Dear Dr. Jeff| Volume 21, ISSUE 8, P4-5, November 2020

A Better World in the Future

      Dear Dr. Jeff: I recently completed a geriatrics fellowship and joined a multispecialty group practice in a small city. A few months ago, I agreed to serve as the Medical Director for a nearby 4-star nursing home. We have survived the pandemic rather successfully but as I reviewed patient charts, I was pleased by the nursing documentation but appalled at the medical care our residents receive. Our physicians have all been on staff for years and generally have practices in the community. One is even from my group. But polypharmacy, overmedication, and inappropriate medications for the elderly seem like the standard while documentation of actually speaking with residents and families or examining the residents is sparse. Medical orders are largely entered remotely with little time spent in the facility. Our corporate sponsor is beginning a strategic planning process to prepare for the nursing home of the future, but I am not sure we are ready for the nursing home of today. Any suggestions?
      Dr. Jeff responds:
      Sadly, the general level of care provided to older adults, and particularly frail older adults, in the United States is discouragingly low. This applies to hospitals, post-acute and long-term care — whether in nursing homes or assisted living facilities — hospices, home care, or office practices. Certified geriatricians are a tiny minority among practitioners in nursing homes or among those who provide care for older Americans. The number of positions in geriatric training programs is not sufficient even to replace the practitioners who are retiring or dying, and many of the positions available in practices go unfilled. This process was not reversed when fellowship programs were shortened from two years to one in the hope that this might encourage more trained clinical geriatricians. The trend will probably not improve with the recent approval of four-year combined geriatrics and family practice or internal medicine training programs.
      Further, many recent fellows have used the geriatrics programs as placeholders until they are accepted in other subspecialty programs for more prestigious or higher reimbursed subspecialties, and they never actually enter the field as geriatricians. Few medical schools give more than token training in geriatrics, which is still more than many older physicians received during their education and training. When I was designated as my hospital’s official geriatrician in the 1980s, it was to meet our affiliated medical school’s new requirement that third-year students receive one hour of geriatrics during their medicine rotation. My residency program offered no subspecialty experience in geriatrics, nor did most others. The gradual addition of some minimal requirements from the Accreditation Council for Graduate Medical Education (ACGME) has only slightly improved the knowledge and skills base for most primary care physicians, even when those requirements are actually met. The medical care that you are reviewing is probably no worse than these same patients would have received in any other setting.
      Medical care in nursing homes is typically better than the community standard even when vastly below your standard. The Omnibus Budget Reconciliation Act of 1987 (OBRA ’87) regulations, along with periodic updates, created a mandatory framework for documentation and care which was designed by experts in gerontology and geriatric care. (Editor’s note: The OBRA regulations are explored in detail in the series of OBRA Regs Revisited columns by Steven Levenson, MD, CMD [].) Through the periodic Minimum Data Set (MDS) process, all the residents in your facility are periodically screened for dementia and depression using standardized instruments. They are weighed monthly with significant changes documented. Their functional status is assessed and reviewed for potential improvements, with rehabilitation therapy available on site. Their medication regimens are reviewed monthly by a trained pharmacist with notes to your practitioners regarding potential discrepancies and concerns. All identified clinical problems must be addressed in written interdisciplinary care plans. Quality of care measurements, albeit imperfect ones, are collected and published.
      In recent years, the growth of post-acute programs, driven by medical economics, has encouraged many more physicians and consults to become involved in long-term care to meet the needs of these more complex residents. Unfortunately, that process has brought hospital levels of care into nursing homes, often to the detriment of the overall quality of care. Poorly conceived medication reconciliation processes adopted in medical facilities have led to the false notion that nursing home medication regimens should mirror the deplorable practices typical in American hospitals, even highly regarded ones.
      This has helped to open nursing homes to many of the polypharmacy excesses and inappropriate medications that are standard in acute care. Fingerstick glucose measurements with sliding-scale coverage, while not recommended for older adults, are the norm for patients with diabetes and sometimes even for those without diabetes who have been on steroids or intravenous dextrose, and may continue as routine orders for years. Prolonged treatment courses with broad-spectrum antibiotics for asymptomatic bacteriuria are typically continued after discharge. When the laboratory finding or same symptoms that triggered the original treatment recur, there is pressure to retreat. Patients who clearly experienced delirium in the hospital are at risk for prolonged use of psychotropic medications and cholinesterase inhibitors, even after they transition to long-term care.
      The fatal phrase “history of…” becomes a justification for lifetime usage based on inaccurate diagnoses of schizophrenia or other major mental health disorders, or poor performance on an inappropriately used screening test with subsequent normal functioning demonstrating that medication is effective. Of course, this would have been no better if the resident had been discharged to an assisted living facility or general community care.
      As post-acute programs grow, becoming more central to the financial survival of most nursing homes, you need to take steps to improve the level of care within your facility. The Patient Driven Payment Model (PDPM) reimbursement system for Medicare places greater emphasis on elements of medical care over the central role of minutes of time devoted to rehabilitation, which was emphasized before PDPM took effect. For the near future, this process will continue to encourage skilled nursing facilities to accept medically complex patients.
      Most projections for the future of long term care suggest that there will be an ongoing need for facilities providing care for frail and medically complex patients, which will probably be some version of current skilled nursing facilities. Less complex residents, whose needs are primarily custodial, may be redirected into intermediate level facilities such as a new generation of memory care units to provide a more supportive and less medicalized level of care, combined with enhanced home care programs. Even those comparatively stable patients deserve better care than is routinely available now.
      However, if your facility plans to survive as a skilled nursing facility, medical care issues will absolutely need to be addressed. There are two possible approaches to improving the medical care in your building: modify your medical staff or change your medical care processes. These are, of course, not mutually exclusive.
      The care model in which community-based physicians follow a small number of nursing home residents as a component of a largely office-based practice was the predominant pattern in most small to medium-sized facilities but has been gradually changing to one where a smaller number of practitioners have predominantly or exclusively nursing home practices. Their enhanced presence in the facility allows them to be more available to residents and to address changes in condition with in-person visits. Antibiotic stewardship, skin and wound care, pain management, and nonpharmacologic approaches to behavioral issues are all markedly enhanced by regular in-person examination. Moreover, the associated documentation for these visits vastly exceeds simple telephone orders or signed faxes.
      Today many of these providers are nurse practitioners (NPs); less frequently they may be physician assistants (PAs), due to regulatory requirements related to on-site supervision. Although federal regulations still require licensed physicians as the attending physician, they need only provide periodic regulatory visits. Indeed, last year NPs and PAs made more than half of all billable nursing home visits. Studies have confirmed that the care provided is at least as good as that provided through community-based physician models. Experience in patient and family education, which is a routine part of nursing education, is an additional positive. Many NPs obtain extensive nursing home experience before beginning their master’s level practitioner training or doctor of nursing practice (DNP) degree, increasing their familiarity with the common problems encountered in nursing home residents and applicable regulations.
      Special needs plans (SNPs) offer a mechanism to bring NPs into the building at no cost to the facility—indeed, SNPs generally offer financial benefits to the institution as well, without necessarily displacing your current attending physicians. Most SNPs require the NPs to document routine communication with families, including brief updates for the residents who are stable or improving. The NPs are usually extremely diligent about obtaining advance directives, particularly Do Not Intubate and Do Not Hospitalize orders for those who make those choices. SNPs can only provide care for long-term residents because their capitated model forbids admission of post-acute patients.
      NPs can be employed by practice groups or directly by the facility to enhance care on post-acute units. Most attending physicians welcome collaboration with NPs, particularly when they discover the dramatic decreases in disruptive telephone calls from worried relatives, demands to implement and sign routine recommendations from consultants, and notifications regarding accidents or incidents as well as less paperwork to sign and return.
      Many physicians have also chosen full-time nursing home practices. Some are physicians who have transitioned from mixed practice to close their private offices while concentrating their time in long-term care. Others have entered the field directly from residency programs or from employment as hospitalists. The term “SNFist” was briefly popular to describe these practitioners, whose practices extend beyond skilled nursing facilities and into care of long-stay nursing facility residents, assisted living, and even home care.
      Some of these practitioners remain in private practice, particularly those who have gradually assumed the care of additional panels of residents while moving away from a traditional office-based practice. However, the majority are employed by staffing companies, which provide them with salaries and benefits while performing and collecting all their billing. Large staffing groups also typically make the arrangements for the practitioner’s vacations or extended sickness, ensuring that the facility will have adequate coverage.
      Although AMDA – The Society for Post-Acute and Long-Term Care Medicine has proposed clinical competencies for physicians practicing in long-term care, SNFists have rarely chosen to complete this curriculum. Some of these physicians are excellent, but the level of expertise and knowledge among these practitioners varies tremendously. At a minimum, their presence in a facility enhances the direct-care medical presence in response to residents’ changes in condition and provides at least the basic documentation required to justify billing.
      These practitioners may be added as a facility builds or expands its post-acute program, as current practitioners retire or die, or when current medical staff members who have failed to perform mandatory visits or return message are encouraged to resign. Most facilities are reluctant to remove medical staff privileges from current staff out of loyalty for years of service, out of fear of backlash from the local medical community, or over concerns about potential litigation after they report the removal to the National Practitioner Data Bank as required.
      In the second part of this column, I will discuss changes to medical care systems that can improve quality of care. The COVID-19 pandemic has finally made clear to state and national health leaders the key role the medical director can play to enhance patient care. You are entering the field when the potential to improve care is dramatically increasing — both for the nursing homes of today and those of the future.
      Part 2 of this article will be published in the next issue of Caring for the Ages (22/1).