Getting physicians on-board.

Hospital and freestanding skilled nursing facilities, sub-acute care programs, assisted living centers, and home and community care agencies are requiring intensified physician involvement because of patients' ever-changing acuity and complexity. As a result, medical directors, attending physicians and consultants are becoming more attracted to this service area. How do you take advantage of this?

The savvy administrator recognizes that the physician is not only the facility's "customer," but also a valuable messenger. Physicians often represent the facility to patients and caregivers, as well as to payers, referring parties, other professionals such as lawyers and accountants, and to community resources. This means ensuring that all physicians who interface with the facility are educated regarding its services and how they might be accessed.

Respecting the physician's time limitations is crucial. The physician is likely juggling the post-acute center with hospitals, other centers, private practice, teaching responsibilities and personal obligations. The facility can assist the attending physician by having the patient, the chart and any necessary test results, the equipment and appropriate assigned staff ready. It is also helpful to make available a quiet place with paper, pens, phone, a dictation machine and other tools needed for the physician to complete the required documentation.

The single most important thing for any post-acute care organization to do is to arrange for an initial meeting with the physician(s) in order to exchange ideas and discuss objectives about combining skills and efforts to provide effective services. Recently, Nursing Homes asked some experts, "What advice would you give to facilities that provide post-acute care?"

Monte Levinson, MD, CMD, Past President of the American Medical Directors Association (AMDA) and Medical Director for Presbyterian Homes in Evanston Illinois: "Don't bite off more than you can chew! In other words, make sure that you admit patients to programs where there are skilled staff available. Complex illness often requires advanced technology and a myriad of consultants who are specialists. Also, it is important to monitor subacute patients closely as they may be more unstable than traditional nursing home patients. The post-acute care medical director should actively participate in the education and training of facility staff members."

Richard D. Della Penna MD, Regional Physician Coordinator for Elder Care at Kaiser Permanente, Southern California: "A post-acute care medical director should provide strong leadership and participate in the organization's policies, procedures and quality improvement activities. The physician should be well-grounded in appropriate regulatory issues and also have an understanding of the principles of managed care. The medical director should be available to discuss quality of care as well as operational issues and have the ability to manage conflict productively. Physicians should be willing to admit subacute/skilled patients 24 hours a day, seven days a week, and be flexible about expanding services and care that can be provided safely. Also, medical directors should be open to working with health plans such as Kaiser and should display a strong collaborative spirit."

Steven C. Castle, MD, Associate Professor of Medicine at the University of California Los Angeles (UCLA) and Clinical Director of the Geriatrics Research Education and Clinical Center, Los Angeles, California: "Focus treatment on the primary condition - the disease that impairs the patient's functional capacity. Determine the impact of the treatment and its benefits. Use function-specific markers in eliciting the chronology of disease - i.e., determine if deterioration in function is rapid or chronic and, therefore, whether it is more likely to be treatable and/or reversible. Improvement as a result of medications should be more specifically monitored. If there is no improvement, the medications should be stopped. Finally, don't underestimate the ability of the facility staff to motivate patients and caregivers, and reward them for doing so."

Katherine Chavigny, PhD, FACE, Director of Related Health Programs for the American Medical Association (AMA), Chicago, Illinois: "Physicians should encourage a formal credentialing process for post-acute care facilities. This would better structure the relationship between the organization and the physician, lend validation and credibility, and assist the physicians in peer review and quality of care issues. Also, physicians involved in post-acute care should work toward adding geriatrics as part of the curriculum in medical schools."

For more information regarding physicians and post-acute care, contact AMDA at [phone] and the AMA at [phone].

If you have suggestions that you think would be helpful to others working in the area of post-acute care, please forward them to Laura Hyatt, Hyatt & Associates, 2956 Kelton, Los Angeles, CA 90064.

Laura Hyatt is President of Hyatt & Associates, Los Angeles, CA.