Knowledge and Participation in the Care Planning Process by Physicians in the Nursing Home Setting: The Case of Falls

Comprehensive Interdiscipilinary Geriatric Assessment has been shown to be associated with mixed outcomes in various clnical settings.¹ However, studies evaluating Comprehensive Interdisciplinary Geriatric Assessment in the long-term care (LTC) setting are nonexistent. A very similar process in the nursing home (NH) setting involves the Interdisciplinary Care Plan process, which must be performed on admission, quarterly, and with acute change of condition of the patient. Federal regulations indicate that a facility must develop a comprehensive care plan for each resident. It must include measurable objectives and timetables to meet needs determined by the comprehensive assessment to achieve the resident’s highest practicable well-being.²

Traditionally, membership of the NH interdisciplinary team includes nursing, dietary/nutrition, social service/case manager, rehabilitation (physical, occupational, and speech therapy), wound care, and the care plan/MDS coordinator. The process of care plan development and specific issues addressed are based on the Minimum Data Set (MDS), a huge data set of demographic, physical, cognitive, functional, and nutritional parameters, as well as geriatric syndromes (falls, urinary incontinence, dementia, delirium) and the use of chemical and physical restraints.

The rationale or assumption for the use of care planning for the frail, advanced-age NH population includes the following: that this population is characteristically plagued with multiple chronic and comorbid illnesses and geriatric syndromes; that the provision of care is time-consuming when done in isolation; that these residents require the expertise of each member of the team—medical, nursing, social service, rehabilitation, dietary/nutrition, activities, and wound care; and that the best approach to care is an interdisciplinary one that will result in the highest quality of care possible.^1,3

Medical directors and primary care physicians traditionally have not attended regular meetings of the interdisciplinary care team, in part due to the busy nature of physicians’ schedules, the time element involved, and the lack of reimbursement for this activity. They may also perceive the issue of care planning as mostly a nursing issue. Other possible reasons may be lack of expertise and training regarding geriatric syndromes and comprehensive geriatric assessment.⁴ Though a federal regulation indicates that nursing homes must have a designated medical director, there is no associated state regulation regarding reimbursement.

However, the role of the medical director in the NH setting has received increased attention in the last several years with the revision of the Medical Director F-Tag that expands the role. CFR §483.75(i).2 F-Tag 501 indicates that the medical director is responsible for implementation of resident care policies and the coordination of medical care in the facility. It also indicates that the medical director should collaborate with facility staff to develop, approve, implement, and evaluate resident care policies and assist the facility to identify, evaluate, and address medical and clinical concerns.⁵

Falls are a major reason for admission to the NH and a major reason for medical malpractice ligitation against facilities and physicians.^6,7 Causes include intrinsic (medical or medication-related) and extrinsic (environmental) causes.⁸ Falls in the NH setting may be associated with significant morbidity and mortality, due mostly to compression fractures of the spine and hip fracture.⁹ Between 20-50% of survivers of hip fracture cannot live independently, and approximately 20% of patients die within one year.¹⁰ The high fracture rate after a fall is the result of the high prevalence (60-80%) of osteoporosis in this setting.¹¹

On admission, quarterly, and with acute change of condition, residents should be evaluated for fall risk (high, medium, or low).¹² Those at high risk should be care planned for falls with the goal of preventing falls or injury from falls with appropriate interventions. Recommended falls care planning interventions implemented in the NH setting may include: use of a low bed, mat on the floor, and bed and chair alarms; reduction of polypharmacy; calcium, vitamin D, and osteoporosis medication administration; and physical and occupational therapy interventions or exercise.^13-16

A brief written survey of a captive audience of medical directors/attending physicians who worked in NHs and were members of that state chapter of the American Medical Directors Association in 2007 was performed to determine their knowledge regarding the interdisciplinary care planning process, and specifically as it relates to fall risk and osteoporosis, and to determine their general attendance at interdisciplinary care plan meetings. The request to complete the survey actually followed a presentation on fall risk.

Of 50 physicians who attended, 30 (60%) completed the survey. Of the 30 responders, 24 served as both medical director and primary care physician in the NH setting. Four served only as medical director, and two served only as primary care physician. None of the 30 responders indicated they attended weekly interdisciplinary care plan meetings, 15 indicated they attended monthly, and 14 indicated they did not attend them at all. Thirteen indicated they employed nurse practitioners (NPs) in the NH, and 17 indicated they did not. When surveyed about their knowledge of appropriate care plan interventions for falls, instructions per survey asked them to list appropriate interventions for an adequate interdisciplinary fall risk care plan. Responses were categorized into the following:

(1) history and physicial examination/visual/hearing evaluation
(2) low bed
(3) mat on the floor
(4) bed and/or chair alarm
(5) toileting program for the resident
(6) medication reduction/review
(7) rehabilitation intervention (physical and/or occupational therapy, restorative nursing, regular exercise)
(8) environmental evaluation
(9) calcium and vitamin D supplementation; osteoporosis pharmacotherapy
(10) orthostatics evaluation; restraint evaluation

An average of 3.8 interventions were recommended per physician. The most commonly recommended intervention was for medication reduction/review (13 responses), followed by rehabilitation interventions (12 responses). The least types of recommendation listed by physicians were for calcium and vitamin D (1 response), followed by osteoporosis pharamacotherapy and restraint evaluation, (2 responses each), and bed and/or chair alarm, mat on the floor, and orthotics evaluation, (3 responses each). There was no correlation between employment of a NP and either attendance at the care plan meeting or interventions recommended. Lastly, 33% of physicians indicated they address osteoporosis “sometimes,” 4 indicated they address it “never” or “seldom,” 9 indicated they address it “often” or “frequently,” and 6 (20%) indicated they address it “always.”

The results of this study indicate that physicians view osteoporosis evaluation and treatment separately from the issue of falls prevention and prevention of injury, since the most common answer to how often they address osteoporosis was in the “often” category— yet osteoporosis evaluation and treatment, and even calcium and vitamin D therapy, were the least mentioned interventions. This is understandable considering the silent nature of the disease and the frequency of residents with contraindications to therapy (immobility, gastrointestinal disease, lack of practical screening tools). In addition, screening for osteoporosis in the NH setting is time-consuming and expensive (transportation, DEXA testing).

The results are skewed due to the very small numbers and may only represent a localized region of the country. However, since the physicians who filled out the survey were also attending a continuing education conference regarding NH issues, the results are disturbing in that major and appropriate interventions were listed only in a minority of cases (use of a mat on the floor, bed and/or chair alarms, and a toileting program). As only over one-half of the physicians surveyed stated that they attend interdisciplinary care plan conferences monthly, and none indicated that they attend weekly, this is also disturbing considering the expanded role the medical director should be playing in monitoring quality of care within the respective facility. In all fairness to these physicians, this may be explained by time limitations and expertise and training of primary care physicians who work in the NH setting, since there is a critical shortage of geriatricians or certified medical directors in the United States. In addition, limited reimbursement for primary care visits and medical direction may also explain the lack of attendance at care plan meetings.

There appears to be a need to educate medical directors regarding their expanded role in the nursing home, as per the F-Tag for Medical Direction. In addition, primary care physicians should receive additional continuing education regarding intrinsic and extrinsic causes of falls, the relationship between fall risk and injury and subsequent morbidity and mortality, appropriate fall risk intervention strategies for the high-fall-risk NH resident, and the value of interdisciplinary team evaluation of geriatric syndromes, particularly falls. This is particularly relevant considering the increased liability associated with inadequate fall care plan development and implementation, falls, and subsequent morbidity and mortality.

Considering the emphasis placed on Geriatrics and interdisciplinary team training by the recently released Institute of Medicine report and the evolving Medical Home concept, national LTC organizations should stress and emphasize the importance and value of interdisciplinary team managemnet of frail older patients in the LTC setting. This can best be accomplished by suggesting that the medical director/practitioner regularly attend interdisciplinary care plan meetings to address team management of geriatric syndromes such as falls, urinary incontinence, and dementia, as well as proper nutrition, hydration, and function, and prevention of chemical and physical restraints.

However, it is also important that the Centers for Medicare & Medicaid Services and Congress mandate funding for attendance of the medical director/practitioner at care plan conferences and other administration functions in the NH setting. Reality dictates that with the multifaceted aspects of primary care and constraints on time and reimbursement, practitioner reimbursement of these functions is crucial.

Dr. Cefalu is Medical Director and a primary care physician, Louisiana State University Affiliated Nursing Homes, New Orleans.