“There is no heavier burden than an unfulfilled potential.” – Charles M. Schulz, cartoonist The COVID-19 pandemic has focused renewed attention on the medical aspects of care in the nursing home. The many complications of managing these patients and the complexities of infection control have pointed out the challenges inherent in contemporary PALTC. Medical practitioners and medical directors have played a central role in managing patients and guiding facilities. It is a good time to take a fresh look at medical direction. This month’s column will consider why it is so important and how it relates to the Omnibus Budget and Reconciliation Act of 1987 (OBRA) regulations. The 1960s and 1970s saw some early discussions of the critical role of medical care and physicians in the nursing home (J Am Coll Nursing Home Adm 1973;1:19; J Long Term Care Adm 1974–1975;3:19–59). In 1974, the first medical director requirements were approved for skilled nursing facilities. In 1977 — the same year that AMDA – The Society for Post-Acute and Long-Term Care Medicine was founded — the American Medical Association (AMA) published a series of articles about the nursing home medical director. Herman Gruber, secretary of the AMA’s committee on aging, explained and supported the key role of medical directors (J Am Geriatr Soc 1977;25:497–499). Mr. Gruber noted that “the area of greatest responsibility and greatest challenge to the medical director lies in promoting the quality of care within the nursing home. The medical director should not only assess quality but also promote it.” Four decades later, this idea is still on target. The 1980s and 1990s saw further development of the medical director job responsibilities (JJ Pattee and O Otteson, Medical Direction in the Nursing Home, Northridge Press, 1991; SA Levenson, Medical Direction in Long-Term Care, Carolina Academic Press, 1993) and the beginning of medical director training programs. In the 2020s, medical direction is a well-developed discipline that still seeks optimal implementation. The medical director requirement was a part of early SNF regulations dating to 1974. The OBRA ’87 regulations expanded the requirement to include intermediate (i.e., residential long-term) care as well. In the most recent revision (2016–2019) of OBRA regulations and surveyor guidance, F841 (formerly F501) covers medical direction. Section 483.70(h) requires every facility to designate a physician to serve as medical director. The two key medical director functions are (1) implementation of resident care policies and (2) coordination of medical care in the facility. The facility must identify how the medical director will fulfill his/her responsibilities to effectively implement resident care policies and coordinate medical care, and must have a process to review and address the medical director’s performance. “Resident care policies” refers to the facility’s overall goals, directives, and governing statements that direct the delivery of care and services to residents consistent with current professional standards of practice. “Coordination of medical care” refers not only to the care provided by medical practitioners but also to the integration of all care in the facility. Another key medical director role identified in the State Operations Manual (SOM) is helping ensure the appropriateness and quality of medical and medically related care. OBRA identifies that the overall objective of medical director activity — as it is for everyone — is to ensure that residents attain or maintain their highest practicable physical, mental, and psychosocial well-being, consistent with current professional standards of practice. Surveyor guidance defines “current professional standards of practice” as “care, procedures, techniques, treatments, etc., that are based on research and/or expert consensus and that are contained in current manuals, textbooks, or publications, or that are accepted, adopted or promulgated by recognized professional organizations or national accrediting bodies.” While that is a reasonable definition on paper, it is quite another matter to determine just what parts of the vast literature and numerous guidelines should be followed and promoted. It is noteworthy that the Centers for Medicare & Medicaid Services does not identify the OBRA regulations, or practicing by the regulations, as the basis for “current standards of practice.” In other words, the OBRA survey process is specifically for reviewing compliance with the conditions of participation for reimbursement under Medicare and Medicaid, but it is not the principal means for such compliance. So, from a regulatory standpoint, a medical director is essentially the principal clinician in a facility. The SOM identifies specific medical director responsibilities in approximately 50 different places (e.g., feeding tubes, dialysis, rehabilitative and restorative care, incontinence, and whether nursing staff have the competencies to care for the residents). Interdisciplinary team (IDT) members should be aware that the medical director is specifically expected under OBRA to be part of an effective collaborative effort to optimize all resident policies and practices in the facility. Over the past year, this column has covered reasons for having this degree of medical oversight. It has nothing to do with the politically contentious notion that physicians are telling everyone else what to do. Instead, it relates to the fact that providing care requires a comprehensive approach with a scientifically valid foundation. The 1986 Institute of Medicine report, which provided the basis for the OBRA regulations, specifically identified geriatrics as a key foundation of appropriate nursing home care. It emphasized the many advances in geriatrics, including the key idea that many conditions that were previously assumed to be the result of old age could be treated or alleviated (Institute of Medicine, Improving the Quality of Care in Nursing Homes, National Academies Press, 1986). However, as discussed in this column (March 2020 through January 2021), clinical practice goes well beyond just the medical aspects. All resident and patient outcomes are affected by how we think about and try to address symptoms and their underlying causes. Person-centered care requires that all treatment be given in the proper context and should focus on how it affects optimal physical, functional, and psychosocial well-being. Conversely, all psychosocial and functional aspects of care must be correlated with the underlying medical issues (J Am Geriatr Soc 2016;64:15–18). The medical director must collaborate closely with facility management and all IDT members to promote and support holistic, person-centered care in practice, not just in theory, by advising about current standards of practice and guiding adherence to the care delivery process. This includes influencing methods: how IDT members draw conclusions or render opinions about causes or recommend management of patients’ symptoms and conditions. The medical director must be a major influence on overall practice and performance. For example, no matter what the symptom or situation (falls, weight loss, aggressive behavior, etc.), multiple symptoms may have common causes, and there may be multiple causes of a single symptom or problem. The medical director should guide and advise about the benefits of formulating a unified picture of the patient that provides a foundation for everyone’s subsequent work, as opposed to the drawbacks of “vertical integration” — a siloed care plan that results from multiple simultaneous but separate activities and decisions. For example (as per our January 2021 column), all behavior emanates from the brain, and the brain is influenced by everything else going on in the body. Therefore, the medical director must collaborate with others (e.g., nurses, social workers, management, and psychiatric consultants) to guide policies and practices regarding behavior and psychiatric symptoms. Not everyone needs to be skilled at adequate problem definition and cause identification, but everyone should know that behavior and mood disturbances often have correctable medication-related causes (Med Lett Drugs Ther 2008;50:100–104). Therefore, all IDT members — including medical practitioners — must consider the impact of all current medications for any resident with behavior and mood issues, including individuals with dementia. Nursing home admissions often come from elsewhere with unresolved issues such as pain, falls, and impaired function. Some of these problems result from age and irreversible illnesses. However, much of geriatrics care is, “in effect, remedial. It addresses problems produced by the care of others, errors of both commission and omission. Were other medical practitioners to become more sensitized to the needs of their frail older patients, the need for geriatric care as a separate activity would decline” (C Boult et al., “How Effective Is Geriatrics? A Review of the Evidence,” in PR Katz et al, eds., Quality Care in Geriatric Settings: Focus on Ethical Issues, Springer, 1995). The medical director has a major responsibility to promote collaboration in identifying remediable issues in nursing home residents and to try to optimize care after admission to minimize the need for subsequent remediation. Opinions have always varied widely as to desirable medical director roles. For example, a 1978 article presented the views of over 1,000 administrators, nurses, and physicians about the responsibilities, authority, and impact of the nursing home medical director (J Am Geriatr Soc 1978;26:157–166). Despite some areas of agreement, the respondents were divided on the desirability of more “activist” roles. Many physicians were reluctant to have medical directors become a chief of service or act in a consultant role. Over 40 years later, many medical directors nationwide are supported and do a stellar job. Others do a limited job, and some do little or nothing noteworthy. Many facilities use their medical directors effectively, some use them partially, and still others want medical directors to just improve their census, do as little else as possible, and mostly stay out of everyone’s way. Many still don’t understand what medical directors do or how to get what they need from them. Basically, a medical director who does the job right is going to have some impact on the care of patients and the prerogatives of IDT members. There is a huge need for uniform processes and totally coordinated care, where each professional discipline must subordinate its practices to some extent to a bigger picture. Although some professionals understand and accept the practical implications of this approach, many still resist or reject it. The problem is that nursing homes have changed dramatically over the past half-century. Their residents reflect both an aging, increasingly disabled population and a vast array of complex medical and clinical issues, including a post-acute population with numerous conditions and challenging problems. Furthermore, the medical director’s responsibilities require familiarity with current professional standards of practice and the administrative and management aspects of the role. Knowledge and training are still major issues, although more than enough good-quality material exists. Only some physicians and facilities are aware of, or have utilized, the substantial curriculums and numerous other references and resources for attending physicians and for medical directors. Thus, after half a century, there are still major challenges to the practical implementation of the medical director’s role to meet regulatory expectations and fulfill the potential that has been acknowledged in the OBRA regulations and subsequent guidance. There are also many practical challenges such as on-call coverage and malpractice insurance. Next month’s column will explore in detail how we can address these challenges regarding medical direction in order to help move PALTC forward. Dr. Levenson has spent 42 years working as a PALTC physician and medical director in 22 Maryland nursing homes and in helping guide patient care in facilities throughout the country. He has helped lead the drive for improved medical direction and nursing home care nationwide as author of major references in the field and through his work in the educational, quality, and regulatory realms.