Yes, Things Will Change in Your Facility

Difference Without a Distinction 

Technically, there is no change in the role or responsibilities of the medical director when short-term, subacute residents are added to a facility. From the regulatory viewpoint, there is no change in the Medicare and OBRA federal Title 42 483.75 (i)(2) or the F-501 tag or guidance for surveyors. These essentially describe the responsibilities of the medical director for “implementing resident care policies” and “the coordination of medical care within the facility.”

AMDA's House of Delegates updated its previous position on the roles and responsibilities of the medical director in 2006 (Resolution A06, March 2006, available at www.amda.com). Neither does this resolution differentiate between responsibilities to long-term and short-term residents.

Although different payment sources for these two populations may alter the frequency with which the facility must complete the Minimum Data Set, the expectation that a resident will return home may determine which bed a resident is assigned but not his or her formal status in a nursing home.

That said, as a practical matter, your responsibilities and work hours are likely to increase exponentially as a substantial number of short-stay residents are added to the facility. Obviously, their care needs will be different from what you've been dealing with.

Many policies will need to be reevaluated, starting with admissions and proceeding through practically every aspect of care. Similarly, coordination of care becomes more complicated with a sicker patient population, particularly when they are completing regimens of care initiated by physicians not on your facility's staff. This complexity is increased if your facility has been placed in the middle of a referring physician's plan of care.

Finally, because Medicare Part A payments, although substantial, are comprehensive payments to include all Medicare A and D components, the facility will now be financially responsible for many costs that vendors previously passed through to insurance carriers, such as radiology and laboratory services, prescription and nonprescription medications, and medical transportation when ordered for use while the patient is residing in the nursing home. The administrator will inevitably be looking to you for help in controlling many of these costs.

Over the past decade, many nursing homes have tried to reexamine their basic role. The Pioneer Movement, culture change, person-centered care, the Eden Alternative, mission-driven care, and the Quality First Initiative, to name a few, are all attempts to refocus care for the frail senior toward higher quality of life.

Facilities typically redefine themselves away from providers of health care and toward a new identity as providers of quality living environments for seniors with functional limitations. In the 1970s and 1980s, nursing home design often tried to imitate hospitals. By the 2000s, designers were creating “neighborhoods.”

Medical directors have supported many of these changes, not because they don't recognize the need for the highest quality of medical care in America's long-term care facilities, but because many elements of the old paradigm of care were not consistent with good, evidence-based medicine.

Restrictive diets, polypharmacy, and inappropriate sedation are more care, but they're worse care. AMDA's clinical practice guidelines typically include discussions of medical interventions that are not necessary or should at least be modified when life expectancy is short. The development of subacute or short-term rehabilitation units inevitably creates a new subculture within the facility that trends counter to these culture changes.

Changing Philosophies of Care 

In 1979, when I first became a nursing home medical director, the code in our state required every facility to have a utilization review committee restate quarterly a “discharge plan” for every resident. We had 91 residents, and for every one their discharge plan was their burial plot.

Subacute units usually have discharge planning rounds at least weekly, and a resident's typical length of stay is the 20 days that Medicare fully covers. As in the hospital, discharge planning begins upon admission.

The goal of my old facility was to have a new resident bond with roommates and with the nursing staff in order to feel comfortable. The goal of the medical staff was to prevent or slow further medical deterioration. Specialty consultations, except for podiatry, were rare because most residents' medical problems were well defined and irreversible.

On the contrary, the goal of a subacute unit is to make patients better and to send them home. While some adjustment to the facility may be desirable, residents who aren't motivated to leave are a source of concern to the social worker or perhaps need psychological services.

Many admissions to a short-term unit come directly from hospitals after their qualifying 3-day stay there. Many residents and family members feel that they were forced out of the hospital too quickly, and they are sometimes right.

The expectation of most families and residents is of an environment similar to that of the hospital, where their care was totally driven by doctor's orders and modified by daily rounds by primary care and specialty physicians as well as rehabilitation personnel.

Imagine such a patient now admitted to a nursing home and told that after an initial exam the next doctor's visit could be in 30 days (10 days after discharge!). Because patients who have suffered a recent functional loss and undergone a recent hospitalization are often unstable, medically necessary visits must be frequent, and medical visits and therapy sessions tend to be the focus of the resident's day.

Short-stay residents are often shocked by the liberalized diets offered in most long-term care facilities. A diabetic may be horrified by the appearance of a small piece of cake on the dinner tray. He or she may see this as evidence that the facility is ignorant, unprofessional, or simply indifferent to patients' needs. It may not be possible to challenge the holy writ of the American Diabetes Association diet on the day of admission.

As the medical director, you will need to address a new schizophrenia of care in your facility. Whether separate units have different resident care policies or an attempt is made to modify existing policies to the needs and expectations of a new patient population, major changes are necessary.

New protocols for physician notification, new approaches to credentialing nonstaff physicians who wish to consult on “their” patients, new technologies introduced into the facility, and new procedures to guarantee safe discharges back to the community must all be put in place alongside the cultural changes being implemented for long-stay residents.

In the end, many medical directors and attending physicians find the new subacute units more comfortable than the culture changes of the last decade. The units often have the feeling of the floors of the old hospital where we all served as house officers.

When the DRG (diagnosis-related group) for hip fracture was first introduced, the average length of stay for an uncomplicated fracture was slightly more than 20 days. Now, that same patient would spend 4 or 5 days in the hospital and 20 days in a nursing home. The same divided stays apply to many patients with heart failure or pneumonia. These are very familiar patients, and your responsibility to them is very clear. As medical director, it is to make sure that your facility is organized to give them the care they need.