much larger team that was involved, and we appreciate all of their efforts. Right, and I guess it's kind of an obvious question, but what was your impetus for exploring this issue? Yeah, Carl, so you gave a good introduction that the goal of reducing hospitalizations

is important for a number of reasons. Part of that is because of the trauma of the hospitalizations. If they're not needed, they can cause a lot of trauma for those residents who are being hospitalized. They can lead to unintended harm for those residents when they're hospitalized. And hospitalizations are also very costly to Medicare. care. So a lot of reasons why policymakers, clinicians, and so on have been interested in reducing avoidable hospitalizations over a long period of time.

One of the causes for those hospitalizations is misaligned incentives between Medicare and Medicaid. So Medicaid paying for long-term care in a nursing home often, and Medicare not paying for long-term care in a nursing home, Medicare paying for the acute care for the hospitalizations.

And these two payment mainstreams having these conflicting incentives not to necessarily invest sufficiently in the clinical resources, clinical care in a nursing home, which would be needed to prevent a hospitalization for long-term residents. And so CMMI, CMS created this initiative as a way of trying to test different policy levers, different interventions to see if a dent could be made in this problem and to be able to reduce some of these unneeded hospitalizations.

There is previous research which shows that a greater investment in these clinical resources could make a difference in reducing hospitalizations. Nurse practitioners have been shown to be important. Better staffing is important and other factors. In this particular initiative from CMS, which took place over two phases over a number of years, there were a total of three interventions that were tested, a clinical intervention, what we call clinical only, because it didn't involve payment.

This This was the first phase, and there were clinical and educational interventions delivered across a number of nursing homes spread out across seven states. There was a payment-only model where. This took place during phase two of this initiative, where nursing facilities were able to bill for providing care to residents who were diagnosed with particular conditions and were considered to have a high enough level of severity of those conditions that they could, they should,

or not should, but they could go to the hospital. It could justify that. And they were being paid to treat them in the facility because it was considered appropriate for these residents to be treated outside the hospital in the facility. Based on the judgment of the clinicians. And there was also the clinical, what we call the clinical plus payments model, which involved both the clinical interventions and the payment. So these were all tested as part of this initiative.

And I'll just mention that there were six particular conditions that were the focus of this phase two of the payments where residents who were diagnosed with six particular conditions were eligible for these payments. So, that was the overall goal of the larger initiative and larger evaluation. For the present study that we conducted as a part of this evaluation that was published in JAMDA.

This was an opportunity to compare the outcomes for residents treated on site versus those treated in the hospital for the same conditions. And this is important in order to demonstrate that there are no negative consequences associated with treating the residents in the facility, in the nursing home, as opposed to sending them to the hospital.

We obviously want to do no harm. And if it's better for them to be treated in the hospital, those are not the types of residents that we want to be encouraging nursing homes to treat on site. So the purpose of this study was to counter any misconceptions and to verify that, in fact, the residents would have the same or better outcomes treated in the facility. There is previous research on that question as well, mostly observational studies.

I'm aware of one randomized controlled trial, which was done also specifically with pneumonia, comparing outcomes for residents treated in the hospital versus those who were kept in the facility to be treated there. That previous research mostly focused on either pneumonia or respiratory infections. And for the most part, that previous literature does support on-site treatment, that residents treated on-site do have good outcomes.

There are details there. There are recommendations from the literature that in some cases it is better to treat residents in sight. So in very specific cases, residents with pneumonia are better off treated on site. In many cases, I'm sorry, are better treated in the hospital. And in often many cases, they're better off treated on site, but there are specific cases where the recommendation is that they should be hospitalized.

So this study was able to use a novel source of data because we had data on when residents were treated on site based on the bills, based on the facilities billed for treating these residents who were diagnosed with these conditions and they were considered to be severe enough that they could be hospitalized. And so that enabled us to compare those residents treated on site to those treated in the hospital.

Right. Yeah. And I mean, Medicare Advantage plans have taken kind of a beating lately, but I do remember over the years, I mean, 20 plus years ago, if we had a long-term resident who got sick, I mean, we would just basically skill the patient, put a higher reimbursement to the facility so they could give the IV antibiotics or what have you. And that seemed to work out well. I think it was definitely a kindness to the residents themselves. themselves.

Can you just tell our listeners what were the conditions that were considered to be treatable in-house? Thank you. Yes. So the six conditions were pneumonia, UTI, urinary tract infection, skin infections, congestive heart failure, CHF, COPD, and dehydration or electrolyte disorder. Great. Well, I think probably a lot of our listeners are accustomed to treating those things in-house when we can.

But as you said, the malaligned incentives and the fact that with a straight Medicare patient, if you send them to the hospital and they stay three days, they come back and then you get the Medicare A reimbursement. It kind of creates a real push to probably unnecessarily hospitalized people.

So what are your take-home messages other than obviously we can treat some of these conditions in-house and we probably should when we can, and how do you think these findings might change clinical practice? Thanks so much. Yes. So a number of points, both in terms of the larger evaluation in the particular study that we just published.

So we did observe, in general, better outcomes for those residents who were treated on site for all of the conditions, but that's pneumonia, UTI, CHF, COPD, and skin infection, except for dehydration, where we didn't see a difference. Dehydration was kind kind of unusual. It was very rarely diagnosed. It was the least common to be reported. But for all the other ones, in those residents were very sick. They were dehydrated. And so they had poor outcomes in either setting.

But in general, they had better outcomes, those treated on site. We do talk in the paper limitation of not being able to fully address, fully adjust for disease severity. That's just an important limitation. So the better outcomes are some combination of those differences in their initial state and also the differences in the care that they received. But in general, no indication of any harm and indication that it was beneficial for them to be treated on site.

So this does lend support, as you said, to treating residents on site. It's important to point out that this took place in the context of an evaluation of the initiative where there was a strong focus on supplying resources to nursing homes and in nursing homes developing these resources so that they could treat residents on-site. Some of these nursing homes had participated, like I said, in this initiative in the first phase as well as the second phase.

So they'd been involved for years in this effort, trying to make it more possible to treat residents on-site. And some of them had shown improvement in this area over the course of the initiative in the first phase. So these were not necessarily typical typical nursing homes. These were nursing homes that did have this investment in these resources, did have perhaps better staffing, nurse practitioners.

But they were able to develop these resources and deliver good care to their residents, enabling them to stay, to be treated successfully on site.

And from the broader evaluations, it's just important to point out that we saw a very important impact of the advanced practice providers, the APNs, the nurse practitioners, clinical nurse specialists, that they did really make a big difference in the facilities, and they helped enable facilities to, in fact, reduce their rates, in some cases, of avoidable hospitalizations. So that was an important finding from the broader evaluation.

In terms of impacting clinical practice, so this study lends support that it's

important for nursing homes to be able to develop the staffing, the resources, the higher level staffing, the nurse practitioners, et cetera, to be able to treat residents on site. And from a policy perspective, we have to say from the broader initiative, while we know that's important, it's not easy to encourage nursing homes to do that. And for the most part, it's three parts to the initiative, the clinical only, the payment only, the clinical plus payment.

The clinical only initiative did show some success, the payments less so, not really. And so it's not easy to design those policy levers so that nursing homes have the right incentives and are able to make these investments. But when it can be done, it does make a difference that they have, when they have that additional staffing, that nurse practitioners and so on, and to be able to reduce hospitalizations, to be able to treat residents on site successfully.

Great, great. Dr. Katz, any questions or comments? Yeah, Micah, you just answered my question, I think, but I'm going to rephrase. If you had to choose the one factor that is most important in successfully treating nursing home resident sites, would it be the composition of the medical staff or provider education or reimbursement? And I know you kind of answered that. Of course, without enhanced reimbursement, how do you change medical staff? So let me put it to you that way.

Right. So, yeah, that's an important question. And so I would have to say that the composition of the staff was really key. We heard from sites, we heard from nursing homes that they really appreciated the extra set of hands that the initiative provided them with, in some cases, nurse practitioners, and they made a big difference.

So definitely composition of staff was a key. The particular way in which the reimbursement was constructed for this initiative in phase two with the payment reform didn't end up making a huge difference in terms of moving the needle and improving care, enabling facilities to really reduce hospitalizations. We published in a different paper that to a large degree, they were being paid for things they already were doing.

So it's not that payment doesn't matter, but the particular way in which this payment was structured didn't necessarily achieve the desired result from our perspective. But not to say that wouldn't be some way of doing that. In terms of provider education, that was part of this as well. And we did hear about, in this initiative in phase one, particularly the nurse practitioners and training other staff, where it was only about training other staff and not about delivering clinical care.

So if the nurse practitioners weren't delivering clinical care, they were just training other staff, we didn't necessarily see as strong results. That was a health affairs paper published a number of years ago, that where they're able to deliver clinical care, that was better. So, yeah, delivering clinical, you know, the composition of the staff being able to deliver that clinical care was key. But, right, from a policy perspective, how do you structure payments?

How do you incentivize facilities to actually, you know, staff up in that way is a really important question that hasn't fully been solved. Thank you very much. Right. Yeah. Yeah. Micah Siegelman, thanks so much for your great work. And we'd like to see more of this. And, you know, for all of our listeners, I really hope, you know, we can try to treat people in-house whenever we can, whenever it's safe and we've got the resources to do it.

Whether there's a nurse practitioner outside or not, just always keep that resident front of mind. So, all right. Well, Paul, we're going to conclude with some discussion about one additional article for which I'm hoping you'll be able to provide our listeners a synopsis. This article is by Colleen Maxwell, Ph.D., and her colleagues from the University of Waterloo in Ontario, Canada.

And this paper is entitled Psychotropic, Anticonvulsant, and Opioid Use in Assisted Living Residents Before and During the COVID-19 Pandemic.

Thanks, Carl. The authors of this article examined whether prescribing patterns of psychoactive meds changed during the COVID pandemic. The concern, of course, is that pandemic-related restrictions and gaps in care may have led to an increased use of antipsychotics and other high-risk central nervous system medications, particularly in cognitively vulnerable residents.

The authors linked clinical and health administrative databases for all All residents of publicly subsidized assisted living homes in Alberta, Canada, that is 256 such homes, from January 2018 to December 2021. And what they found was antipsychotic use increased during the pandemic and was significantly greater for assisted living residents living in dementia. A more modest increase was seen in antidepressant use. use.

Interestingly, a decrease in benzodiazepine use was observed during much of the pandemic, while there was a small increased use of anticonvulsants for AL residents who did not reside in dementia care. And there was no significant pandemic effect observed for opioid use. So although the rationale for the pandemic-related increase in psychoactive meds isn't specifically known. The presumption is that resident isolation, staffing shortages, and attendant care disruptions were likely key factor.

And if even a small proportion of these medications was deemed unnecessary, the potential harm to frail AL residents would likely be significant. And I think that is the take-home message of this article. Yeah. Hey, Paul, you spent a lot of time in Canada. I was intrigued. So I guess assisted living, when it says publicly subsidized, does that mean it's sort of like Medicaid? The government just pays for people to reside in assisted living in Canada? No, I'm not as familiar with Alberta.

But no, most of the assisted living in Canada is still a lot of it's out of pocket. There may be some subsidies, but a lot of it is much like the US. Okay, I was just curious about that. Well, these are interesting findings. And again, you know, the geographic limitation of the study to Alberta makes it unclear whether this was a more generalized trend, you know, in other locations. I was also a little surprised that benzo use did not increase similarly to antipsychotics.

Maybe the docs taking care of Alberta's assisted living residents are more evolved than some of us are here in the U.S. Because I'm perennially shocked to see how many benzos are used in this setting and antipsychotics for that matter.

But it seems intuitive that behavioral disturbances would increase in persons with dementia who no longer have access to family and where people are coming into their rooms wearing spacesuits and, you know, that kind of thing that would certainly prompt increased resistance to personal care and other agitated behaviors in turn leading to prescriptions for antipsychotics. So, I don't know, any last comments on this or any of our other studies, Dr. Katz?

No, no. I think I want to, again, thank our presenters. And of course, thank you and our AMDA staff for making these podcasts possible. All right, great. Well, that's going to wrap it up for January's JAMDA On The Go podcast. Thanks again to our guest presenters, Drs. Alexander and Siegelman, for a great discussion and for the excellent research you're doing. Please keep that up.

And thanks, as always, to our editors, associate editors, and staff from Elsevier at AMDA, whose efforts continue to generate one great JAMDA volume after another. Please take a look at the January 2024 issue, and I wish each and every one of our listeners and readers a fabulous 2024 to come. References for this podcast can be found at www.jamda.com. That's J-A-M-D-A. Until next month, this is Dr. Carl Steinberg, signing off for JAMDA On The Go. Music.

If you are a physician and interested in obtaining a BPLM, pre-approved certified medical director credits for certification or recertification, visit paltc.org. Music.