Profile of Physicians in the Nursing Home: Time Perception and Barriers to Optimal Medical Practice
To describe physician medical practice in nursing homes, including actual time spent for routine encounters with nursing home residents and demographic characteristics of the physicians who serve as medical directors; to determine the congruence between actual time spent for routine encounters with nursing home residents and the physician's view of the optimal time; and to identify barriers to providing optimal visits.
A mail survey of a national random sample of 200 medical directors of all Medicare-certified nursing facilities using the Dillman Total Design mail survey methodology.
100 medical directors (50% response rate).
The survey consisted of open- and closed-ended items on the following: the demographic characteristics of the medical director; demographic characteristics of the nursing home; the extent of the medical director's nursing home practice, including the ideal and actual time spent in nursing home visits for 4 common types of visits; and perception of barriers to providing optimum visits in the nursing home.
Medical directors were most likely to be primary care physicians, the majority of whom were male; had practiced in long-term care for more than 18 years; were medical directors in 2 facilities; provided, on average, primary care in 4 facilities; spent 31 hours per month in the nursing home with nursing staff; and devoted 44% of their practice to nursing homes. Most, (74%) were members of the American Medical Directors Association (AMDA), 41% were certified medical directors (CMD), 42% had a certificate of added qualification (CAQ) in geriatrics, and only 15% had fellowship training. Reports of actual time spent on 4 common types of nursing home visits were significantly less than optimal visit times, but fellowship-trained physicians reported significantly greater discrepancies between the optimal and actual time spent for the 30- to 60-day reviews and readmissions compared with physicians who were not. A parallel pattern was seen comparing physicians with and without CAQs. Nursing support and accurate/accessible information were recorded as most problematic and reimbursement the least problematic barrier to providing optimal nursing home visits.
The present study provides a snapshot of current physician practice in US nursing homes. Such information is needed as the debate over the physician's role in the nursing home continues and new policy is framed that will ultimately define the future of medical practice in the nursing home. That 74% of the national survey respondents were members of AMDA suggests that the AMDA membership is representative of the national medical director population.
Available from: Rhonda L Stuart
- "Two recent studies have described pharmacist-led or infectious diseases expertise consultation in their AMS models; however, both studies were carried out at hospital-affiliated and Veterans Affairs long-term care facilities with the on-site support of relevant health care professionals.137,138 In the US, higher expert support was more commonly available in the Veterans Affairs affiliated facilities than in the generic nursing homes.138,139 The feasibility of these labor-intensive AMS models in other RACF settings warrants further investigation. "
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ABSTRACT: 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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