When I speak to nursing home teams about having their own full-time physician on staff, visions of Dr. McDreamy inevitably dance in their heads.
Indeed, when I mention the fictional TV character played by Patrick Dempsey on Grey’s Anatomy, staff members often smile and clap. After all, what would it be like to have a handsome doctor at your beck and call at all times? The prospect inevitably sounds too good to be nonfiction to members of an industry that has, historically, tried to make do without—or in spite of—a full-time doctor.
With that history in mind, when nursing homes do choose to add a full-time physician to their staff, there is a bit of a learning curve in how to properly take advantage of and ultimately adapt to the practice. Let’s review Medicare regulations for nursing home care and the growing pains that need to be addressed by both the nursing home staff and full-time doctor alike before they can truly work together for the overall good of the patient.
Medicare regulations for the participation of a doctor in a nursing home are broad and general. In a nutshell, the rules are as follows:
- Each patient/resident must have a doctor of record in charge of their care.
- The doctor must see the patient at least once in the first 30 days to perform a history and physical exam, and then once every 30 days for the next three months. Subsequent follow-up visits can alternate monthly between a doctor and a nurse practitioner.
- After the first 90 days, a doctor or nurse practitioner must see the patient at least once every 60 days.
- There must be a doctor who functions in an administrative role as the medical director for the nursing home, overseeing quality of care.
A doctor can follow these rules with dedicated exactness and still be absent more than present within the walls of their specific facility. Consequently, nursing homes have coped by learning to do the best they can in the absence of a doctor. Thus, when working on a proposal to place a doctor full-time in a nursing home, you’d be surprised how often the response from both the nursing home and the doctor centers around the question of “What will the doctor do all day?”
Usually, within three months of initiating the program, the doctor reports back that they had no idea how sick patients in nursing homes really were but now fully understand why a doctor needs to be there on a daily basis. For the nursing home, however, the transition to figure out how the program is supposed to work often takes a little longer.
When signing on for a full-time physician, the initial gut response from facility staff members is to call on the doctor for every little complaint a patient has. Initially, this is a good exercise for both the physician and the nursing home staff. After all, good patient care centers around excellent communication between the doctor and the nursing home staff.
Communication between a doctor and nurse can be enhanced and rapidly improved upon in this type of environment as well. For example, when a nurse reports something firsthand to a doctor, the doctor can immediately go and see exactly what the nurse is reporting and what their concern is. When done right, this provides a wonderful educational opportunity for both parties involved and can strengthen the communication skills and working relationship between the staff and the physician.
Breaking Old Habits
It can be difficult to break habits forged over the decades of operating a nursing home in the absence of a doctor, and the process will naturally produce growing pains. In one building where I had hired a full-time physician, things seemed to be going well for the first few months—until I received a distress call from the director of nursing.
“You need to come deal with this doctor ASAP,” the nursing director said. “He keeps yelling at the nursing staff.”
Arriving at the building, I sat down privately with the nurses and then the doctor to better understand exactly what the issues were. It turned out that there was one main issue troubling both parties: Although the doctor was attentive to the patients and took care of most issues during the day, occasionally a patient would get sick at night and need additional care. The night nurses had been conditioned over many years to not bother the doctors at night. Typically, if they called a doctor and woke them up at night, they would receive a stern lecture asking them why they are calling in the middle of the night and instructing them to send the patient to the emergency room at the nearby hospital to be evaluated. It got to the point where, rather than hearing that lecture, nurses would just call the ambulance and have the patient transported directly to the ER.
The new full-time doctor, however, had made it clear that he wanted to be called, even at night. He knew the patients and felt that in most instances, he could take care of them without transporting them to the ER. After coming to the nursing home in the morning on several occasions and finding his patients missing because they had been sent to the hospital, he became increasingly frustrated. He had reminded them several times to call him, yet they continued to send the patient to the hospital without talking to him. He began to raise his voice in frustration.
I reminded the doctor that these nurses had been conditioned over many years not to bother the doctor at night. Now they were having to get used to a new paradigm, and his frustration and raising his voice was only reinforcing what they already felt: “Don’t bother the doctor.” I suggested that he remind them gently and even show up to meet the night shift on occasion so they would get to know him as the day shift had already done. He had to earn their trust and convince them that it was truly all right to call him at night.
A New Dawn of Care
In the old system, the on-call doctor at night was not the partner that actually showed up at the nursing home. Naturally, this doctor was going to say, “Send the patient to the ER,” since they most likely did not really know the patient at all. In the new model, however, the full-time doctor is already well familiar with individual patients and a good working knowledge of their health situation, and can often keep them comfortable and stable at the nursing home.
Adjusting to the New Model
Doctors in the hospital have clear-cut goals of patient care: Stabilize them and get them well enough to be safe for discharge. Decision-making in the nursing home, however, is complicated by psychosocial factors involving the patient and their family’s wishes around end-of-life issues, the ability to rehabilitate, and how best to keep a patient comfortable without all the high-tech support that a hospital affords. Add to that the fact that nursing homes truly are free-standing med-surg wards, and the complexity of decision-making escalates to a whole new level complicated by the fact that testing, especially at night (lab, X-ray, and immediate access to new pharmaceuticals) is either unavailable or greatly prolonged.
Nurses, used to working in the post-acute and long-term care world understand that testing is difficult to obtain, and timing is complicated by how long it takes a doctor to call back when paged, either at night or during the day where the doctor is stretched between office appointments and emergencies in the hospital. Thus, at the first sign of trouble (a minor change in condition), the nurse places the first call, hoping that before there is a major issue, they will hear back from the doctor. This creates frustration for the doctor because most calls are of a minor issue that could have waited until the morning or at the end of a busy day. Thus, doctors get conditioned to not be in a hurry to answer multiple pages that all seem very minor.
With a full-time, in-house physician, the doctor will often be awakened several nights in a row until the staff and the doctor have communicated well enough for the staff to feel comfortable with what can wait until the morning, being assured, by example, that the doctor will truly show up the next morning.
A Sure and Steady Process
I was concerned about one of my first physicians because he was placed in a busy nursing home. After several weeks of being on-call 24/7 at the facility, I called to see how he was doing. He stated that the first week was a little rough, but he would come in the following morning and thank the nurses for the calls during the preceding night, and then they would discuss which ones needed to be called immediately and which ones could have waited until the following morning. Over time, the nurses got used to this, and seeing him arrive every day gave them confidence that their concerns were going to be addressed in a timely manner without them having to call early just to get on the doctor’s call-back list.
After several weeks, he reported that his life had never been better. Before, he rarely slept through the night. Now he was sleeping most nights and only waking up for actual and occasional emergencies. Meanwhile, the nursing workflow improved, and overtime in the facility decreased. Nurses weren’t getting multiple calls at the end of their shift from all the doctors that they had left messages for, requiring hours of extra charting and orders to be entered all at once. Furthermore, having the doctor available during the day allowed for orders and treatments to be given in a timely manner during the nurses’ regular schedule.
Thirty years ago, the complexity of a patient in the nursing home was such that a doctor did not need to show up regularly at the home. The mindset of many physicians is still in this mode of thinking. Although the nursing home of today realizes the complexity of the patients they serve, they continue to try and meet those needs without having a full-time doctor on staff, either because they don’t know how to procure a full-time doctor or because they are concerned about the complexity of adding a doctor to the staff on a full-time basis.
Coming to terms with the necessity of this change is necessary to provide the level of quality that the consumer and Medicare now demand.