Long-term Care Physicians Research Articles

Liability Insurance Issues Still Vex Members

One-quarter of AMDA members reported problems obtaining or renewing professional liability insurance coverage, with some carriers refusing coverage or imposing conditions on long-term care physicians, according to a recent AMDA survey of 409 members. More than 5% said they were refused coverage because they worked in nursing facilities, while 7% had carriers impose conditions on their coverage policies. This comes at a time when the insurance market seems to be stabilizing, with reports of carriers who ceased coverage down from 26% last year to 5% this year. In the results released last month, members indicated that they have pieced together coverage for their varied practices. The majority, or 73%, said they have in place coverage for their practices. Sixty-two percent said they have coverage in place for attending physician services, and (59%) for their administrative duties as medical director. Two-thirds paid for their own office practice policies, but facilities paid for two-thirds of medical director policies. When coverage was available, some carriers attached provisions to policies, including restricting practice to current patients, ceasing nursing facility work, or ceasing medical director work. When medical directors were covered for their administrative responsibilities, 46% were listed on the nursing facility policy by title as medical director. Others were covered by being listed on facility liability policy by name (8%), or by having responsibilities listed (11%). Still others were covered through an indemnity clause in the physician's contract with the facility (12%), or directly by an individual insurance carrier on a medical director policy (5%). Coverage for medical director responsibilities seems to be improving somewhat. In the past 3 years, there has been a 15% increase in nursing facilities adding medical directors to their institutional policies by name, title, or responsibilities. An additional 3% of facilities added an indemnity clause to the medical director's contract. Less than 2% reported that facilities removed medical director coverage from policies or removed an indemnity clause from the contract. Still, the informal survey showed that liability concerns influenced 17% of medical directors to modify their practices in the past year. More than 4% have stopped working as medical director at one or more facilities, while 8% said they have limited their work as medical directors. The issue of medical liability remains a concern for long-term care physicians. Still, only two indicated that they had had claims against them in their capacities as medical directors. More than 12% reported no coverage for their medical director responsibilities, and 27% said they believe they are covered but do not know how. “We remain concerned about the percentage of physicians who are without coverage for their medical director responsibilities, or those who are unsure how they are covered,” said Lorraine Tarnove, AMDA's executive director. Despite “modest reports of liability claims against medical directors, we believe it not prudent to ‘go bare’ in long-term care. Those physicians who have coverage should be very clear about how they are covered and any conditions that may be attached to their coverage,” she added.

Part D ‘Doughnut Hole’ Could Weigh into the Election

Part D ‘Doughnut Hole’ Could Weigh into the Election

Physician Involvement in Long-Term Care: Bridging the Medical and Social Models

Long-term care is not easy to define. The boundaries between primary and acute and long-term care have become blurred.1,2 It is not surprising, therefore, that there is no consensus on the extent to which physicians are, and should be, involved in long-term care delivery. The purpose of this article is to explore the current and potential role of physicians in long-term care and the challenges to their involvement, to identify models of successful physician engagement in long-term care settings, and to suggest strategies that should be explored to increase appropriate physician participation in the long-term care system to help adequately meet the demand for quality services in our aging society.

AMDA Guidelines Clarify Treatment Goals

AMDA Guidelines Clarify Treatment Goals

Dealing With Dilemmas of Advance Directives

Dealing With Dilemmas of Advance Directives

‘Caring for the Ages’ Marks Shift in Leadership

‘Caring for the Ages’ Marks Shift in Leadership

A Call to Improve Part D Implementation

A Call to Improve Part D Implementation

Alzheimer’s Treatment in Nursing Homes: Room for Improvement

Managing Alzheimer's disease (AD) continues to challenge long-term care physicians and administrators. Although pharmacologic treatment can substantially benefit AD patients in the nursing home setting, common misconceptions and skepticism about its value are barriers to treatment use. Aggressive treatment for AD maximizes patient function and independence and is cost-effective. Herein we discuss state-of-the-art treatment of AD with a view to providing nursing home physicians a framework from which to make treatment decisions.

Consensus sur la démence de type Alzheimer au stade sévère

Under the auspices of the French Society of Gerontology and Geriatrics, a multidisciplinary group of experts, including geriatricians, neurologists, epidemiologists, psychiatrists, pharmacologists, and public health specialists developed consensus recommendations about care for patients with severe dementia. They defined 21 recommendations for general practitioners, long-term care physicians, and specialists, based on the knowledge currently available (2005). The aim of care at all stages is to mitigate the quality-of-life of patient, caregiver, and family insofar as possible, combining care and future planning until the end of life. Management, to take into account problems including nutritional status, behavior disorders, and ability (or inability) to perform activities of daily living, must be global, multidisciplinary, and coordinated and must optimize use of local medical and social resources. The group also stressed the importance of clinical research to improve knowledge of disease course and assess management strategies and recommended specific area for research.

Consensus sur la démence de type Alzheimer au stade sévère

Under the auspices of the French Society of Gerontology and Geriatrics, a multidisciplinary team including geriatritians, neurologists, epidemiologists, psychiatrists, pharmacologists and public health specialists developed a consensus on care for patients with severe dementia. They defined 21 recommendations for general practitioners, long-term care physicians and specialists based on knowledge available in 2005. At all stages of the disease, the objective of care is to improve as much as possible quality-of-life for the patient and his/her family, including a life project until the end of life. It is always possible to do something for these patients and their family: nutritional status, behavior disorders, and incapacities to deal with basic activities of daily life have to be taken in consideration. Resource allocation and proximity care have to be targeted. Research areas necessary to improve the care of patients with severe dementia has been selected.

A Pilot Study of CME on Risk Management in Long-Term Care

This pilot study's purpose was to evaluate behavioral changes among medical directors and physicians following CME on risk management in long-term care (LTC) facilities. The setting was a satellite conference at the AGS Meeting Symposium 2000. CME participants included 51 medical directors, attending physicians, and nurses. Evaluations were based on 20 LTC medical directors and physicians. Descriptive statistics were used for outcome measurements. Respondents (n = 15, 75%) “committed” to an average of 3 changes. Of the 45 commitments, no progress was reported on 8 (17.7%); another 8 commitments were reported as fully completed. The mean implementation rate was 60%. LTC physicians departed the course with intentions to alter their behaviors, but important obstacles such as “lack of time” and “staff not available or interested” interfered with implementation.

Dehydration in frail, older residents in long-term care facilities.

All human beings require adequate fluid and electrolyte balance to survive and to function normally. Water (also called “fluid”) and electrolyte imbalances often cause, exacerbate, or are exacerbated by, significant clinical illness. Adequate hydration must be considered carefully in determining the overall needs of frail, older individuals, because dehydration is the most frequent fluid and electrolyte disorder observed in long-term care (LTC) populations. Not infrequently, a subtle, complex picture challenges the clinical insights of the LTC staff and primary care provider. Hydration deficits range over a spectrum from minor or asymptomatic to profound and life threatening. While the term “dehydration” is often used to identify any degree of hydration deficit, it should be reserved for more advanced stages. Dehydration is the reduction of total body water due to limited intake of fluids and/or pathological fluid loss. The frail elderly are at high risk for dehydration, which may increase the severity of an illness as well as the risk of death. Indeed, dehydration renders frail older people residing in LTC facilities more susceptible to developing a number of morbidity-inducing conditions and infections (Table 1). To reduce the risk of such occurrences, LTC physicians and health care professionals must focus on fluid and electrolyte balance as much as on essential nutrients such as calories and vitamins. This article is the first in a series of three articles that are dedicated to hydration issues in LTC. It focuses on the important scientific and medical basis for managing fluid and electrolyte balance. The second article will focus on facility and medical director roles in managing fluid and electrolyte balance, and the third will discuss survey issues related to hydration.

CME DIGEST INTRODUCTION

For the third year, we are pleased to provide this annual CME Digest of articles from the Journal of the American Medical Directors Association. This year, JAMDA joined the ranks of journals indexed by Index Medicus, proclaiming that long-term care is finally coming into the broad consciousness of scientists, physicians, and other clinicians across the scope of medicine. This year, as we have worked collaboratively with other medical associations, we have found a growing recognition that thousands of primary care physicians are seeing patients in nursing homes and other long-term care facilities. The challenge for the American Medical Directors Association, an organization whose members recognize it for its unique and practical education and information, is to reach out and touch all those clinicians. This publication is one such effort. We know that we cannot expect every long-term care physician, nurse practitioner, or physician assistant to make their way to an AMDA meeting, but surely the Digest and other distance learning on our web site allows these clinicians the opportunity to read the best articles from the year and to gain some CME credits in the bargain.

The Ombudsman Program: An Overview of the History, Purpose, and Role of Ombudsmen in Long-Term Care Facilities

Long-term care ombudsman programs were established by Congress in the early 1970s to provide a community presence in long-term care facilities. Ombudsmen are advocates who identify, investigate, and resolve individual and systems level complaints that affect residents in nursing homes and assisted living facilities. This article provides an overview of the program and addresses ways in which ombudsmen can work with long-term care physicians and nurses as addressed by the following scenario.

The Ombudsman Program: An Overview of the History, Purpose, and Role of Ombudsmen in Long-Term Care Facilities

Long-term care ombudsman programs were established by Congress in the early 1970s to provide a community presence in long-term care facilities. Ombudsmen are advocates who identify, investigate, and resolve individual and systems level complaints that affect residents in nursing homes and assisted living facilities. This article provides an overview of the program and addresses ways in which ombudsmen can work with long-term care physicians and nurses as addressed by the following scenario.

Basic Standards for Physicians in Long-Term Care

I have been a medical director since 1986 and am grateful for the expertise I have developed through my involvement with the American Medical directors Association (AMDA) and the California Association of Long-Term Care Medicine (CAL-TCM). Our work is done in a highly regulated environment, and our patients' problems are multifaceted and complex. Unfortunately, most of my colleagues, even the medical directors, seem complacent about their lack of knowledge in these areas.

The Ombudsman Program: an overview of the history, purpose, and role of ombudsmen in long-term care facilities.

Long-term care ombudsman programs were established by Congress in the early 1970s to provide a community presence in long-term care facilities. Ombudsmen are advocates who identify, investigate, and resolve individual and systems level complaints that affect residents in nursing homes and assisted living facilities. This article provides an overview of the program and addresses ways in which ombudsmen can work with long-term care physicians and nurses as addressed by the following scenario. An elderly nursing home resident is anxious about the uncaring attitude and impatience shown by one of the nursing assistants providing care. She is afraid to say anything for fear of retaliation, but one day decides to talk to the local ombudsman who is visiting the facility. As an advocate for long-term care residents, the ombudsman assures her that anything she says is in confidence. In listening to more residents, the ombudsman learns that several are afraid of this particular aide, and the ombudsman meets with the charge nurse who assures her that she will follow up with the director of nursing. The in-service coordinator conducts sessions on stress reduction and abuse prevention, and the ombudsman talks to the resident council about resident rights. The ombudsman continues to monitor the situation until it improves. Events like this are happening every day with the help of the Long-Term Care Ombudsman Program, as dedicated people volunteer their time to make a difference in the quality of care and lives of residents in long-term care facilities throughout the country. WHAT IS THE OMBUDSMAN PROGRAM?

Physician Behavior Changes Following CME on the Prospective Payment System in Long-Term Care: A Pilot Study

Physicians must understand regulatory changes in long-term care (LTC) and adhere to prospective payment system (PPS) guidelines for minimum data set (MDS), resource utilization groups (RUG) and resident assessment instrument (RAI) processes, documentation, and evaluation. We pilot-tested "Prospective Payment System in LTC," a 7.5 hour continuing medical education (CME) program designed to help participants make plans to implement and adhere to PPS guidelines and regulatory requirements. Twelve medical directors or attending physicians participated. A "commitment to change" evaluation assessed whether participants' plans were reasonable and were implemented, and what barriers interfered. Participants identified 3-5 changes they intended to make. Three months later, participants estimated actual implementation of intended changes, identified obstacles to success, and rated PPS's impacts on patient care. Respondents "committed" to an average of 3.4 changes ranging from "better monitor transfers from LTC to acute care" to "train nurses re MDS and RUGs." Of 40 commitments, 0%100% progress were reported on 9 (23%) each. Mean implementation rate was 41%. Removing responses reporting 0% implementation, the rate was 53%. Common barriers were "lack of time," and "can't get attending MDs to meetings." MDs' ratings of PPSs' impacts were neutral (2.9 on a scale where 1 = "PPS causes great deterioration in quality of care," 3 = "...no change." and 5 = "...great improvement.") both immediately and 3 months post-course. Participants made reasonable plans consistent with course objectives and made progress implementing most intentions. LTC physicians who attended the CME course intended to alter their behaviors, but significant obstacles interfered, at least in the short term. Most thought PPS would not change the quality of care provided in their institutions. Future courses should address implementation barriers.

Physician Behavior Changes Following CME on the Prospective Payment System in Long-Term Care: A Pilot Study

<h3>Introduction</h3> Physicians must understand regulatory changes in long-term care (LTC) and adhere to prospective payment system (PPS) guidelines for minimum data set (MDS), resource utilization groups (RUG) and resident assessment instrument (RAI) processes, documentation, and evaluation. We pilot-tested "Prospective Payment System in LTC," a 7.5 hour continuing medical education (CME) program designed to help participants make plans to implement and adhere to PPS guidelines and regulatory requirements. <h3>Methods</h3> Twelve medical directors or attending physicians participated. A "commitment to change" evaluation assessed whether participants' plans were reasonable and were implemented, and what barriers interfered. Participants identified 3–5 changes they intended to make. Three months later, participants estimated actual implementation of intended changes, identified obstacles to success, and rated PPS's impacts on patient care. <h3>Results</h3> Respondents "committed" to an average of 3.4 changes ranging from "better monitor transfers from LTC to acute care" to "train nurses re MDS and RUGs." Of 40 commitments, 0% and 100% progress were reported on 9 (23%) each. Mean implementation rate was 41%. Removing responses reporting 0% implementation, the rate was 53%. Common barriers were "lack of time," and "can't get attending MDs to meetings." MDs' ratings of PPSs' impacts were neutral (2.9 on a scale where 1="PPS causes great deterioration in quality of care," 3="…no change…" and 5="…great improvement…") both immediately and 3 months post-course. <h3>Conclusions</h3> Participants made reasonable plans consistent with course objectives and made progress implementing most intentions. LTC physicians who attended the CME course intended to alter their behaviors, but significant obstacles interfered, at least in the short term. Most thought PPS would not change the quality of care provided in their institutions. Future courses should address implementation barriers.

Content and Boundaries of Medicine in Long-Term Care: Physicians Talk About Stroke

Twenty physicians were interviewed about roles, treatments, goals, and relationships with older patients, especially stroke patients. Findings from this descriptive, anthropological investigation address the problem of congruence between needs and existing services, and in doing so, recast the ongoing debate about the medicalization of long-term care. This study emphasized the nonmedical features of geriatric medicine in general and stroke care in particular. In many instances, these physicians attempt to bridge gaps between medical and emotional needs and clinical and social services with social and psychotherapeutic as well as biomedical interventions. Because we found physicians' activities with stroke patients to be so broadly construed, treatment and management of stroke may be seen as paradigmatic for the role of physicians in long-term care.