The Long-Term Care Team of the Future

The long-term care (LTC) team of today is significantly different than it was a few years ago, when all of those working in a facility existed in silos instead of working as a team. Today’s LTC team is far more extensive and integrated than ever before, now that skilled-nursing facilities (SNFs) are accountable for increased levels of frailty and outcomes.

As the average lifespan continues to rise due to medical and technological advancements, more older adults are living longer with complex health needs that produce significant disability and demand specialized care.² Residents of SNFs typically have multiple chronic conditions and take an average of 8 to 10 medications per day; these patients require health care providers who possess the expertise and skills to appropriately care for them and work in a team to produce better health-related outcomes.¹

State and federal regulations for SNFs focus on hospitalization prevention and support the role of an interdisciplinary team that helps each resident achieve the highest attainable quality of life.¹ For older people who are admitted to a hospital following an acute change in condition, a transition of care occurs when they are discharged from the hospital to a SNF. Such transitions require careful teamwork to avoid adverse events.¹ Given the hospital readmission penalties now in place, improving the care of residents to prevent hospital readmission events is an outcome for which SNFs are being held accountable.^3,4

The Interdisciplinary Team

SNFs employ an interdisciplinary team of health care professionals (Table 1) who assess, coordinate, and manage each resident’s comprehensive health care, including his or her medical, psychological, social, and functional needs.¹ This practice is mandated in SNFs, and the roles and descriptions of diverse specialists are detailed below.^1,5

Administrative

Nursing Home Administrator. As the managing officer of the facility, it is the administrator’s responsibility to plan, organize, direct, and control the day-to-day functions of a facility and to maintain the facility’s compliance with applicable laws, rules, and regulations. The administrator should be vested with adequate authority to comply with the laws, rules, and regulations relating to the management of the facility. Typically, a certificate program of ~120 hours is required before sitting for a licensing examination. Most are required to have completed a bachelor’s degree program as well as preceptor training as a nursing home administrator.

Medical Director. Roles and responsibilities of the medical director in the nursing home can be divided into four areas: physician leadership, patient care and clinical leadership, quality of care, and education. Nursing facilities are required to have a medical director, as outlined in the Federal Nursing Home Reform Act. Currently, Maryland is the only state that requires medical directors to be a Certified Medical Director  (CMD) in Long Term Care or have similar training. CMD was established by the American Medical Directors Association to professionalize the field of medical directorship.

Primary Care Providers

Attending Primary Care Physician. This position is responsible for initial patient care and support discharges and transfers. Attending primary care physicians also make periodic, pertinent on-site visits to patients and ensure adequate ongoing coverage. In addition to 4 years of medical school, most nursing home attending physicians complete a primary residency, which is typically 1–3 years. Some go on to complete a geriatric fellowship as well.

Physician Assistant. Physician assistants (PAs) communicate closely with the primary care physician, patients, and their families to coordinate treatment and guide patient management. PAs have become increasingly incorporated into the LTC team, performing follow-up, acute, and regular care visits. Their generalist training and emphasis on patient relationships make them qualified for essential patient care responsibilities and help them to bolster patient and family morale. Following undergraduate coursework in science, PAs complete a 2-3 year master’s degree in an accredited PA program. PAs need to pass the Physician Assistant National Certifying Exam (PANCE) and obtain a state license before they can practice. PAs can also specialize in specific fields by obtaining additional board certification.

Nurse Practitioner. Nurse practitioners (NPs) are advanced practice nurses who provide high-quality health care services similar to those of a doctor. NPs diagnose and treat a wide range of health problems. They have a unique approach and stress both care and cure. Besides clinical care, NPs focus on health promotion, disease prevention, health education, and counseling. The entry-level training for NPs is a graduate degree, requiring completion of either a master’s or doctoral degree program. This means that NPs earn a bachelor’s degree in nursing (4 years of education), then their graduate NP degree (2-4 years of education).

Specialty Consultants

Consultant Pharmacist. The consultant pharmacist focuses on reviewing and managing the medication regimens of patients, particularly those in institutional settings such as nursing homes. Consultant pharmacists ensure their patients’ medications are appropriate, effective, as safe as possible, and used correctly. They also identify, resolve, and prevent medication-related problems that may interfere with the goals of therapy. The doctorate of pharmacy (PharmD) is the only professional pharmacy degree, and the five-year bachelor’s of science in pharmacy is being phased out as a professional degree. Because the PharmD program traditionally follows 2 years of pre-pharmacy education, students typically require 6 years of post-secondary education to obtain their PharmD.

Podiatrist. Podiatrists diagnose and treat disorders of the foot, ankle, and related structures of the leg. Podiatrists perform patient evaluations and design treatment plans. Proper care of foot and ankle problems can significantly improve the quality of life for patients who already face reduced mobility due to age and other health conditions. Doctors of podiatric medicine (DPMs) complete 4 years of training in a podiatric medical school and 3 years of hospital residency. Podiatrists can specialize in areas such as surgery, sports medicine, wound care, or diabetic care.

Psychologist. A growing number of clinical or counseling psychologists, geropsychologists, rehabilitation psychologists, and neuropsychologists address the behavioral needs of patients in LTC. Psychologists from different specialties support the care of patients struggling with depression, anxiety, dementia, and other mental health conditions. Typically, a bachelor’s degree in psychology or clinical psychology is required, followed by a master’s and/or doctoral degree in clinical psychology.

Wound Care Specialist. Different health care providers are trained in the care and treatment of various types of acute and chronic wounds. The most commonly treated wounds are those sustained from an injury, surgical wounds, diabetic wounds, and sores, as well as wounds that will not heal. Nurses provide an initial assessment and plan of care, often cleaning, treating, and dressing wounds in addition to educating patients and families about continuing wound care at home. Physicians are instrumental in coordinating communication and therapy among wound care specialists. Physical therapists specialize in wound treatment modalities such as ultrasound and compression therapy, among others. A wound care specialist must accrue at least 3 years of experience in wound care and pass a written exam to prove their specialized knowledge and competence. Wound care specialization status requires continuing education credits and periodic re-certification testing.

Dietitian. This role is responsible for planning food and nutrition programs, supervising meal preparation, and overseeing the serving of meals. They prevent and treat illnesses by promoting healthy eating habits and recommending dietary modifications. They perform nutrition screenings for their clients and offer advice on diet-related concerns such as weight loss and cholesterol reduction. Although licensure, certification, and registration requirements vary by state, dietitians must have at least a bachelor’s degree.

Nursing

Certified Nurse’s Aid. Certified nurse’s aids (CNAs) work under the supervision of a nurse and provide assistance to patients with daily living tasks. In addition to a high school diploma or GED, CNAs must complete a 6- to 12-week CNA certificate program at a community college or medical facility.

Registered Nurse. Registered nurses (RNs) work directly with patients and their families. They are the primary point of contact between the patient and the health care team, both at the bedside and in outpatient settings. RNs perform frequent patient evaluations, including monitoring and tracking vital signs, performing procedures such as IV placement, phlebotomy, and administering medications. Because the RN has much more regular contact with patients than physicians, the RN is usually first to notice problems or raise concerns about patient progress.

The three major educational paths to registered nursing are a bachelor’s degree, an associate degree, and a diploma from an approved nursing program. Nurses most commonly enter the occupation by completing an associate degree or bachelor’s degree program. Individuals then must complete a national licensing examination in order to obtain a nursing license.

Licensed Practical Nurse. Licensed practical nurses (LPNs) provide patient care on a very personal level. They usually report directly to physicians and RNs and are responsible for taking vitals and monitoring in-and-out volumes, treating common conditions like bedsores, and preparing or performing several procedures such as dressing wounds, bathing and dressing, and giving enemas. In some states, but not all, LPNs and licensed vocational nurses may administer prescribed medicines or start intravenous fluids. LPNs are required to pass a licensing examination, known as the National Council Licensure Examination for Practical Nurses (NCLEX-PN), after completing a state-approved practical nursing program. A high school diploma or its equivalent usually is required for entry.

Director of Nursing. The Director of Nursing (DON) has the responsibility of overseeing the standards of nursing practices for the organization’s nursing services. The DON participates with other members of Nursing Services and Administration in the development of patient care programs, policies and procedures to meet all requirements including ethical and legal concerns.

Registered Nurse Assessment Coordinator. The registered nurse assessment coordinator (RNAC) assists the DON with ensuring that documentation in the center meets Federal and State Certification guidelines. The RNAC coordinates the process of administering the Resident Assessment Instrument, ensuring the accuracy, timeliness, and completeness of the Minimum Data Set, the Resident Assessment Protocols, and the Interdisciplinary Care Plan. The RNAC conducts the nursing process—Assessment, Planning, Implementation, and Evaluation—under the state’s Nursing Practice Act for registered nurse licensure.

Other Roles

Infection Prevention and Control Officer (IPCO). This role is responsible for incorporating practices that achieve three core goals identified by the Centers for Disease Control and Prevention: preventing infections and the spread of those infections, tracking and monitoring infections, and improving antibiotic prescribing and stewardship. The IPCO oversees proper vaccination procedures and antibiotic use protocols. Each facility is required to review and update its Infection Prevention and Control Program, analyze the performance of their LTC resident population and facility, establish proper procedures, and properly train all staff. In addition to a post-secondary degree, a health care professional must have at least 2 years’ experience in infection prevention and control before passing an exam given by the Certification Board of Infection Control and Epidemiology (CBIC). Recertification is required every 5 years.

Physical Therapist. Physical therapists provide a variety of medical services to help individuals who have been injured or physically affected by illness to recover or improve function. A physical therapist must be able to evaluate a patient’s condition and devise a customized physical rehabilitation and treatment plan to enhance strength, flexibility, range of motion, motor control, and reduce any pain, discomfort and swelling the patient is experiencing. Physican therapists must complete a physical therapist educational program with a master’s or doctoral degree.

Occupational Therapist. Occupational therapists help patients improve their ability to perform tasks in living and working environments. They work with individuals who suffer from a mentally, physically, developmentally, or emotionally disabling condition. Occupational therapists use treatments to develop, recover, or maintain the daily living and work skills of their patients. The therapist helps clients not only to improve their basic motor functions and reasoning abilities, but also to compensate for permanent loss of function. The goal is to help clients have independent, productive, and satisfying lives. A master’s degree or higher in occupational therapy is the minimum requirement for entry into the field.

Recreational Therapist. Recreational therapists devise programs in art, music, dance, sports, games, and crafts for individuals with disabilities or illnesses. These activities help to prevent or to alleviate physical, mental, and social problems. A bachelor’s degree with some additional training is usually required for this field.

Social Worker. Social workers assist people by helping them cope with issues in their everyday lives, deal with their relationships, and solve personal and family problems. All states and the District of Columbia have licensing, certification, or registration requirements regarding social work practice and the use of professional titles. Although standards for licensing vary by state, a growing number of states are placing greater emphasis on communications skills, professional ethics, and sensitivity to cultural diversity issues. Most states require 2 years (3,000 hours) of supervised clinical experience for licensure of clinical social workers.

Teamwork

SNFs are highly regulated, interdisciplinary environments with increasing patient acuity and, consequently, a growing need for health care provider specialization.⁴ People are living longer with conditions that were previously fatal but still cause substantial health problems, such as diabetes or chronic obstructive pulmonary disease, resulting in increasing long-term health care resource utilization by older Americans.² Hospital stays are becoming shorter as more patients transition to SNFs for post-acute care and recovery from surgery or illnesses; this change gives SNFs a more critical role in the continuum of patient care.² The unique roles and responsibilities provided by members of the SNF teams will help prevent hospital readmissions and enhance the overall quality of care, but this can only occur if each member functions as a part of a cohesive, coordinated team. 

NOTE: This article is meant to open a dialogue on what a comprehensive LTC team should include. As such, this is not an all encompassing list but rather we would appreciate your thoughts on additional roles and responsibilities that you consider critical to your facility’s LTC team. 

References

1.    Stefanacci R, Brown G, Reich S. Behind the Scenes at Nursing Facilities. In: Post-Acute and Long-Term Medicine. 2nd ed. Fenstemacher PA, Winn P, eds. Springer International Publishing; 2016:51-72. 

2.    Lax JR, Gossett D. Physicians and Long Term Care: Current and New Models of Integration, the Regulatory Framework, and Reimbursement Part I. https://www.healthlawyers.org/Events/Programs/Materials/Documents/LTC12/papers/H_lax.pdf. January 30, 2012. Accessed February 7, 2016. 

3.    Centers for Medicare & Medicaid Services. Readmissions Reduction Program (HRRP). CMS.gov. https://www.bls.gov/oes/current/oes291141.htm. Published February 4, 2016. Accessed February 22, 2016.

4.    Zigmond J. ‘SNFists’ at work: nursing home docs patterned after hospitalists. Modern Healthcare. 2012;42(13):32-33.

5.    Bureau of Labor Statistics. May 2014 National Industry-Specific Occupational Employment and Wage Estimates: NAICS 623100 – Nursing Care Facilities (Skilled Nursing Facilities). Bureau of Labor Statistics website. https://www.bls.gov/oes/current/oes291141.htm. Published March 25, 2015. Accessed February 22, 2016.