Background and Purpose
Nationwide, nursing facility care is changing from long-term custodial care of frail elders to complicated and resource-intensive post-hospital care. The population of people receiving care in nursing facilities is more medically complex as patients are discharged ‘sicker and quicker’ from the hospital to skilled nursing facilities. This has resulted in an increased need for highly trained, committed, and available healthcare practitioners willing to provide care on-site to nursing facility residents.
In recognition of the increased need of nursing facility residents for physician services and the vital role that physicians must play in both providing and overseeing care to nursing facility residents The Nursing Home Reform Act (“OBRA ’87”) strengthened the requirement for physician medical directors in nursing facilities, ascribed specific responsibilities to them, and set minimum requirements for physician visits to facility residents. As long-term care has assumed a more essential role in the care of recently hospitalized Medicare beneficiaries and as expectations for quality nursing facility care have risen, the importance of physicians and other healthcare practitioners in long-term care settings has been reaffirmed. At the same time, with overall population aging, the fastest-growing segment of Medicaid spending in all 50 states has been long-term care. In an effort to control Medicaid spending and ensure that money is well spent on high-quality care, individual states, most notably Maryland and Florida, have enacted their own long-term care legislation to ensure timely access to physician services as well as adequate medical director training and oversight.
A shortage of qualified practitioners willing to care for nursing facility residents has been recognized. This prompted Congress to commission a federal study, conducted by the Institute of Medicine (IOM), which concluded with the IOM report to Congress, “Retooling for an Aging America: Building the Health Care Workforce.” Simultaneously, nursing facility operators have expressed interest in hiring nurse practitioners and other non-physician practitioners to supplement or perhaps even replace scarce physicians in long-term care settings.
As state and federal governments continue to examine these issues, particularly in light of the recent IOM study and proposed legislation to address healthcare workforce shortages, AMDA—Dedicated to Long Term Care Medicine (AMDA) has an obligation to inform the ongoing discussion and to guide planning and decision making that has the potential to affect access to attending physician and medical director services in long-term care, as well as the quality of care overall. AMDA is committed to promoting the highest possible quality of care for many of the nation’s most vulnerable and needy citizens.
AMDA's Position
Physicians and others providing medical care to residents of nursing facilities and other long-term care facilities must possess a unique set of knowledge and skills. This includes understanding the principles and practice of geriatric medicine, drug prescribing for older patients, familiarity with pertinent regulations governing long-term care facilities, understanding systems of care delivery, and the ability to work effectively as part of an interdisciplinary team. Likewise, in long-term care facilities providing care to non-elderly residents (children, young and middle-aged adults with lifelong disabilities), an intimate understanding of those branches of medicine and other relevant knowledge, along with the skills necessary to meet the special needs of individual facility residents, is vital.
The mission of AMDA is to continuously improve the quality of care in long-term care settings. AMDA strives to achieve that mission by providing ongoing education and training to physicians and other healthcare professionals working in long-term care.
Federal regulations governing nursing facilities make physician medical directors responsible for specific duties and functions. Under these regulations, the physician Medical Director assumes responsibility for coordination of medical care as well as involvement in developing and implementing resident care policies and procedures.
Several states have their own state-specific regulations pertaining to medical directors. In order to carry out these essential functions, physician medical directors likewise must possess a unique set of necessary knowledge and skills.
AMDA provides training and educational resources to attending physicians and other providers in Long-Term Care Medicine. AMDA also provides training and educational resources in medical direction to medical directors of long-term care facilities. In addition, AMDA’s affiliated organization, the American Medical Directors Certification Program (AMDCP), provides Certification in Medical Direction to qualified physicians who have demonstrated proficiency in Medical Direction through training and experience.
AMDA strongly endorses appropriate training and education for all physicians and other health care professionals treating residents of long-term care facilities, and is committed to making such training available through a variety of methods and in a variety of settings and locations.
Likewise, AMDA strongly endorses the appropriate training and education of all physician medical directors working in long-term care settings, and is similarly committed to providing a wide variety of opportunities for comprehensive education and training in medical direction.
AMDA believes that physician medical directors in long-term care should have as a professional career goal to seek and obtain sufficient training to ultimately qualify for AMDCP Certification in Medical Direction, and that such training and certification is clearly beneficial to residents of long-term care facilities.
In addition, AMDA encourages long-term care facilities, administrators, owners and operators to support the Medical Director in carrying out their various professional roles and responsibilities, including providing support, encouragement, and opportunities for Medical Directors to seek and obtain continuing professional education in Medical Direction and Long-term Care Medicine.
AMDA does not specifically seek to promote new legislation aimed at further regulating the roles of attending physicians, nurse practitioners, clinical nurse specialists, physician assistants, or medical directors in long-term care. Neither does AMDA seek to avoid regulation for its own sake. For states considering legislation to address physician shortages in long-term care settings or to further delineate the medical director role, AMDA is willing to offer guidance in keeping with its mission to promote quality care. Toward that end, AMDA feels strongly that the problem of insufficient access to qualified physicians in long-term care is best met by increasing the number of qualified physicians in long-term care.
AMDA further recommends that nurse practitioners and other non-physician practitioners work collaboratively with attending physicians and medical directors to maximize the value of all members of the interdisciplinary care team, and that physicians commit to fostering and strengthening this collaboration. AMDA is strongly committed to strengthening the long-term care workforce, including both the physician and the non-physician practitioner workforce. AMDA is likewise committed to supporting and promoting the role of both physicians and non-physician practitioners in long-term care. AMDA supports and encourages interdisciplinary, team-based care and is committed to promoting and celebrating the many unique and valuable contributions and perspectives of all disciplines to enhance the quality of care. We agree with the IOM recommendations, specifically recommendations to create incentives such as loan forgiveness programs and other efforts at reallocate resources, to encourage excellent, committed LTC physicians. We also endorse efforts to improve the training of all health care providers in the principles and practice of geriatric medicine, and direct exposure to care at all sites across the care continuum.