Paul R. Katz, MD; Jurgis Karuza, PhD; Orna Intrator, PhD; Vincent Mor, PhD
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.
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Simon G Kassabian
Jewish Home Lifecare
March 19, 2009
Physicians as Nursing Home Specialists
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variable', will need to prove its convincing value in quality of care more broadly, for any economic reluctance to be superseded.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.
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.
Edward J. Volpintesta
Primary care to nursing home physicians:Where were you when we needed you?
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.
March 20, 2009
Nursing home physicians: Response to workforce crisis or primary care crisis?
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.
University of Washington School of Medicine, Long Term Care Service
March 23, 2009
Make long-term care more accessible to a variety of providers
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.
Leslie S. Libow
Mount Sinai School of Medicine
March 25, 2009
Nursing Home Physician Specialists and Geriatric Medicine
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.
Heidi K. White
North Carolina Medical Directors Assocition (President) and Duke University School of Medicine
Physicians in the Trenches Agree
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.
Cheryl L Phillips
On Lok Lifeways
March 27, 2009
Nursing Home Physician Specialists: Perhaps a Start but the Bigger Challenge is Ahead
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.
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.
William B Freedberg
Tufts Medical Cenrer
March 30, 2009
NURSING HOME SPECIALISTS
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.
Katz PR, Karuza J, Intrator O, et al. Nursing Home Physician Specialists: A Response to the Workforce Crisis in Long-Term Care. Ann Intern Med. 2009;150:411–413. doi: 10.7326/0003-4819-150-6-200903170-00010
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