Every skilled nursing facility (SNF) must have a medical director, but there is a wide spectrum of knowledge, competencies, and engagement among nursing center medical directors nationwide. It is natural for a skilled nursing care center to want a medical director who can also drive admissions, but this does not necessarily correlate with a high-quality medical director. 

Nursing centers are increasingly being called upon to care for high-acuity, complex post-acute patients, and it behooves them to engage the services of a medical director who is familiar, comfortable, and expert at understanding the needs and nuances of caring for this population—and in navigating the regulatory and risk-management aspects of this unique care setting that is both like a hospital and like a home. 

In this recurring column, topics around important roles of the medical director will be discussed, and some best practices or victories associated with interdisciplinary collaborations with engaged medical directors will be shared.

​​​​Scrutiny Ahead

The federally mandated duties for a medical director have not changed with the recent revision of the Requirements of Participation (RoPs), but they almost certainly will be scrutinized more carefully moving forward. 

Indeed, now under 42 CFR§ 483.70 and F Tag 841, these responsibilities remain simple and brief, but a tall, twofold order: implement resident care policies, and coordinate the medical care in the facility. 

The proposed new guidance to surveyors goes on to specify that the medical director is responsible for coordinating medical care, including intervening when there are issues with other practitioners in the facility and helping to implement and evaluate resident care policies that reflect current professional standards of practice.

The medical director must participate in the Quality Assessment & Assurance (QA&A) Committee, and must participate in formulating the now-required facility self-assessment, along with strategies for quality improvement via Quality Assessment and Process Improvement (QAPI).

T​ime for Assessment

It would behoove all skilled nursing centers to assess their medical directors’ current knowledge level around QAPI and ensure that medical directors have indeed rev​iewed and shared input into individual facility p​olicies and procedures (P&Ps)—even when the center may use handed-down-from-corporate P&Ps. Surveyors will be asking these questions, and deficiencies may well be written if the medical director is not engaged in these processes. 

In the proposed new guidance under 483.70(h), surveyors are told that, “If a deficiency has been identified regarding a resident’s care, also determine if the medical director had knowledge or should have had knowledge of a problem with care, or physician services, or lack of resident care policies and practices that meet current professional standards of practice and failed…to get involved or to intercede with other physicians or practitioners in order to facilitate and/or coordinate medical care; and/or…to provide guidance for resident care policies.” 

Additionally, surveyors are directed to “interview the medical director about his/her…involvement in assisting facility staff with resident care policies, medical care, and physician issues; understanding of his/her roles, responsibilities, and functions and the extent to which he/she receives support from facility management for these roles and functions; [and] process for providing feedback to physicians and other health care practitioners regarding their performance and practices, including discussing and intervening (as appropriate) with a health care practitioner regarding medical care that is inconsistent with current professional standards of care.”

Obviously, these kinds of questions to the facility medical director may come up anytime deficient practices—such as continued use of sliding-scale insulin or inappropriate use of antibiotics for asymptomatic bacteriuria—are identified in the building. 

As Phase 2 of the new RoPs is ramping up (as of Nov. 28, 2017), it is important for facility QA&A Committees to address these issues and ensure that the medical director is an active participant and a source of up-to-date clinical knowledge and practices.​​​​​​​

O​ther Duties

A few other duties that the ideal medical director should consistently fulfill include being available 24/7 if there is an emergency or if the nursing center cannot get hold of another attending physician or designee about a resident care issue, being around and available anytime the state agency is in the building, intervening promptly when other practitioners are delinquent in their required visits or otherwise deficient in their care, and being a representative of the center and its good reputation within the community and with residents and family members within the center. 

Every nursing center’s administrator and director of nursing should periodically ask themselves if their medical director is meeting their needs. If not, consideration should be given to some additional education, obtaining assistance from other physicians in affiliate roles, or if other measures fail, ultimately replacing their medical director. With the latest regulatory guidance, the presence of an engaged and competent medical director in the nursing center has never been more important. 

AMDA – The Society for Post-Acute and Long Term Care Medicine (www.paltc.org), formerly known as the American Medical Directors Association, is the professional society representing the community of over 50,000 medical directors, physicians, nurse practitioners, physician assistants, and other practitioners working in the various post-acute and long term care settings. The Society’s 5,500 members work in skilled nursing facilities, long term care and assisted living communities, CCRCs, home care, hospice, PACE programs, and other settings. AMDA and the American Health Care Association/National Center for Assisted Living partner frequently on areas of mutual interest, including clinical, quality, and regulatory matters. ​ 

Tessa and KarlKarl Steinberg, MD, CMD, HMDC, is a long term care geriatrician in Oceanside, Calif. He is chief medical officer for Mariner Health Central and medical director of Life Care Center of Vista and Carlsbad by the Sea Care Center. He is chair of AMDA’s Public Policy Committee and editor-in-chief of their monthly periodical, Caring for the Ages. A hospice and nursing home medical director since 1995, Steinberg is probably best known for taking his dogs on rounds in nursing homes, assisted living facilities, and on hospice and palliative care home visits with him on most days. ​