218MEDICINE & HEALTH/RHODE ISLAND

Nursing Home Physicians: Roles and ResponsibilitiesAman Nanda, MD, CMD, and Tom J. Wachtel, MD,FACP�

In the United States, roughly 16,100nursing homes house 1.5 million persons.Most (62%) of the homes are for-profit fa-cilities; nearly 54% are part of regional ornational chains; 31% are not-for-profit facili-ties; 7.7% are government-affiliated.1 In thelast 20 years, as nursing homes have assumedresponsibility for more acutely ill residents, thejobs of the Administrator, Director of Nurs-ing, Medical Director, attending physicianand direct care staff have become more com-plex. In this article, we describe the roles andresponsibilities of attending physicians andmedical directors in the NH.

ROLE OF ATTENDING PHYSICIANThree concepts highlight the nature

of NH medical care: competence in careof older and disabled persons; the inter-disciplinary team approach; and govern-ment regulation.

NH physicians are expected to be fa-miliar with geriatric care principles, includ-ing experience and knowledge about geriat-rics syndromes and problems common in eld-erly residents. The ability to manage poly-pharmacy, delirium, dementia, falls, os-teoporosis, malnutrition, pressure sores, incon-tinence and multiple interacting co-morbidconditions is essential. For example, olderpatients with pneumonia or urinary tract in-fection may present with a change in mentalstatus or behavior rather with fever. The at-tending physician must assess behavioralchanges, cognition, affect, gait, sphincter func-tion, and overall physical function, as well asbe familiar with interventions to maintain orimprove functional outcomes.2-5

Virtually all residents are debilitated,with multiple co-morbid chronic conditions.Residents require the services of nurses, re-habilitation personnel, dietitians, social work-ers, personal care attendants and others, withwhom the attending physician should in-teract often - by phone, e-mail, fax or face-to-face. These ongoing interactions are nec-essary for the physician to receive informa-tion about the residents and to make better,often collaborative decisions.

The NH physician must work as amember of a team whose leader is a nurse.Attending physicians provide oversight andassume ultimate responsibility for the medi-

cal care of residents, and physicians writethe orders that the other professionals carryout. Yet because physician presence in thefacility is intermittent, nurses are the “eyesand ears” of the physician.

The nursing assessment is crucial,but nurses unfamiliar with a particularresident, as well as temporary pool nurses,may not give accurate assessments.

Physician responsiveness to nurse callspromotes better communication and providesattending physicians with the opportunity toteach and assist nursing staff in care and as-sessment. Concerns about nursing perfor-mance should be brought to the attention ofthe Director of Nursing or Medical Director.Interaction with residents’ families (andfriends) is also important for exchange of in-formation in both directions. Families needto know what to expect and the attendingphysician should ask families to participate inestablishing the goals of care and expectationsfor frequency and medical follow-up.

Transitions are times of high residentvulnerability because the resident is new tothe care team, and because the transfer ofinformation between institutions (usuallyhospital and NH) often is incomplete ordelayed. The high prevalence of dementia(>50%) among residents undermines reli-ability of medical histories. Interagency trans-fer forms filled out by the hospital staff atthe time of discharge, or by the nursing homenurse at the time of transfer, often incom-pletely or inaccurately reflect allergies, medi-cal diagnoses and medications. Ideally, nursesand physicians from both institutions shouldcommunicate directly; in practice, the mul-tiple transitions, low priority accorded to pa-perwork, multiple providers and rush tomove the patients act against such an ideal.

NHs are highly regulated. Providingmedical care to NH residents differs from boththe hospital setting and the outpatient setting.Hospitalized patients are acutely ill and seendaily. Ambulatory care patients receive epi-sodic visits for chronic disease management,health maintenance or acute conditions. Butsuch patients are generally independent, cancarry out their physicians’ recommendationson their own or with minimal assistance, andcan control the visit schedule. Nursing homeresidents are at risk of physician under-use,

resulting from regulations establishing a mini-mum frequency of physician visits. Skilled NHresidents (short term rehabilitation) are seenat least 2-3 times in the first month, and oncea month thereafter; long-stay residents are seenroutinely at least once every two months.Medically necessary visits can be performedas frequently as necessary, but billed no morethan once daily.

Many state and federal regulations areintended to promote better care. By accept-ing responsibility for the medical care of NHresidents, the attending physician implicitlyagrees to comply with those rules and regu-lations, including the regulatory visitationschedule, provision of 24/7 coverage, re-sponsiveness to report change in residentcondition and other concerns or questionsfrom nurses, care documentation and medi-cations and treatment orders and reviews.

Unfortunately, many physicians choosenot to practice in NHs. One barrier is thepublic image of NHs as a place of last resortwhere older persons go to die. Second, the“magnetism of the acute care world” attractsmedical students, residents and attendingphysicians to hospitals and specialty practices.Third, the paucity of training in geriatricmedicine during medical school and residency,and worsening shortage of geriatricians, dis-courages physicians from entering geriatrics.Fourth, the lack of specialists willing to visitNH residents often requires NH attendingphysicians to extend their scope of practicebeyond their ordinary hospital or office prac-tice. There are no regulatory limitations onconsultations, but few specialists visit NH resi-dents, who must be transported to consult-ants’ offices. Fifth is a financial disincentive:Medicare does not reimburse physicians forcoordinating services or providing interdisci-plinary care across settings. NH physiciansspend time traveling between facilities, prac-ticing telephone medicine and managingpaper flow without reimbursement. Finally,high liability risk is generated by the fact thatmost long-term care NH residents die in theNH, with the potential for “wrongful death”claims. And the problem of persistent un-der-funding of NH care can limit services.The practical difficulty to comply and docu-ment compliance with over 100,000 pagesof rules and regulations, and the resulting sub-

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stantial increase in malpractice insurance ratesfor physicians practicing in NHs create an-other major impediment.6

Medical care of NH residents is poten-tially rewarding. Optimal NH care is inter-disciplinary, preventative, curative and pal-liative, and the physician may be able to im-prove residents’ lives beyond purely clinicalinterventions by taking on administrativeroles collaboratively with or as the medicaldirector. Listed below are the responsibili-ties of the physician practicing in the NHsetting.7 These responsibilities reflect appro-priate care, as well as specific regulations. Theregulations encompass several domains, eachof which corresponds to a regulatory codeknown as a Federal tag (F-tag) number. Alsolisted below are suggested time managementguidelines for efficient NH practice.

Physician Responsibilities inthe NH (examples)1. Physically attend to each resident in a

timely manner consistent with stateand federal guidelines (visit every 30days for the first 90 days following ad-mission, and at least every 60 daysthereafter) while assuring that the ap-propriate diagnostic tests are per-formed (Tag F 387, F 500-512).

2. Respond in a timely fashion to aresident’s change in function orcondition (F 157).

3. Assess each patient comprehensively,assist in care plan development, peri-odically review it and assure that the goalsfor each care plan are rational and rel-evant (Tag 272, 279, F 250, F 309).

4. Implement treatments and servicesconsistent with good geriatric practiceto enhance or maintain physical andpsychological function and to avoid ac-cidents (TAG F 502-512, F 310, F311, F 323 and F 324).

5. Assure that residents are free fromunnecessary drugs by periodic re-view of drug regimens and consult-ant pharmacist recommendations(Tag F 329-F331, F 428 and F 429).

6. Inform residents of their health sta-tus and enable residents to exerciseself-determination including advancedirectives (Tag F 151, 152 and 154).

Time Management Advice• Establish regular days for rounding

in a particular NH• Cluster routine visits, avoid single

resident visits unless urgent• Limit practice to only a few facilities• Use protocols or established clinical prac-

tice guidelines for common problems• Employ a nurse practitioner or physi-

cian assistant who can manage routineand acute care, and serve as liaisonamong you, nursing staff and families

• Address care plan, expectations,and advance directives with residentand family soon after admission

• Establish strong relationships withNH nursing and administrative staff

• Conduct rounds with the floornurse to ensure acquisition of keyinformation and to make sure careplans are being carried out.

• Collaborate with the medical directorto train staff to limit after-hours calls tourgent medical problems, and establisha system for conveying routine informa-tion (e.g., regularly scheduled calls)

ROLE OF MEDICAL DIRECTORA medical director oversees certain as-

pects of medical care and services for anorganization or a health-care system. Hos-pitals have department chairs, chiefs of staff,division directors or vice-presidents formedical affairs. The Omnibus Reconcilia-tion Act of 1987 (OBRA ’87) requires thatall long-term care facilities designate a medi-cal director who is a licensed physician topractice in that state. Interpretive guide-lines describe the following duties:8

• Ensure that the facility provides ap-propriate medical care

• Monitor and ensure implementa-tion of resident care policies

• Provide oversight of physician services• Play a role in overseeing the overall clini-

cal care of the residents to ensure to theextent possible that care is adequate

• Evaluate potential inadequate medi-cal care and take appropriate stepsto try to correct the situation

• Consult with residents and their at-tending physicians concerning care andtreatment when needed and requested

General StatementServices provided to nursing home

residents can be broken into 3 categories:(a) Domains of care that fall under phy-

sician expertise include physician and otherpractitioner services, including timeliness ofvisits, appropriateness of medical care,

credentialing of physician/practitioners; in-fection control; formulating advance direc-tives; employee health; and medical records(e.g., admission notes, progress notes, dis-charge summaries). The medical directorshould be actively involved, in collaborationwith the facility’s leadership (administratorand director of nursing) in oversight of theabove domains, and shares responsibility forsatisfactory performance of the NH in thoseareas. If problems are discovered during in-spections or quality assurance activities, themedical director should provide assistanceand recommendations pertaining to correc-tive action plans. The medical director mayneed to intervene directly with attendingphysicians and practitioners who are not per-forming according to expectation.

(b) Domains of care that are primaryresponsibility of other health professionals (e.g.nursing, physical therapy, dietary, socialwork), but require some degree of medical di-rector input. The medical director shouldbe aware of those departments’ policies andprocedures, and how they are fulfilling theirfunction. If problems are identified inter-nally (e.g., as a result of a mishap or duringthe quality assurance process) or by an ex-ternal party (state inspectors), the medicaldirector should be informed and may beinvolved in helping the NH to formulateplans to correct the problem(s). The medi-cal director should not be held responsiblefor actual implementation of corrective ac-tions, given that the medical director hasno authority over any NH employees andhas no access to NH financial resources.

(c)Domains of services to NH residents thatshould not be under medical director oversightor responsibility include cleaning, laundry ser-vices, food services, plumbing, fire, safety et al.Physicians have no training or expertise in theseareas. Accordingly, if problems are identified(e.g., a “deficiency” during an inspection), themedical director can be informed of thoseproblems (as may be required by the regula-tory process), but there should be no expecta-tion that the medical director has responsibil-ity in the plan of correction.

AREAS OF RESPONSIBILITY:91. Generala) Overall coordination, and monitor-

ing of physician/practitioner activitiesb) Monitoring the outcomes of the

health care services; i.e., quality assur-ance/improvement (QA/QI).

220MEDICINE & HEALTH/RHODE ISLAND

2. Physician/practitioner oversighta) Establish a procedure to review phy-

sician/practitioner credentials andgrant privileges to attend

b) Establish rules that govern the per-formance of physicians/practitioners

c) Establish a formal procedure to over-see physician/practitioner perfor-mance (QA)

d) Define the scope of practice for non-physician practitioners (would usuallyuse state/federal regulations).

3. Ensure physician performance in thefollowing activities:a) Accepting responsibility for the care

of residents assigned to themb) Performing timely admissions, includ-

ing review of medical recordsc) Making scheduled and as-needed visitsd) Providing adequate ongoing 24/7

medical coveragee) Providing appropriate medical caref ) Documenting care and doing so legiblyg) Formulating and approving advance

directives/end-of-life ordersh) Others (may be physician, resident,

or facility specific)

4. Cover for the attending physicianwhen the latter is unavailable or not per-forming appropriately.

5. Policies and procedures: the medi-cal director is responsible for the con-tent and implementation of those poli-cies and procedures that fall under thephysician’s domain (see above), andmonitoring of their execution. Themedical director should review policiesand procedures that pertain to othertypes of health care professionals (e.g.,nursing) but not be held responsible fortheir execution.

6. Quality Improvement (QI): Themedical director (or designee) must at-tend the quality assurance meetings andbe an active participant in the QI pro-cess, including areas that are not in themedical domain; a physician is often themost knowledgeable and able member ofthe QI committee in the managementand interpretation of statistical data.

7. The medical director is involved withpolicies that cover employee health.

8. Infection Control: The medical direc-tor advises and consults with designatednursing staff regarding communicablediseases, infection control and outbreaks.

9. Review the reports of formal inspec-tions by the state department of health.When deficiencies are identified, themedical director should be involved inthe plan of correction of problems thatare in the medical domain.

Sources of Medical DirectorResponsibilities, Accountabilityand Caveats

The federal and state regulations de-fine a broad outline of NH medical direc-tor responsibilities. Pursuant to the FederalNH Reform Act of 1987, and specifically,42 C.F.R. 483.75(i) (also designated as TagF501 for survey reference), each NH cov-ered by the Act must designate an indi-vidual to serve as a medical director.10 Theregulations further state that each medicaldirector is responsible for

• the implementation of resident carepolicies; and

• the coordination of medical care inthe facility.

While these may appear simple andstraightforward, the variety of responsibili-ties included within each function calls forinterpretation. Indeed, taken literally, thejob description implied by the regulatorylanguage goes far beyond the role of a hos-pital chief of staff or department chair. Thevague regulations preclude a direct trans-lation into a functional and realistic job de-scription. Additionally, the breadth of theregulatory scope of responsibilities of themedical director job is unreasonable; itcould be interpreted to include domainsin which physicians have no expertise. Fi-nally, the authority bestowed upon medi-cal directors is limited by the part-time na-ture of the position and its advisory status,without authority over the NH employeesand budget.

During 2006, CMS introduced newsurveyor guidance to clarify the federal re-quirements for Tag F 501. The medical di-rector is now viewed as a medical leader whoshould actively help facilities provide effec-tive medical care. The updated surveyorguidance expects the medical director to:

• Coordinate medical care in the fa-cility;

• Collaborate with the facility leadershipand provide clinical guidance to helpdevelop, implement and evaluate resi-dent care policies and procedures thatreflect current standards of practice;

• Help the facility identify, evaluate,and address/resolve clinical con-cerns and issues that affect residentcare, medical care or quality of life,and are related to the provision ofservices by physicians and other li-censed health care practitioners.

The revitalized F-501 tag addressesmedical direction concerns raised duringstate inspections, and specifically whetherthe medical director, in collaboration withthe facility, coordinates medical care andis involved in the implementation of resi-dent care policies. Two types of medicaldirection failures can be identified:

1. The facility has failed to involve themedical director in his/her role.

2. The medical director has not per-formed his/her role.

The survey team must first identifywhether noncompliance cited at other tagsrelates to the medical director’s roles and re-sponsibilities. In order to cite at F501 whennoncompliance has been identified at an-other tag, the team must link the identifieddeficiency to a failure of medical direction.

NHs are subjected to considerableoversight by government agencies andother parties (e.g., ombudsperson, fami-lies of residents). The frail nature of NHresidents and their multiple co-morbidi-ties can lead to medication errors, injuries,pressure ulcers or malnutrition, and evendeath; accordingly, complaints aboutNHs, their medical directors and theirphysicians are not uncommon. The state’sdepartment of health and the state’s boardof licensure and discipline may be askedto adjudicate those complaints. Despitethe breadth of responsibility imposedupon the medical director, that responsi-bility is not matched by the medicaldirector’s regulated authority over the NHoperations. The 2001 Institute of Medi-cine report “Improving the Quality ofLong Term Care” urged facilities to giveMedical directors greater authority formedical services and care. Furthermore,

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most medical director contracts only re-quire that the director work at the facilityfor a brief period, often 2-4 hours weekly.In combination with the regulations, sucharrangements make the medical directoran easy target for liability, investigation bystate licensing boards, and even criminalprosecution, but do not provide an obvi-ous mechanism whereby the directors canimplement sound policies and practicesconsistently in facilities. A carefullyworded employment contract may offersome protection. Medical directorsshould also maintain a written record oftheir activities; for example, in the form ofa quarterly report to the QA committee.

Despite its pitfalls, NH medical direc-tion and patient care can be a rewardingexperience. Physicians can enhance the wellbeing of medically complex frail patientsadmitted for short-term rehabilitation, as wellas for long-term residents in the final phaseof their lives. Medical directors and attend-ing physicians are encouraged to become themembers of American Medical DirectorsAssociation (AMDA), attend AMDA’s an-nual symposium, and learn more about thesepositions. [http://www.amda.com]

REFERENCES1. Katz P, Karuza J. Nursing Home Care. In Pompei

P and Murphy JB (eds): Geriatric Review Sylla-bus, ed 6th, American Geriatric Society; 2006,119-25.

2, Ouslander JG. Medical care in the nursing home.JAMA1989;262(:2582-90.

3. Sloane P, Boustani M. Institutional Care. In HamR, Sloane P, Warshaw G (eds): Primary Care Ge-riatrics, ed 4, St. Louis, Missouri, Mosby 2002,199-216.

4. Katz P. Nursing Home Care. In Hazzard W, BlassJ, Halter J, et.al. Principles of Geriatric Medicineand Gerontology, ed 5, New York, McGraw-Hill,2003, 197-209.

5. Fanale JE, Markson, et al. Role of the Physician.In Besdine RW, Rubenstein LZ, Snyder L. Medi-cal Care of the Nursing Home Resident. ACP, Phila-delphia: 3-13.

6. Stone RI. Physician involvement in long-term care.JAMDA 2006;7:460-6.

7. Dimant J. Roles and responsibilities of attendingphysicians in skilled nursing facilities. JAMDA2003;4:231-43.

8. Levenson S. The Medical Director. Caring for theAges 2004:46-51.

9. Levenson SA. The Maryland regulations. JAMDA2002;3:79-94.

10. Levenson SA. The Impact of laws and regulationsin improving physician performance and careprocesses in long-termcCare. JAMDA 2004;5:268-77.

Aman Nanda, MD, CMD, is AssistantProfessor of Medicine, The Warren AlpertMedical School of Brown University.

Tom J. Wachtel, MD, FACP, is Profes-sor of Community Health and Medicine,The Warren Alpert Medical School ofBrown University.

CORRESPONDENCEAman Nanda, MD, CMDDivision of Geriatrics, APC-424Rhode Island Hospital593 Eddy StreetProvidence, RI 02903Phone (401) 444-5248Email: Aman_Nanda@Brown.edu

Disclosure of Financial InterestsAman Nanda, MD, CMD, Speaker’s

Bureau: Forest Laboratories, Inc.Tom Wachtel, MD, Speaker’s Bu-

reau: Pfizer, Takeda, Procter & Gamble,Sanofi-Aventis, Boehringer-Ingelheim.