The Role of the Medical Director in Long-term Care

The population admitted to homes has evolved over time. Nursing-home residents are often sicker, have dementia more than ever before, and have numerous chronic diseases treated with multiple . This article examines the changing role of the medical director in response to this evolving patient population.

By Graeme Bethune, CCFP, FCFP, COE

he traditional role of the Nursing Home History ing homes. That legislation (from medical director in our A brief summary of the history of the mid-1970s in ) Tnursing homes is long nursing-home populations and mandated medical direction for overdue for change. Before exam- the who served them nursing homes, particularly those ining the issue further, it is impor- may be useful. Several decades that were licensed. tant to define some of this article’s ago, residents of nursing homes The role of the medical direc- terminology. were mobile enough to visit their tor was to ensure that residents In this article, the term “nursing own doctors’ offices for routine received medical care, to chair homes” will be used rather than care. When the residents became or be a member of the pharmacy the more generic, broader term ill, there were sufficient beds in committee and, in general, to be “long-term care facilities.” The to care for them until a liaison between those provid- latter term may include small- they were well enough to return ing medical care to the residents options homes or assisted-living to the nursing home. and the administration. In time, facilities where the role of the Over time, the population a credentialing function was medical director is often less evi- admitted to nursing homes has often given to the medical direc- dent. As well, the terms “medical become less mobile, necessitat- tor. Remuneration for this director” and “medical advisor” ing house calls from family administrative work was often may be used interchangeably, physicians. Some nursing homes token. Specialized education in although these two terms have dif- initiated house doctors who care of the elderly was not ferent connotations. would look after other residents required and job descriptions as well as their own patients. would have been unusual and As the number of residents likely cursory. Of course, the Dr. Bethune is the Medical and facilities increased, legisla- field of geriatrics was in its Advisor, Ocean View Manor, Eastern Passage and a family tion was required to establish a infancy in Canada in the 1970s in Halifax, Nova Scotia. standard of medical care in nurs- and 1980s.

18 • The Canadian Review of Alzheimer’s Disease and Other Dementias It would appear the role of the around, demanding that every- Table 1 medical director will have to thing be done, the RN feels there Potential roles for Medical change in response to the growing is no option but to send the resi- Directors/Advisors demands placed on nursing dent to the emergency room. homes. With significant increases The author recently visited the Traditional in longevity and chronic diseases, and saw nursing • credentialing • discipline increasing medical pressures on homes with broader functions • recruiting physicians nursing homes have become than are traditionally seen. For • creating on-call schedules apparent. “ … It is difficult to dis- example, Dutch nursing homes Administrative tinguish the nursing home of may provide areas for stroke • sit at senior leadership table today from the of the rehabilitation, orthopedics rehab • sit at planning, renovation table • initiate new commitees (e.g., 1960s.”1 and several separate areas for palliative care) palliative care. Many homes Education Problems Facing have day centers providing rehab • plan workshops • put on educational lunches for staff Modern Nursing Homes and/or social activities for the • organize conferences Those who work in nursing frail elderly. Facility Representation homes appreciate that the resi- Willging states that “this influx • attend regional, provincial and dents entering in the 1990s and of higher acuity patients in nurs- national meetings and conferences on behalf of the facility beyond are not as mobile, are ing facilities has helped propel Research often sicker, have dementia more sub-acute care forward as the • encourage facility to be involved than ever before, and often have most rapidly growing segment of in seniors research long-term care today.”2 • initiate research within nursing numerous chronic diseases treated He homes with multiple medications. defines subacute care as “…a Advocacy for Long-term Care Furthermore, there is often an comprehensive program designed • lobby local and provincial health attitudinal and informational dis- for the individual who has had an departments connect between nursing homes acute event, as a result of an ill- • seek increased funding from public and private sources and their cousins, acute-care hos- ness or injury, or exacerbation of a • advocate for greater educational pitals. For example, Emergency disease process and does not opportunities for all staff in areas Department personnel may ques- require intensive diagnostic or such as dementia tion why a late-stage Alzheimer invasive procedure.”2 disease (AD) resident is sent to There will be increasing pres- latter stages. “The acuity and their department for investigation sures for nursing homes to devel- diversity of these patients will of chest pain when that person op expertise in dealing with older make the role of the physicians could stay in their own facility adults who have dementias, and medical directors more com- and receive appropriate comfort AIDS, recent and stable strokes, plex and challenging.”2 care. In the same situation, the recent and stable hip fractures, The foregoing was an attempt nursing home’s lone registered and those who are strictly pallia- to illustrate how nursing-home nurse (RN), trying to look after 20 tive. In addition, nursing homes populations have changed over to 50 residents, may not easily get may be expected to care for late- the past few decades. Dr. Jacob a physician to come in to assess stage congestive heart failure, Dimant says “they [the residents] the resident. With family hovering renal disease, and COPD in its need high-acuity, post-acute, or

The Canadian Review of Alzheimer’s Disease and Other Dementias • 19 end-of-life care, are increasingly The Changing Role on resident outcomes and to have frail and medically complex, and of the Medical Director a basic knowledge of government more than half suffer from With the changing of the nursing- regulations and guidelines.”2 dementia. But the paradigms of home population, not only should There are several medical care have not shifted significant- the attending physician’s role schools in Canada which offer ly in tandem with these changes. change, but so must that of the six- to 12-month diplomas or cer- The current nursing-dominated medical director. It is the medical tificates in healthcare for the eld- process of care, combined with director who should lead the med- erly. The Dutch were forward- staffing shortages and compe- ical staff into new paradigms of thinking 30 years ago when they tency issues, simply does not care in nursing homes in the 21st began discussing the concept of suffice.”3 century. “The medical director’s nursing-home medicine, which Furthermore, he states, “in most important role in the facility is was introduced as a new specialty. addition to apparent and difficult- as a leader of the medical staff. The The discipline of nursing-home to-recognize acute or subacute medical director should develop a medicine exists as an independent problems (e.g., delirium), atten- professional and educated group of two-year with its tion must be directed to chronic MDs dedicated to the care of the own training.4 There are now over problems, functional impairments residents, the environment of long- 1,000 qualified nursing-home physi- and disabilities, palliative care, term care and the special needs of cians in the Netherlands. risks and preventive care, psy- the population they serve.”3 The modern nursing-home med- chosocial and family issues, all in To lead this group of nursing- ical director could have several use- the context of resident choices, home physicians, the medical ful and important roles. In addition preferences, or advance directives director should receive appropri- to the traditional functions, such as and quality-of-life concerns. In ate education. “With increasing credentialing, physician discipline, scheduling, and chairing the phar- macy and therapeutics committee, “The current nursing-dominated process of care, com- there are several other roles with bined with staffing shortages and competency issues, sim- potentially greater impact. ply does not suffice.”3 One valuable responsibility might include a seat at the senior leadership or management table. addition, all this needs to be done long-term care diversification This role allows for significant within a difficult regulatory, insti- into sophisticated areas of care two-way communication between tutional and reimbursement envi- including subacute and special- the non-medical administrators ronment, requiring teamwork and ized areas such as AD, the med- and the physician leader. This specific documentation. It is the ical director will need clinical allows for medical input into key medical director’s responsibility expertise on specific disease strategy sessions, budget consid- to educate attending physicians states and conditions such as erations, advance planning, and about these issues, as well as pro- AIDS, head injuries and demen- major staffing decisions. vide them with tools and process- tia. […] The director will also Another huge potential role for es that help them practice quality have to understand the impact of the medical director is that of care.”3 design and environmental factors education. Possibly one of the

20 • The Canadian Review of Alzheimer’s Disease and Other Dementias biggest shortfalls and greatest adequate sample sizes, especially burgeoning numbers of those older desires in nursing homes is the for clinical studies addressing adults with dementia has largely need for frequent, high-quality issues important to typical com- been ignored by health planners. continuing education. This is true munity-based, long-term care The nursing homes do the best they for all levels of staff, including facilities such as nutrition, pres- can to manage with staff shortages, dietary, non-licensed care workers, sure ulcers, incontinence or end- inadequate allied health staff, out- nursing staff, allied health staff and of-life issues.”1 The medical moded information technology and physician staff. A motivated med- director is uniquely positioned to a physician-payment system which ical director can urge the organiza- encourage research within the is driving doctors from the practice tion to promote education for its nursing home. The staff and resi- of medicine in nursing homes. staff, can plan workshops, and organize conferences. He or she will often have good contacts in It is the medical director who should lead the medical the broader health community that staff into new paradigms of care in nursing homes in the can be used for the educational 21st century. benefit of the staff at the facility. Given time, a medical director can represent the facility at vari- dents will often feel privileged to The average GP doing primary ous municipal, regional, provin- take part in relevant, appropriate care in a nursing home does not cial, national, or even international research, which may help those have the time or breadth of knowl- venues. This type of representa- coming after them. The teaching edge to be a lobbyist or advocate tion allows the director to interact nursing home is very much in evi- for the home. On the other hand, with other people in the same field, dence in the Netherlands, as these the medical director will, over thus building the all-important facilities are extensively utilized by time, become well acquainted network for sharing innovative the three Dutch universities who with the issues facing nursing ideas. These ideas may then train nursing-home physicians.4 homes and will be in a position become items of discussion at the Another crucial role for the med- to speak about them. Examples senior leadership table, which ical director of a nursing home is that might include writing to provin- may then progress to action. This of advocacy for long-term care, cial or municipal politicians to type of activity also shows the especially within the nursing- argue for improvements in this community that the medical direc- home sector. For many years, the sector, making the case that tor comes from a visible and com- increasing complexity and acuity of physicians be remunerated for mitted nursing home, which spon- illness within nursing-home resi- attendance at team meetings, or sors his or her time to attend vari- dents has been unrecognized by speaking out in public forums on ous meetings. The profile of the departments of health. While busily behalf of long-term care. The nursing home is thereby raised, enforcing regulations spawned by director may join the Long Term which is helpful in attracting new legislation in the 1970s, health Care Medical Directors Association high-quality staff and volunteers. departments have overlooked the of Canada formed in July 2003 And what about research? larger picture of more frail resi- (visit www.cmda.ca). This organi- “Research in the nursing home dents with more complex diseases zation advocates for improvements must increase in order to obtain entering our nursing homes. The in the quality of long-term care

The Canadian Review of Alzheimer’s Disease and Other Dementias • 21 through development and inte- been a growing lack of commu- in caring for these challenging gration of the medical director nication and understanding of older adults is waning and needs in the management, education, the limits under which acute- to be revitalized. As the scope and service delivery of compre- care hospitals and nursing of our nursing homes broadens, hensive long-term patient care. homes must operate. competent, dedicated medical Finally, the medical director In order to fulfill an expand- directors will be essential to can facilitate communication ed role of medical director, he help steer these changes and to between nursing homes and or she should have adequate attract and educate new physi- acute-care hospitals. Staff in office space, secretarial assis- cians willing to provide high- nursing homes are often critical tance, report to the CEO, meet quality medical care to this pop- of the care that their residents the board regularly and chair or ulation. “The medical director receive while in acute-care hos- co-chair such committees as can no longer expect to fulfill pitals. They complain that hos- quality assurance, pharmacy his or her role by coming in to pital staff do not fully under- and therapeutics, infection con- the facility a few hours a month stand how to deal with a resi- trol, and ethics. The medical and signing documents.”1 dent who has dementia, for director should be an integral example. Nutrition problems part of the planning process Conclusion and pressure sores are often when remodeling or renovating, The author recently conducted a brief survey of the 74 nursing In summary, the role of the medical director/advisor in homes in Nova Scotia to examine nursing homes is going to change. The populations of the role of the medical director in our nursing homes have become sicker and their needs these facilities. Seventy-four ques- more complex. tionnaires were mailed out in April, 2004 and 52 were returned. The average number of beds per blamed on hospital care. This is and be involved in changes facility was 93, with a range of 10 a reflection of the critical frailty which occur in leadership of to 420. Forty-seven out of 52 of many of our nursing-home nursing, social services, pas- facilities (90.3%) had a medical residents so that if the balance toral care, and physiotherapy advisor. Of these facilities, 13 beam of health/disease on and occupational therapy.1 (25%) had a written job descrip- which they are perched is tilted In summary, the role of the tion for their director. Twenty-one toward disease they become medical director/advisor in (44.7%) of the medical directors very complex and require time- nursing homes is going to sat at the senior leadership table consuming care. Acute-care change. The populations of our or its equivalent. Thirty-three hospitals are not generally set nursing homes have become (70%) of the medical directors up to provide this multifaceted sicker and their needs more received remuneration for their care and, unfortunately, nursing complex. The roles of our nurs- administrative work. No medical homes are not adequately ing homes and acute-care hospi- directors had a budget and in no resourced to care for many of tals with regard to the frail, ill and cases did any facility have a spe- their ill residents on site. Over elderly are becoming blurry and cific budget for the medical direc- the past several years, there has need attention. Physician interest tor to represent the facility at

22 • The Canadian Review of Alzheimer’s Disease and Other Dementias conferences/workshops. Five facilities, however, that its Canadian equivalent is just celebrating its third added a footnote to this question suggesting that if birthday, one might be tempted to conclude that it is asked, some monies would likely be found to support indeed time to examine the role of the medical director attendance at a conference. in our nursing homes. Given the likelihood that our This represents data from only one , so nursing homes will undergo a transformation to institu- Canadian generalizations cannot be made. However, tions which have broader roles in our communities, it taken together with the fact that the American Medical follows that medical direction will need to be more Directors Association is almost twenty years old1 and inclusive, more expert and better supported.

References: 3. Dimant J. Roles and responsibilities of attending physicians in 1. Levinson MJ, Musher J. Current role of the medical director in skilled nursing facilities. J Am Med Dir Assoc 2003; 4(4): 231- community-based facilities. Clin Geriatr Med 1995; 11(3):345- 41. 56. 4. Hoek JF, Ribbe MW, Cees MPMH, et al. The role of the special- 2. Willging P. The future of long-term care and the role of the med- ist physician in nursing homes: the Netherlands’ experience. Int ical director. Clin Geriatr Med 1995; 11(3):533-43. J Geriatr Psychiatry 2003; 18:244-9.

Acknowledgements: I would like to thank the following for their editorial assistance: Dr. Chris MacKnight, Geriatrician, Dalhousie University; Gillian Bethune, Med IV Dalhousie University; Catherine Bethune.

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