Daniel Swagerty, MD, MPH, CMD Professor of Family Medicine and Internal Medicine

1. 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

2. 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. 2

3. LTC Medical Director Roles and Functions 3

4. 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.

5. 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.

6. 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.

7. Functions –The medical director… Pattee JJ, Otteson OJ. Medical Direction in the Nursing Home - Principles and Concepts for Physician Administrators. 1991. Minneapolis, Minnesota: North Ridge Press • 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 7

8. 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 8

9. 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) 9

10. 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 10

11. 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 11

12. The Medical Director’s Role F 501 Tag

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Admissions Treatment Discharge Infection Control Use of Restraints Physician Privileges and Practices Non-MD staff Nursing Rehabilitation services Resident dietary care Emergency care Resident assessment and care planning Medical Director’s Duties OBRA : Resident Care Policies (1 of 2)

21. Ancillary Services Lab Radiology Pharmacy Use of Medications Use and Release of Clinical Information Overall Quality of Care Medical Director’s Duties OBRA : Resident Care Policies (2 of 2) “The medical director is responsible for ensuring that these care policies are implemented.”

22. Medical Director’s Duties • 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

23. Medical Director’s Duties • 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

24. Medical Director’s Duties • 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

25. Medical Director’s Duties Proactive Measures to Ensure Year-Round Compliance • Re-evaluate hiring and credentialing • Ensure that attending physicians provide a thorough, relevant, well-documented initial examination • Help physicians address consent-to-treatment issues

26. Medical Director’s Duties Proactive Measures to Ensure Year-Round Compliance • 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.

27. Medical Director’s Duties Proactive Measures to Ensure Year-Round Compliance • 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

28. Medical Director’s Duties Survey Participation • 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

29. 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

30. 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.

31. Surveyor Investigative ProtocolMedical Director “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.”

32. Surveyor Investigative ProtocolMedical Director • 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

33. Surveyor Investigative ProtocolMedical Director • 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

34. Surveyor Investigative ProtocolMedical Director • 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.

35. Surveyor Investigative ProtocolMedical Director • 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

36. Surveyor Investigative ProtocolMedical Director • 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

37. 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

38. 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

39. 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

40. 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 40