Ageism + COVID19 = Elder Genocide: Podcast on nursing homes with Mike Wasserman

Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: Today we are honored to welcome Mike Wasserman who is a geriatrician and provocateur, and immediate past president of the California Association of Long-Term Care. Welcome to the GeriPal Podcast Mike.

Mike: Great to be here. I look forward to it.

Eric: I am super excited because I watch all of your videos on the CALTCM website. Including the recent one around vaccines and the vaccine hesitancy. I also like that every day that you’re in some other national newspaper. Today you just said you were in what again?

Mike: The Washington Post.

Eric: The Washington Post. Today we’re going to be talking about where we were, where we are and where are we going with long-term care and COVID. But before we get into that subject, do you have a song request for Alex?

Mike: Yeah. I was saying, I played guitar when I was a teenager and I loved Elton John. I always loved the song Sixty Years On. Haven’t really thought about what it meant. But that doesn’t really matter. Being a geriatrician just seems like the right thing to do.

Alex: Right. Great choice. It is a little… I have no wish to be living 60 years on, so…

Mike: I know.

Alex: But we’ll give it a go anyway, here we go. I’m just going to be the first verse.

Alex: (Singing).

Eric: Sixty Years On, man.

Mike: You know-

Eric: Are you sure that’s not Zeke Emanuel listening to that? (laughter)

Mike: I actually have a story about that, I’m not sure I can share it, but it’s funny you say that. But it actually brings me back to when I was 16, so that’s where that impacts me.

Alex: Yeah. You learn about people by the songs they request. Sometimes it’s related to the times and sometimes it’s just a favorite band from when they were in high school.

Mike: Right, exactly.

Alex: Which is a lot of fun to listen to as well and to learn. Thank you.

Eric: Mike, big thank you for joining us. Again, I’m hoping that we talk about where we were, especially February, March, April, with COVID and long-term care. Where we’re at right now and where do you see things are going from here? Maybe taking a big step back, let’s go back to, when did COVID start affecting you and long-term care? I’m trying to even remember the timeline anymore?

Mike: Yeah. This is embedded in my brain in ways that I can’t even begin to describe. February 29th was when I read about Kirkland, Washington and the nursing home and begin internally freaking out. Literally, over the next week, I started thinking, “Oh my god! What’s going to happen?” A lot of it is, being a geriatrician having worked in long-term care for three decades. But also, I ran the largest nursing home chain in California, so I know every angle. Actually, on March 5th, over a year ago, I reached out to the California Department of Public Health and said, “You need us, CALTCM, to help do infection prevention training.”

Mike: They said, “That’s all right, we got this covered. Maybe you guys should do a webinar.” Literally, three days later, we did our first webinar. Which I’m proud of. We responded immediately. Within a week or two, we actually recommended that the governor mandate every nursing home in the state to have a full time infection preventionist. That’s how that evolved, that’s probably the real pivotal moment. Somewhere in that first couple of weeks, I put my CEO hat on, because I had run a large nursing home chain. I said, “If I was still in that position, what would I do?”

Mike: I remembered a couple of years earlier, we had a meeting where we talked about our infection preventionists and the fact that they didn’t have time to do their job. I’m thinking, “Okay, most nursing homes in the country, well actually all of them, have an identified infection preventionist. Almost none of those people are given the time to do their job and we are about to enter a pandemic.” Keep in mind, if you were paying attention to the rest of the world, you were reading about what devastation in Italy and Spain was being left in nursing homes, in the wake of COVID.

Mike: Honestly, I was freaking out. I actually spoke on March 9th last year, I called my parents who are in their 80s and I said, “Don’t leave your house.” I was actually quoted by NBC News a day later, saying that this was going to be the worst thing that we have ever encountered in our lifetime in nursing homes.

Eric: If our memory is correct, so the big surge starts happening in March and April in the U.S., specifically in New York City. I forget what happened. Nursing homes got a ton of PPE and support from the government and they were prioritized just as much as hospitals. Is that right?

Mike: Well, that’s an alternate universe. What really frustrates me as we look at the future, even as we sit here today, different studies are showing anywhere from 10% to maybe 20% of nursing homes around the country still don’t have adequate PPE. Which I consider unconscionable.

Alex: Yeah.

Mike: Yeah. I mean, supply chain dynamics, no one had enough PPE, they didn’t have testing available. Actually, by the end of March, we had gotten a hold of a bunch of test kits from the city of Los Angeles, for the nursing home I’m medical director of. We tested all of our residents and staff, and found that we actually had COVID, which isn’t surprising. We also gave a couple 100 of those test kits to another nursing home in Los Angeles. They tested all their staff and residents and found out they had a massive outbreak. 75% of the residents were positive and 90% of the staff were positive. Almost none of them at that moment were symptomatic.

Mike: They literally locked down, got everyone on PPE, send people home, quarantine, did everything. The interesting lesson we learned from that experience was, even though they had an outbreak, by doing everything right, right away, they limited their mortality to around just under 10%. Which for such an outbreak, back in the early days of the pandemic, was a remarkable achievement.

Eric: Yeah. We did a podcast with Jim Wright and David Grabowski, in the very beginning of April. Where Jim described his experience at Canterbury Rehab Center in Richmond and they were just absolutely devastated. In part because a lot of the staff left, all the physicians left. He as the medical director was really the only, he was delivering food to people’s homes or into people’s rooms as a medical director. My heart just broke for him and all the patients in these nursing homes, because there was just no support?

Mike: The other thing that was going on in March with me, guys like Dave, other folks from Connecticut, Washington, Virginia, elsewhere, were calling me, Philadelphia. I actually heard about the first outbreak in a Philadelphia nursing home before the media, before anyone else did. I was sort of semi-retired at the time. I’ve been around for a long time, I know a lot of people, folks just start calling me and telling me what was happening. In some regards, I felt an obligation to do something for my colleagues. I had one colleague in Philadelphia, who told the story that there was [inaudible 00:09:56]. He was the only one who had PPE on. He was doing a code by himself in PPE, because no one else had PPE. Then other folks would call me and tell me they wanted to order testing on their residents and they were told they couldn’t-

Eric: That’s what I remember from that podcast with Jim was, a lot of that focus in March and April was, test symptomatic patients. I specifically remember from that podcast, if you got five patients who test positive for COVID, who are symptomatic, that means you have five patients who are asymptomatic who would test positive. We knew that at the end of March and the beginning of April, that asymptomatic areas were a fair amount of these patients?

Mike: We knew it as clinicians, we also knew it if we just read the NMWRs coming out of the CDC in the middle of March and the New England Journal by the end of March. It was all published. Yet, the CDC and CMS weren’t acting on their own information.

Eric: Can I ask you another big thing, I remember specifically, this was a Mike Wasserman in specific is. That early on, New York, elsewhere, hospitals, people were really worried about overcapacity and certainly the surge hit hospitals, open up ORs. There was a big push to send COVID positive patients to nursing homes?

Mike: Yeah, and we freaked out. My boss, where I’m medical director, he and I both were like, “If anyone tries to do that we’re standing in front of the door and we’re not letting them in.” Actually, CALTCM, our board voted on a resolution on March 19th, in response to what was happening in New York and what was happening at the time in California. Because, the governor of California was about to do the same thing that Governor Cuomo did. We passed a resolution that said, “Hell no! You can’t do this.” [ANDA 00:12:09] then passed the similar resolution.

Mike: I’d like to think we had some responsibility for keeping that from happening in California. Even to this day, that whole thing’s become political in New York, what brought the virus in? I actually had found myself saying, “Look, sending infected people, certainly into COVID naive nursing homes. Still doesn’t make sense to me. You don’t do it with this virus.”

Mike: Granted, there were staff coming in with the virus because they were asymptomatic and not being tested. Which was more, I don’t know, but it doesn’t matter. Both of them kill people. I think it was a big deal and I’m proud of our colleagues. Many of them around the country literally stood up and said, “We’re blocking the doors if you try to send us COVID patients.”

Alex: Yeah. I’m just stepping back and thinking, what are the meta lessons to be learned from this? Listening to you talk, Mike, one is about the turning away from nursing homes. The lack of resources, lack of PPE, testing, being funneled toward the location that was arguably the ground zero for mortality in COVID in the United States. Then the other story is one of perseverance and struggle to stand up for nursing homes. From people like you, from organizations like California Association of Long-Term Care and other leaders around the country. Fighting against this policy shift and government decrees that might be harmful towards nursing homes. Wonder what your thoughts are on the meta messages, thinking back a year?

Mike: Yeah. I became a geriatrician officially in 1989. Trained by some incredible people, Joe Ouslander, Dave Rubin, Dave Solomon, you name it. Larry Rubinstein. I’ve been working in nursing homes almost that whole time. I’ve been advocating for geriatrics and Long-Term Care Medicine and such, for over three decades. No one cared until now.

Mike: I think to your point, all of a sudden the fact that people are dying in droves, got folks attention. I think if there’s a silver lining to this whole pandemic, it’s that finally there’s a spotlight on nursing homes, on vulnerable older adults with a caveat. That spotlight was really strong last March, April and May. When ironically, if you really look at it, the smallest number of deaths occurred. It’s a little frustrating. We were talking about it and being heard about it. Then the political winds took over here in the U.S. and nursing homes went off the news.

Mike: I think I would encourage all my all of our colleagues, we do have to be willing to be advocates for our field. If there is a profound lesson in this, you said I was a provocateur. I’ve never been shy, for the people who know me, about speaking up.

Mike: I can remember a year ago, I tweeted out something like, ageism and racism equals elder genocide.

Mike: I have some colleagues who were like, “Oh, my God! That’s really provocative.” The crazy thing is, here we are a year later when some of those very colleagues are tweeting out things much more provocative than what I did. I hope, actually no, I don’t hope. There’s been a groundswell amongst our brethren who are willing to speak up. I think we’re more, we like consensus, we don’t like conflict. That’s what geriatricians are all about. But we’re in the big leagues, we’re dealing with the government, with the nursing home industry. It’s a contacts war and you’ve got to be willing to speak up and speak out. The thing we have going for us is, we are passionate about what we do and we care.

Mike: People get that. I think we are in the right place at the right time, I wish it weren’t. We’ll talk more about what’s coming ahead. But I think that’s the key is, we’ve finally got to focus on what we do.

Alex: Yeah. I think, just to build on what you’re saying here, about speaking out. Part of this is speaking out for people who generally don’t have the opportunity to speak for themselves. Not only are nursing home residents generally less likely to speak out for themselves than other members of our society. But also part of the reason they often end up in nursing homes is because they don’t have caregiver support in the home setting to stay at home. They’re less likely to have caregivers who will speak out on their behalf as well.

Alex: You have this extremely vulnerable population who doesn’t have a voice. It’s just so critical that you know, people like you and other people, Dave Grabowski, you mentioned. Others, Joe Ouslander, stand up and give a voice to the concerns and the needs of those most vulnerable folks?

Mike: Yeah. Dave Grabowski and I joke, when there’s an article out there it’s like he and I are often quoted together. We actually published a paper together last month in the Health Affairs blog, on the need for transparency in nursing homes. That’s the other thing about the nursing home industry and this pandemic. It’s allowed us to talk about things that no one had really talked about. The advocates are always talking about the bad things that go on in nursing homes. But no one had really discussed why and what the underlying root causes were.

Alex: Yeah.

Mike: Those root causes are really coming out now. And I think silver linings to hopefully be able to address these things.

Eric: Over the course of the following year, to where we are right now, 40% of COVID deaths were in nursing home patients in the U.S.. Luckily, December/January, there was a prioritization as far as vaccinations to nursing homes. The number of deaths and cases in nursing homes has plummeted. Where do you feel like we are right now, Mike, as far as COVID and Long-Term Care?

Mike: Well, we’re in the best place we’ve been in a year. The vaccine has been everything that it was supposed to be. If we get the residents vaccinated, if we get the staff vaccinated, the profound and precipitous drop in cases and deaths to nursing homes is incredibly telling. Now, I really have striven for a year not to look backwards except where it helps us look forward. All the great things about the vaccine, what we did was, we spent billions of dollars to create a vaccine. Dropped it off on the front door of nursing homes in December and said, “Good luck.” There wasn’t really a lot of planning. We saw this coming, we actually had a group that was trying desperately to make recommendations.

Mike: I have to say, the thing that hasn’t been reported on. If we had been able to effectively roll out the vaccine in nursing homes, and assisted living facilities, and group homes in December. You’re talking 10s of 1,000s of preventable deaths.

Eric: How would you rate the rollout, like the Long-Term Care pharmacy, I’ve read the entire title. How would you rate that rollout?

Mike: Honestly, I give it a D minus. The reason I give it a D minus is, how can I not give it a D minus when we knew what an A look like? The difference between an A and a D minus was 30,000, 40,000, 50,000 deaths. Okay. I mean, that’s the bottom line is, if we’d done what West Virginia did-

Mike: Which is what we were recommending from like October on.

Eric: Which was, go through local pharmacies, if I remember West Virginia, is that right?

Mike: Yeah. The Long-Term Care pharmacies, every nursing home as a Long-Term Care pharmacy.

Mike: Get them the vaccine, get everyone vaccinated right away. West Virginia had their vaccinations done almost by the end of the year. As we sit here today in California, there are still assisted living facilities that haven’t completed their vaccinations. In those facilities live people with Alzheimer’s, who don’t wear masks properly, who can’t physical distance. We missed an opportunity. Now, that said, It’s water under the bridge, what’s done is done. But looking forward, we actually have a group of folks who have been meeting weekly since October, that have just penned a letter that’s going to go to CMS and CDC by the end of the week. Saying, it’s not too late to engage all those Long-Term Care pharmacies.

Mike: So that, as we move forward, we’re going to have new admissions who aren’t vaccinated. They need to be vaccinated. We’re going to have staff turnover and we are going to have staff who have now decided, “I want to get the vaccine.” In order to maximize the level of vaccination amongst residents and staff, it is way past due that we fully engaged the long-term care pharmacies. Also, make it easy for them in the facilities. There should never be a situation where someone says, “Well, we can’t do that because we’ve got to do this, or we got to type this in, or we’ve got to fill this out.” When I ran my nursing home chain, I had two words I didn’t allow. Those words were can’t and won’t.

Eric: Yeah.

Mike: I believe, during a pandemic, when you’re talking putting vaccines in the arms of people. The two words that should be literally important to you are can’t and won’t.

Mike: You got to figure out how to do it.

Eric: Right now, we just did a vaccine hesitancy podcast, published two weeks ago. But the numbers that were striking to me is, 80% of nursing home patients have gotten the shot. But only about 50% of nursing home staff. Does that sound right about to you, from a California perspective?

Mike: Yeah. We knew this. Anyone who took the time and energy, but to think about it back in October knew this was coming. You’ll still see folks, public health officials say, “Oh my God! We didn’t expect this, why aren’t they?” It’s like, well, get your head out of the sand and listen to the experts in geriatrics. Which, by the way, to me for literally the last 13 months, that has been my mantra. Engage geriatricians, engage experts in geriatrics. Not only on advisory committees, which many of those are just bullsh*t. Can I say that on the podcast?

Eric: You can say that. Ear muffs for all the kids out there.

Mike: But we need to be in the room. If there were wildfires running through the state, the governor would be standing there every day with a fire chief. We’ve had a wildfire running through our nursing homes for a year. It still frustrates me that the governor is not standing there next to a geriatrician every day. Honestly, that goes for the feds, that goes for many states.

Eric: Yeah.

Mike: If they had, the reason I went around on that little tangent, we all knew that our frontline staff were going to have issues with vaccine confidence. By the way, that’s one of my [inaudible 00:26:37] things I’ve learned from some of my colleagues. I tried to say everything with positive words. People don’t like negative words.

Eric: Not hesitancy, vaccine confidence.

Mike: So we want to improve vaccine confidence.

Alex: I see.

Mike: Instead of talking about vaccine hesitancy.

Eric: Yeah.

Mike: By the way, those numbers are coming up. I just saw a study today that we may be getting closer to 60% acceptance in the frontline staff. When I got my vaccine at my nursing home, I talked to some of the staff and they said, “Yeah, our colleagues are nervous, but now that they’re seeing me get vaccinated they’re getting willing to do it.” I think we’re going to see more and more acceptance of the vaccine over time.

Eric: Yeah. I mean, it’s still a little bit shocking. Because, Alex and I live in Marin, which I think 50% of adults over the age of 18 have gotten at least one shot. These all adults. To hear that we’re just at the best place, 10% higher for that, for health care providers. It tells us that we have a lot of work to do around vaccine confidence? I’ve learned it, vaccine confidence.

Mike: I think the other thing we have a lot to do around is risk. Again, I’ll credit Lisa Coleman for this. We need to respect, honor and value our frontline staff.

Mike: If they don’t feel respected, and honored, and valued, why are they going to just jump in and take a brand new treatment?

Eric: Yeah.

Mike: I think this is why I’ve been against mandates for these staff. Because, I want my kids growing up in a world where the frontline staff of nursing homes are going to get vaccinated out of their own choice doing what’s right, rather than to be coerced. I mean, these are people who barely make a living wage if they’re lucky, often work two jobs. I was on a press conference yesterday and there was a CNA who talked about literally going home crying every night because the lack of staff to take care of the residents. She’s running around doing it. These are the most-

Mike: Compassionate human beings. Even though, as a clinician, I would love to just say you’re getting the vaccine. As a human being, I can’t do it.

Eric: Yeah. That was from our vaccine, what we called it Hesitancy Podcast. Where David Grabowski said, because we asked him about, “Should we just mandate it?” Really, he came down to it and it will destroy trust. If you mandate it, it will destroy trust. Plus, it probably wouldn’t work because there’s so many ways to get out of it. But fundamentally, this is about building trust rather than destroying it?

Mike: I’ve been trying to avoid this topic, again out of the spirit of being positive. But we started vaccinating nursing home residents in December. We don’t have a clue when immunity begins to wane in 50 year olds, much less, 90 year old nursing home residents. I’m shifting to what’s going to keep me up at night.

Alex: Yeah.

Eric: Yeah. Starting to think about the future.

Mike: The question is, or that maybe the answer is, this is why we have to remain vigilant, we have to keep wearing masks, we have to keep testing. There’s a lot of folks who are like, “Oh, we got vaccines, we don’t have to test.” No, nothing could be further from the truth.

Eric: All right. My question though, do we have to continue the lockdown of nursing homes, this social isolation?

Mike: We can’t. That was my quote in the Washington Post today. I think it might have been a little edgy, not surprising for me.

Eric: You always give good headlines.

Eric: That’s what I’ve always loved about reading you in The Times or LA Times. That was a provocative statement by Mike.

Mike: I’ll give a clue to you and all of our colleagues. If you want to be quoted in the newspaper, you have to be a little edgy, you have to be a little provocative. Otherwise, they’re not going to use your quote. Now, the most provocative quotes have landed me on TV. The moment I get on TV, I pivot to being a geriatrician and giving sound respected answers. Again, we’re not trained with this media stuff and I think there is something to it. But back to the visitor.

Eric: Yeah. Sorry for the tangent.

Mike: No, it’s fun. Here’s what I’ve been telling people. We have 90 year old nursing home residents who haven’t seen their loved ones in a year, who are vaccinated. Some of these folks have 90 year old spouses who haven’t seen them in a year, who are now also vaccinated. How we don’t have the 90 year old vaccinated spouse from the outside, not only visiting, but hugging their 90 year old loved one in the nursing home. While we still have that 90 year old home resident being taken care of by an un-vaccinated staff member, is beyond me. I think the data is abundantly clear that vaccinated nursing home residents should be allowed to see visitors. That guidance is actually now out there. Between the guidance and the fear in the industry.

Eric: Yeah.

Mike: You’re still hearing people say, “Okay, that’s true, but let’s try to focus on outdoor visitation.” Which I’m fine with. And to your point, you can visit between 11:00 and 12:00, when it’s not raining on a Tuesday.

Eric: Right.

Mike: I mean, where has Person-Centered Care gone in the last year? It doesn’t exist. Person-Centered Care who would suggest, if Mrs. Smiths’ grandkids want to come and visit, they should be allowed to. We have to figure out how to make it happen safely, that’s the key. It goes back to your earlier point [inaudible 00:33:56] has reared its ugly head in many ways in the pandemic. Everything we’ve done is to protect the residents, regardless of their wishes, quality of life and desires. I think that’s the lazy way out. Science tells us the vaccine works, science tells us there are safe ways of visiting.

Mike: We need to bend over backwards to make it happen, because these folks have put… This is Normandy beach. For some of them it’s Normandy beach the second time. These folks have been on the front lines of this pandemic, giving their lives and what are we giving them? Yeah, actually a lot of the visitation advocates love my tweets. Because, I am unabashedly pro-visitation. But I also will tell people, “You’ve got to do it the right way.” And I think that’s the key.

Eric: Yeah. What was the quote in the Washington Post?

Mike: Actually, my quote in the Washington Post had to do with the fact that, I gave this quote probably a couple of weeks ago now. Which is a little dangerous during these times, because two weeks is a lifetime. When the guidance from CMS came out, and CDC, and California Department of Public Health, there wasn’t internal consistency. There was a lot of confusion and there still is a degree of confusion there. I did also note, honestly, that facilities are in fear of more outbreaks, of getting sued, of getting penalized. You got CMS saying one thing, you got your state health department saying something else. These guys get penalties based on whether they get it right.

Mike: We can’t have that during a pandemic. I think that’s been the thing that has frustrated me the most. One of the things some of my great mentors in long-term care have taught me, is the concept of always trying to do the right thing. That’s natural for us in geriatrics. I think if the government could find a way of understanding that and filtering it through their regulatory process, we’d probably be better off.

Eric: When you think about where we are now, what are the other things, when you think about the other nine months of 2021, that we have to look forward to? What keeps you up at night, what are you worried about, where do you see COVID going as far as long-term care and how our response to it changes?

Mike: A year ago I was telling folks, “We could see a quarter of a million deaths in long-term care.” No one published that quote, they thought that I’ve been out there, they thought I was out there, they thought I was nuts. That number’s going to be pretty darn close to the truth.

Eric: Yeah.

Mike: What worries me is, between variants and people thinking, “Oh, I’m vaccinated, I don’t have to wear a mask, I can let my guard down.” And waning immunity. The fact that, unlike flu season, where we try to get everyone vaccinated in a fairly tight period of time. We’ve got people vaccinating throughout the whole year. The logistical, the numbers, I have to be concerned that we can’t stop wearing masks. My dad’s 86 and the funny thing he told me about a month ago was, “You know I haven’t gotten the crud this year. I normally get the crud, it puts me out for a couple of weeks.” And he says, “You know, I’m wearing a mask for the rest of my life.”

Mike: I do think we have a cultural issue, just look at Japan. Look, I am never getting on an airplane again not wearing an N95. The irony is, I did the Hawaii Iron Man in 2019.

Alex: Wow!

Mike: I got sick the week before.

Alex: Oh no.

Mike: In retrospect, I wished I’d worn a mask for the two/three weeks prior to the event.

Alex: But you finished the Iron Man despite being sick the week before?

Mike: Yeah. That’s a whole other story.

Alex: That is impressive. There is a theme here about, it’s a people’s voices not being heard again. Who else would tolerate being confined in solitary confinement essentially for a year? As you’re thinking forward again, Dave Grabowski tweeted the other day, what this pandemic has showed us is the long-term care system is broken. It’s broken and that’s clear. Normally, we give people a magic wand with one wish that one thing they could change. I feel like in your case, we should give you a genie, like a one of those vases or whatever it is, to rub the magic bottle. Then the genie comes out and then you get three wishes. If genie would grant you three wishes to change the long-term care system for the better, what would those be for you?

Mike: The first wish would be, I’ll take a little liberty with this one, to instill geriatrics training throughout medical education. Starting in medical school, carried out all the way through residency. The reason for that is, my second wish won’t really matter if that first wish doesn’t. If we don’t have more of us who understand geriatrics and more of us who can teach it and practice it, then the second wish is not going to matter.

Mike: The second wish is, geriatricians, again not only need to be making recommendations, we have to be in the room with policymakers. I think on a very pragmatic level. I don’t think there’s ever been a political appointee at CMS or HHS, who’s a geriatrician or who has a strong geriatrics background. Those are the guys who make the policy. We have geriatricians working at CMS, they’re great people, but they carry out the policy and the regulations that the bean counters, and the lawyers, and the MBAs give to them. None of those folks understand what we understand. That’s my second wish.

Mike: My third wish is that we can always human beings just care about each other and wear the damn mask. Because, honestly, if we look back over the last year. If as a country everyone had followed mask wearing and physical distancing from the beginning, we would be more like Japan and not Brazil.

Alex: Yeah.

Eric: Well, Mike, first of all, I want to really thank you for joining us on this podcast. Your leadership and your willingness to put your voice out there over the last year was inspiring to me. I think it has actually made a ton of important changes in how we care for a population that is, in some way by design, ignored by most people in the U.S.. They don’t have a voice and their family members often don’t have a voice. I love that you were willing to put yourself out there as a voice. Really, to all of our listeners, just loved your lessons too Mike on how to be that voice. Big thank you for joining us and for being who you were this year.

Mike: Thanks for doing what you guys do. I love your podcasts and just keep it up.

Eric: Any quick resources that you just want to plug, as far as long-term care and COVID?

Mike: Well, go to the ANDA website, go to the CALTCM website, follow me on twitter @wassdoc. I promise you, 95% of my tweets are related to geriatrics, long-term care, aging. I really tried to avoid politics, except when they’re egregiously ageist.

Eric: Yeah. Encourage everybody follow Mike. David Grabowski, another great one to follow. I loved his recent tweet, I think it was from yesterday, he was on a panel discussion. His boat was, the U.S. has more nursing homes and Starbucks. Then Nathan Stall, another great person to follow if you’re interested in this subject, Canada has twice as many Tim Hortons as nursing homes. It’s unclear if this reflects a relatively supply issue of Canada nursing homes versus just their love for Tim Hortons.

Mike: Those are great.

Eric: Alex do you want to give us a little bit more of that song?

Alex: (Singing).

Eric: Thank you Alex.

Alex: Thank you Mike.

Eric: Big thank you to all of our listeners for continuing to support the GeriPal Podcast and to Archstone Foundation for your ongoing continued support. Good night everybody.

Alex: Good night.