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What Nursing Home Administrators Expect From Their Medical Director
Ask a nursing home (NH) administrator or facility owner what they want—or expect—from their medical directors, and you will hear a range of responses. At one end of the spectrum are those that say not much is expected. That is, their medical directors are mostly there to fulfill the 1974 regulatory requirement, §483.75, which says a facility must designate a physician to serve as medical director.1 This medical director is responsible for coordinating medical care in the facility and providing clinical guidance and oversight regarding the implementation of resident care policies through leading staff, consultants, and other practitioners.
At the other end of the spectrum are those facilities that expect their medical directors to be very actively involved in many aspects of the home. This view is consistent with recommendations included in the 2001 Institute of Medicine (IOM; now the National Academy of Medicine) report Improving the Quality of Long-Term Care.2 In this report, the IOM urges facilities to give medical directors greater authority and hold them more accountable for medical services. The report further states that NHs should develop structures and processes that enable and require a more focused and dedicated medical staff responsible for patient care. These organizational structures should include credentialing, peer review, and accountability to the medical director.2
As value-based care delivery and reimbursement become the standard in US health care, NH administrators will be holding medical directors more accountable for metrics. Facilities will require a knowledgeable and fully engaged medical director adept in the areas outlined below.
Key Functions of an LTC Medical Director
To assist facilities and medical directors in adjusting to such an expanded role, AMDA-the Society for Post-Acute and Long-Term Care Medicine developed the Certified Medical Director (CMD) in long-term care credential to reinforce the leadership role of the medical director in promoting quality care and offers an indicator of professional competence to long-term care providers, government, quality assurance agencies, consumers, and the general public.3 AMDA has identified several key functions of a long-term care medical director (Box 1).
While this is an extensive and detailed list, a more focused role for medical directors is what most NHs are asking from their medical directors. This includes focus in 4 areas: admissions, malpractice prevention, cost controls, and regulatory compliance.
Admissions
Historically, medical directors were selected by administrators purely on the basis of the delivery of admissions. These referrals came directly from the medical director through their large practice and hospital practice as they were personally able to refer patients. Today, this custom is increasingly rare due to a host of market changes including the introduction of the hospitalist, elimination of private primary care practices, and development of hospital-preferred skilled nursing facility (SNF) networks. As a result, referrals are based on an NH’s ability to be part of the preferred network from today’s channel for patients—hospitals, accountable care organizations, and payers. The basis for inclusion into these networks comes from consistently delivering value illustrated by the Centers for Medicare & Medicaid Services’ (CMS’) Star Rating, hospitalization rates, and length of stay. Securing this position was previously discussed at length in this journal in a 2017 article that highlighted what it takes to be in a preferred network.4 These efforts also include not only being part of preferred networks but getting patients in through unique pathways such as direct admissions.5
Malpractice Prevention
Medical directors are also on the frontline when it comes to saving an NH from malpractice suits. This comes from ensuring the delivery of quality medical care and improving communication. The provision of physician services for the facility, which can come through the medical director, guarantee the following:
- Availability of physician services 24 hours a day in case of emergency;
- Review of the resident’s overall condition and program of care at each visit, including medications and treatments;
- Documentation of progress notes with signatures;
- Frequency of visits, as required;
- Signing and dating all orders, such as medications, admission orders, and readmission orders; and
- Review of and response to consultant recommendations.
Duties also include securing systems to ensure that other licensed practitioners (eg, nurse practitioners), who may perform physician-delegated tasks, act within the regulatory requirements and within the scope of practice as defined by state law. Procedures and general clinical guidance for facility staff regarding when to contact a practitioner are also necessary, including information that should be gathered prior to contacting the practitioner regarding a clinical issue/question or change in condition.
In terms of quality of care, there needs to be oversight of attending services not only during the day, which is increasingly being provided by nurse practitioners dedicated to the SNF, but also after hours. After hours oversight can be provided through the use of virtual after-hour services, which had demonstrated success on several levels.6
Administrators also expect directors to facilitate strong communication between the clinical team and patients and their families, as many malpractice cases are the result of failures here. Communication is needed regarding management of expectations, especially during the end-of-life phase where hospice and palliative care services can be introduced.7 These efforts lead by the medical director can greatly contribute to the avoidance of malpractice claims against a facility and by doing so save the facility not only through direct savings of payouts but also reputation, which impacts admissions.
Cost Control
For their subacute stay/Medicare Part A, NHs receive a fixed sum from Medicare or commercial payers, which includes the cost of almost all the medications needed during this stay. As such, reducing the costs of these medications directly contributes to the profitability for the nursing home (NH). Management of these costs occurs even before admission through a pre-admission assessment that is often completed by the pharmacy provider, who completes a financial assessment of the medication profile. In a case where expensive medications are needed, the medical director can assist in working with discharging hospitals to optimize the discharge medications to the greatest extent possible.
Once admitted, the medical director can ensure that expensive medications are only ordered in the face of no alternatives. Further, the medical director can make sure that medications that should be paid outside of the facility’s payment, such as vaccinations and end stage renal disease medications, are billed directly. In the case of vaccinations, this means that vaccines are billed through either Medicare Part B or D directly and that medications such as erythropoietin-stimulating agents and antibiotics are covered by the dialysis provider. These efforts can save NHs much needed funds—funds needed to better serve residents.
Regulatory Compliance
State surveys can impact not only the CMS Star Rating but also, for facilities having issues, can mean significant sanctions in the form of financial penalties or even closure of the facility to Medicare admissions. As a result, the medical director’s involvement in the survey process can be extremely valuable.
Beyond their involvement in the survey process is their involvement in specific F-Tags. The medical director requirement as outlined by CMS does not imply that the medical director must carry out the policies and procedures or supervise staff performance directly, but rather must guide, approve, and help oversee the implementation of the policies and procedures (Box 2). Through these efforts the medical director can keep the facility safe through the survey process.
Conclusion
As the US health care system moves toward value-based reimbursement, NH administrators need to hold medical directors accountable to metrics. In fact, facilities will be sitting down with their medical director outlining specific requirements and then later with a score card of how they performed. Success for NHs will require a knowledgeable and fully engaged medical director.
References
1. Centers for Medicare & Medicaid Services (CMS). CMS Manual System, Pub. 100-07 State Operations Provider Certification, Medical Director Guidance. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R15SOMA.pdf. Published November 28, 2005. Accessed February 19, 2019.
2. Institute of Medicine. Improving the Quality of Long-Term Care. Washington, DC: The National Academies Press; 2001. https://doi.org/10.17226/9611.
3. MDA—The Society for Post-Acute and Long-Term Care Medicine. The nursing home medical director: leader & manager. https://paltc.org/amda-white-papers-and-resolution-position-statements/nursing-home-medical-director-leader-manager. Published March 2011. Accessed February 19, 2019.
4. Stefanacci RG. How to be included in a health system’s preferred SNF network. Ann Longterm Care. 2017;25(5):24-26. doi:10.25270/altc.2017.10.00007
5. Stefanacci RG. Direct admissions to skilled nursing facilities—are you ready? Ann Longterm Care. 2018;26(7):10-11. doi:10.25270/altc.2018.12.00049
6. Chess D, Whitman JJ, Croll D, Stefanacci R. Impacat of after-hours telemedicine on hospitalizations in a skilled nursing facility. Am J Manag Care. 2018;24(8):385-388.
7. Lester PE, Stefanacci RG, Feuerman M. Prevalence and description of palliative care in US nursing homes: a descriptive study. Am J Hosp Palliat Med. 2016;33(2):171-177. doi:10.1177/1049909114558585
