The Role of the Medical Director in Person-Directed Care

“Person-directed care” is a philosophy that encourages both older adults and their caregivers to express choice and practice self-determination in meaningful ways at every level of daily life. Values that are essential to this philosophy include choice, dignity, respect, self-determination and purposeful living¹. These values also are at the core of desirable medical care and are embraced by many medical providers. Yet practices that conflict with these principles are common in the long term care setting. Examples include awakening residents at times that are determined by staff convenience, modifying residents’ diets without discussion, and inflexible meal times and medication pass times. In addition, care plans may be created without truly understanding a resident, their history or previous occupation, their recreational and personal preferences, wishes regarding life-sustaining treatment, and other likes and dislikes.

Geriatrics is a discipline that emphasizes medical care in the proper context, including its impact on function, quality of life, and personal preferences. Advocacy groups such as the Pioneer Network also promote person-directed care in the long term care setting². In addition, alternative approaches to nursing home care have become more prevalent over the past decade. Examples include the Eden Alternative, the Green House Project, the Planetree Model and the Wellspring Model. Greater emphasis on resident choice also has found its way into the guidance for surveyors. In April 2009, the Centers for Medicare & Medicaid Services (CMS) revised the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities as it relates to in several federal tags concerning quality of life and environment. Noteworthy changes to the interpretive guideline for F-Tag 242 (Self-Determination and Participation) included the statement: “Residents have the right to have a choice over their schedules, consistent with their interests, assessments, and plans of care. Choice over “schedules” includes (but is not limited to) choices over the schedules that are important to the resident, such as daily waking, eating, bathing, and the time for going to bed at night. Residents have the right to choose health care schedules consistent with their interests and preferences, and the facility should gather this information in order to be proactive in assisting residents to fulfill their choices.” ³

While care that promotes resident choice and dignity is essential, approaches that focus only on these psychosocial issues while ignoring the resident’s complex medical needs invite poor outcomes. For example, some residents may be at greater risk for developing pressure ulcers if they are allowed to stay in one position in bed for too long or may have problematic loss of diabetic control or increased blood pressure if allowed to eat indiscriminately. Or, giving higher risk analgesics based on resident insistence may increase their risks for avoidable adverse outcomes such as medication-related adverse consequences or even death.

Identifying the proper balance between medical complexity, which may require medications, modifications, and restrictions, and allowing for personal choice, is the essence of good geriatric medicine. However, a blanket or rote approach to these issues (for example, easing restrictions on everyone without regard to impact) is inconsistent with sound approaches. Individualized care should seek to understand the entire person, to focus attention on the medical, functional and psychosocial aspects of the resident. The interdisciplinary team should consider the potential effects of proposed interventions on the resident, rather than simply the treatment or protocol’s effect on a disease.⁴ For example, some residents who remain in bed until they awake on their own may develop pressure ulcers or lose weight, although most will not. Most residents will appreciate having these choices and the team can weigh the benefits against the risks and work with the resident and/or family/POA to establish an effective individualized plan of care. This approach is especially helpful in situations where the benefits of the intervention are modest and the risks are significant. Examples of this include the use of restricted diets to treat diabetes and hypertension. Such dietary restrictions may benefit some individuals, but more lenient blood pressure and blood sugar goals in the frail elderly^5,6,7 may be desirable while a less palatable restricted diet may lead to weight loss and its associated complications^8,9.

Residents with dysphagia present a comparable challenge. While dysphagia may place the resident at increased risk for choking and aspiration pneumonia, intervention with thickened liquids is of questionable value in reducing these risks and can increase the risk of dehydration and malnutrition^{10,11,12,13,14.} Proper person-directed care requires an effective interdisciplinary team that can consider the risks and benefits of potential interventions, effectively discuss these issues with the resident and/or their family/POA, and develop and monitor an individualized plan of care. Furthermore, given the often complex medical needs of nursing home residents, person-directed care highlights the critical role of the medical director in leading the interdisciplinary team.

AMDA supports the philosophy of person-directed care and believes that it can promote improved quality of life for long term care residents. The medical director has an essential role in promoting this individualized care as well as helping to ensure quality of care. In 2007, supported by funding from the Commonwealth Fund, AMDA began working with the Pioneer Network, on developing person-directed care competencies for medical directors. An advisory panel was formed as part of this project, and included several AMDA members as well as representation from the Pioneer Network and the CMS. Using AMDA’s Medical Director: Role and Responsibilities as Leader and Manager-Functions and Associated Tasks document, created in 1991, as a foundation, the panel crafted more than 40 person-directed care competency statements that were felt to define the role of the medical director in facilitating person-directed care. Initially, this list and the original 8 functions and tasks document was redundant. A person-directed care task force was created and consisted of 25 AMDA medical directors with clinical and medical direction experience in nursing homes that practiced person-directed care. In an effort to limit redundancy, the initial list of competency statements was consolidated to less than 20. A survey was then created that asked each member of the task force to grade the competency statements, using a 5-point Likert scale; on the importance of each competency to the role of the medical director in facilitating person-directed care and how measurable the competency was. The results allowed for further consolidation and a second round of surveys resulted in the final selection of 6 competencies that all received a score of at least 75% agreement or strong agreement on being both essential and measurable.

AMDA’s original eight medical director functions and associated tasks served to define the role of the medical director in the nursing home and helped to shape the educational content of the current Core Curriculum on Medical Direction in Long Term Care1. The faculty organized the results into 8 categories of functions. The current task force developed this present set of competencies using a similar methodology to define the role of the medical director in facilitating person-centered care. The task force believes that there should be a 9th function statement, regarding defining person-directed care, and that the six competency statements would serve as the associated tasks for this function statement. The function statement and associated tasks are below.

Function 9: Person-Directed Care—the medical director will support and promote person-directed care.

1. Provides oversight to clinical and administrative staff to help maintain and continuously improve the quality of care (e.g., help develop metrics and periodically analyze processes and results to monitor the success of person-directed approaches).
2. Encourage active resident participation in, and promote the incorporation of resident preferences and goals into development of an individualized plan of care.
3. Helps 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 risk/benefits regarding medicalized diets, medications and treatments).
4. Collaborates with the interdisciplinary team (IDT), the family, 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.
5. Educates physicians and other medical professionals on maintaining clinical standards in the context of individualized care.
6. Collaborates with nursing home leadership to create a person-directed care environment while maintaining standards of care.

1. Amend the initial functions and tasks document to include a 9th function, person-directed care, and its associated 6 task statements.
2. Develop education based on these competency statements that will enable medical directors to support and promote person-directed care in the long term care setting.

Person-directed care promotes resident choice and self-determination in ways that are meaningful to the resident. It has been a key component of geriatric medicine for decades. The interdisciplinary team and the medical director have essential roles both in facilitating this process as well as in monitoring it for desired outcomes. Medical directors and clinicians should help nursing home administration and staff understand how to provide person-directed care while maintaining clinical excellence. To ensure success, nursing home leadership must support these efforts. In addition, regulations and related surveyor guidance should permit the flexibility to individualize care.

1. Culture Change. Pioneer Network Website. 2010. Available at: http://www.pioneernetwork.net/CultureChange/. Accessed January 17, 2010.
2. About Us. Pioneer Network Website. 2010. Available at: http://www.pioneernetwork.net/AboutUs/. Accessed January 17, 2010.
3. Policy and Regulation. Pioneer Network Website. 2010. Available at: www.pioneernetwork.net/Data/Documents/CMSInterpretivememo.pdf. Accessed January 17, 2010.
4. Levenson, S. The Basis for Improving and Reforming Long-Term Care. Part 3: Essential Elements for Quality Care. J Amer Med Dir Assoc 2009; 10: 597-606.
5. American Medical Directors Association (AMDA) Clinical Practice Guideline: Diabetes Management in the Long-Term Care Setting 2008.
6. Beckett, NS, Peters, R, Fletcher, AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med 2008; 358:1887.
7. Oates DJ, Berlowitz DR, Glickman ME, Silliman RA, Borzecki AM. Blood pressure and survival in the oldest old. J Am Geriatr Soc 2007; 55(3):383-8.
8. Kamel HK, Malekgoudarzi B, Pahlavan M. Inappropriate Use of Therapeutic Diets in the Nursing Home. J Am Geriatric Society, 2000;48(7):856-857
9. American Medical Directors Association (AMDA) Clinical Practice Guideline: Altered Nutritional Status. 2009.
10. Campbell-Taylor I. Oralpharyngeal Dysphagia in Long-term Care: Misperceptions of Treatment Efficacy. J Amer Med Dir Assoc 2008; 9: 523-531.
11. Logeman JA, Gensler G, Robbins, et al. Design, Procedures, Findings, and Issues from the Largest NIH Funded Dysphagia Clinical Trial entitled Randomized Study of Two Interventions for Liquid Aspiration; Short and Long-term Effects. (Protocol 201) Presented at ASHA Annual Conference, November 16-18, 2006. Available at http://www.dysphagassist.com/major_randomized_studies. Accessed Dec 20, 2009.
12. Robbins J, et al. Comparison of 2 Interventions for Liquid Aspiration on Pneumonia Incidence. Ann Int Med 2008; 148:509-518.
13. Messinger-Rapport B, et al. Clinical Update on Nursing Home Medicine: 2009. J Amer Med Dir Assoc 2009; 10: 530-553.
14. Steele C. Food for Thought: Primum Non Nocere: The Potential for Harm in Dysphagia Intervention. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 2006: 15: 19-23.