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Nursing Home Physician Specialists: A Response to the Workforce Crisis in Long-Term Care FREE

Paul R. Katz, MD; Jurgis Karuza, PhD; Orna Intrator, PhD; and Vincent Mor, PhD
[+] Article and Author Information

From the University of Rochester School of Medicine and Dentistry, Rochester, and State University of New York at Buffalo, Buffalo, New York; and Brown University, Providence, Rhode Island.


Grant Support: Dr. Katz was supported by the National Institute on Aging (grant R21 AG025246).

Potential Financial Conflicts of Interest:Consultancies: P.R. Katz (Omnicare Pharmacy and Therapeutics Committee board member).

Requests for Single Reprints: Paul R. Katz, MD, University of Rochester School of Medicine and Dentistry, 435 East Henrietta Road, Rochester, NY 14620; e-mail, Paul_Katz@urmc.rochester.edu.

Current Author Addresses: Drs. Katz and Karuza: University of Rochester School of Medicine and Dentistry, 435 East Henrietta Road, Rochester, NY 14620.

Drs. Intrator and Mor: Brown University, 164 Angell Street, Providence, RI 02912.


Ann Intern Med. 2009;150(6):411-413. doi:10.7326/0003-4819-150-6-200903170-00010
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Marginalization of physicians in the nursing home threatens the overall care of increasingly frail nursing home residents who have medically complex illnesses. The authors propose that creating a nursing home medicine specialty, which recognizes the nursing home as a unique practice site, would go a long way toward remedying existing problems with care in skilled nursing facilities and would best serve the needs of the 1.6 million nursing home residents in the United States. Reviewing what is known about physician practice in nursing homes and hospitals, and taking a lead from the hospitalist movement, the specialty would be characterized in 3 dimensions: the degree of physicians' commitment, physicians' practice competencies, and the structure of the medical staff organization in which they practice. Challenges to the adoption of a nursing home specialist model include mainstream medicine's failure to recognize the nursing home as a legitimate medical practice, the need for the nursing home industry and policymakers to appreciate the links between physician practice and quality, and assurance of financial viability. Implications for quality of care, health policy, and research needs are discussed in this article.

A recent Institute of Medicine report (1) highlights the disturbing trend of a net reduction in board-certified geriatricians and a reduction in the number of physicians entering geriatric fellowships. Clinical and leadership positions in nursing homes are often filled by geriatricians (2), and to address the shortage of geriatricians in nursing homes, the Institute of Medicine recommends expanding the role of midlevel providers, such as nurse practitioners. Rather than accepting that disengagement of physicians in nursing home practice is inevitable, we make the case here that quality of care in the nursing home is directly linked to physician practice, and that only by moving toward a nursing home specialist model will the needs of residents with complex postacute problems, who are burdened by multiple comorbid conditions, chronic illness, and functional limitations, be met.

The nursing home population of the United States stands at 1.6 million and will double by the year 2030 (3). Even with declining disability rates and increases in housing options, the lifetime risk for nursing home admission remains high at 46% (4). Nursing homes have become an integral and unique component of the health care continuum in the United States, in part because they accommodate increasingly frail residents whose hospital stays have been dramatically shortened (5). This “sicker-but-quicker” trend has manifested as increasing functional dependence, comorbid conditions, and use of “high-tech” interventions in both short- and long-term nursing home residents (6). A large proportion of deaths overall occur in nursing homes (7), and expenditures currently exceed $120 billion per year—a figure projected to almost double by the year 2015—with Medicaid footing 44% of these costs (89). Of all Medicare fee-for-service dollars, 7% are spent in nursing homes (10).

Despite these trends, the quality of care in nursing homes remains inconsistent and in many respects suboptimal (11). Nursing home practice is only 4% of work time among the 20% of physicians who practice in a nursing home, one third of whom are internists (12). Often rooted in reality, perceptions among nursing home physicians of excessive regulation, paperwork, professional liability, and lack of nursing support remain barriers to developing a widespread nursing home specialist culture (13). Perhaps more important, many physicians still find it difficult to overcome logistic challenges (for example, caring for a sufficient number of patients while traveling from one facility to another), even though reimbursement for nursing home visits has increased. Without salary derived from administrative duties associated with being a medical director, many practitioners find nursing home care untenable. Waning interest in primary care and geriatrics (14), coupled with few credible role models (15), further constrains physician involvement in nursing homes. In a survey of graduating residents, fewer than 15% felt “very prepared to provide nursing home care” (16). Finally, fear of cost increases and underappreciation of the link between physician care and quality may obviate support from the nursing home administration.

Taking a lead from the adult and pediatric hospitalist movements (1718), we propose that creating a nursing home medicine specialty would remedy the problems with care in skilled nursing facilities. On the basis of existing literature (1921), we propose that the specialty be characterized in 3 dimensions: the degree of physicians' commitment, physicians' practice competencies, and the structure of the medical staff organization in which they practice.

Commitment is conceptualized as the physicians' degree of involvement in nursing home care, recognizing the links between quality of care and the time spent in a given nursing facility and with individual residents. We think that nursing home specialists could practice under many different models, ranging from a full-time practitioner to a primary care physician in the community who devotes 1 day per week to nursing home residents. However, we propose that nursing home specialists devote at least 20% of their practice to nursing home care. Recognizing that physicians may visit multiple facilities, the time spent in any given nursing home should equate to at least 4 hours a week. Arguably, this is the minimum amount of time necessary to become facile with processes of care and the site-specific culture.

Competency in nursing home medicine would be defined by training or experience in handling complex medical care in a highly regulated, interdisciplinary care context that accommodates both postacute and long-term care. Training should be flexible enough to attract the broadest cross-section of primary care physicians, because limiting recognition initially to board-certified geriatricians or to certified medical directors would needlessly exclude other qualified practitioners. Future training might include an additional “mastery” year of residency training, flexible nursing home fellowships that would accommodate both early and midcareer candidates (22), or a certification process similar to that for medical directors. Examples of specific competency domains for training and certification include management of issues related to quality improvement, transitions of care, frailty, polypharmacy, and cognitive and behavioral disorders.

Nursing home medicine would also require a more structured, “closed” medical staff model, which restricts privileges to a limited number of providers. Support for a structured model can be found in the work of Roemer and Friedman (23) and others (2426) who have shown an association between structured medical staff and quality of care. In our own work, which examines the impact of medical staff organization in nursing homes, physicians working within a closed staff model seemed to be more committed, knowledgeable about long-term care practice, and available (20). Existing policies, regulations, and care standards that define the role of the attending physician and medical director in the nursing home reinforce such a model (2728), as do programs for formal certification of medical directors (29).

Change in the practice of nursing home medicine will occur only if organized medicine addresses several issues. Mainstream medicine must reinforce the nursing home as a legitimate medical practice site. Recruitment and retention of a competent, trained workforce will demand incentives (for example, loan forgiveness) and assurance of financial viability. In the Netherlands, nursing home physician specialists exist and are fully subsidized by the government (30). Health care reimbursement in the United States is clearly more complex than in the Netherlands, but options include increasing Medicare reimbursement for cognitive services, developing organizational efficiencies under the current reimbursement system, implementing new policies that reward providers for enhanced quality and cost savings (that is, decreased hospitalizations), and making pay-for-performance both equitable and feasible in nursing homes without electronic medical records. Market forces may eventually provide incentive to reward nursing home specialists for the value inherent in their practice specifically related to enhanced quality of care in the nursing home and during care transitions.

Such organizations as the American Medical Directors Association and the American Geriatrics Society are critical in defining the physician's importance to the nursing home. Their efforts, however, must complement those of broader-based medical organizations, such as the American Medical Association, American College of Physicians, and American Academy of Family Physicians. These organizations, representing most primary care physicians in the United States, can enhance legitimacy of the nursing home specialist, help define career paths, establish curriculum, and craft relevant policy and regulations that preserve medicine's role in nursing home care. Nursing home practice accommodates a flexible rounding schedule and requires little overhead, in keeping with younger physicians' demand for work–life balance (31). The specialty could be marketed as having these attractive features coupled with the opportunity to manage a diverse patient population with postacute and long-term care needs in an easily navigable environment. Many of these same characteristics helped attract practitioners to hospital practice and fueled the growth of hospital medicine as a specialty.

Literature reporting on increased patient satisfaction and lower hospitalization rates in nursing homes that employ nurse practitioners and physician assistants have not considered physician involvement as a moderating variable (32). Physician care positively influences residents' hospitalization rates, functional status, and satisfaction (3335). Marginal physician involvement impedes communication and integration of the physician into the nursing home culture, with detrimental patient outcomes (3638). We contend that rather than accepting a diminished presence of physicians in nursing homes and finding alternative care models, it is time to fully consider, appropriately fund, and test the nursing home specialist model (3940). If nearly half of the baby boomers spend some time in a nursing home, the question “Is there a doctor in the house?” will take on new urgency and meaning.

Institute of Medicine.  Retooling for an Aging America: Building the Health Care Workforce. Washington, DC: National Academies Pr; 2008.
 
Medina-Walpole A, Barker WH, Katz PR, Karuza J, Williams TF, Hall WJ.  The current state of geriatric medicine: a national survey of fellowship-trained geriatricians, 1990 to 1998. J Am Geriatr Soc. 2002; 50:949-55. PubMed
CrossRef
 
Jones A.  The National Nursing Home Survey: 1999 summary. Vital Health Stat 13. 2002; 1-116. PubMed
 
Spillman BC, Lubitz J.  New estimates of lifetime nursing home use: have patterns of use changed? Med Care. 2002; 40:965-75. PubMed
 
DeFrances CJ, Hall MJ.  2005 National Hospital Discharge Survey. Advance data from vital and health statistics; no 385. Hyattsville, MD: National Center for Health Statistics; 2007.
 
Kasper J, O'Malley M.  Changes in Characteristics, Needs, and Payment for Elderly Nursing Home Residents: 1999 to 2004. Washington, DC: Kaiser Family Foundation; 2007. Accessed athttp://www.kff.org/medicaid/upload/7663.pdfon 15 May 2008.
 
Gruneir A, Mor V, Weitzen S, Truchil R, Teno J, Roy J.  Where people die: a multilevel approach to understanding influences on site of death in America. Med Care Res Rev. 2007; 64:351-78. PubMed
 
Spillman BC, Lubitz J.  The effect of longevity on spending for acute and long-term care. N Engl J Med. 2000; 342:1409-15. PubMed
 
Borger C, Smith S, Truffer C, Keehan S, Sisko A, Poisal J. et al.  Health spending projections through 2015: changes on the horizon. Health Aff (Millwood). 2006; 25:w61-73. PubMed
 
Medicare Payment Advisory Commission.  A Data Book: Health Care Spending and the Medicare Program. Washington, DC: MedPAC; 2008. Accessed athttp://www.medpac.gov/documents/Jun08DataBook_Entire_report.pdfon 26 October 2008.
 
Scanlon WJ.  Nursing Homes: Prevalence of Serious Quality Problems Remains Unacceptably High, Despite Some Decline. Testimony before the Committee on Finance, U.S. Senate, GAO 03-1016T, 17 July 2003.
 
Katz PR, Karuza J, Kolassa J, Hutson A.  Medical practice with nursing home residents: results from the National Physician Professional Activities Census. J Am Geriatr Soc. 1997; 45:911-7. PubMed
 
Caprio T, Karuza J, Katz PR.  Profile of physicians in the nursing home: time perception and barriers to optimal medical practice. J Am Med Dir Assoc. 2009 Feb;10(2):93-7. Epub 2008 Dec 20. [PMID: 19187876]
 
Iglehart JK.  Grassroots activism and the pursuit of an expanded physician supply. N Engl J Med. 2008; 358:1741-9. PubMed
 
Katz PR, Williams TF.  Medical resident education in the nursing home: a new imperative for internal medicine. J Gen Intern Med. 1993; 8:691-3. PubMed
 
Blumenthal D, Gokhale M, Campbell EG, Weissman JS.  Preparedness for clinical practice: reports of graduating residents at academic health centers. JAMA. 2001; 286:1027-34. PubMed
 
Wachter RM.  The state of hospital medicine in 2008. Med Clin North Am. 2008 Mar;92(2):265-73, vii. [PMID: 18298978]
 
Landrigan CP, Conway PH, Edwards S, Srivastava R.  Pediatric hospitalists: a systematic review of the literature. Pediatrics. 2006; 117:1736-44. PubMed
 
Katz P, Karuza J, Lawhorne L, Schnelle J.  The nursing home physician workforce. J Am Med Dir Assoc. 2006; 7:394-8.
 
Karuza J, Katz PR.  Physician staffing patterns correlates of nursing home care: an initial inquiry and consideration of policy implications. J Am Geriatr Soc. 1994; 42:787-93. PubMed
 
Shortell SM, LoGerfo JP.  Hospital medical staff organization and quality of care: results for myocardial infarction and appendectomy. Med Care. 1981; 19:1041-55. PubMed
 
Glasheen JJ, Siegal EM, Epstein K, Kutner J, Prochazka AV.  Fulfilling the promise of hospital medicine: tailoring internal medicine training to address hospitalists' needs. J Gen Intern Med. 2008; 23:1110-5. PubMed
 
Roemer M, Friedman J.  Doctors in Hospitals: Medical Staff Organization and Hospital Performance. Baltimore: Johns Hopkins Univ Pr; 1971.
 
Shortell S, Becker S, Neuhauser D.  The effects of management practices on hospital efficiency and quality of care. Shortell S, Brown M Organizational Research in Hospitals. Chicago: Blue Cross Assoc; 1976.
 
Flood AB, Scott WR.  Professional power and professional effectiveness: the power of the surgical staff and the quality of surgical care in hospitals. J Health Soc Behav. 1978; 19:240-54. PubMed
 
Shortell SM, Schmittdiel J, Wang MC, Li R, Gillies RR, Casalino LP. et al.  An empirical assessment of high-performing medical groups: results from a national study. Med Care Res Rev. 2005; 62:407-34. PubMed
 
United States.  Public Law No. 100-203, Omnibus Budget Reconciliation Act of 1987, 22 December 1987. Annu Rev Popul Law. 1987;14:473-5. [PMID: 12346743]
 
American Medical Directors Association.  CMS Implements Revised Surveyor Guidance for Medical Director Tag. Accessed athttp://www.amda.com/advocacy/medicaldirection.cfmon 5 February 2009.
 
Certified Medical Director in Long Term Care Program. Accessed athttp://www.amda.com/certification/overview.cfmon 20 October 2008.
 
Schols JM, Crebolder HF, van Weel C.  Nursing home and nursing home physician: the Dutch experience. J Am Med Dir Assoc. 2004; 5:207-12. PubMed
 
Kirch DG, Vernon DJ.  Confronting the complexity of the physician workforce equation. JAMA. 2008; 299:2680-2. PubMed
 
Caprio T.  Physician practice in the nursing home: collaboration with nurse practitioners and physician assistants. Ann Long Term Care. 2006; 14: (3) 17-24.
 
Zimmerman S, Gruber-Baldini AL, Hebel JR, Sloane PD, Magaziner J.  Nursing home facility risk factors for infection and hospitalization: importance of registered nurse turnover, administration, and social factors. J Am Geriatr Soc. 2002; 50:1987-95. PubMed
 
Sloane PD, Zimmerman S, Hanson L, Mitchell CM, Riedel-Leo C, Custis-Buie V.  End-of-life care in assisted living and related residential care settings: comparison with nursing homes. J Am Geriatr Soc. 2003; 51:1587-94. PubMed
 
Intrator O, Castle NG, Mor V.  Facility characteristics associated with hospitalization of nursing home residents: results of a national study. Med Care. 1999; 37:228-37. PubMed
 
Baron RJ, Cassel CK.  21st-century primary care: new physician roles need new payment models. JAMA. 2008; 299:1595-7. PubMed
 
Schmidt IK, Svarstad BL.  Nurse-physician communication and quality of drug use in Swedish nursing homes. Soc Sci Med. 2002; 54:1767-77. PubMed
 
Leibovitz A, Baumoehl Y, Habot B, Gil I, Lubart E, Kaplun V. et al.  Management of adverse clinical events by duty physicians in a nursing home. Aging Clin Exp Res. 2004; 16:314-8. PubMed
 
Katz PR, Karuza J.  Physician practice in the nursing home: missing in action or misunderstood [Editorial]. J Am Geriatr Soc. 2005; 53:1826-8. PubMed
 
Katz PR.  The sky is falling [Editorial]. J Am Med Dir Assoc. 2003; 4:115-6. PubMed
 

Figures

Tables

References

Institute of Medicine.  Retooling for an Aging America: Building the Health Care Workforce. Washington, DC: National Academies Pr; 2008.
 
Medina-Walpole A, Barker WH, Katz PR, Karuza J, Williams TF, Hall WJ.  The current state of geriatric medicine: a national survey of fellowship-trained geriatricians, 1990 to 1998. J Am Geriatr Soc. 2002; 50:949-55. PubMed
CrossRef
 
Jones A.  The National Nursing Home Survey: 1999 summary. Vital Health Stat 13. 2002; 1-116. PubMed
 
Spillman BC, Lubitz J.  New estimates of lifetime nursing home use: have patterns of use changed? Med Care. 2002; 40:965-75. PubMed
 
DeFrances CJ, Hall MJ.  2005 National Hospital Discharge Survey. Advance data from vital and health statistics; no 385. Hyattsville, MD: National Center for Health Statistics; 2007.
 
Kasper J, O'Malley M.  Changes in Characteristics, Needs, and Payment for Elderly Nursing Home Residents: 1999 to 2004. Washington, DC: Kaiser Family Foundation; 2007. Accessed athttp://www.kff.org/medicaid/upload/7663.pdfon 15 May 2008.
 
Gruneir A, Mor V, Weitzen S, Truchil R, Teno J, Roy J.  Where people die: a multilevel approach to understanding influences on site of death in America. Med Care Res Rev. 2007; 64:351-78. PubMed
 
Spillman BC, Lubitz J.  The effect of longevity on spending for acute and long-term care. N Engl J Med. 2000; 342:1409-15. PubMed
 
Borger C, Smith S, Truffer C, Keehan S, Sisko A, Poisal J. et al.  Health spending projections through 2015: changes on the horizon. Health Aff (Millwood). 2006; 25:w61-73. PubMed
 
Medicare Payment Advisory Commission.  A Data Book: Health Care Spending and the Medicare Program. Washington, DC: MedPAC; 2008. Accessed athttp://www.medpac.gov/documents/Jun08DataBook_Entire_report.pdfon 26 October 2008.
 
Scanlon WJ.  Nursing Homes: Prevalence of Serious Quality Problems Remains Unacceptably High, Despite Some Decline. Testimony before the Committee on Finance, U.S. Senate, GAO 03-1016T, 17 July 2003.
 
Katz PR, Karuza J, Kolassa J, Hutson A.  Medical practice with nursing home residents: results from the National Physician Professional Activities Census. J Am Geriatr Soc. 1997; 45:911-7. PubMed
 
Caprio T, Karuza J, Katz PR.  Profile of physicians in the nursing home: time perception and barriers to optimal medical practice. J Am Med Dir Assoc. 2009 Feb;10(2):93-7. Epub 2008 Dec 20. [PMID: 19187876]
 
Iglehart JK.  Grassroots activism and the pursuit of an expanded physician supply. N Engl J Med. 2008; 358:1741-9. PubMed
 
Katz PR, Williams TF.  Medical resident education in the nursing home: a new imperative for internal medicine. J Gen Intern Med. 1993; 8:691-3. PubMed
 
Blumenthal D, Gokhale M, Campbell EG, Weissman JS.  Preparedness for clinical practice: reports of graduating residents at academic health centers. JAMA. 2001; 286:1027-34. PubMed
 
Wachter RM.  The state of hospital medicine in 2008. Med Clin North Am. 2008 Mar;92(2):265-73, vii. [PMID: 18298978]
 
Landrigan CP, Conway PH, Edwards S, Srivastava R.  Pediatric hospitalists: a systematic review of the literature. Pediatrics. 2006; 117:1736-44. PubMed
 
Katz P, Karuza J, Lawhorne L, Schnelle J.  The nursing home physician workforce. J Am Med Dir Assoc. 2006; 7:394-8.
 
Karuza J, Katz PR.  Physician staffing patterns correlates of nursing home care: an initial inquiry and consideration of policy implications. J Am Geriatr Soc. 1994; 42:787-93. PubMed
 
Shortell SM, LoGerfo JP.  Hospital medical staff organization and quality of care: results for myocardial infarction and appendectomy. Med Care. 1981; 19:1041-55. PubMed
 
Glasheen JJ, Siegal EM, Epstein K, Kutner J, Prochazka AV.  Fulfilling the promise of hospital medicine: tailoring internal medicine training to address hospitalists' needs. J Gen Intern Med. 2008; 23:1110-5. PubMed
 
Roemer M, Friedman J.  Doctors in Hospitals: Medical Staff Organization and Hospital Performance. Baltimore: Johns Hopkins Univ Pr; 1971.
 
Shortell S, Becker S, Neuhauser D.  The effects of management practices on hospital efficiency and quality of care. Shortell S, Brown M Organizational Research in Hospitals. Chicago: Blue Cross Assoc; 1976.
 
Flood AB, Scott WR.  Professional power and professional effectiveness: the power of the surgical staff and the quality of surgical care in hospitals. J Health Soc Behav. 1978; 19:240-54. PubMed
 
Shortell SM, Schmittdiel J, Wang MC, Li R, Gillies RR, Casalino LP. et al.  An empirical assessment of high-performing medical groups: results from a national study. Med Care Res Rev. 2005; 62:407-34. PubMed
 
United States.  Public Law No. 100-203, Omnibus Budget Reconciliation Act of 1987, 22 December 1987. Annu Rev Popul Law. 1987;14:473-5. [PMID: 12346743]
 
American Medical Directors Association.  CMS Implements Revised Surveyor Guidance for Medical Director Tag. Accessed athttp://www.amda.com/advocacy/medicaldirection.cfmon 5 February 2009.
 
Certified Medical Director in Long Term Care Program. Accessed athttp://www.amda.com/certification/overview.cfmon 20 October 2008.
 
Schols JM, Crebolder HF, van Weel C.  Nursing home and nursing home physician: the Dutch experience. J Am Med Dir Assoc. 2004; 5:207-12. PubMed
 
Kirch DG, Vernon DJ.  Confronting the complexity of the physician workforce equation. JAMA. 2008; 299:2680-2. PubMed
 
Caprio T.  Physician practice in the nursing home: collaboration with nurse practitioners and physician assistants. Ann Long Term Care. 2006; 14: (3) 17-24.
 
Zimmerman S, Gruber-Baldini AL, Hebel JR, Sloane PD, Magaziner J.  Nursing home facility risk factors for infection and hospitalization: importance of registered nurse turnover, administration, and social factors. J Am Geriatr Soc. 2002; 50:1987-95. PubMed
 
Sloane PD, Zimmerman S, Hanson L, Mitchell CM, Riedel-Leo C, Custis-Buie V.  End-of-life care in assisted living and related residential care settings: comparison with nursing homes. J Am Geriatr Soc. 2003; 51:1587-94. PubMed
 
Intrator O, Castle NG, Mor V.  Facility characteristics associated with hospitalization of nursing home residents: results of a national study. Med Care. 1999; 37:228-37. PubMed
 
Baron RJ, Cassel CK.  21st-century primary care: new physician roles need new payment models. JAMA. 2008; 299:1595-7. PubMed
 
Schmidt IK, Svarstad BL.  Nurse-physician communication and quality of drug use in Swedish nursing homes. Soc Sci Med. 2002; 54:1767-77. PubMed
 
Leibovitz A, Baumoehl Y, Habot B, Gil I, Lubart E, Kaplun V. et al.  Management of adverse clinical events by duty physicians in a nursing home. Aging Clin Exp Res. 2004; 16:314-8. PubMed
 
Katz PR, Karuza J.  Physician practice in the nursing home: missing in action or misunderstood [Editorial]. J Am Geriatr Soc. 2005; 53:1826-8. PubMed
 
Katz PR.  The sky is falling [Editorial]. J Am Med Dir Assoc. 2003; 4:115-6. PubMed
 

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Physicians as Nursing Home Specialists
Posted on March 19, 2009
Simon G Kassabian
Jewish Home Lifecare
Conflict of Interest: None Declared

TO THE EDITOR: The proposals by Katz and colleagues (1), about physicians as nursing home specialists, provide a worthy and laudable vision for future possibilities. While it was correctly acknowledged that some of the positive characteristics in nursing home practice, for example "˜little overhead' and others, have similarly attracted practitioners who became hospitalists, an important factor in growth of hospitalists was the role of administrative support. Such support in nursing homes may be lacking if outcomes like "˜increased patient satisfaction and lower hospitalization rates' (2) are perceived by administrators as more economically attainable with nurse practitioners and physician assistants. It may be added that physician involvement, cited as a "˜moderating variable', will need to prove its convincing value in quality of care more broadly, for any economic reluctance to be superseded. As the comprehensive value of physicians is appropriately appreciated, such recognition by non-medical decision makers would allow nursing home specialists to follow the hospitalist experience.

Another factor impacting on clinicians' likelihood of choosing such a career is the exposure of students and residents to others in this field who can act as role-models. The limited familiarity currently would have to reach a certain critical mass to have a meaningful effect on trainees.

Despite the challenges, our profession should strive to ensure Katz' proposals prove not quixotic but visionary.

References:

1. Katz PR, Karuza J, Intrator O, Mor V. Nursing home physician specialists: a response to the workforce crisis in long-term care. Ann Intern Med. 2009;150:411-3. [PMID: 19293074]

2. Caprio T. Physician practice in the nursing home: collaboration with nurse practitioners and physician assistants. Ann Long Term Care. 2006;14(3):17-24.

Conflict of Interest:

None declared

Primary care to nursing home physicians:Where were you when we needed you?
Posted on March 19, 2009
Edward J. Volpintesta
No Affiliation
Conflict of Interest: None Declared

The authors cite a "waning interest in primary care" as one of the reasons to develop nursing home physician specialists. Since it has traditionally been primary care doctors who have provided the major portion of nursing home care, any decline in their numbers will naturally diminish their availability.

It should be mentioned however that one of the reasons why primary care waned over the past several years is because seeing patients in the nursing home added too much work to the already hectic lives of primary care doctors who had trouble enough trying to keep up with hospital rounds and their office patients. With the advent of hospitalists, some got a little relief.

To say that we need nursing home specialists because there is a lack of interest in primary care may lead future historians of medical history to draw the wrong conclusions. If nursing home specialists (and hospitalists) had existed thirty or so years ago, primary care might have evolved then into what it has become now for those who still practice it"”an office-based profession. It might have remained a popular and vital area and the primary care crisis as we know it today might not exist.

Conflict of Interest:

None declared

Nursing home physicians: Response to workforce crisis or primary care crisis?
Posted on March 20, 2009
Edward J. Volpintesta
No Affiliation
Conflict of Interest: None Declared

I agree with the authors' insights . Nursing home specialists like hospitalists are a good and a necessary idea.

As an afterthought , the title of the article would have had more meaning (to me anyway) if it had stated that nursing home physician specialists are a response to the primary care crisis instead of the workforce crisis.

The "workforce crisis" that the authors used in their title is true but it takes emphasis away from how the decline in primary care is primarily responsible.

Conflict of Interest:

None declared

Make long-term care more accessible to a variety of providers
Posted on March 23, 2009
Marie-Luz Villa
University of Washington School of Medicine, Long Term Care Service
Conflict of Interest: None Declared

Although well intentioned, making skilled nursing facility (SNF) practice a specialty might impede entry of practitioners into long-term care, which could be a big tactical error. I witness fine practitioners start to attend residents of SNFs, then become quite attached to this practice setting. They ask questions, become informed, and then proceed to do an excellent job. The level of mentoring involved matters, as well as the emphasis placed on excellent care. Lack of exposure to SNF practice implicates training programs as a cause of long-term care practitioner scarcity. Paperwork involved in providing care to SNF residents deters many. The American Geriatrics Society focuses much attention on the mentoring/teaching roles that geriatricians provide, as well as the regulatory and documentation burden that inhibits viable practices in long-term care. More advocacy from a wider range of medical societies would be great!

Medical director roles improve overall quality of care as well, if SNFs choose active Medical Directors instead of the typical rubber-stamp models. Full integration of the expertise of good medical directors rests heavily on corporate leaders and administrators of SNFs. Encouraging SNFs to fully embrace federal regulations pertaining to expanded roles of medical directors in quality assurance would improve overall quality of health care delivery in SNFs. The American Medical Director's Association spearheads the effort to promote excellence in SNF care delivery on multiple levels.

Greater involvement in nursing home care also could increase home visits. Our frail patients, their families and the health care system are better served if more practitioners include home visits in their practices. SNF care expense as well as cultural mores deter admittance to nursing homes for some groups. The Independence at Home model saves money, increases satisfaction with health care, and provides an exciting option to provision of excellent care. The American Academy of Home Care Physicians advocates this mode of health care delivery, and many patients and insurers embrace it wholeheartedly (http://www.aahcp.org/iahpr.pdf).

Perhaps physicians need a change in self-perception and training. Mid-level practitioners function well in most settings, and benefit from the accessibility of a physician when facing difficult clinical cases. If mid-level practitioners could provide most routine care, and physicians attend for more complicated care, then our scarcity might be transformed into abundance. But prior to instituting another specialty, we should look to the resources already available, and encourage wider participation in long-term care rather than a narrower entry gate.

Conflict of Interest:

None declared

Nursing Home Physician Specialists and Geriatric Medicine
Posted on March 25, 2009
Leslie S. Libow
Mount Sinai School of Medicine
Conflict of Interest: None Declared

The suggestion by Katz and colleagues (1) of creating a Nursing Home medical specialty in the hope of ameliorating the serious shortage of physicians in long term care is creative and bold. It is a natural outgrowth of the field of geriatric medicine and is an appropriate response to the quite modest manpower progress (2), though vigorous academic growth, experienced thus far within the field of geriatric medicine. In addition to this new specialty idea, Katz et al disagree with the Institute of Medicine's recommendation (3) to expand the role and supply of mid-level providers, such as nurse practitioners, in the nursing home as a response to the need not met by physicians. We believe that this acceptance of a "2- level" health system - nurse practitioners, as primary care for the frail elderly in nursing homes and physicians as primary care for most everyone else - needs to be openly discussed for its clinical and ethical implications.

When in 1968, the American Board of Internal Medicine approved as an innovation, the first U.S. residency-fellowship in geriatric medicine, (created by one of the authors, LSL), the primary site of the geriatrics training program was indeed the nursing home (4, 5). Geriatric medicine was defined in the residency-fellowship, as focusing on those multiple "sites and phases" of illness and of health which physicians and the health establishment did not usually embrace. Today there are millions of sub-acutely ill older persons admitted every year to the nursing homes directly from the hospital. Most are complexly ill, recover and return home though many remain for life-long care Needed in the nursing home are large numbers of astute clinicians, their teams and enlightened medical directors. Yet too few physicians select careers in geriatrics and too many fellowship positions remain unfilled (2).

The shortage of physicians in nursing homes can be explained, in part, by the modest financial rewards, the emotional difficulties for some which out- weigh the positives, and the understandable need to deny one's own ultimate aging, frailty and mortality.

The development of a Nursing Home specialty, together with the vigorous struggle within geriatric medicine to keep the field alive and move geriatric knowledge, approaches and skills into the hands of all clinicians, will likely improve the relationship and balance between physicians and their nursing homes. Our nursing home patients remain hopeful of receiving the care they expect and deserve from their "doctor".

1. Katz PR, Karuza J, Intrator O, Mor V. Nursing home physician specialists: a response to the workforce crisis in long-term care. Ann Intern Med. 2009 Mar 17;150(6):411-3.

2.Butler RN. Thoughts on the development of geriatrics. J Am Geriatr Soc. 2007,Dec,(55)2086- 2087.

3.Institute of Medicine. Retooling for an Aging America: Building the Health Care Workforce,Washington, DC; National Academies Pr. 2008.

4. Libow LS. A fellowship in geriatric medicine. J Am Geriatr Soc. 1972, Dec, 20(12):580-4.

5. Libow LS. A geriatric medical residency program. Ann Intern Med. 1976, Nov; 85(5):641-647.

Conflict of Interest:

None declared

Physicians in the Trenches Agree
Posted on March 25, 2009
Heidi K. White
North Carolina Medical Directors Assocition (President) and Duke University School of Medicine
Conflict of Interest: None Declared

Dear editor:

The nursing home in the U.S. and other countries entails a heterogeneous population of short-stay and long-stay residents. Short-stay residents include individuals who come for rehabilitation after a hospital admission, respite stays and palliative care or end of life. Long-stay residents include individuals with cognitive, physical or a combination of impairments that require extensive assistance with activities of daily living. Providing excellent care to these individuals requires extensive knowledge not only of chronic disease management, acute disease management, and geriatric syndromes but also knowledge of the capabilities of the health system, its regulations, and the advantages of the interdisciplinary care team. In this setting physicians need to be adept at quality improvement, transitions of care, dementia diagnosis, the appropriate use of medications, and dementia behavioral management.

New models of care are emerging. In North Carolina we have two thriving long-term care specialty practices. We have many physicians who spend 20% or more of their professional time caring for nursing home patients. We have an active state chapter of the American Medical Directors Association (AMDA). Currently 62 physicians in our state have completed the requirements to become certified medical directors through a process provided by AMDA. We believe that excellent care means being in the nursing home on a predictable schedule so that members of the interdisciplinary care team can discuss relevant issues, family meetings can be scheduled and routine care can be provided and discussed with nurses and other care providers.

Physicians are the best trained practitioners to manage the care of nursing home patients. This care may be provided in collaboration with nurse practitioners and physician assistants, but should not be abdicated to non-physicians providers without physician involvement. There are excellent and experienced nurse practitioners and physician assistants who are providing comparable and in some cases better care, than what is currently provided by physicians. However, the complexity of the clinical cases, the frequency of care transitions to the hospital, home and other intermediate settings, the expectations of patients and their families, and the leadership needed to ensure quality healthcare in the nursing home requires that physicians remain in a role of providing and managing care for individual patients in the nursing home.

We are strongly in favor of creating a nursing home specialty that would highlight the degree of involvement in nursing home care, recognize the unique competencies of these physicians, and require a medical staff model that fosters the specialty and improves the quality of care provided to individuals in need. We are not in favor of hindering physicians who only spend a small percentage of their professional time in nursing homes. Moving toward creating a nursing home specialty should be done in such a way that would not in anyway restrict young physicians or experienced physicians from participating in nursing home care even at a level of less than 20% of their time, especially if this will eventually lead to a greater time commitment or will fulfill a need in a rural setting. Since physicians-in-training currently receive little exposure to this care setting, it will continued to be important for physicians at all experience levels to have the opportunity to tryout this practice setting, hopefully with the availability of appropriate mentors.

Conflict of Interest:

None declared

Nursing Home Physician Specialists: Perhaps a Start but the Bigger Challenge is Ahead
Posted on March 27, 2009
Cheryl L Phillips
On Lok Lifeways
Conflict of Interest: None Declared

The authors, Katz, et al, present a provocative and appealing model to address the present challenge and looming crisis of attracting committed and trained physicians into nursing home care (1). The barriers to such practice are already assumed. Drs. Katz, Karuza, Lawhorne, and Schnelle, in a 2006 report noted that only 1 and 5 physicians who were identified as primary care stated that they had any involvement in nursing home care and of those that did, the average was only 2 hours per week (2). Furthermore, the survey of the American Medical Directors Association, the national association of approximately 4000 nursing home medical directors, found in their survey published in 2006 that 18 percent of member respondents had reduce their attending physician hours in the preceding three years, and 7 percent had stopped working as an attending in nursing home entirely (3). While assumptions abound as to why physicians do not seek to provide care in nursing homes, one point that the authors make clear is that nursing home care is not just like other settings of health care. Although the individual patients are often the same ones that primary care physicians saw in their office the week before, or even discharge from the hospital the day before, the domain of the nursing home poses for many physicians a complex and highly regulated world. It is team-based, a dynamic that many physicians have little experience or comfort with. It requires knowledge of the regulatory world, the skills of functional assessment and rehab and requires the ability to integrate patient and family goals into care plans that may extend into years, rather than the few days typical of the acute hospital. In addition, the population served is not homogenous by age, goals of treatment or functional limitations. In many ways the nursing home is the ideal setting to apply clinical skills in the care of complex patients in the context of person-centered values over an extended time frame. But without the knowledge, vocabulary and training that follows any unique delivery of care system or specialty, the challenge for most physicians is simply daunting.

So, would specialty recognition, defined time requirements for on-site service and "closed" medical staffs provide the bridge to cross this perceived chasm for physicians? While I believe such a concept has considerable appeal and potential, it is important to point out that not only do other significant barriers continue to exist as a deterrent to physician nursing home practice, but that this set of recommendations creates some challenges as well. The first issue is that of liability risk. M. Kapp, JD, in his 2008 issue brief to the California HealthCare Foundation noted that while not the sole reason physicians avoid NH care, liability risk is often mentioned as a negative factor4. While specialty status might afford some theoretical "protection" to lawsuits, the incentives for including the attending physician in such litigation are often entirely separate from his/her level of training or experience. Success in attracting significant numbers of physicians who would wish to identify themselves as "SNFist" or nursing home specialists, will require both torte reform and demonstration that the real and perceived risks are balanced and manageable (and insurable by liability carriers).

Another barrier to advanced training requirements and closed staff models are often the very nursing home leaders (owners, executive officers, and administrators) themselves. In communities with competitive markets and excess available nursing home beds, the performance measure for success is "a head in the bed." Thus, a "good" physician is one that provides a volume of admissions, and allows the NH to primarily manage the care. While we all recognize the short-term thinking of such logic, and know that well-trained, committed physicians will far better support the success of the nursing home over time (both financially and in regulatory compliance), it is often difficult to get the NH to end a relationship with a physician who provides poor quality of care but can be counted on for frequent admissions.

Lastly, the authors seek to compare the advantages to the growing prevalence of the hospitalist model to the described nursing home specialist model. It is important to note that, while much good has been part of this hospitalist trend, all is not perfect. The challenges of transitions of care are multiplied. Advance care planning is often moved to a lower priority after focusing on reducing the length-of-stay and moving the patient to the next level of care as quickly as possible. Families and patients bemoan the loss of physician continuity and remember when "my doctor used to see me here". Specialty designation will do little to resolve these challenges of fragmented care and the stated specific time requirements may be a disincentive to those few primary care physicians who are still willing to follow their own patient into post-acute and custodial long term care settings.

Clearly the challenges to attract physicians to the specialty nursing home care, with its unique settings and specific required skills, are significant. Yet it is unacceptable and unsustainable to continue to nursing home care as separated from the professional standards, peer review and specialty expertise found in "regular" medical care. Not only will the status quo further drive the work force crisis, but the quality of care delivered to these vulnerable patients will suffer. While I believe that full implementation of the elements defined by the authors will take decades to resolve and implement, the value to the development of a core curriculum and some level of professional recognition of advanced training in nursing home practice will have an immediate value to those who presently commit their professional services to the nursing home environment, and for those who are yet to join.

References:

1. Katz P, Karuza J; Intrator O, Mor V. Nursing Home Physician Specialists: A Response to the Workforce Crisis in Long-Term Care. Annals of Internal Medicine. 2009; 150: 411-413.

2. Katz P, Karuza J, Lawhorne L, Schnelle J. The Nursing Home Physician Workforce. JAMDA. 2007; 7: 394-398.

3. American Medical Directors Association. "Medical Liability and the AMDA Physician" member survey. www.amda.com/about/liabilityfacts 2006.

4. Kapp M. Is There a Doctor in the House? Physician Liability Fears and Quality of Care in Nursing Homes. California HealthCare Foundation Issue Brief; September, 2008.

Conflict of Interest:

None declared

NURSING HOME SPECIALISTS
Posted on March 30, 2009
William B Freedberg
Tufts Medical Cenrer
Conflict of Interest: None Declared

As a partly retired board certified internist and geriatrician who has spent most of the past dozen years primarily caring for patients in the nursing home setting, I was very interested to read the recent article by Katz et al, in the March 17 Annals. More than 80 percent of my "evaluation and management" encounters in a typical month are for patients in Nursing Homes, including subacute care, long term care, or hospice. I wish to offer some comments.

Firstly, do we really need another specialty type of certification, replete with more examinations, more requirements, more paperwork, more fees, and its own small bureaucracy to administer things? Would this form of "certification" then become a further barrier to keeping those doctors who already see nursing home patients "in the game" as well as a barrier to having more doctors become involved?

Secondly, I did not know that we were involved in a less than legitimate medical practice setting. Those of us who see nursing home patients come to that type of practice from a variety of levels of experience and different types of credentials, but share a commitment to caring for this very deserving and complex group of patients, often no longer "connected" to their previous primary care doctors and sent to our care from the hospital frequently with incomplete information. Much important history can easily be lost in the series of hand-offs from the community physician to the hospitalists and house staff and then from the hospital team to the providers at the nursing home who will often be caring for them for the rest of their lives.

It is true, though, that those of us who care for patients in the nursing home often feel, not that we are not legitimate, but that [to quote Rodney Dangerfield] "we don't get no respect." I believe that the best cure for this is the telephone---I feel better taking over the care of the patient when I have heard directly from the hospitalist or house staff team with their report on the patient and what needs to be done. The discharge paperwork, or electronic summary, can often be ambiguous or contain conflicting statements.

It is also true that nursing home providers need to pick up the phone and do their detective work, calling up the patients' family members and previous community doctors, as well as the hospital team, This may take extra time in the beginning, but prevent mistakes form being perpetuated "down the line."

Finally, I have had the rewarding privilege of bedside teaching of residents and geriatric fellows, as well as physician assistant and nurse practitioner students in the nursing home setting. Whether rounding with the nursing home practitioner for just a few days or for a month or longer rotation, this should be an important part of every new practitioner's training. Those numbers of elderly confined to the nursing facilities 1.6 million and growing will surely challenge us all.

I am grateful to be able to read an article about doctors who do what I and doctors like myself do. Nonetheless, I think it is important to state that we and our practice settings are "legitimate" in every sense of the word, and that creation of a new certification program, while an appealing idea in some respects, does not directly address the greatest need that nursing home practitioners have: improved communication with our peers in the hospital and community settings.

Conflict of Interest:

None declared

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