Teaching doctors to really be effective in the post-acute and long-term care setting isn’t just a simple matter of placing them within the four walls of a nursing facility. Getting doctors to fully understand their role and how to best serve in these settings can also be a bit of a challenge.
As I’ve written previously, the first two pain points to getting full-time doctors placed in nursing homes is working with facility administrations to understand the inherent value of taking that action and recognize that they absolutely need it to best serve the exigencies of patients and their families.
The third pain point is training doctors in how to best adapt their own training and procedures to working in a nursing home. The nursing home environment is vastly different than a physician’s office or the hospital and provides its own set of unique challenges. This naturally requires a bit of adaptation for physicians new to this aspect of care. For example, for doctors who have primarily practiced in the hospital setting, not having all the typical ancillary services—such as radiology, lab, and pharmacy capability readily available in-house—incrementally increases the complexity of decision-making and critical thinking.
In this article, I will discuss how hospitals and long-term care facilities have different missions, how effective communication is necessary to bridge those differences and why medical directors must be fully invested to be successful in the nursing home realm.
Hospitals and Nursing Homes Have Different Missions
Policies curated to care for patients in the acute hospital setting are hard to apply to the post-acute and long-term care environment. The reason comes down to differences in their respective goals, who they’re treating, and where they place their focus.
Surviving vs. Thriving
Hospitals and nursing homes have different but equally important goals. In the hospital setting, the general goal is to save the patient’s life and set them on the right course for recovery. In the nursing home, however, care goals center around helping a patient achieve and maintain their highest level of functioning, which includes psychosocial aspects of care that physicians tend to think about less and struggle more to deal with.
Typically, patients in post-acute and long-term care facilities are not sick enough to require a hospital stay, but they are too ill or frail to return home. Although many of them will be transported to a doctor’s office (primarily a subspecialist) for follow-up, every trip to a doctor’s office risks exposure to the illnesses and/or infections that are present in that doctor’s waiting room, increasing the likelihood of another illness while they are still very frail. In fact, some outbreaks of influenza in a nursing home can be attributed to patients being transported to another doctor’s office. Their health status, like that of infants, can often change on a dime. One moment, they appear stable—the next, they can be at death’s door.
Focus on the Doctor
The hospital team revolves around making a doctor efficient. Nursing homes, in contrast, were not developed with a doctor in mind. In fact, nursing homes were not even required to have a medical director until 1974, when Medicare began to require them for certification. The Omnibus Budget Reconciliation Act of 1987 eventually extended this requirement to all nursing homes.
Today, the involvement of doctors who care for patients in the nursing home setting varies widely. Medical directors, who have responsibility for oversight of a nursing home, may remain relatively uninvolved in their facility or be highly active. For medical directors who wish to be involved, understanding how to be effective in the nursing home environment can be challenging.
Effective Communication Is a Challenge
An important part of a doctor’s training is learning to think critically and to diagnose and treat problems. However, in the world of medical management, this key aspect is often seen as a negative contribution, which can produce the unwanted side effect of making communication difficult between physicians and facility administration.
It is one thing, for example, when a patient comes to a physician’s office complaining of a symptom to investigate and the doctor diagnoses the problem. There is always some inherent trepidation in waiting to receive the diagnosis. “How serious is it? Will I get better?”
It is another thing entirely, though, when physicians use these same skills in the health care administration role. Often, no one is asking for the diagnosis of an administrative problem. Making the diagnosis and informing the facility’s team can come across much more negatively than intended.
Admittedly, physicians are used to being the center of the universe—in the hospital or their own office. Conversely, many of the diagnostic conclusions they bring to the nursing home environment surround the fact that they are just another celestial body in that facility’s orbit. It can be a daunting task and often ego-bruising for a doctor to try to communicate effectively in the nursing home setting and create meaningful change that would be useful for the facility.
What Does the Law Require?
The volume of literature surrounding the rules and regulations concerning management of a nursing facility is huge and must be understood to be effective in a leadership position. The Society for Post-Acute and Long-Term Care Medicine (AMDA) provides excellent education to help physicians understand and function effectively in this setting.
Congress is also recognizing the important work medical directors should be doing. The House of Representatives, in an effort to improve transparency, introduced a bipartisan bill on September 15, 2022, that would require nursing homes to declare the credentials and background of their medical directors to the Centers for Medicare & Medicaid Services (CMS). The proposed legislation, sponsored by Mike Levin (D-CA) and Brian Fitzpatrick (R-PA), is intended to ensure care facilities are held accountable for hiring qualified medical directors and helping consumers make more informed decisions when it comes to long-term care.
How Engaged Is Your Medical Director?
One of the greatest obstacles to effective physician leadership in the nursing home setting is the small amount of time a physician (medical director or attending) spends inside the walls of the nursing home. It can be difficult to offer meaningful solutions to quality-of-care issues without rubbing elbows with the staff providing direct care and witnessing inefficiencies or opportunities for educating firsthand.
The effectiveness of individual medical directors primarily comes down to how engaged they are. Do they show up once a month for perfunctory patient visits and to peruse a litany of straight facility stats without having any real context to the numbers? Or are they actively available by phone during the week to discuss issues in the building and specific patient care? Clearly, there is a big difference between the two approaches. The greatest difference, however, occurs when the physician/medical director practices daily inside the walls of the facility, is intimately acquainted with their patients, and actively engages with the nursing home team.
Running in to see your patients or to attend a monthly quality assurance performance improvement (QAPI) meeting and then simply returning to your regular hospital or office does not allow time to understand the culture of the building or to dialogue with management about challenges the facility may be facing. According to the CMS, “effective QAPI programs are critical to improving the quality of life, and quality of care and services delivered in nursing homes.”
As far as diagnoses go, they don’t come more accurate than that.
At SilverSage, our business model champions the importance of having a full-time physician on staff at individual nursing homes. It’s the most effective way to care for the needs of patients and their families. As AMDA reported in June, physicians with expertise in nursing home care share a strong consensus that full-time physicians in that environment provide a higher level of care than other doctors and develop better relationships with patients and their families.
The nursing home of today is not the same place of 50 years ago. In 1974, Medicare acknowledged the need for physician oversight. At that time, nursing homes were more like assisted living facilities are today. The level of complexity of patients residing in the nursing home today has dramatically increased. In fact, nursing homes are much more like free-standing, med-surg wards without lab, X-ray, or pharmacy in-house.
If Medicare saw the need for a medical director to provide oversight in 1974, certainly a case should be made for the need for a full-time doctor in a nursing home in 2022.
Dr. Kenneth Scott has dedicated much of his 30-year career to improving the quality of life for nursing home residents. He is the CEO and founder of SilverSage Management Services, a company he started in 2016 to provide physicians to the post-acute and long-term care industry as well as consulting services to nursing homes and assisted living companies. Dr. Scott earned his doctorate degree in osteopathic medicine from Kansas City University of Medicine and Biosciences. He also holds a bachelor of science degree in microbiology from the University of British Columbia.