Choosing a medical director: one size does not fit all.

The medical director of a skilled nursing facility must wear many hats and please many people, and this professional's dual roles as both physician and administrator might seem, at times, contradictory. This person is expected to juggle regulatory pressures and clinical best practices with all the aplomb of a seasoned circus performer.

How does a skilled nursing facility go about finding a physician who can attend to clinical matters while staying on top of the many administrative duties the job of medical director entails? Editor Linda Zinn asked longtime medical director Keith Krein, MD, CMD, the corporate medical director for Cleveland, Tennessee-based Life Care Centers of America, and former president of the American Medical Directors Association (AMDA), to share his insights on finding a well-qualified medical director and, once hired, what to expect from him or her.

Zinn: What qualities should nursing home administrators look for in a prospective medical director?

Dr. Krein: In addition to the appropriate medical credentials, he or she should have a genuine interest in caring for the frail elderly. Enthusiasm for individual patient care is, of course, important, as well as enthusiasm for medical management of the population as a whole. For example, the medical director will need to assist in the oversight of infection-control surveillance, vaccination programs, efforts to reduce the risk of falls and use of restraints, adequacy of nutrition, hydration and skin-integrity programs, and quality-improvement analysis and processes. Additionally, the medical director can be very influential in establishing a professional and caring culture in the organization.

Well-qualified medical directors also should complete the appropriate continuing education in administrative medicine and medical-management curricula. He or she should be a team player with good interpersonal and conflict-resolution skills, to enable him or her to work effectively with the interdisciplinary team. He or she should have a flexible nature and be a good listener, with tolerance for addressing regulatory-compliance issues.

It will be helpful if the prospective medical director has an interest in administrative medicine and/or previous administrative experience, having served in such capacities as committee chair, department chair, or chief of staff of a hospital or in some other civic or community leadership/administrative role. Simply finding a physician with the largest or busiest medical practice in town is not the answer. Such a physician might hate dealing with administrative and regulatory issues and participating in committee meetings. If you hire someone like this, you will both be disappointed.

Zinn: Do you think it's a good idea for a facility's medical director to have a percentage of his/her own patients residing in the facility?

Dr. Krein: This is a much more complicated question than it might seem. As a result of both Medicare reimbursement rules and the Stark Regulations (which deal with patient referrals and "fair market value" payment for services, etc.), facility administrators must realize that the compensation a physician receives for his/her administrative responsibilities as medical director is separate from his/her patient practice as an attending physician. In light of the Stark Regulations, one could even argue that having a medical director with no patients in the facility would be the least complicated and cleanest scenario. However, I want to be quick to point out that these regulations certainly do not require such a scenario, but rather create "safe harbors" for patient referrals, compensation, etc.

On the other hand, one could argue that if the medical director were also the attending physician for several of the facility's residents (say 10 to 30%), he/she would experience firsthand the adequacy or inadequacy of clinical policies, communication between nursing staff and community physicians, medical record documentation, resident care outcomes, etc.

In most facilities across the country, it is the norm for a facility medical director also to care for some percentage of the resident population; how much varies greatly, from a handful to 90% or more, with perhaps 10 to 40% being the most common range. I am not, however, implying that there is one clear answer to the question of what percentage is advisable. I have witnessed situations that could only be described as extremely successful and productive, in which a medical director provided no direct patient care but was otherwise highly skilled and qualified. On the other hand, I've seen situations in which the medical director cared for more than half the facility's residents, yet was not even conversant with the adequacy of facility policies, documentation, communication, care outcomes, etc.

Of course, this discussion brings us back to the qualities of a good medical director. If those qualities are present, success is likely regardless of the number of patients to whom he or she provides attending physician services.

Zinn: Do you think it's a good idea for facilities to hire medical directors who are retired from private practice? Why/why not?

Dr. Krein: We have an interesting phenomenon occurring across the country. In addition to the traditional medical specialties, we continue to see a trend toward physicians' narrowing their scope of care to do it well. Common examples in the last two decades would be emergency medicine specialists who work in the ER and hospitalists who function primarily in complex-care units within hospitals. What is interesting about this is that the site of service defines the type of special skills needed to function productively.

Today we are also seeing the early signs of a trend toward physicians' specializing in caring for patients in skilled nursing facilities and other long-term care entities. It would be hard to argue against this trend. Certainly, familiarity with the needs of the patient population and their families, knowledge of the attendant workforce and their capabilities, familiarity with the psychosocial and ethical dilemmas inherent in this site of service, and knowledge of regulation and reimbursement all would be critical in providing the best possible care to residents and patients of skilled nursing facilities.

Perhaps caring for nursing facility residents is the physician's "private practice," and if the physician has some of the desirable qualities we discussed earlier, who could possibly be a better medical director? There was a time when physicians tried to do it all, from the critical care unit of a hospital to delivering babies, to an ambulatory office practice, to the community nursing facility, to the high school football team; and there still are a few physicians out there who are doing that. But I would not shy away from a medical director candidate who has purposely narrowed his "private practice."

For example, a physician might have discontinued the hospital portion of his practice and kept an office and nursing home practice, or he might have discontinued an office practice and kept a hospital and nursing home practice. I know many extraordinary physicians who only practice within nursing facilities, who are well qualified to be medical directors, and who have obtained extensive formal education in LTC medical direction, such as the Certificate in Medical Direction offered by AMDA. You could say that physician is "retired" from a traditional private practice, but I would submit that such a physician would be a tremendous asset to a nursing facility as its medical director.

Zinn: It seems to be a common complaint among nurses that they'd love to talk to the medical director--"if only they could find him." Why does this happen so often, and what measures can be taken to correct it?

Dr. Krein: That's a good question, and the answer depends on the situation. Are the nurses looking for the medical director to respond to some administrative issue as outlined in the medical director agreement, or are they looking for him/ her to respond as an attending physician to a care issue with one of his/her patients? In the case of the former, it would depend on the types of duties agreed upon by the facility and the medical director. In the case of the latter, the medical director who also attends patients in the facility should respond in a timely manner, just as any other attending physician would be expected to do. However, it would help enormously to have mutually agreed-upon protocols for physician notification, so that there is clear differentiation between what is urgent versus what is not (e.g., situations that could wait until the next office day or be addressed by a faxed response at a time more convenient to the physician's schedule). AMDA has created a When to Call the Doctor protocol tha t could be quite helpful in dealing with this situation.

Time and again I see situations in which a nursing facility's administrator seeks to hire as its medical director the physician with the biggest or busiest practice in the community. Then that administrator is perplexed when the physician does not seem to have the time to respond repeatedly to what he/she would consider issues that are not urgent. Additionally, if an administrator hires a medical director who is focused only upon seeing patients and is not interested in and/or qualified to carry out the position's administrative duties, it should be no surprise if that medical director is slow to respond to administrative, personnel, or regulatory problems.

Zinn: How much time, as a minimum, should a medical director spend at a facility to effectively carry out his/her role? And for what size facility would you recommend a full-time medical director?

Dr. Krein: The standard answer is 2 to 4 hours per week for the typical community-based, 120-bed facility. This, however, begs the question, What is the typical 120-bed facility? There may no longer be such a thing.

I recently visited a 120-bed nursing facility that averaged 10 admissions per month and had an average resident length of stay (LOS) of just over 4 years. I have also recently visited another 120-bed nursing facility that averaged 110 admissions per month, including a distinct short-stay patient population with an 11-day LOS and another distinct long-stay resident population with a 580-day LOS. Indeed, both facilities were 120-bed, community-based facilities, but they were very different in their patient mix, patient acuity, licensed-nurse staffing, and requirements for physician visits and medical administrative oversight.

I think nursing facilities are in the midst of significant transition, and it is becoming increasingly difficult to characterize the needs of a facility by its bed count. For example, urban facilities located next to large hospitals may increasingly need to provide specialty subacute services to meet the needs of the community. Facilities in cities with a mature managed-care market may be in a similar situation. For those reasons, I would hesitate to speculate on the need for a full-time medical director based solely on bed count.

Zinn: How should the medical director divide his/her time when at the facility? In other words, can you prioritize his/her functions?

Dr. Krein: A number of medical administrative components should be regularly and consistently reviewed. Usually this review can be accomplished within the context of the monthly Quality Assurance Committee meeting. The quality-assurance process should encompass the core care components found within the 24 GMS Quality Indicators and the new Quality Measures.

Most facilities also have some type of ongoing programs for assessing and managing fail risk, skin integrity, incidents and accidents, weight loss, and restraint use. Additionally, ethics issues, behavior-management issues, resident and family satisfaction concerns, and staff training needs should be regularly assessed.

The national Quality Indicators and Quality Measures can be most helpful in identifying opportunities for improvement, and a knowledgeable medical director can certainly augment the process. All of that being said, the seasoned medical director would also benefit from simply making the rounds, either alone or with the administrator and/or DON, and spending a few moments visiting with facility staff, residents, and their families to keep a finger on the pulse of the current "buzz" and concerns in the facility.

Zinn: Do you recommend that attending physicians take someone from nursing (e.g., a charge nurse) on rounds with them, and if so, why?

Dr. Krein: Anything that improves communication between the nursing staff and physician staff is a good thing. Conducting rounds together has many advantages, including the chance for nursing staff to update the physician on patient status since the last visit and the opportunity for an informal dialogue between nurse and physician about expectations and prognosis. The nurse also may be aware of family concerns that should be brought to the attention of the physician. And finally, patient assessments and examinations can be completed more efficiently with nursing assistance.

Zinn: Who are the key staff members with whom medical directors must stay in close, frequent contact, and why are these individuals so important to the medical director's fulfilling his/her responsibilities?

Dr. Krein: Effective leaders certainly will know how to appropriately delegate responsibilities to various department heads and staff, but in my experiences with highly successful facilities, a good working relationship existed between the administrator, director of nurses, and the medical director. The administrator and DON are the two full-time, on-site leaders of a nursing facility and, in my opinion, should also be leading the quality-improvement process.

The MDS coordinator also could be instrumental in assisting not only the medical director, but also other attending physicians--for example, in keeping up with significant condition changes of residents. This helps ensure that these situations are appropriately addressed in light of both the physician's medical viewpoint and the care plan.

Zinn: What are the greatest challenges medical directors face in long-term care facilities, and how are these challenges overcome?

Dr. Krein: Something everyone in long-term care deals with is the rising acuity level of LTC patients, which is occurring in concert with nursing facility management's need to carefully monitor labor costs in order to be able to survive financially. Remedying this ongoing problem will likely require action on the part of legislators.

Another problem is the accuracy and reliability of nursing assessments and communication transmitted by phone or fax. This problem can be eased by introducing nurse practitioners and physician assistants into the long-term care milieu and by providing ongoing training and competency evaluations for the facility nursing staff. NPs and PAs may be more adept at both "nurse speak" and "doctor speak" and can facilitate the dialogue between the attending physician and a resident's family. Adding these practitioners to the equation brings another level of professional caregivers into the facility who are less encumbered by the administrative and regulatory burdens of the facility and therefore can focus more exclusively on patient care and communication with families and physicians.

Also challenging are the myriad phone calls and paperwork allegedly mandated by nursing facility regulations. I say "allegedly" because there is often great misunderstanding on this topic--among nursing staff and surveyors alike. The solution is developing or obtaining physician-notification and -communication protocols that are mutually agreed upon and used consistently.

Dealing with unrealistic expectations and guilt feelings of family members is another common challenge. This can be addressed by developing or obtaining resident and family educational materials, such as handouts and/or videos that address the frailties associated with the aging process. Likewise, you can offer educational materials on what can realistically be expected from nursing facility care. I'd suggest that facilities make these educational efforts part of the admission process.

Medical directors also have to deal with the fact that patient information often doesn't follow a patient when he or she moves from one site of service to another (e.g., hospital to nursing home). It's a good idea for the medical director to meet with the appropriate hospital personnel and create or obtain mutually agreed-upon transfer criteria and information-sharing protocols. Most likely the hospital personnel will also have issues that need be addressed--working together in a collegial manner is beneficial for all concerned.

Finally, we have to deal with the fact that there is an increasingly litigious climate in long-term care, with consequent increases in professional liability (malpractice) premiums. The long-term care industry must continue to improve the quality of the care and services it delivers and provide educational opportunities that create realistic expectations about nursing facility care. That will be, and can only be, accomplished one facility at a time. Additionally, all those working or interested in healthcare should write/call their elected representatives about the current malpractice crisis.

Zinn: Do you have any other advice for administrators who wish to hire the best medical director and receive the best services he/she can provide for residents?

Dr. Krein: I'd like to remind them that "you get what you pay for" and that administrators and prospective medical directors both should have a clear understanding of each other's expectations before entering into an agreement.

That being said, if you find a physician with the desirable qualities mentioned in this article and, in my view, if he/she is an AMDA-certified medical director, you should be on your way to a good relationship. NH

Keith Krein, MD, CMD, is the corporate medical director for Life Care Centers of America, Cleveland, Tennessee, an organization that operates long-term care and senior-Living facilities in 28 states. He was one of the first recipients of the American Medical Directors Association's (AM DA) Certified Medical Director designation and is a past president of AMDA. For more information, contact Dr. Krein at [phone]. To comment on this article, send e-mail to [e-mail].