By Dr. Kenneth Scott, DO, CMD, CEO
SilverSage Management Services.
When it comes to diagnosing the placement of full-time physicians in nursing homes, there are two primary pain points: The first is getting nursing home administrations to understand the inherent value of having a full-time doctor on duty. The second is getting them to understand they absolutely need it.
At first glance, those two observations sound extremely similar in nature. In this article, I intend to tackle the first part of that equation by showing how nursing homes have evolved in purpose and practice over the years, essentially changing from long-term care facilities to med-surg wards, and how having a full-time physician on staff provides an elevated level of value for both the patient and the facility.
We will look at how the first model of nursing homes evolved from being more of an independent or assisted living facility into becoming freestanding med-surg wards. The rehospitalization rates of nursing home patients also show the advantages of having a physician on staff that is more intimately familiar with each patient’s condition.
Nursing Homes of the Past
In the past, nursing homes took care of patients in a custodial way, and they really didn’t need a doctor to accomplish this level of care. In those earlier years, the type of patient that went to live in a nursing home was similar to the patient that today goes to an independent or assisted living facility. These were people that needed a certain level of help to handle their day-to-day lives, but not necessarily very much.
What that longstanding manner of nursing home needed most was, like the name implies, nurses. Even today, the most important factor in taking care of patients in a nursing home is the number of nurses on staff and the competency of those nurses. However, there is widespread variation state-by-state when it comes to minimum staffing requirements. While some states require a minimum number of staff hours per resident per day, other states mandate nursing homes provide direct care staff 24/7, without a set number of hours per resident. Eleven states introduced changes to minimum staffing requirements since the onset of COVID-19.
When Medicare set up a payment system to help cover the costs of caring for these individuals, the reimbursement was based, essentially, on a modified room-and-board scenario. That payment system, although modified, remains largely in effect today. Thus, just as renters pay rent once a month, so do patients (or their families or insurance) to keep their loved ones in a nursing home.
Evolution to Med-Surg Wards
Over time, nursing homes came to resemble freestanding med-surg wards instead of a place where patients could mostly take care of themselves. The new wave of nursing homes weren’t just freestanding because they weren’t connected physically to a hospital, though that is one consideration. Additionally, they had no emergency room, no operating room, no telemetry units, and no in-house pharmacy, lab, or X-ray capabilities.
When a patient was deemed ready for discharge from a hospital but too sick to go home, the plan was to send them to a nursing home where they could continue their recovery. The hope was that these patients would eventually make it back home. At that point, those who failed to progress would be transferred to the long-term care side of the facility for continued nursing care for the rest of their lives.
Unfortunately, many patients did not fare well in this environment and eventually needed to be readmitted to the hospital. Upon readmission, however, these patients were usually sicker than when they previously left the hospital, often with a worsening of the diagnosis they were last admitted with. This was because they had never regained their strength or fully recovered from the first hospitalization. In fact, upon readmission, these patients would often be placed in the ICU due to how sick they were. This resulted in an even greater cost to the patient’s health and finances, with an even poorer prognosis than the first time they were admitted. Eventually, doctors got used to the idea that they would discharge a patient to the nursing home and then wait to see which ones came back to their service at the hospital.
As the level of expertise needed to care for these patients grew, nursing homes attempted to rise to the occasion by hiring RNs rather than just LPNs or CNAs. The push for nursing homes to accept more-complicated patients was driven in part by the advancement in medicine resulting in patients living longer, but with many complicated medical issues.
At the same time, Medicare realized that many patients, due to the complexity of their health care issues, were spending countless days in the hospital at a very high cost to Medicare. Thus, if these patients could be managed at a facility with lower cost, where nurses attended to them around the clock, it would be better for the patient, the health care system, and the economy to make that happen.
Rehospitalization of Patients
In 2004, the New England Journal of Medicine published an article explaining that almost 20 percent of Medicare patients that had recently been hospitalized were rehospitalized within 30 days, and nearly 35 percent of Medicare patients were rehospitalized within 90 days. These rehospitalizations came at a staggering cost to Medicare of over $17 billion per year.
This was seen as a quality of care concern and formed the cornerstone of new rules initially penalizing hospitals for excessive rehospitalization rates and eventually penalizing nursing homes as well. Meanwhile, another study found that nearly 50 percent of nursing home residents experience one or more hospitalizations in their last year of life.
In 2010, the Archives of Internal Medicine published an article reporting on the Dutch solution to quality of care in the nursing home setting. Since 1990, the Netherlands has developed specialty training for physicians in the long-term care setting. The article illustrated that while almost 30 percent of US nursing home patients were rehospitalized, the Dutch experienced less than a 1 percent rate of rehospitalization.
One of the primary differences for these outcomes seemed to be that Dutch physicians based decisions on an intimate knowledge of the patient, whereas American physicians reported limited knowledge of their nursing home patient as a result of lack of contact time. Over the past 20 years, the Netherlands has developed distinct working methods based on the Chronic Care Model, where Dutch nursing homes employ a full-time physician—who has treatment responsibility for all aspects of medical care for 100 residents.
In my experience with nursing programs, early incorporation of similar models in the US realized a general reduction in rehospitalization rates—dropping from 25–35 percent all the way down to 10 percent—by placing full-time doctors in nursing homes. This was without any type of formal education on the role or responsibilities of the physician. As time has progressed and training has developed within the SilverSage model—including the emphasis on our physicians becoming certified medical directors through AMDA, The Society of Post – Acute and Long – Term Care Medicine— we have seen our own rehospitalization rates drop consistently to the 3–6 percent range per month. Other programs have seen a reduction, but not nearly as substantial.
I believe these results clearly show the value of having a full-time physician on staff in nursing homes. It’s about what the doctor can do at the bedside—through evaluation and diagnosis—that can make a huge difference in the treatment, and lives, of nursing home patients.
– Dr. Kenneth Scott has dedicated much of his 30-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.