06/15/11

TAMPA – A drive to determine competencies for a nursing home physician specialist is fueled by a recognition that long-term care residents are increasingly sicker and more clinically complex than they’ve been in the past, according to two AMDA leaders.

"Care of nursing home residents, now more than ever, we believe, requires a unique set of skills and knowledge base – in other words, competencies that everyone here possesses," outgoing AMDA President Paul Katz, MD, CMD, told an audience at the annual meeting.

The organization began the initiative in the summer of 2010, when its board of directors formed a work group on competencies. The committee named major domains of skills that are required to work in the long-term care setting, including medical knowledge, resident care, professionalism, and interpersonal and communication skills.

"Evidence suggests that if you attain these specific competencies, it has a direct relationship to quality," said Dr. Katz, professor of medicine at the University of Toronto and vice president of medical services at Baycrest, an academic geriatric health center affiliated with the university.

"AMDA is committed to defining nursing home physician competencies, and thus setting the bar, in order to optimize quality – which, after all, is our core mission," Dr. Katz said.

AMDA’s move to define competencies also reflects the state of health care in the United States, AMDA President-Elect Matthew Wayne, MD, CMD, said during a meeting presentation with Dr. Katz. "As we move forward with health care in these times of really profound change, [there is a push] to look at outcomes," said Dr. Wayne.

Improvement of the overall nursing home–care system is another goal, AMDA President-Elect Matthew Wayne, MD, CMD, said during a meeting presentation with Dr. Katz. "The current process in place for the practice of long-term care medicine is horribly inefficient," Dr. Wayne said. "It provides for increased frustration for the providers in how we interact and communicate not just with the resident but with their families, as well as the administration leadership and nursing in the long-term care community."

"The group felt very passionate about an initial focus on the attending physician in the nursing home setting," he said. "But we are not doing this to be exclusive." The initiative could expand to other settings of care and to collaborate with other disciplines "to get the outcomes we are all working toward" in long-term care, said Dr. Wayne, an internist specializing in geriatric and nursing home medicine at University Hospitals Richmond Medical Center, Cleveland.

A nursing home–physician specialty recognized by the Accreditation Council on Graduate Medical Education is a potential outcome of this endeavor.

"This question is still open as to whether this development of competencies is a first step toward some sort of specialization, akin to where the hospitalist movement has gone," Dr. Katz said. Hospitalists are now recognized as specialists through the American Board of Internal Medicine even though additional fellowship training is not required, Dr. Katz said. "We may choose, if we develop a consensus through AMDA, to go in this direction in years hence."

A "nursing home specialist" designation would not be exclusive to any one physician group. "It will be inclusive of everyone who is currently practicing in long-term care: family physicians, internists, and geriatricians," Dr. Katz said.

Enhanced efficiency, quality of care, and professional credibility would be the presumptive benefits of this new specialty, he added. Also, "you can make an argument that as credibility is enhanced, reimbursement will follow."

The issue of whether to work toward a nursing home specialty "is going to be an ongoing discussion," Dr. Katz said. "It’s going to have to be a decision that AMDA, as an entire organization, makes eventually."

The initial work group on competencies recently expanded from fewer than 10 to more than 25 members. "They are all actively engaged in the practice of long-term care medicine," Dr. Wayne said. "We firmly believe [that] the people who are best able to define the skill sets required to practice are the people who are doing the practice of this medicine."

A work group meeting is planned for summer 2011 to produce a draft of competencies within the defined domains. Then the proposal may be available to all AMDA members and some external multidisciplinary parties via a survey, Dr. Wayne said. This process will "ultimately and hopefully" lead to a consensus conference among interdisciplinary teams in the long-term care setting "so that we can collaboratively move the practice of long-term care medicine forward."

Damian McNamara is with the Miami bureau of Elsevier Global Medical News.

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