1 The Role of The Physician In Improving Nursing Home Quality Jonathan M. Evans MD MPH CMD President, AMDA
2 Questions For Discussion: What should residents and families expect from their physician in the nursing facility? What is the role of the Medical Director? What is the role of a Nurse Practitioner or a Physician s Assistant? How can any of these individuals improve nursing home quality?
3 What should Residents and families expect from their physician in the nursing facility?
4 What should Residents and families expect from their physician in the nursing facility? Availability Competency Frequency of visits- admission, routine, sick visits Role/responsibilities Care oversight Orders Communication: what s going on? What s expected to happen? Why? Advocacy
5 Changing Nursing Facility Environment Greater proportion of patients are sick (acutely ill) upon admission Come straight from hospital, just as sick as yesterday Greater complexity, acuity of medical and nursing care needs More and more patients admitted to nursing facility will stay for 3 months or less Changing expectations of physicians, facility, others as a result
6 Physicians and Others In Nursing Homes Minimal, if any training in geriatric medicine incl. drug prescribing in older patients among overwhelming majority of practitioners Minimal, if any exposure to LTC sites during training Highly variable experience, involvement among practitioners working in LTC sites Federal Regulations affect what doctors, others do in nursing facilities but not in any other site for same patient, same episode of illness E.g. antipsychotic drugs, unnecessary drugs, required visits even if patient not sick or asking to be seen
7 What is the role of the Medical Director? Who are they and what do they do? Licensed physicians who serve an administrative function Usually function as attending physicians as well Physician Medical Director a Regulatory Requirement (OBRA87) Roles/responsibilities developed by regulation, profession over time (AMDA)
8 What is the role of the Medical Director? Role/responsibilities By regulation: Assure availability of physician services Be involved in development, implementation of policies/procedures Quality oversight role, serve on quality committee Training MD or DO degree Additional training and CMD Certification by AMDA (professional society) Additional training not mandatory in most states Certification is not required in any state
9 What is the role of a Nurse Practitioner or a Physician s Assistant?
10 What is the role of a Nurse Practitioner or a Physician s Assistant? Role similar but not identical to physician role Training, tradition differences State by state laws affect NP/PA role (e.g. prescribing narcotics) Every patient has an attending physician who is ultimately responsible for the NP/PA Collaborative practice arrangement with supervising physician Comprehensive admission assessment, some periodic visits can only be performed by physician
11 How can these individuals improve nursing home quality?
12 Nursing Home Quality What is it and who decides? Quality in eye of beholder CMS Quality Measures/Quality Indicators
13 CMS Quality Measures/Quality Indicators Data is self-reported From MDS Most are measures of poor quality rather than good quality Available to consumers on internet Nursing Home Compare site on Forms basis of annual survey Data reported back(delay) to facility monthly (CASPER report) with comparison to other facilities in state, nationally (averages) Percentile ranks given. 75%ile ( worst 1/4 th of facilities) flags - surveyor scrutiny required
14 CMS QM/QI Short stay measures are related to: Self-reported moderate to severe pain Provision of flu vaccine Provision of pneumococcal vaccine Antipsychotic Drugs
15 Long stay measures are related to: Provision of flu vaccine Self-reported moderate to severe pain Provision of pneumococcal vaccine High risk residents with pressure ulcers Utilization of physical restraints Falls with major injury Depressive symptoms
16 Long stay measures are related to: Urinary tract infection Catheter inserted and left in bladder Low risk residents who lose Bowel/Bladder control Excessive weight loss Increase in need for help with ADL s Antipsychotic drugs (in pts. Without schizophrenia/tourettes)
17 How can doctors/other practitioners affect NH quality? Directly through acts/omissions Timely, appropriate eval, treatment Appropriate prescribing/discontinuation of unnecessary medications Advocacy for patient/family needs and preferences Care plan development and oversight Monitoring of care provided by others Quality oversight at facility level (QM/QI) Involvement in meetings, committees Policies and procedures/systems of care Direct observation Education
18 Barriers to Quality Improvement for Doctors/Others Lack of availability/competing demands/roles within facility/absence from facility Education/training in quality management/systems thinking Lack of training/experience working in interprofessional teams Willingness/ability of facility to integrate physician as part of team Lack of quality program/infrastructure within facility Attitudes
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