Commentary on “Medical Direction and the Future of Assisted Living”

In his article “Medical Direction and The Future of Assisted Living,”¹ the author is to be commended for taking a stand on a critical and controversial topic, medical direction, and specifically medical involvement and direction in assisted living facilities (ALFs). Certainly, we wholeheartedly agree with his comments and concerns about our dwindling number of geriatricians, nurses, and nurse practitioners dedicated to the care of older adults. One might even add, particularly with regard to geriatricians, that there are even fewer that are willing and interested in working in long-term care facilities. On a positive note, at least 50% of geriatric nurse practitioners (GNPs) have a nursing facility practice. One recommendation that we would add to his comments/proposed solutions would be to increase our dissemination of geriatric-focused knowledge to all students within the disciplines of medicine, nursing, social work, pharmacy, law, and rehabilitation, so that all who are exposed to older adults have the skills to provide the care that these individuals deserve. As we educate, we should celebrate our differences, teach smart, and work smart. Physicians are increasingly expected to be “jacks of all trades,” to be expert diagnosticians and interventionists, as well as nurses, social workers, pharmacists, and to oversee and prescribe physical and occupational therapy. This seems unfair and unrealistic.

The author indicates that ALFs will likely move toward requiring the presence of a medical director, given the increasing medical needs of residents living in those facilities. While this point could be debated, as clinicians working in these sites we also recognize this need, appreciating the medicalization that is occurring. Assuming medical direction is required, or desired, the author proposes a joint approach with the GNP/physician working together in this endeavor. We concur that this co-direction would be ideal, although our rationale for the plan goes beyond the need to simply increase the numbers of available individuals to serve as medical directors. Further, we have some difficulty with the leader/helper concept in the Don Quixote metaphor (ie, the nurse as helper to the physician director). Rather, co-direction would/could ideally bring together the best of both disciplines.

One of the major concerns in long-term care is the emphasis on medical needs, denial of functional decline, and lack of choices in daily activities, bathing, and sleep. ALFs do not want this medicalization, although we agree with the author that, like it or not, the healthcare needs must be addressed and sometimes take priority over other concerns. We believe that there is a way to meet all needs. Together, a combined discipline approach to medical direction could help us develop another model of care in ALFs with greater attention to optimization of function and quality of life—approaches more common to nurses, therapists, and social workers. The “Medical Director” in the ALF might be better conceptualized as the combined role of the “Healthcare Team Facilitators.” The role for the physician on the team would be as a member of this team and a leader for quality in medical care, perhaps to lead or consult on initiatives to reduce polypharmacy, manage heart failure, etc. It would further allow the physician to focus his or her time on responding to medically relevant questions, hopefully focused not on bowel problems or falls that are best addressed by nursing in conjunction with other disciplines, but rather on those complex medical and ethical challenges that occur daily in these settings. Conversely, the nurse practitioner could help with policy and procedure-related activities if appropriate, and implementation of programs of care such as a restorative care philosophy, falls prevention, and safe medication monitoring and use. Overall, residents would benefit from the unique contributions of both the NP and physician.