View From the Trenches: Interview with Dr. Zachary Palace, MD, CMD
Dr. Zachary Palace, MD, CMD is the Medical Director of the Hebrew Home of Riverdale (“Hebrew Home”). The Hebrew Home has taken care of residents for more than 100 years.
Apart from being one of the largest skilled nursing facilities in the country with 751 skilled nursing beds, the Hebrew Home has been recognized for both the quality of care it provides, as well as its many innovative programs. For example, it has been on the forefront of dealing with areas such as Elder Justice, Sexuality and Dementia, and medical marijuana, just to name a few of the many trailblazing avenues the Hebrew Home has pioneered.
With that in mind, we want to share some of the innovative programs the Hebrew Home has instituted as well as how it managed to get through the worst healthcare pandemic in more than a century.
AH: Let’s begin by talking a bit about your background. When and how did you become the medical director of the Hebrew Home?
ZP: During my internal medicine residency I was disturbed by how many nursing home residents we were admitting through the ER and wondered why these conditions could not be effectively managed in the nursing home. It was that curiosity that prompted me to pursue a fellowship in Geriatric Medicine. My first job after fellowship was as a staff geriatrician at the Hebrew Home. It was a great opportunity to implement the skills I had honed in residency and fellowship.
I found great satisfaction in treating patients in place and avoiding the hospital experience for these vulnerable elderly nursing home residents. When I was appointed Medical Director of the Hebrew Home in 2006, I had the opportunity to expand this philosophy facility-wide. These initiatives pre-dated the well-known Centers for Medicare and Medicaid Services (CMS) programs that introduced value-based purchasing and the 30-day re-hospitalization penalties. Nowadays, I am so pleased to see that treating nursing home residents in place is much more of a priority for facilities.
AH: I’d like to ask you some questions about discrete areas where the Hebrew Home was and continues to be ahead of the curve and remains a trendsetter.
Emotional & Physical Intimacy
AH: Without a doubt, the Hebrew Home has been a national trendsetter in the area of recognizing and respecting residents’ rights regarding sexual expression and intimacy. In fact, more than two decades ago, when most nursing facilities had not even begun to seriously think about the issue, the Hebrew Home had a sophisticated Policy and Procedure that addressed the importance of emotional and physical intimacy. Can you tell our readers about that policy and why it is important to recognize residents’ rights to engage in emotional and physical intimacy so long as they are able to safely do so?
ZP: The Hebrew Home’s policy, which pre-dated my tenure, is truly a trendsetting document. The first of its kind, the policy recognized the social needs of adults living in the skilled nursing facility and supported their rights to intimacy and sexual activity. Furthermore, the policy laid a groundwork for staff education and sensitivity. It has become a model that has been adopted by many facilities nationally and internationally.
AH: What about residents who have some degree of cognitive decline? How does the Hebrew Home determine if those residents have sufficient decision-making capacity (DMC) to engage in various forms of intimacy, from hand-holding to more intimate interactions?
ZP: One of the most important aspects of geriatrics is the team-based approach to care. When we are dealing with an individual with impaired cognition it is very important to convene the resident’s interdisciplinary team to assess consent in a manner that is non-judgmental and free of personal bias.
AH: Many nurses, nurse aides and other healthcare workers seem to feel that “old people” in nursing homes should not be intimately involved with others, including other residents, even if they both have the legal and medical ability to consent to such interactions. Putting aside the issue of ageism, has there been any pushback from the staff based on their biases or have they accepted the well-developed policy and procedure at the Hebrew Home?
ZP: Staff are educated on the policy during orientation and annually. Overall they have been very accepting of the Home’s policy.
AH: This may be an obvious question, but is there a therapeutic value in such basic human-to-human contact and have you personally witnessed those results?
ZP: Definitely. The need for human contact is a basic need that we all have. It transcends the boundaries of cognition and cognitive awareness. Working on a floor with cognitively impaired patients it is not uncommon to see two residents sitting together having parallel unrelated conversations and both of them appreciating the social encounter. Sometimes residents sitting next to one another will just hold each others hand. No doubt this provides a feeling of human connection and comfort.
AH: Let’s talk about medical marijuana. The Hebrew Home has been featured in the New York Times and other publications for its appropriate use of medical marijuana for select residents. Additionally, you have authored and co-authored, along with Dan Reingold, the CEO of the Hebrew Home, articles in medical publications such as the Journal of the American Medical Directors Association (JAMDA) and others describing the Hebrew Home’s experience treating residents with medical marijuana.
You have described your experience treating residents with medical marijuana to national audiences and are considered an expert in the area. Can you tell our readers about your experience in that regard and whether, for example, residents consuming medical marijuana – under the guidance of a physician – have been able to be weaned from addictive and dangerous medications, such as the opioids?
ZP: I feel very fortunate to collaborate with Dan Reingold on this initiative. He has been a champion of medical cannabis since his experiences with his own father, and was in strong support of introducing cannabis at the Hebrew Home from the moment that medical cannabis was legalized in New York State. As a geriatrician, I was impressed how many of the NYS approved diagnoses for medical cannabis were conditions that are so germane to the skilled nursing facility.
The neurobiology of cannabinoids and their medicinal benefits was not part of my medical school training. As I learned more about cannabis, I appreciated its potential role in treating our residents. We have been able to significantly reduce the opioid burden in some of our residents and that’s a big win. As is the case with any therapy, some individuals respond better than others.
AH: Have you personally observed other benefits from the appropriate use of medical marijuana in addition to a decreased dependency on addictive and otherwise dangerous narcotic pain medications?
ZP: Absolutely. I have seen dramatic effects in reducing seizure activity. One of our residents, an 84-year-old lady with advanced dementia, suffered with frequent breakthrough seizures which were essentially eliminated with the introduction of medical cannabis.
AH: Because you have referred to a resident named “Zelda” in many of your presentations and there is a video of Zelda on YouTube, can you tell our readers about how she responded to medical marijuana?
Like many residents in the over-80 generation, [Zelda had] a negative stigma associated with cannabis. Knowledge is power. Dispelling myths and educating residents to help them make informed decisions about their treatment options is so important. Since she began using medical cannabis several years now, she has been able to reduce other analgesics that she had been taking a long time.
AH: Is Zelda’s response typical, in your experience?
AH: How were the policies and procedures for medical marijuana developed at the Hebrew Home?
ZP: We were very mindful of the fact that at present cannabis remains a Schedule 1 substance, and that as such it is federally prohibited for the facility to possess and/or dispense. We recognize as well that as residents of New York State, our residents were entitled to participate in the NYS Medical Marijuana Program if they chose to. We developed a policy and procedure that requires the resident to store the cannabis in a lockbox to which only they have the key, so it remains exclusively in their possession. In addition, they are required to self-administer or can designate an individual who is not a facility employee to administer it to them.
AH: How is the determination made regarding whether a particular resident would likely benefit from medical marijuana?
ZP: Firstly, they need to have one of the qualifying diagnoses that are approved in New York State. In addition, they must be able to self-administer.
AH: What about dosing? Given all of the different types and forms of cannabis as well as the various forms they come in, how do you and the physicians who operate under your supervision know how to recommend a specific dose and type of medical marijuana?
ZP: In New York State medical cannabis can only be obtained from a licensed dispensary. Medical grade cannabis is a pharmaceutical product that is very standardized for dose-to-dose consistency. As such, we know that residents are getting the same amount with each dose. We see the greatest therapeutic benefits with a product that is predominantly cannabidiol (CBD) with little or no delta-9-tetrahydrocannabinol (THC). Due to the psychoactive nature of THC we avoid using formulations that have higher concentrations of THC in the elderly.
AH: Given the growing body of scientific evidence regarding the medicinal benefits of medical marijuana, do you feel it is likely we will continue to see wider use in the post-acute and long-term care sectors?
ZP: Recently medical cannabis was approved by the FDA for seizures in the pediatric population. I do feel that in the next few years we will see more widespread adoption as practitioners gain more experience with recommending medical cannabis.
AH: The Hebrew Home has existed and provided excellent care to residents for over 100 years. During the COVID-19 pandemic, was it difficult to keep the staff motivated?
ZP: Throughout the pandemic, our executive management was present at the Hebrew Home seven days a week. That sent a very powerful message of camaraderie to our staff that we are one team and “all in this together.”
AH: What were some of the biggest challenges during the past year as all health care facilities dealt with the devastating effects of the pandemic?
ZP: Early on in the pandemic we were faced with a tidal wave of residents who were being struck with a fatal infection like nothing we had ever learned about or prepared for in medical school or residency. Our biggest challenge was that we were both unable to test for and unable to treat COVID-19. As clinicians we all felt so helpless. I was appreciative of the frequent updates that AMDA provided us throughout the pandemic
AH: How has the Hebrew Home been able to foster and maintain a positive attitude and morale among its staff during such a challenging time?
ZP: Dan Reingold, Hebrew Home Chief Executive Officer, and David Pomeranz, Chief Operating Officer met daily with all department heads and middle management. This daily morning meeting promoted staff unity and open communication. It was a daily morale boost through some of the darkest days of the pandemic.
AH: What are some of the ongoing operational issues that skilled nursing facilities such as the Hebrew Home face as they confront the COVID-19 pandemic?
ZP: Developing a system of twice a week testing for over 900 employees, collecting and managing these results, and reporting on this data on a daily basis to state and CDC portals is an ongoing task that requires much effort.
AH: How has COVID-19 affected your clinical practice as an attending physician and Medical Director?
ZP: As Medical Director, I have always seen the role as a great opportunity to meet with and educate our staff and residents on clinical practice issues. I appreciated the many opportunities I had to discuss the importance of masks and exercising proper infection control practices to prevent spread of disease. In the winter, I held town hall meetings about the COVID-19 vaccine with all shifts to provide clinical updates, educate about the vaccine, and reduce vaccine hesitancy among our staff.
AH: Are there “lessons learned” from the coronavirus pandemic and what could we do to be better prepared for future disasters that may adversely affect skilled nursing facilities? Do you see a change in the way skilled nursing homes operate in the future as a result of the coronavirus pandemic?
ZP: I believe that there will be a much greater emphasis on maintaining the strict infection control practices that we have become accustomed to during the past year. This is crucial to prevent further outbreaks in the future.
AH: The federal agency that regulates and oversees all nursing facilities that participate in the Medicare program, CMS, requires an “infection preventionist” to be at each Medicare-certified nursing facility. At this time, there is no federal regulation requiring a full-time infection preventionist. Do you feel that there ought to be full-time infection preventionists at every nursing facility?
ZP: I believe that the role of a full time infection preventionist is essential in the skilled nursing facility. At the Hebrew Home we have had a full time infection preventionist in place since the CMS-updated regulations went into effect several years ago. Prior to the pandemic, in early 2020, we were dealing with a norovirus outbreak. Having an infection preventionist full time significantly helped us control the spread of that outbreak. Shortly thereafter, when the COVID-19 pandemic began, our staff were already primed on isolation precautions and infection control practices.
AH: There are currently different types of tests for COVID-19 such as the polymerase chain reaction (PCR) test and the antigen tests. Do you have an opinion regarding which tests are preferable for residents and staff?
ZP: Due to concerns with missing asymptomatic positives, as a facility we have made the decision to only accept the PCR test for all resident and staff testing.
AH: There is a controversy regarding both state and federal law concerning mandating vaccines for health care workers and the various state courts are not entirely unified in their decisions, often leaving skilled nursing homes in a quandary. How does the Hebrew Home deal with the issue and does it have a position regarding mandatory vaccines for its healthcare and other employees?
ZP: At the Hebrew Home we continue to educate and continually remind our staff about the importance of every health care worker “doing the right thing” and vaccinating to protect themselves as well as the residents who are vulnerable and elderly. Although we are not mandating the vaccine, we have taken the position of only hiring new staff who have been vaccinated. This is such an important step in keeping COVID-19 out of our facility.
AH: As the Medical Director of a 751-bed skilled nursing facility, do you feel it has been challenging to motivate the physicians, nurse practitioners, physician assistants and other members of the healthcare team whom you oversee?
ZP: These are very challenging times. It is so important to lead by example. My approach has always been to maintain a sense of calm. Analyze and address the situation with rational composure, rather than allowing yourself to get caught up in the chaos of the moment.
AH: Can you describe a challenge created by COVID-19 and how the Hebrew Home successfully dealt with that?
ZP: We were faced with the severely painful isolation and loneliness that our residents were experiencing. David Pomeranz, COO, came up with a novel approach to this challenge. The Hebrew Home created a drive-through lane where residents could visit families who were in their cars through a glass-enclosed area and communicate through an intercom. This was an overnight success that greatly helped our residents connect with their families during the year-long period of prohibited in-person visits.
AH: How has using technologies helped to promote resident care and quality of life during the pandemic?
ZP: In March 2020, soon after the pandemic began, we began broadcasting a weekly family webinar that included myself, our COO, DON, and Directors of Social Work and Therapeutic Activities. The webinar provided our residents’ families with a live weekly update on the status of the pandemic at our facility and was an amazing forum for information sharing and answering family questions.
In addition, we began a round-the-clock virtual visit program for residents with their family members using tablets mounted on a cart. This technology helped reassure families that their loved ones were all right, and provided the opportunity for a final farewell for residents approaching end-of-life.
AH: What have you done during the pandemic that has brought you the most satisfaction?
ZP: Spending time with my family.
AH: You are a very positive person. How have you managed to help other members of the Hebrew Home’s healthcare team to stay positive?
By nature I am a perpetual optimist. Taking time to listen to others is so important. Especially during difficult times people need to feel that they are being heard.
AH: What is the most rewarding aspect of being a physician and the Medical Director at the Hebrew Home?
ZP: As a geriatrician, I feel very gratified to practice medicine in a facility that maintains a mission to promote the principles of good geriatric care. As a Medical Director, I feel fortunate to be a part of a management team that embraces innovation and technology and promotes creativity.
AH: These are perhaps the most challenging times for skilled nursing facilities. Do you have any advice for the members of the post-acute and long-term care healthcare team as they continue to heroically provide care to our nation’s most vulnerable segment of the population?
ZP: Take off your white coat before you leave work for the day. We need to maintain a work-life balance and enjoy our time away from work in order to function optimally in our careers.
Alan C. Horowitz, Esq., is a partner at Arnall Golden Gregory LLP, where he focuses his legal practice on regulatory compliance for skilled nursing homes, hospices and home health agencies and manages cases where the Centers for Medicare and Medicaid Services (CMS) has imposed an enforcement action. He is a former assistant regional counsel Office of the General Counsel, U.S. Department of Health and Human Services. As counsel to CMS, he was involved with hundreds of enforcement actions and successfully handled appeals before administrative law judges, the HHS Departmental Appeal Board and in federal court. He also has clinical healthcare experience as a registered respiratory therapist and registered nurse. He can be reached at email@example.com.
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