Roles and responsibilities of attending physicians in skilled nursing facilities.

There is an ongoing public debate on the perceived lack of quality care in many nursing facilities and the best means for improvement. Suggested solutions include improving reimbursement, mandating staffing levels, implementing practice guidelines and other care processes, reducing the regulatory burden, increasing the use of managed care, and much more. Little research has been done on the relationship between physician involvement and quality of care in nursing facilities. Recent literature suggests that quality of care in various settings, including nursing facilities, is related to physician involvement and physician staffing patterns. The Committee on Improving Quality in Long-Term Care of the Institute of Medicine believes that “nursing homes should. . .enable and require a more focused and dedicated medical staff” as part of the solution for improving quality. The American Medical Directors Association (AMDA) has always maintained that physician involvement in long-term care is essential to the delivery of quality care. Beginning with the shift in hospital reimbursement some two decades ago, there has been a shift in the type of population cared for in skilled nursing facilities. With the compression of morbidity, today’s older people have less disability, enabling them to take advantage of new options in community-based and assisted living programs. Today’s nursing facility residents are those for whom no other option exists: they need high acuity postacute or end-of-life care, are increasingly frail and medically complex, and more than half suffer from dementia. But paradigms of care have not shifted significantly in tandem with these changes. The current nursing-dominated process of care, combined with staffing shortage and competency issues, simply does not suffice, as evidenced by reports of inadequate care and the mounting liability crisis. Despite increasing medical complexity and acuity over time, physician involvement in nursing facilities has been inadequate. Physicians are reluctant to get involved for various reasons related to reimbursement, regulations, negative public perception, liability, and the unfamiliar nursing home culture and practice environment. Yet today’s nursing facility population requires much more medical attention than what is generally available. Given the acuity and medical complexity of today’s nursing facility residents, improvement in quality of care and resolution of the liability crisis can be achieved if attending physicians change the way they provide care to their nursing facility residents and treat them in the same manner they treat residents in the office or hospital. For example, physicians should be prepared to be available, personally or via adequate coverage arrangements, to see residents as often as medical conditions require, as well as proactively anticipating and arranging for follow-up visits. The attending physician must also understand that nursing facility residents require an approach to care that combines chronic and acute elements. In addition to attention to apparent and to difficult-to-recognize acute or subacute problems (for example, delirium), attention must be directed to chronic problems, functional impairments and disabilities, palliative care, risks and preventive care, psychosocial and family issues, all in the context of resident choices, preferences or advanced directives and quality of life concerns. In addition, all this needs to be done within a difficult regulatory, institutional, and reimbursement environment requiring team work and specific documentation. It is the medical director’s responsibility to educate attending physicians about these issues as well as to provide them with tools and processes that help them practice quality care. Attending physicians should be educated in geriatric care principles, a process of care that includes recognition of multiple problems, cause assessment, care goals and planning, evidence-based intervention, geriatric prescribing, and care monitoring. They should be vigilant in attempting to obtain clinical information that is often minimal and provide adequate documentation rather than leaving it to others. They should have a working knowledge of available geriatric assessment tools the Resident Assessment Instrument (RAI), Minimum Data Set (MDS), and Resident Assessment Protocols (RAPs) as well as various state-specific assessment and transfer documents. Finally, they should understand and document the basis for billing level decisions as well as their supervision of midlevel practitioners. Medical practice in nursing facilities is different than in other practice locations. Because of the special population served, physicians must work as members of the care team, and must understand regulatory and other requirements that are different than those in other practice settings. A previous review listed regulatory and accreditation requirements related to the role and responsibilities of attending physicians. The majority of recommendations in this review regarding physicians’ roles and responsibilities are driven by regulatory requirements. Few are based on evidence from the Medical Director, Lutheran Augustana Center for Extended Care and Rehabilitation, Director of Geriatrics, Lutheran Medical Center, Brooklyn, New York.