The COVID-19 pandemic seems to be settling down at the time of writing this article, but no one knows what the future may hold as far as variants, future surges, duration of vaccine immunity, and many other unknowns go. What is known is that COVID-19 has been absolutely devastating in post-acute and long term care centers, first and foremost to residents and their families, but also to staff.
Providers have also learned some lessons from the pandemic about leadership (and lack thereof) on many levels, about infection prevention and control, and about the courage and dedication their frontline workers have demonstrated.
It is impossible to express how grateful providers are to their nurse assistants, nurses, and all of the other heroes who have placed themselves and their families at personal risk day after day.
Probably every reader can appreciate the magnitude of the pandemic’s swath through long term care settings in the United States and worldwide. Even as health care professionals edge back toward normalcy, there will be profound and enduring changes to the way they do things. The full gravity of this pandemic will not be understood and appreciated for years to come.
What the Pandemic Revealed
The pandemic has clearly shed light on some of the shortcomings of the current paradigms in long term care. Providers have learned the vital importance of emergency preparedness, robust infection prevention and control measures, and the need for ample personal protective equipment (PPE).
There have been many calls for an overhaul of the long term care industry and increasing scrutiny on issues of equity, staffing, workforce, and infection prevention and control.
One lesson some nursing centers and corporations have learned is that medical leadership from the facility medical director can be of immense value. While there has been a federal mandate since 1975 for every nursing center to have a medical director, and while the duties of the medical director have been defined since the Omnibus Budget Reconciliation Act of 1987 (implementation of resident care policies and coordination of medical care in the facility—a tall order), there is huge variability in the extent to which medical directors actually fulfill their duties.
The Plus Side
Some nursing centers employ medical directors who demonstrate clear dedication, engagement, knowledge of geriatric medicine and infectious disease principles, and awareness of the complex regulatory framework in which they operate.
These medical directors for the most part have stepped up throughout the pandemic, helping residents, families, staff, and the administration navigate the difficult, confusing, often frankly contradictory guidance on PPE, cohorting, testing, vaccination, and visitation from a variety of agencies and public health authorities.
These leaders have helped create and roll out mitigation plans and other policies and procedures to protect their residents and staff and have helped ensure that goal-concordant medical treatments have been provided whenever possible—including attention to comfort and dignity with appropriate advance care planning.
Different Approaches, Results
Many medical directors have been in direct contact with survey teams and representatives of local and state public health departments. Many of these dedicated medical directors have also devoted their time and passion to helping educate staff about vaccination, and these efforts have been evidenced in an increased vaccine uptake among staff.
Conversely, there are medical directors who appear to have little interest in performing their federally mandated duties of implementing resident care policies and coordinating the medical care in their nursing centers.
There have been many tragic consequences of lapses on the part of these medical directors, perhaps none as infamous as what occurred at one nursing center in the northeast, where staff were directed to let symptomatic presumed COVID-positive residents eat in a common dining room with asymptomatic, COVID-negative residents.
But a common thread in facilities where strike teams from Doctors Without Borders had to come in and assist was that the medical directors of these facilities were largely missing in action.
Tightening Ship
Historically, some nursing centers and corporations have sought to retain medical directors who can drive census, such as doctors affiliated with hospitalist groups, Accountable Care Organizations, or other entities. There’s nothing wrong with having a medical director who will refer patients to a nursing center, but that medical director needs to also have some basic competencies, and many do not.
Other nursing centers have chosen to retain medical directors who have little knowledge or interest in geriatrics or long term care (sometimes retired surgeons or pediatricians) and who will essentially not “make waves” and just sign whatever paperwork they are handed.
This is no longer going to be acceptable, and this would be a good time to plan ahead to avoid future problems.
The sheer devastation related to COVID-19 in nursing centers has brought attention to the role of the medical director, and federal authorities are among those taking notice. It is reasonable to expect now that routine surveys are getting underway that there may be more of a focus on the role of the medical director in the Infection Prevention and Control Program and Quality Assurance/Performance Improvement (QAPI), and nursing centers should prepare for this.
Value of Certification
So, how does a nursing center find a qualified, competent medical director? One simple strategy is to make certification (available through the
American Board of Post-Acute and Long term Care Medicine,) a requirement for the position, either as a condition of initial hire or as an expectation within a set time frame.
The Certified Medical Director (CMD) certification requires about 40 hours of continuing medical education specific to the nursing care setting, including more than 20 core areas that encompass clinical, regulatory, bioethical, and other topics.
California has legislation pending (AB 749) that will require all licensed skilled nursing facilities to engage a medical director who has a CMD certificate within five years, and a handful of other states have similar requirements for minimal credentialing or knowledge.
Short of the actual certification, nursing centers can also contractually require their medical directors to be members of medical societies like AMDA – The Society for Post-Acute and Long Term Care Medicine and maintain a minimum number of annual educational hours from such organizations that focus on geriatrics and long term care.
Some facilities also engage an associate medical director (or director of post-acute or a variety of other titles) to assist with quality initiatives, and this can be helpful.
Considering the high acuity of the case mix these days in most nursing centers, and especially in light of hard lessons learned from the pandemic, this would be an excellent time for all nursing centers to assess their current medical director’s level of dedication, engagement, knowledge base, and accessibility—and if lacking, strongly consider remediation or replacement.
Nursing centers pay reasonable stipends for these duties and deserve to have qualified, competent medical directors. Their residents, families, and staff deserve nothing less.
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.