Graphical Abstract
When asked to describe the ideal medical director, nursing home administrator Mike Moranz’s face beamed with a broad smile. “Well, to understand today’s ideal, you must understand how far we have come over the past 20 years.” Mike Moranz, MPH, started his health care career as a respiratory therapist 50 years ago and ventured into nursing home administration in Maryland 20 years ago. “My first nursing home medical director was an internist with a busy office and hospital practice. He did not have the time or knowledge to really help the nursing home staff in any sort of leadership role. We were pretty much on our own.”
The demands of the position also have evolved, as Mr. Moranz explained: “Twenty years ago, we were doing some post-acute care, but nothing like the volume and acuity we see today. Today we really need nursing home medical directors who are engaged and knowledgeable about our regulatory and risk management concerns, quality improvement initiatives, infection control requirements, and upgrading clinical services to decrease rates of hospital readmission. In addition to having administrative knowledge, we need medical directors who are expert clinicians and can guide residents, families, and staff when tough clinical issues arise, especially about goals of care and end of life decision-making.”
Engagement is key for medical directors, Mr. Moranz said. “Clinical and administrative expertise are necessary but insufficient without both the time and interest on the part of the medical director to be involved in the life of the nursing home. I have worked with numerous medical directors over the past two decades. Some were like my first medical director. A few were truly ideal.”
Mr. Moranz led a 200-bed, high-acuity, urban nursing facility through the COVID-19 pandemic. “Having an ideal nursing home medical director during the time of COVID has been essential,” he said. Early on the availability of and recommendations about personal protective equipment, testing, and isolation were rapidly evolving. “Our medical director was in frequent communication with the corporate chief medical officer and helped us keep the medical staff updated. Our medical director was able to educate the clinicians about how to accurately code diagnoses on COVID-related death certificates and helped keep the medical staff in compliance. He meets weekly with the nursing staff, and we have seen a real improvement in their clinical knowledge and acumen. I am not sure how we would have made it through the time of COVID without such expert medical direction.”
Twenty years ago, Maryland became the first state in the United States to require that all nursing home medical directors complete education regarding their clinical and administrative role. The Maryland regulations specify that nursing home medical directors complete AMDA – The Society for Post-Acute and Long-Term Care Medicine’s Core Curriculum on Medical Direction in PALTC or a similar course of study approved by the state licensing agency. This ensures that nursing home medical directors in Maryland have an understanding of their roles and responsibilities, which is the first step to becoming an ideal medical director.
Roles and Responsibilities
The Society’s Core Curriculum is divided into two parts: an online course and a synthesis weekend, which was held live before the time of COVID and is currently offered as a virtual symposium. The course provides comprehensive instruction on management and leadership within PALTC settings — the knowledge base necessary to become an ideal medical director. The course outlines the four basic roles of the medical director: physician leadership; patient care–clinical leadership; quality of care; and education, information, and communication. These roles are further refined as the nine main functions of the medical director, which in turn are further delineated into the various tasks performed by the medical director to carry out the roles and functions. (Visit https://apex.paltc.org/page/core-curriculum-on-medical-direction for more information.)
Physicians who have completed the Core Curriculum have invested time into obtaining the knowledge to perform their duties. Physicians who have been awarded the Certified Medical Director (CMD) credential by the American Board of Post-Acute and Long-Term Care Medicine (ABPLM) have demonstrated they have the knowledge, experience, and professional standing to assume a medical leadership role in PALTC settings.
Most nursing homes in the United States rely on part-time medical directors, who may be present in the home to perform administrative duties anywhere from 2 to 20 hours per week, depending on the home’s size and medical acuity. The part-time medical director will need to select from the comprehensive list of medical director roles and responsibilities which activities should be prioritized to monitor and improve care. The administrator and director of nursing should meet with the medical director to communicate their perceptions of the home’s areas of greatest need.
An engaged medical director can act as an advocate for both patients and families, often helping the nursing home resolve difficult situations. A knowledgeable medical director can help create a stable and engaged staff who feel valued, are continuously learning, and can work together as a highly functioning team. A committed medical director can facilitate strong relationships with hospitals, helping ensure that the nursing home is seen as a preferred provider in this era of narrow networks.
The priorities will likely change over time, so the medical director will need to be able to adapt. This was conclusively demonstrated with the advent of the COVID pandemic. As Mr. Moranz said, “Having an ideal medical director is the difference of night and day for the success of the nursing home.”
Dr. Elon is an associate professor of medicine, serving on the voluntary faculty in the Division of Geriatric Medicine at Johns Hopkins University School of Medicine. Opinions expressed in this article do not represent those of the employers of Dr. Elon and Mr. Moranz.
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