Effective LTC Medical Direction: Challenges and Opportunities Virginia Medical Directors Association...

Effective LTC Medical Direction:Challenges and Opportunities

Virginia Medical Directors Association 2012 Annual Meeting

Daniel Swagerty, MD, MPH, CMD

Professor of Family Medicine and Internal Medicine

Associate Chair for Geriatric Medicine and Palliative Care, Department of Family Medicine

Associate Director, Landon Center on Aging

University of Kansas School of Medicine

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Learning Objectives

Define the roles and functions as they apply to long term care (LTC) medical direction

Describe the behavioral expectations for an active LTC medical director in the collaborative, interdisciplinary care of LTC residents

Delineate the role of the medical director is assisting the facility in complying with local, state, and federal regulations, including the associated investigative protocol for F501.

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LTC Medical Director Roles and Functions

LTC Medical Director Role Involved at all levels of patient care. Serves as the clinician who oversees and

guides care. Leader who helps define a vision of quality

improvement. Direct supervisor of the medical practitioners. Operations consultant for day to day issues.

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Key Roles Administrative Leadership: responsible

for overall care and clinical practice in the facility.

Clinical Leadership: applies clinical and administrative skills to help guide facility in providing quality care.

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Key Roles

Quality of Care: helps the facility develop and manage both quality and safety initiatives.

Education, Information and Communication: provides information that helps others understand and provide care.

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Functions –The medical director…

Participates in administrative decision making Recommends and approves administrative policies and

procedures Organizes and coordinates physician services and services

provided by other professionals as they relate to patient care

Participates in the QA process to ensure the appropriateness and quality of medical care and medically-related care

Participates in the development and conduct of educational programs

Pattee JJ, Otteson OJ. Medical Direction in the Nursing Home - Principles and Concepts for Physician Administrators. 1991. Minneapolis, Minnesota: North Ridge Press

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Functions – The medical director . . .

Helps articulate the long-term care facility’s mission to the community

Participates in the surveillance and promotion in the health, safety, and welfare of employees

Participates in establishing policies and procedures for assuring that the rights of individuals (resident, staff members, and community members) are respected

Acquires, maintains, and applies knowledge of social, regulatory, political, and economic factors that relate to patient care services

Person directed care

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LTC Medical Director: Integral Part of a System of Care

You have great influence and power in these environments by your presence that is derived from:

Professional expertise Personality (leadership ability) Demonstrated interest Title Ethical behavior (or lack of it)

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LTC Medical Director: Integral Part of a System of Care

Your influence and power extend as far as you wish to exert it ! For example:

Nutritional practices Admission standards Skin care protocols Quality assurance plan and emphasis Team building Pharmacy practices

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Medical Care Delivery Systems

The LTC medical director should make an explicit and deliberate effort to incorporate the principles of systems theory and systems thinking into their administrative practice

Systems theory should be used to Examine typical care delivery processes in LTC Understand the role and functions of the Medical

Director, as well as other members of the LTC interdisciplinary team

The Medical Director’s Role

F 501 Tag

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Medical Directors & Federal Regulations

Medicare regulations have required medical directors in SNFs since 1974

OBRA ’87 extended the requirement to nursing facilities (NFs)

Federal regulations specify only two duties

Implementation of resident care policies Coordination of medical care in the facility

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Importance of the Medical Director

Improving the Quality of Long-Term Care (Institute of Medicine report, 2001) Medical directors accountable for the quality of care in

LTC, but have little authority within facilities and over attending physician

Recommended vesting greater authority and responsibility in medical directors for medical services and require attending physicians and nurse practitioners to follow facility medical policies and procedures

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Importance of the Medical Director

“An Insider’s View: The Role of the Nursing Home Medical Director” (OIG Report, Feb 2003)

Medical directors are committed

Medical directors value role more than administrators do

Inadequately defined regulatory role results in underutilization

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Revised Investigative Protocol for F-501 Tag (2005)

No fundamental change in expectations or requirements BUT

Better defined the medical director’s importance Clarifies the meaning of the original requirements More details of essential functions and tasks Standardized expectations for providers Consistent with the core roles/functions identified by

medical directors themselves

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Medical Directors & Interpretive Guidance

Interpretive Guidance Clarify meaning and implementations of basic federal

regulations Subject to periodic revision Stakeholders can provide input

Original CMS Interpretive Guidelines defined seven functions for medical directors

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Medical Director’s Functions

Assuring that the facility is providing appropriate care as required

Monitoring and ensuring implementation of resident care policies

Providing oversight and supervision of physician services and medical care of the residents

Overseeing overall clinical care of residents to ensure to the extent possible that care is adequate

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Medical Director’s Functions

Evaluating possibly inadequate medical care- including drug irregularities- identified or reported, evaluate and try to correct the problem

If necessary, consult with resident and resident’s physician about care and treatment

Assure the support of essential medical consultants, as needed

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Medical Director’s Duties

Admissions Treatment Discharge Infection Control Use of Restraints Physician Privileges

and Practices

OBRA : Resident Care Policies (1 of 2)

Non-MD staff Nursing Rehabilitation services Resident dietary care Emergency care Resident assessment

and care planning

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Ancillary Services Lab Radiology Pharmacy

Use of Medications Use and Release of

Clinical Information Overall Quality of

Care

“The medical director is responsible for ensuring that these care policies are implemented.”

OBRA : Resident Care Policies (2 of 2)

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The medical regimen must be part of an interdisciplinary care plan designed to achieve highest practicable physical, mental

and social well-being

preserve function

minimize injury/falls

minimize psychoactive medications/restraints

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Restraint use requires rigorous individualized clinical assessment, should be appropriate, and implemented only after considering other less risky alternatives

additional functional decline may be caused by inappropriate restraint use

type, duration, indications, review, revision

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The resident’s drug regimen must be justifiable necessary, appropriate indications appropriate dose, duration and monitoring not duplicated unnecessarily monitoring of adverse affects attempts at drug/dose reduction, when indicated

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Re-evaluate hiring and credentialing

Ensure that attending physicians provide a thorough, relevant, well-documented initial examination

Help physicians address consent-to-treatment issues

Proactive Measures to EnsureYear-Round Compliance

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Ensure that physicians address the broad range of patient conditions, overall functional status, and quality-of-life issues in the proper context.

Ensure that physicians develop documentation skills that reflect OBRA awareness – not OBRA obsession.


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Develop medical policies and procedures geared to effective geriatrics and compatible with OBRA guidelines

Help physicians in their relationships with residents and families

Actively help develop and implement an aggressive quality-assurance program

Participate in the survey process and in challenging questionable deficiencies


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Pre-Survey Follow proactive measures listed above

During the Survey Introduce yourself if possible to surveyors in the

building- business card? Be available to administration and to surveyors Show your presence and interaction with the staff and

administration, at least some time during the survey Participate in exit conference, if possible

Survey Participation

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Surveyor Investigative ProtocolMedical Director (2005)

Objective: “To ascertain whether the medical director, in collaboration with the facility, coordinates medical care and the implementation of resident care policies.”

Use this protocol when: The facility does not employ a licensed medical director, or the

medical director is not currently licensed by the State Concerns with the provision of resident care or medical care or Concerns with quality assurance related to the provision of

medical or resident care

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Surveyor Investigative ProtocolMedical Director

During the survey process, the surveyor should attempt to communicate with the medical director about concerns related to:

admission of residents whose care needs cannot be readily met by the facility

access to or provision of physician or consultant services identification, assessment, or provision of services to meet resident needs capabilities and credentials of staff or other providers/contractors facilities success in honoring residents rights and enhancing personal dignity implementing and maintaining current standards of practice for resident care

and quality of life effectiveness of the various committees responsible for overseeing resident

care and quality of life.

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“When concerns are identified regarding the quality of care, quality of life, or protection and promotion of resident rights, the surveyor should evaluate the possibility of isolated or systemic failure of the provision of medical care in the facility.”

“If the survey process identifies the facility’s lack of a functioning medical director or the lack of medical director involvement in implementing resident care policies and coordinating care, use the Medical Director Investigative Protocol.”

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Facility/medical director responsibility for resident care policies

If the survey team identifies concerns related to the provision of resident care, investigate how the medical director, in coordination with the facility, provides input into the new development, review, revision, and oversight of the implementation of resident care policies.

How was it determined that the policy reflected current standards of practice

If not available, interview the medical director about his/her involvement in implementing resident policies

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Coordination of medical care/physician leadership

If the survey team discovers issues or concerns with resident care/medical care, determine how the facility obtains the medical director’s input in developing policies related to these issues and involvement in the coordination of medical care.

Determine how the facility has involved the medical director in establishing and maintaining policies and procedures for credentialing physicians, nurse practitioners, physician assistants and other licensed or certified health care practitioners

Determine how the facility has involved the medical director in monitoring the provision of physician services

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Coordination of medical care/physician leadership Ensuring that provisions are in place for physician services 24 hours a day

and in case of emergency.

Ensuring that visits and orders are provided as required

Ensure that rules and procedures are established for ongoing coverage for physician services.

Ensuring that practitioners, who are used to perform physician delegated tasks, act within the regulatory requirements and within their scope of practice as defined by State law; and ensure that they are under a physician’s supervision.

Whether the facility identified problems related to care that needed her/his consultation, i.e. notification of a physician about resident changes.

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Once the survey team has determined that non-compliance exists, the team will select the appropriate level of severity

AND they must also find a deficient practice at another tag

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The citation of a deficiency at F 501, Medical Director, is a deficiency regarding the facility’s failure to comply with this regulation

The facility is in compliance if the medical director has assured that the facility has adopted and implemented relevant policies and procedures based on current standards and if the medical director has coordinated the provision of medical care and services in the facility

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Surveyor Investigative ProtocolMedical Director Citation Examples

Severity Level 4Must have a related care tag with actual harm and the medical director had knowledge of the issue- timely antibiotic/medication delivery problem (widespread and known to the medical director) in a patient with pneumonia

Severity Level 3 The surveyor must identify the relationship between the

failed practices cited at other regulatory tags and the failure of the medical director to perform his/her functions- stage 2 pressure sores in a facility with no pressure sore treatment protocols reviewed by the medical director

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Surveyor Investigative ProtocolMedical Director Citation Examples

Severity Level 2Must have a related care tag with no actual harm and the potential for more than minimal harm and the medical director had knowledge of the issue- Repeated lack of reporting of INR levels with the result that a patient’s anticoagulation profile is very high, but not bleeding. This is a facility wide problem and the medical director was aware

Severity Level 1 There is a deficient facility practice but no negative resident

outcome- The facility is searching for a new medical director

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Survey and F-Tags

Revision of the investigative protocol for F-501 created anxiety for many medical directors.

As it’s played out to date, this has not appeared to add additional work or legal liability (but the legal impact is perhaps not yet evident)

But there is always some issue rising to the top

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Summary

Physicians need to master a basic core of knowledge, skills and attitudes to work effectively in long term care as administrators

Experiential learning of attitudes and skills is needed to function effectively as a medical director to optimize performance

Medical directors can improve the quality of care for LTC residents

Effective LTC Medical Direction: Challenges and Opportunities Virginia Medical Directors Association...

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