The Nursing Home Medical Director: Leader & Manager

In 1974, in response to identified quality of care problems, Medicare regulations first required a physician to serve as medical director in skilled nursing facilities and to be responsible for the medical care provided in those facilities. Following the passage of the Nursing Home Reform Act in 1987, AMDA—Dedicated to Long Term Care Medicine (AMDA) House of Delegates, in March 1991, approved the Role and Responsibilities of the Medical Director in the Nursing Home, a document setting forth AMDA’s vision for nursing facility medical directors. It outlines the medical director’s roles in nursing facilities and is the foundation for:

• AMDA’s Certified Medical Director credentials;
• AMDA’s Model Medical Director Agreement and Supplemental Materials: Medical Director of a Nursing Facility and;
• Resolutions on medical direction in other long term care settings.

Since 1991, the long-term care field has been affected by changes in medical knowledge, clinical complexity of patients, societal attitudes, legal influences, demographics and patient mix, reimbursement, and shifts in the scope of care in various settings. Increasingly, medical directors are held accountable by state legislators, regulators, and the judicial system for their clinical and administrative roles in these diverse facilities. At least one state1 has enacted legislation outlining the specific regulatory responsibilities and educational pre-requisites for medical directors, and other states may follow its lead.

The 2001 Institute of Medicine report Improving the Quality of Long Term Care urges facilities to give medical directors greater authority and hold them more accountable for medical services. The report further states, nursing homes should develop structures and processes that enable and require a more focused and dedicated medical staff responsible for patient care. These organizational structures should include credentialing, peer review, and accountability to the medical director (Institute of Medicine 2001, 140). These developments required AMDA to revise and update its 1991 document to develop a clearer vision for enhanced medical director responsibilities.

In April 2002, AMDA convened a panel to review the document in the context of changes within long-term care. Their work product outlined the medical director’s major roles in the facility and was geared toward ensuring that appropriate care is provided to an increasingly complex, frail, and medically challenging population. These concepts were considered when the Centers for Medicare & Medicaid Services revised the Surveyor Guidance related to F-Tag 501 (Medical Director) in 2005. This AMDA policy statement has therefore been updated to be congruent with current regulatory requirements and their related interpretive guidelines, and as such reflect the current roles and responsibilities of the medical director.

AMDA’s Core Curriculum Faculty has further developed and teaches the roles, functions and tasks of the medical director. The functions and tasks were last updated in 2009 to include person-directed care. This current document has been revised in late 2010 for presentation to the AMDA Board of Directors and the AMDA House of Delegates at the March 2011 meeting in Tampa, Florida. It is AMDA’s most recent position statement to harmonize the leadership role and management responsibilities of today’s medical director.

The mission of the American Medical Directors Certification Program (AMDCP) is to recognize and advance physician leadership and excellence in medical direction throughout the long-term care continuum via certification. The Certified Medical Director in Long Term Care (AMDA CMD) recognizes the dual clinical and managerial roles of the medical director. The CMD credential reinforces the leadership role of the medical director in promoting quality care and offers an indicator of professional competence to long term care providers, government, quality assurance agencies, consumers, and the general public.

Due to the expanded role of medical director, some facilities or organizations have identified a need for an assistant or associate medical director. The assistant or associate medical director should be a physician who has comparable knowledge and skills to those of the medical director.

The position of the nursing home Medical Director can be identified in terms of the Role, Functions, and Tasks hierarchy.

• Roles: the set of behaviors that an individual within an organization is expected to perform and feels obligated to perform.
• Functions: the major domains of activity within a role.
• Tasks: the specific activities that are undertaken to carry out those functions.

In defining the role of the medical director, and ultimately the foundation for the individual medical director agreement, it is important to begin with a framework that identifies core principles. This framework is based on functions related to providing high quality of care to the individuals served. These functions include providing input into the clinical policies governing the organization or facility, supervising the medical staff, reviewing and participating in quality assurance activities, and directly overseeing clinical safety and risk management.
The medical director is involved at all levels of individualized patient care and supervision, and for all persons served by the facility. The medical director serves as the clinician who oversees and guides the care that is provided, a leader to help define a vision of quality improvement, an operations consultant to address day-to-day aspects of organizational function, and a direct supervisor of the medical practitioners who provide the direct patient care.

AMDA has identified four key roles of the long-term care medical director, as follows.

Role 1—Physician Leadership
The medical director serves as the physician responsible for the overall care and clinical practice carried out at the facility.

Role 2—Patient Care-Clinical Leadership
The medical director applies clinical and administrative skills to guide the facility in providing care.

Role 3—Quality of Care
The medical director helps the facility develop and manage both quality and safety initiatives, including risk management.

Role 4—Education, Information, and Communication
The medical director provides information that helps others (including facility staff, practitioners, and those in the community) understand and provide care.

Although individual job duties will vary among organizations, there are basic, universally relevant functions that are embedded in the overarching roles. The functions represent the foundation for developing the individual medical director’s tasks. The relevance and nature of some tasks may vary; for example, due to different patient populations, facility requirements, or state or local regulations. Therefore, it is useful to divide tasks related to various functions into 1) essential tasks that all medical directors should perform (Tier 1) and 2) tasks that, while desirable, may vary in importance depending on a medical director’s situation or setting (Tier 2).
The manner in which different medical directors perform various tasks (regardless of whether a task is essential or optional) may vary.

Function 1—Administrative
The medical director participates in administrative decision making and recommends and approves relevant policies and procedures.

Function 2—Professional Services
The medical director organizes and coordinates physician services and the services provided by other professionals as they relate to patient care.

Function 3—Quality Assurance and Performance Improvement
The medical director participates in the process to ensure the quality of medical care and medically related care, including whether it is effective, efficient, safe, timely, patient-centered, and equitable.

Function 4—Education
The medical director participates in developing and disseminating key information and education.

Function 5—Employee Health
The medical director participates in the surveillance and promotion of employee health, safety, and welfare.

Function 6—Community
The medical director helps articulate the long-term care facility’s mission to the community.

Function 7—Rights of Individuals
The medical director participates in establishing policies and procedures for assuring that the rights of individuals (patients, staff, practitioners, and community) are respected.

Function 8—Social, Regulatory, Political, and Economic Factors
The medical director acquires and applies knowledge of social, regulatory, political, and economic factors that relate to patient care and related services.

Function 9—Person-Directed Care
The medical director supports and promotes person-directed care.

The tasks are listed as they relate to the nine functions and are divided into two tiers.

• Tier 1—essential, universally applicable tasks
• Tier 2—tasks that may vary with the individual’s situation, availability, facility needs, and so on.

Function 1—Administrative

Tier 1

Task 1
The medical director communicates regularly with the administrator, the director of nursing, and other key decision makers in the nursing home and provides leadership needed to achieve medical care goals.

Task 2
The medical director participates in the development and periodic evaluation of care-related policies and procedures.

Task 3
The medical director guides and advises the facility’s committees related to quality assurance / performance improvement, pharmacy, infection control, safety, and medical care.

Task 4
The medical director participates in licensure and compliance surveys and interacts with outside regulatory agencies.

Task 5
The medical director informs medical staff about relevant policies and procedures, including updates.

Task 6
The medical director collaborates with the administrator to identify a job description that clearly defines the medical director’s roles and functions in the facility.

Tier 2

Task 7
The medical director stays informed about factors that affect long term care and incorporates relevant information about social, medical, and fiscal issues into policies and procedures.

Task 8
The medical director helps the facility develop or incorporate policies and procedures and utilize pertinent strategies to effect and manage change.

 

Function 2 -Professional Services

Tier 1

Task1
The medical director organizes, coordinates, and monitors the activities of the medical staff and helps ensure that the quality and appropriateness of services meets community standards.

Task 2
The medical director helps the facility arrange for the availability of qualified medical consultative staff and oversees their performance.

Task 3
The medical director assures coverage for medical emergencies and participates in decisions about the facility’s emergency equipment, medications, and supplies.

Task 4
The medical director collaborates with the DON and other clinical managers to help ensure that practitioners in the facility have adequate support from staff to assess and manage the patients (e.g., when they are making patient rounds or responding to calls about changes in condition).

Task 5
The medical director develops and periodically reviews and revises, as indicated, policies that govern practitioners in the facility other than physicians, including physician assistants and nurse practitioners; and guides the facility regarding the professional qualifications of other staff related to clinical decision making and the provision of direct care.

Task 6
The medical director guides the administrator in documenting the credentials of the facility’s practitioners.

Task 7
The medical director collaborates with the facility to hold practitioners accountable for their performance and practice, including corrective actions as needed.

Tier 2

Task 8
The medical director develops and periodically reviews and updates, as needed, key documents governing physician services, such as by-laws or rules and regulations.

Task 9
The medical director helps the facility establish affiliation agreements with other health care organizations and helps the facility establish effective outside relationships; for example, with regulatory agencies, various professional groups, insurers, ambulance companies, and emergency medical systems.

Task 10
The medical director helps support the care-related activities of the interdisciplinary team.

Task 11
The medical director helps the facility ensure that its medical records systems meet the needs of patients and practitioners.

Task 12
The medical director helps the facility ensure adequate documentation of patient care and related information.

Task 13
The medical director advises the facility on interacting with utilization review organizations.

Task 14
The medical director develops policies and procedures related to activities of health care trainees within the facility (e.g., physicians in residency programs, medical students).

Task 15
The medical director advises the facility about the appropriateness of admissions and transfers, including related orders and the facility’s case mix.

Task 16
The medical director advises and supports the practitioners and the facility regarding family issues; for example, concerns about the appropriateness and timeliness of the care.

Function 3—Quality Assurance and Performance Improvement

Tier 1

Task 1
The medical director participates in monitoring and improving the facility’s care through a quality assurance and performance improvement program that encourages self-evaluation, anticipates and plans for change, and meets regulatory requirements.

Task 2
The medical director applies knowledge of state and national standards for nursing home care to help the facility meet applicable standards of care.

Task 3
The medical director monitors physician performance and practice.

Task 4
The medical director helps ensure that the facility’s quality assurance and performance improvement program addresses issues that are germane to the quality of patient care and facility services.

Task 5
The medical director helps the facility use the results of its quality assurance and performance improvement program findings, as appropriate, to update and improve its policies, procedures, and practices.

Task 6
The medical director participates in quality review of care, including (but not limited to) areas covered by regulation (e.g., monitoring medications, laboratory monitoring).

Tier 2

Task 7
The medical director helps the facility interpret and disseminate information gained from the quality assurance and performance improvement program in a form that is useful to patients, family members, staff members, attending physicians, and others as appropriate.

Task 8
The medical director helps the facility consider the feasibility and appropriateness of any proposed research projects and helps ensure that they meet pertinent standards and contain appropriate safeguards.

Task 9
The medical director periodically reviews admission, transfers, and discharges of patients.

Task 10
The medical director helps the facility identify private and public funding for research activities.

Task 11
The medical director provides medical leadership for research and development activities in long term care.

Task 12
The medical director includes physician input in identifying and applying quality assurance standards.

Function 4—Education

Tier 1

Task 1
The medical director sustains his or her professional development through self-directed and continuing education.

 

Task 2
The medical director helps the facility educate and train its staff in areas that are relevant to providing high quality patient care.

Task 3
The medical director serves as a resource regarding geriatric medicine and other care-related topics, and helps the staff and practitioner identify and access relevant educational resources (e.g., books, periodicals, articles).

Task 4
The medical director informs attending physicians about policies and procedures and state and federal regulations, including updates.

Tier 2

Task 5
The medical director participates in the development, organization, and delivery of education programs for patients and patients’ families, board members, and the community at large.

Task 6
The medical director encourages the facility to support staff membership in professional organizations.

Task 7
The medical director contributes to facility publications, as appropriate.

Task 8
The medical director supports educational opportunities within the nursing home for trainees in the health care professions.

Function 5—Employee Health

Tier 1

Task 1
The medical director helps the facility foster a sense of self-worth and professionalism among employees.

 

Task 2
The medical director advises the facility about infectious disease issues related to employees.

Tier 2

Task 3
The medical director helps the facility identify, evaluate, and address situations that increase the risk of employee injury and illness.

Task 4
The medical director helps the facility implement a program to identify job requirements and assess employee capabilities relative to those requirements.

Task 5
The medical director advises the facility's safety committee, in areas where medical expertise is helpful.

Task 6
The medical director advises the facility on establishing and implementing employee wellness programs (e.g., weight reduction, stress reduction, cholesterol reduction, blood pressure reduction, nutrition, exercise).

Task 7
The medical director guides the facility in developing and implementing programs for employees experiencing physical, social, or psychological problems.

Task 8
The medical director advises the facility on policies related to the health and safety of staff, visitors, and volunteers.

Task 9
The medical director advises the facility on preventing and managing employee injuries.

Function 6—Community

Tier 1

Task 1
The medical director helps the facility identify and utilize collaborative approaches to health care, including integration with community resources and services.

 

Tier 2

Task 2
The medical director acts as an advocate for the facility, encourages and facilitates community involvement in the activities of the facility, and helps the facility educate the community about its capabilities and services.

Task 3
The medical director participates in the activities of geriatrics and long term care committees of medical organizations and identifies issues and seeks solutions to problems that involve other institutions and programs.

Task 4
The medical director participates in health care planning in the community, including innovative cost-effective alternative health care programs for long term care.

Task 5
The medical director serves as a mentor to physicians-in-training within the facility.

Task 6
The medical director helps the facility address and communicate regarding situations that have brought the facility to the attention of the public and/or the media.

Task 7
The medical director meets with other long-term care professionals in the community as appropriate.

Function 7—Rights of Individuals

Tier 1

 

Task 1
The medical director helps the facility ensure that its policies and practices reflect and respect resident rights, including the opportunity for self-determination; e.g., via tools such as living wills and durable powers of attorney.

Task 2
The medical director helps the facility ensure that the ethical and legal rights of residents (including those who lack decision-making capacity, regardless of whether they have been deemed legally incompetent) are respected. This includes the right of residents to request practitioners to limit, withhold, or withdraw treatment(s).

Task 3
The medical director helps the facility accommodate patients’ choice of an attending physician.

Tier 2

Task 4
The medical director participates in the activities of the institutional biomedical ethics committee and identifies community resources that can assist in resolving ethical and legal issues.

Task 5
The medical director helps the facility establish a system for identifying and reporting abuse, as well as criteria for identifying potential abuse among both residents and staff.

Task 6
The medical director helps the facility identify and use available community resources to help address ethical issues (e.g., ombudsman, health department, ministerial association).

Task 7
The medical director participates, when necessary, in family meetings and similar activities to help the facility and attending physicians promote and protect resident rights.

Function 8—Social, Regulatory, Political, and Economic Factors

Tier 1

Task 1
The medical director helps the facility identify and provide care that is consistent with applicable social, regulatory, political, and economic policies and expectations.

 

Task 2
The medical director helps the facility identify, interpret, and comply with relevant State and Federal laws and regulations.

Tier 2

Task 3
The medical director seeks and disseminates information about aging, long-term care, and geriatric medicine to the facility's practitioners, staff and residents.

Task 4
The medical director helps the facility make decisions about resource allocation including financial considerations that affect medical care (e.g., use of formularies, contracts, appropriate use of lab tests).

Task 5
The medical director participates in the facility budget process to help the facility allocate sufficient resources for essential medical functions and patient care activities.

Task 6
The medical director provides feedback, as appropriate, to legislators and public policy makers about existing and proposed laws and regulations.

Function 9—Person-Directed Care

In addition to the following tasks, many of the tasks covered under the other functions relate directly or indirectly to the provision of person-directed care.

Tier 1

Task 1
The medical director oversees clinical and administrative staff, to help maintain and improve the quality of care including the success of person-directed care and patient and family satisfaction with all aspects of the care.

Task 2
The medical director guides the physicians and other health care professionals and staff to provide person-directed care that meets relevant clinical standards.

Task 3
The medical director collaborates with facility leadership to create a person-directed care environment while maintaining standards of care.

Tier 2

Task 4
The medical director helps the facility encourage active resident participation in, and promotes the incorporation of resident preferences and goals into development of, a person-directed plan of care.

Task 5
The medical director helps the facility develop, implement, and review policies and procedures that ensure residents are offered choices that promote comfort and dignity (e.g., choices regarding awakening, sleep, and medication administration times, discussions of risks/benefits regarding therapeutic diets, medications and treatments).

Task 6
The medical director collaborates with the interdisciplinary team (IDT), families, and allied services within and outside of the organization to encourage planning, implementing, and evaluating clinical services to maximize resident choice, quality of life, and quality of care.

Appendix I- Break down of the numbers of tasks (Tier 1 and 2) for each function

Function	Tier 1 Tasks	Tier 2 Tasks
1	6	2
2	7	9
3	6	6
4	4	4
5	2	7
6	1	6
7	4	4
8	2	4
9	3	3
TOTAL	35 (44%)	45 (56%)