On Oct. 6, 2021, Governor Gavin Newsom signed into law California’s Assembly Bill 749, which will require that all skilled nursing centers engage only medical directors who are certified by the American Board of Post-Acute and Long-Term Care Medicine (ABPLM, www.abplm.org) or will be so certified within five years.
This bill, which was sponsored by the California Association of Long Term Care Medicine and supported by the California Association of Health Facilities, did not receive one single “Nay” vote in any of the committee votes or in the state’s Assembly and Senate and faced virtually no opposition from any stakeholder.

Need is Established

The COVID-19 pandemic has demonstrated unequivocally that engaged, knowledgeable medical directors can make a huge difference in the outcomes in skilled nursing centers, which helps explain the overwhelming popularity of this bill.

Many lawmakers and others were surprised to learn that in California, and in most states, the only requirement to be a nursing center’s medical director was an active medical license—allowing nursing centers to hire retired surgeons or pediatricians or engaging medical directors whose sole purpose appeared to be referring admissions without any discernible interest in ensuring competent geriatric medicine or adherence to the regulations was practiced in the building.

Still more shocking to some legislators and public health officials was the fact that unlike in hospitals, which have robust and rigorous credentialing and proctoring requirements for physicians to obtain admitting privileges, nursing centers are not required to do any more than the most rudimentary verification of a clinician’s licensure and, if they are wise, proof of liability insurance.

While some nursing centers and management organizations do have formal credentialing requirements, a great majority do not—so it falls to the medical director to perform quality assurance functions in ensuring that the other physicians and advanced practice practitioners are providing appropriate care and treatment within the standard of care.

Theoretically, the most incompetent physicians can practice in nursing centers, caring for medically complex, frail, vulnerable patients, with a similarly disengaged medical director not really monitoring the care that’s being provided. Not surprisingly, this was an alarming realization.

Require Credentials

The Certified Medical Director (CMD) certification from ABPLM involves physician candidates completing the Core Curriculum, which comprises 46 hours of content spanning 22 critical areas of long term care management. Each topic builds on information shared and interactive exercises of the topics that precede to create a comprehensive and cohesive picture of medical direction in long term care.

These include clinical topics that ensure basic knowledge of geriatric medicine and palliative care, leadership and bioethics content, and a detailed coverage of the federal regulations and requirements of participation for skilled nursing centers. The cost for the certification is about $3,000 in total.

There have been more than 4,000 physicians certified as CMDs since the inception of this program in 1991, and a study by Frederick Rowland et al. published in the July 2009 issue of the Journal of the American Medical Directors Association found that quality metrics are better in facilities that have a CMD for their medical director.

Personal History

As a physician who was hired as a medical director back in the mid-1990s, I was admittedly clueless about many of the complex regulatory, clinical, and risk management issues associated with being a nursing center medical director. I looked for a professional medical society that could help educate me and quickly found AMDA (then called the American Medical Directors Association, but now called the Society for Post-Acute and Long-Term Care Medicine, www.paltc.org).

This organization, which is affiliated with the ABPLM, was a godsend to a young doctor just learning about nursing centers and how they operate. Though I may be biased, I strongly recommend that every nursing center exert any possible influence on its medical director to become a member of AMDA and its state or regional chapters, and to get CMD-certified.

Some physicians may balk at a request to take additional coursework or join a professional organization. It is clear that younger physicians are not “joiners” in the way that older doctors have traditionally been. So it may take a little persuasion, or even inserting language into medical director agreements that require a minimum number of CMD continuing education credits annually—or, better yet, an expectation that they become certified within a specified period of time.

It’s reasonable to consider time spent on obtaining a CMD, or attending courses that confer CMD credits, within the covered hours outlined in a medical director agreement or contract.

What Residents Deserve

Nursing centers today are like the hospitals, or at least the medical/surgical floors of hospitals, of a decade or two ago. Their residents deserve to have a competent, knowledgeable, and dedicated medical director as the medical leader and an integral part of the leadership and Quality Assurance and Performance Improvement team.

The CMD certificate through ABPLM is one way to guarantee at least a baseline level of knowledge that can move the needle on the quality of care provided.

It is likely that more states will follow California’s lead, and while a CMD requirement may pose a bit of a burden on the physicians serving in the medical director capacity, it may also help weed out those who really are not committed to the resident population—and is well worth it to give those residents and nursing centers the level of medical leadership they deserve.
Karl Steinberg, MD, CMD, HMDC, is president of AMDA – The Society for Post-Acute and Long Term Care Medicine. He has been a nursing home and hospice medical director in the San Diego area since 1995 and is chief medical officer for Mariner Health Central and Beecan Health. ​