Increasing the quality of medical care in the nursing home setting.

Abstract

To the Editor: I attended the biannual meeting of the Special Interest Group on Long-Term Care (jointly sponsored by the AGS and the American Medical Directors Association (AMDA)) at the annual AMDA meeting in San Antonio, Texas, on April 8, 1998. One of the issues discussed was the increasing number of medical malpractice lawsuits against nursing homes, especially in the state of Florida. One of the physicians in the audience also mentioned the issue of qualifications for medical directors. I discussed it with various physicians in attendance at the meeting and I realized that it also is an issue of concern to other physicians involved in long-term care. Because I am the only geriatrician member of the Longterm Care-Rehab Council of the American Hospital Association (AHA), I broached this issue with the other Council members at a quarterly meeting in San Antonio the next day. Most of the Council members are hospital and long-term care administrators. The Council represents approximately 2600 AHA member institutions, all of which have either long-term care or rehabilitation components. I mentioned the concern about increasing malpractice litigation. I stated my opinion that quality of medical care begins with a qualified medical director who can significantly influence the risk of medical malpractice in that institution. I then stated the options available to physicians who might serve as medical directors. These include: (1) the certificate of added qualifications in Geriatric Medicine (CAQ) available to internists and family physicians; (2) geriatric fellowship training; (3) certification as a medical director (CMD) by AMDA; and (4) the new program initiated by the AGS encouraging physicians to seek geriatric continuing education (Geriatrics Recognition Award — 150 hours every 4 years). Approximately 8000 physicians hold a CAQ, another 800 plus are fellowship trained, and approximately 2000 physicians are certified medical directors (CMD). Because of the newness of the GRA, only a small number of physicians have completed this program. I was stunned during the discussion when these administrators told me they were not aware that such options actually existed. They wanted to know more; they requested that representatives of the AGS and AMDA be invited to the next meeting and that efforts be made to collaborate and network for the benefit of the member institutions. Though federal and state guidelines require that a nursing home have a medical director, they are not specific about time commitment nor specific qualifications. The regulations state simply that the medical director is responsible for quality assurance. Unwritten responsibilities of the medical director include attendance at and assistance with other functions such as infection control, utilization review, and credentialing. This role is often assumed by those who are retired or semi-retired and is often complicated by the lack of reim-bursement for the position. One study of 50 nursing homes in Texas indicated that 28% of medical directors received no reimbursement for medical direction, and the mean monthly earnings was $345.00.1 Another study of 45 nursing homes in upstate New York showed that the self-reported time spent on medical direction activities averaged 12 hours per month, with 45% of medical directors spending 8 hours or less per month on this function.2 Evidence of improved quality of care is shown in a recent study of provider practice patterns in nursing home-acquired pneumonia involving six nursing homes in Seattle, Washington.3 Providers with CAQ in Geriatric Medicine were more likely to achieve a significantly higher cure rate. This is not to say that there are not exceptional physicians who are providers and who are in medical director positions who do not meet one of these four options. Also, these four options may not be realistic for certain nursing homes because of the geographical maldistribution of physicians who meet these criteria. Likewise, physicians who meet one of these options may elect not to serve as medical directors because of the necessary time commitment, lack of interest, or the reimbursement issue. It is also noteworthy to mention that the largest group of physicians who meet one of these options, those who hold a CAQ, may be dwindling in number because many of them may elect not to become recertified. Nevertheless, opportunity exists for the AGS, AMDA, and AHA to collaborate to educate its members about the need for increasing the quality of care in the long-term care setting with an expected outcome of reducing medical malpractice litigation. Equally as important is for the three organizations to lobby the appropriate federal agencies that regulate nursing homes. In order to achieve optimum quality of medical care, issues that must be addressed in federal and state regulations include specific qualifications of the medical director, minimal and maximum numbers of hours worked per week or month, and adequate reimbursement.