Roles
Related functions and tasks
Supervise individual resident care
• Approve a resident’s admission to the facility, e.g., this may be done by giving and approving orders upon admission
• Be familiar with, and contribute to, a patient’s assessment and care planning; e.g., by helping staff identify and manage underlying causes of impaired function and significant condition changes
• Ensure that there is backup medical coverage if the attending physician is unavailable; e.g., by providing the facility with information about on-call coverage and addressing any issues with that coverage
Make resident visits
• Take an active role in supervising their patients’ care
• At the time of each visit:
− Review the total program of care, including medications and treatments rendered by other disciplines
− Write, sign, and date a progress note
− Sign and date all orders except immunization orders that may be periodic without a new order
− Evaluate the resident’s condition and continued appropriateness of the current medical regimen
Make timely visits
• See a patient at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter (the next scheduled visit date should be determined by this interval, not by the actual date that the last visit occurred; a visit is timely if it occurs not later than 10 days after the date it was required)
• Make all required physician visits personally (required visits after the initial visit may alternate between visits by the attending physician and visits by a physician assistant, nurse practitioner, or clinical nurse specialist under the physician’s supervision)
Arrange for provision of emergency services
• Designate backup coverage; e.g., individual physician, physician group, or advance practice nurse
• Ensure that backup coverage is available as needed
• Address issues related to backup coverage, as needed by the facility
Delegate tasks appropriately
• Delegate tasks to physician assistants, nurse practitioners, or clinical nurse specialists consistent with OBRA’87 requirements and state requirements related to licensure and scope of practice
Increasingly, physicians have a more intensive involvement with long-term and post-acute care facilities. Traditionally the practitioner who occasionally visited his or her patients and did the minimum has changed to one of active involvement to assess and provide in-depth management of patients, to avoid hospitalization wherever possible, and to address the many issues (for example, adequate diagnosis, delirium, medication-related complications) that arise before and after admission to a long-term and post-acute care facility. Currently, AMDA—The Society for Post-Acute and Long-Term Care Medicine is developing a curriculum and certification program for attending physicians covering diverse areas of physician competency and to promote a more uniform standard of practitioner knowledge and skill.
As the health care system changes, hospitals are partnering more with long-term and post-acute care facilities to develop integrated care models (see chapters “Behind the Scenes at Nursing Facilities” and “Preventing Hospital Admissions and Readmissions” for further discussion). In the process, more hospitalists are becoming involved in providing care in these non-hospital settings.
Table 2 identifies key practitioner responsibilities in long-term care that are integral to quality resident care [7]. The practitioner must work with the facility’s leadership, usually its administrator and nursing staff as conflicts or problems arise.
Table 2
Practitioner’s roles and related functions and tasks
Practitioner’s role | Related functions and tasks |
|---|---|
Accept responsibility for resident care | • Assess new admissions in a timely fashion • Seek, provide, and analyze information regarding a patient’s current status, recent history, medications, and treatments • Provide information and documentation that helps staff determine appropriate level of care for a new admission • Authorize admission orders in a manner that enables the facility to provide safe, appropriate, and timely care • If pending transfer, continue to provide all necessary medical care and services, until another physician takes over the care |
Support discharges and transfers | • Follow up, as needed, when an acutely ill or unstable patient is transferred from the facility • Provide necessary documentation and other information needed at the time of transfer to enable care continuity • Provide a pertinent discharge summary within 30 days of patient discharge or transfer from the nursing facility |
Make periodic, pertinent resident visits | • Visit patients in a timely fashion, based on their needs and on regulatory requirements, including an alternate visit schedule as appropriate • Maintain progress notes that cover pertinent aspects of a patient’s condition, current status, and goals • Review and approve a patient’s treatment and care program • Determine a patient’s medical condition and address active issues at visits • Respond to issues requiring a physician’s expertise, such as diagnosis of causes of a recent condition changes and review of current medications and treatments for continued relevance and safety • Provide legible progress notes in a timely manner |
Provide adequate ongoing coverage | • Designate alternate coverage • Update the facility about communicating with his/her practice and designated alternate coverage • Help ensure that alternate coverage provides adequate and timely support • Notify the facility of any extended absence and related coverage arrangements |
Provide appropriate resident care | • Perform accurate, timely, and relevant medical assessments • Define and describe resident symptoms and problems, clarify and verify diagnoses, and help establish prognosis and realistic care goals • Help determine appropriate services and programs for the patient • Verify the medical necessity and appropriateness of treatments and services, including rehabilitation services, in accordance with relevant practice standards and regulatory requirements • Respond in an appropriate time frame to emergency and routine notification by staff • Analyze and address laboratory and other diagnostic test results • Assess and promptly manage significant acute changes in a patient’s condition when notified • Guide ethics-related decisions (for example, options for life-sustaining treatments) • Order appropriate comfort and supportive measures as needed • Periodically review continued relevance of all prescribed medications for patients and identify and address possible medication-related adverse consequences |
Provide appropriate and timely medical orders | • Provide timely and legible medical orders • Sign and verify the accuracy of verbal orders |
Provide appropriate, timely, and pertinent documentation | • Document pertinent explanations of medical decisions, helping the facility comply with its legal and regulatory requirements • Complete all physician information required on death certificates in a timely manner |
Perform and act appropriately | • Abide by pertinent facility and medical policies and procedures, and collaborate with the medical director/facility leadership to help the facility provide high-quality care • Contact the medical director/facility leadership about issues and concerns • Keep the well-being of patients in mind in all situations • Be alert to any observed or suspected violations of resident rights, including abuse or neglect • Interact in a courteous, professional manner with facility staff, patients/residents, family/significant others, facility employees, and management • Inform the medical director/facility leadership of disputes or problems with other parties (e.g., staff, patients, or other practitioners) that the physician cannot readily resolve |
Clinical Reasoning and Diagnostic Quality
Medical practitioner s play a crucial role in a facility’s care quality by their individual performance and practice as well as by influencing facility processes related to clinical decision making and cause identification.
Diverse disciplines (e.g., therapists, nurses, and dieticians) in long-term and post-acute care facilities must work collaboratively to solve clinical problems and to make clinical decisions. However, many clinical decisions are often made in other settings before patients are admitted to a long-term or post-acute care facility. Staff, patients, and families need to query whether the right decisions were made. Thus all disciplines have a great responsibility to think critically and act prudently. The care delivery process is key to providing safe, effective, efficient, patient-centered, equitable, and timely evidence-based care. Using the care delivery process of recognition, cause identification/diagnosis, management, monitoring and continual reassessment of response to treatment interventions is critical. The medical practitioner’s role is to paint an accurate picture of the patient over time and to determine what is causing and contributing to illness and impairment. Patients often have symptoms that require a detailed and thoughtful differential diagnosis. Improving function and reducing or preventing further impairments is essential to the provision of patient -centered care.
Key steps in developing and implementing a patient-centered medical plan include:
1.
Clarifying relevant medical issues (including physical and psychiatric conditions as well as patient prognosis).
2.
Determining decision-making capacity.
3.
Identifying the primary or proxy decision maker.
4.
Identifying the “big picture.”
5.
Reviewing an individual’s values, goals, wishes.
6.
Reconciling patient goals and medical goals.
7.
Ordering appropriate interventions.
8.
Monitoring and when needed, adjusting those interventions.
All staff, practitioners and the medical director must support a culture of consistent care, competent clinical reasoning, and problem solving that actively supports the QAPI process. Diagnostic quality includes efforts to minimize and recognize diagnostic errors that contribute to adverse events. Facilities and medical practitioners should be able to recognize and distinguish between a proper and “misguided” care process where skipped critical steps lead to diagnostic errors and inappropriate or harmful treatment.
The Role of the Medical Director
Medical directors serve in various other settings, including hospitals, insurance companies, specialty programs or services (e.g., dialysis, hospice, wound care, PACE), and assisted living facilities (only some of which have a medical director). However, medical directors are predominantly in nursing facilities as a result of federal regulation where the role of the medical director is defined as “a physician who oversees the medical care and other designated care and services in a health care organization or facility” [8].
Medical Director Characteristics
The background, characteristics, and performance of medical directors have been researched over the years [9, 10] and also investigated by AMDA: The Society for Post-Acute and Long-Term Care Medicine (formerly known as the American Medical Directors Association ). In nursing homes, most medical directors have an internal medicine or family medicine background, and approximately 23 % are also geriatricians [11]. A medical director may cover one or several facilities. Although most medical directors also serve as attending physicians in their facilities, a significant number act solely as a medical director with no individual patient care responsibilities.
Origins of the Medical Director Role
The need for a nursing facility medical director concept evolved out of government investigations stemming from a 1970 salmonella outbreak in a Maryland nursing facility [12, 13]. In the 1970s, the American Medical Association’s Committee on Aging attempted to define the roles and functions of a medical director and promoted educating physicians about these basic roles and responsibilities [14]. By 1974, every skilled nursing facility (those certified to provide skilled nursing services to Medicare beneficiaries) was required to retain a full- or part-time medical director [15].
The 1987 Omnibus Budget Reconciliation Act (OBRA) and its related regulations expanded the medical director requirements to include residential as well as skilled portions of nursing facilities. For regulatory purposes, both skilled and residential facilities were referred to as “nursing facilities.” Subsequently, surveyor guidance (as written in 42 CFR 483.75(i) Medical Director [F501]) has clarified expectations. Beginning in the late 1980s and early 1990s, physicians serving as medical directors [16, 17] and their representative organization (AMDA) [18] have reviewed and summarized information and perspectives on medical direction. In 2001, the Institute of Medicine recommended that nursing facility medical directors be given greater authority and that structures and processes be developed not only to enable but also to require a more focused and dedicated physician participation [19].
Key Medical Director Responsibilities
Based on these initiatives, there are now regulatory and professional organizations that have developed the medical director’s roles and responsibilities. Collaboration among physician organizations and regulatory agencies has helped to make those requirements more consistent throughout the USA. In contrast, requirements for medical direction in assisted living facilities vary among states. As of 2015, most states did not require a medical director in assisted living facilities.
Regulatory Foundation
Federal regulations require every nursing facility in the USA to retain a physician to serve as its medical director. The primary source of medical director regulations is OBRA ‘87 and the State Operations Manual on surveyor guidance; but there may also be some individual state regulations regarding medical director’s responsibilities [20]. Federal nursing facility regulations divide requirements into discrete segments called “F-Tags ,” related to one or more specific regulatory requirements and used for state and Federal survey purposes.
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