U.S. Department of Health and Human ServicesU.S. Department of Health and Human Services
This report was prepared under contract#HHS-100-03-0028 between U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the University of Colorado. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Jennie Harvell, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Her e-mail address is: Jennie.Harvell@hhs.gov.
The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.
The Assistant Secretary for Planning and Evaluation (ASPE) contracted with the University of Colorado Health Sciences Center (UCHSC) to examine and describe models of physician practices in nursing homes; the financing arrangements and payment rates associated with these models; and determine what is known about the impact of physician practice models on the quality of care received by nursing home patients and on the quality of care provided in nursing homes.
In the first phase of this project, the UCHSC completed a literature review related to physician practice patterns in nursing homes, including the: requirements related to such practices; extent to which medical schools prepare physicians to practice in nursing homes; level of physician practice and specialization in providing services in nursing homes; barriers to physicians practicing in nursing homes and innovative physician practice arrangements in nursing homes.
The second phase of the study, which is presented in this report, was designed to further explore several issues that were not adequately addressed in the literature. Using information learned during the first phase, discussions were held in nursing homes and with key stakeholders in certain areas of the country to better understand the use and impact of various physician practice arrangements in nursing homes. This report summarizes discussions with stakeholders throughout the country in an attempt to identify obstacles and promising approaches to successful physician practices in nursing homes; synthesizes themes that recurred during the discussions; presents issues for further consideration; and offers potential areas for future research on physician practice in nursing homes.
A purposeful sample of eight facilities was selected for case studies of physician practice models. The objective of the purposeful sampling methodology was to select varied examples of physician practice models in a range of markets and facilities. No attempt was made to select a representative sample from which to draw statistical inferences.
Market, Facility and Practice Models of Interest
The literature review identified multiple market, facility and practice model characteristics related to access to and quality of nursing home physician care. Market characteristics included: (1) managed care penetration, (2) rural location, (3) geographic region, and (4) litigious environment. Facility characteristics included: (1) ownership and (2) size. Practice model characteristics included various types of physician specialization in nursing home care including practices that: (1) emphasize geriatrics and teaching, (2) limit physician practice to only nursing home patients, (3) integrate mid-level providers, (4) limiting the number of physicians in the care of patients in one facility (including the use of closed panel physician groups), and (5) include a variety of other physician practice models.
Stakeholders of Interest
Stakeholders targeted for discussions in each nursing home included: (1) a physician, (2) the nursing home administrator, (3) the medical director, (4) the director of nursing, (5) a social worker, and (6) one stakeholder for each facility who was identified by other respondents as an employee who would add valuable information to the discussions because of their unique perspective on physician care in the facility. Once a facility agreed to participate, a representative from each of the vocational disciplines was contacted by e-mail, telephone or fax to arrange individual stakeholder discussions.
Creation and Administration of the Discussion Guides
Discussion guides (Appendix A) were created to assist interviewers gather information from stakeholders regarding physician practices in the selected nursing homes. The discussion guides focused on four areas: (1) qualifications and training of the practicing physicians and medical directors; (2) practice models and patterns used by physicians; (3) access to care associated with specific practice models; and (4) the quality of care provided in the practice models used in the facility. Six versions, one for each vocational discipline, of the discussion guides were created so that each respondent was asked a set of questions relevant to their vocational discipline.
Three themes emerged from the stakeholder discussions regarding physician practice in nursing homes including: (1) physician specialization in nursing home care; (2) benefits of mid-level practitioners; and (3) importance of information transfer.
Physician Specialization in Nursing Home Care
The form of physician specialization in nursing homes varied, but most stakeholders clearly valued models of care that permitted physicians to specialize in the care of nursing home residents. While the stakeholders did not have precise definitions for nursing home specialists, they generally defined physician specialists as those who spend a substantial portion of time in the delivery of nursing home care or have the majority of their patient care caseload in nursing homes.
The incentives to the physicians who specialize in nursing home care were described as: (1) a reduction in overhead expenses associated with maintaining an office practice among those who practiced exclusively in nursing homes; (2) an ability to develop improved knowledge of regulations in nursing homes and effectively meet the needs of the nursing homes; (3) scheduling flexibility; and (4) the opportunity for long-term relationships with patients and families. Stakeholders felt that if medical students had a greater exposure to nursing home care during medical training, more physicians would select this career path. Based on the literature review, early exposure to the benefits of specializing in nursing home care can increase the number of physicians specializing in nursing home care.1
Benefits cited by stakeholders regarding specialist nursing home physicians included: (1) greater accessibility of physicians to patients, family, and nursing home staff; (2) improved knowledge of and sensitivity by physicians to challenges faced by nursing homes (e.g., regulations regarding use of anti-psychotics); and (3) enhanced medical management of common syndromes faced by nursing home residents (e.g., falls, urinary incontinence, agitated behaviors associated with dementia). The literature review also suggested that selected outcomes are better among patients of physicians specializing in geriatric medicine.1
Nursing home regulatory requirements are unique and unlike the requirements in other health care arenas. The respondents associated lack of knowledge about these regulations with negative effects on physician communication with the nursing staff, medication ordering practices and compliance with regulatory visits. Several respondents found the American Medical Directors Association (AMDA) certification program a valuable resource in the pursuit of information on various regulatory requirements such as the use of physical and chemical restraints and required intervals for physician visitations. Sources identified in the literature review supported early exposure during training as a strategy to increase physician experience and familiarity with nursing homes.2, 3, 4
The stakeholders’ concept of the best model of specialization differed; some stakeholders favored a mid-level provider-based model (e.g., using nurse practitioners (NPs) as is the practice in the Evercare model), others favored a closed physician practice model and still others preferred a model with physicians practicing independently in multiple facilities. The closed models provided a salary to the physicians in contrast to other models in which physicians obtained payments via billing Medicare Part B for physician services rendered to individual patients. In the literature review, selected outcomes (e.g., response to emergencies, hospitalization rates, satisfaction) were superior in mid-level provider and closed models compared to the traditional independent physician practice model.5, 6, 7
The stakeholders differed in their opinion of how physicians should be compensated for the delivery of specialized nursing home care. Stakeholders who practiced in a model with physicians salaried by the nursing home agreed that this model afforded the physicians more time to devote to the care of the patients, but they recognized that payment to physicians under the salaried model could be less than in a model in which physicians bill Medicare Part B for their services.
Differences in opinion also were evident with regard to the ideal mixture of practice across settings of care. For example, one stakeholder felt it was essential for nursing home physicians to practice in outpatient clinics and hospitals and then follow patients from these settings to the nursing home to provide continuity of care. Others felt an office or hospital practice detracted from the physicians' ability to focus on nursing home patients because the physicians were often unavailable for calls during office hours and tended to see their nursing home patients as a last priority in evenings and on weekends. The non-physician stakeholders consistently reported difficulty communicating with physicians who care for only a very few nursing home residents because of the competing demands of physicians’ clinic and hospital-based practices.
Nursing facility staff members uniformly reported a preference for physician practice models that involve regular and frequent presence in the facility. These physicians were described as having a better understanding of the pressures faced by nursing homes and improved relationships with the nursing staff and interdisciplinary teams. Social workers valued models that allowed the physicians to become nursing home specialists and respond quickly to emergency calls. Staff members, and nursing home residents and their families, uniformly were pleased with working with nursing home physician specialists. No patterns in preferences for specific models of care were observed consistently across facility types.
Although the evidence is limited, there is some literature to support that specializing in the care of patients in one care setting improves quality of care and reduces costs. For example, patients who are cared for by physicians who specialize in the hospital setting, have lower mortality rates and reduced hospital costs.2 The literature also suggests that physicians who specialize in nursing home care are on-site at nursing homes more frequently, have quicker response times to emergencies, lower hospitalization rates, and reduced use of medications.7, 8
Stakeholders also alluded to the difficulty researchers may have in determining whether or not specialization results in better care. For example, if one utilizes a higher frequency of lab tests as an indicator of good medical care, there may be factors other than clinical acumen guiding the volume of tests. On one hand, a non-nursing home specialist may order more tests because they are not in the facility to perform an assessment and must instead rely heavily on lab tests to substitute for a clinical examination. Alternatively, a nursing home specialist physician may order more tests than non-nursing home specialists, in part, because he/she are concerned about lawsuits if tests are not ordered to support their clinical assessments. Similarly, one stakeholder commented that more visits from practitioners increased the volume of orders but it is unknown whether or not an increase in orders results in improved care. Thus, future investigations regarding the quality of care provided by specialist versus non-specialist nursing home physicians should use caution in the design of outcome variables.
Increasing Use of and Desire to Work with Mid-Level Practitioners
The literature review and most respondents indicated that mid-level practitioners have the potential to increase the quality of care provided to nursing home residents and provide an important service in nursing home physician practice models. Respondents indicated that operating an efficient, large nursing home medical practice is not possible without the use of mid-level practitioners. Mid-level practitioners were described as enabling physicians to provide more efficient care because of their ability to respond quickly to urgent care needs.
Current Medicare policy permits mid-level practitioners to alternate visits with physicians. However, a concern expressed by several respondents was that physicians relied too heavily on the mid-level practitioners and participated less in the care of patients when a mid-level practitioner was involved.
An additional concern expressed by respondents and reinforced by the literature was that while the overall supply of NPs has increased in the past decade, there are not enough geriatric-trained mid-level practitioners to meet the demand for these practitioners in nursing homes.8, 9 Reasons for this shortage are not well understood, but they may parallel the reasons cited in the literature and offered by respondents regarding the lack of geriatric-trained physicians (e.g., minimal exposure to nursing homes during training).
Information Exchange -- Knowledge About Nursing Home Operations
Stakeholders and the literature review suggest the need for enhanced communications and/or information exchange between physicians and nursing home staff, across settings of care and across providers of care (e.g., communications among physicians, nursing homes, and laboratories).10
Issues and requirements that, in some instances, are unique to the nursing home setting and in other instances common across the health care continuum characterize medical service delivery in nursing homes. Persons treated in nursing homes often are severely functionally and cognitively impaired and/or medically complex, requiring intervention by interdisciplinary teams with substantial family/informal caregiver involvement.11, 12, 13 The literature provides evidence that transitions to and from nursing home care are a common occurrence and a major source of medical errors in relation to medication administration, advanced care directives, allergies, and delivery of essential services.14 An AMDA survey of 3,000 sequential admissions to skilled nursing facilities from 25 different hospitals found the following: 22% of transfers had no formal summary of information; legible summaries were available only 56% of the time; secondary diagnoses were missing in 30% of transfers; test results were omitted in 31%-67% of transfers, advance directives and code status were absent in 81% of transfers; and a legible phone number for the transferring physician was present in only 33% of transfers.15
The stakeholders also expressed similar concerns with respect to transitions from hospitals to nursing homes. They noted that transferring accurate medical information from one care setting to another is time-consuming and often inaccurate. This is because physicians often are not caring for patients across care settings, and there is no standardized process or standard set of information transferred across care settings to communicate health information. As observed by the stakeholders, nursing homes often are separated geographically from hospitals, diagnostic services, and physician offices, creating communication barriers that contribute to medical errors.
A common theme that emerged from discussions with stakeholders was the need for physicians to receive accurate and complete information regarding nursing home patients. Information transfer between hospital and nursing home stays were described as cumbersome and wrought with inaccurate and incomplete transfer of information. In most cases, the nursing facilities did not have computerized health information beyond the software used to record information for the Minimum Data Set. All stakeholders agreed that electronic medical records would vastly improve quality of care by reducing the inefficiencies involved with duplicating documentation that has occurred in other care settings and tracking down information.
The case presentations (Appendix B) provide examples of facilities with varied physician practice models and the issues related to each of these models. Several of these models offer promising approaches for improving physician care in nursing homes. This information could be useful when considering ways to promote effective and efficient medical service delivery to nursing home residents, to researchers in designing future studies examining physician practices in nursing homes, and to nursing homes and physicians in designing and implementing effective efficient physician practice models in nursing facilities.
Issues Requiring Further Consideration
Several overarching issues that arise from the literature review and stakeholder discussions that merit further consideration include availability of mid-level providers in long-term care (LTC). The literature review and stakeholder informants consistently suggested that mid-level providers are useful in extending medical services to nursing home residents and in promoting higher quality medical care to nursing home residents. However, these sources also discussed the limited supply of these mid-level providers. Other issues included physician training in geriatrics and nursing home care; and the need for incentives for enhancing physician care through pay-for-performance.
Availability of Mid-Level Providers in Long-Term Care
One strategy that has demonstrated success in attracting advanced practice nurses to LTC is the teaching nursing home concept in which schools of nursing establish affiliations with LTC facilities providing an advanced practice degree program for nurses with an emphasis in LTC. Funding specialty and advanced practice internship and residency programs for post degree recipients may also increase the availability of advanced practice nurses to nursing home care and help to provide a career ladder for nurses interested in positions of greater responsibility.
Physician Training in Geriatrics and Nursing Home Care
Strategies to stimulate physician practice in nursing homes may include modifications of the Medicare Graduate Medical Education program to provide direct and indirect funds to teaching hospitals in exchanges for placing an emphasis on training in nursing home care and/or geriatrics. Another approach may be to modify Medicare physician payment rules/methods to encourage physicians to provide services in nursing homes. Public Health Service training grants may also be structured in a manner that encourages medical education in geriatrics and nursing home care. Favorable student loan repayment programs for physicians who devote a significant proportion of their practice to nursing home care may also be established. Medical education could also incorporate exposure to nursing home patients for all internal medicine and family practice physician training programs.
The literature indicated few physicians are trained to provide care in nursing homes yet the literature and stakeholder informants indicate that when appropriately trained in the care of nursing home residents, physicians have an ability to effectively manage the frail, elderly population and improve outcomes. Stakeholders suggest that physicians who specialize in nursing home care are more proficient in understanding nursing home regulations and therefore are better able to respond to the medical needs of patients. However, the limited supply of physicians who are adequately trained to care for nursing home patients remains a challenge.
Incentive Payments for Medical Practices in Nursing Homes
Increasingly, purchasers of health care are interested in value-based purchasing. Recently legislation has been enacted to establish various pay-for-performance incentive programs to promote specific outcomes for physician practices. However, pay-for-performance incentive programs do not address clinically relevant outcomes for the frail institutionalized elderly.
Future Research
Currently, research is not available on features identified by stakeholders as important components of nursing home physician practice models. Specifically, the literature does not quantitatively or qualitatively address: (1) the efficacy of nursing home specialization, (2) effective strategies for information exchange between nursing homes and physicians or (3) methods to study physician payment incentives in nursing homes. Study designs are proposed for these topics. Recommendations related to specific research activities that would advance our knowledge related to physician practice in nursing homes include: (1) physician specialization in nursing home care and its impact on quality and costs; (2) health information transfer using technology across providers and settings when caring for nursing home patients; and (3) pay-for-performance incentives for physicians providing nursing home care.
Physician Specialization in Nursing Home Care
To study the effect of physician specialization in nursing homes an investigation could determine the extent to which quality indicators, influenced by physician practice, and avoidable hospitalizations are associated with the degree to which: (1) nursing homes are staffed by physicians who spend the majority of their practice caring for nursing home care patients (facility-level); and (2) a physician's practice is devoted to caring for nursing home residents (physician-level).
Health Information Transfer
Research could identify the issues that support or create barriers for information exchange and strategies that could facilitate information exchange, including electronic information exchange. The investigation would involve a literature review, stakeholder discussions and case studies examining how LTC organizations receive information, what information they receive when they serve patients that are treated by physicians and in hospitals that have the capacity to exchange health information electronically, and the factors that promote or inhibit electronic information exchange. ASPE is funding a study on health information exchange with post-acute and LTC settings.
Pay-for-Performance
A study could be developed under either Section 646 of the Medicare Modernization Act to establish a pay-for-performance demonstration program or, under an expanded demonstration program, to create physician incentive payments to promote high quality medical management by physicians and/or physician practice groups that include physician extenders on behalf of medically fragile nursing home patients. In developing pay-for-performance measures for nursing home care, the unique characteristics of nursing home residents and the environment of the nursing home must be taken into consideration. Such measures will apply specifically to the care of nursing home residents and not to a physician's outpatient population.
A study to pay for physician performance in skilled nursing facilities and nursing homes could test the effects of incentives for physicians (and their mid-level providers) to play a more active role in the care of their skilled nursing facility and nursing home residents. Process performance measures for physician and mid-level provider care in nursing homes could include timeliness of visits, responsiveness to phone calls from nursing home staff, and transfer of necessary information between a physician and nursing home staff. Outcome performance measures would need to target aspects of nursing home care over which the physician has the most influence. For example, use of unnecessary or inappropriate medications, untreated depression and pain, and rates of potentially avoidable hospitalizations might be considered.
Medication data available under the Medicare Part D program could be used to evaluate physician prescribing for nursing home and skilled nursing facility residents and whether unnecessary medications or inappropriate medications were used. Hospitalization for potentially avoidable causes, such as urinary tract infections, respiratory infections, sepsis, wound infections, and conditions such as congestive heart failure where monitoring and early response might avoid the need for hospitalizing a resident, are potential performance measures for physician care. However, physicians are not solely responsible for hospitalization of nursing home residents, and thus these measures should be risk adjusted for resident as well as facility characteristics that research has found to be associated with preventable hospitalization rates (such as nursing home staffing).
Following standard treatment approaches for problems such as pain and depression also can be used as physician performance measures. If such conditions have been identified, treatment is appropriate. However, for some conditions following standard treatment guidelines typically used in outpatient medicine may not be the most appropriate treatment intervention for the elderly nursing home patient.
The Assistant Secretary for Planning and Evaluation (ASPE) contracted with the University of Colorado Health Services Center (UCHSC) to examine and describe models of physician practices in nursing homes; the financing arrangements and payment rates associated with these models; and determine what is known about the impact of physician practice models on the quality of care received by nursing home patients and on the quality of care provided in nursing homes. In addition, the UCHSC was asked to advance research designs that could be used to better understand major issues that emerge with different physician practice arrangements in nursing homes.
In the first phase of this project, the UCHSC completed a review of the literature related to physician practice patterns in nursing homes, including:
The second phase of the study involved case studies to further explore several issues that were not adequately addressed in the literature including the:
Changes in Medicare payment policy (e.g., implementation of the acute care inpatient prospective payment policy) and in the availability of long-term care (LTC) alternatives (e.g., the growth in the assisted living industry) have led to a nursing home population that is increasingly frail and medically complex.16, 17 With almost two million Americans currently residing in nursing homes and an expected increase to almost five million by 2030, the need for physicians to practice in nursing homes will increase dramatically.16
Physicians are responsible for the medical care for all nursing home residents. The increase in medical complexity of nursing home residents suggests the need for greater involvement of physicians to oversee medical care. However, the literature provides limited information about specific models for the delivery of medical care to nursing home residents that will help meet the needs of a growing and increasingly medically complex and frail nursing home population.
Federal regulations specify that physicians oversee the medical care for all residents of nursing homes and that they participate in the design of care plans for nursing home residents based upon the residents' current clinical conditions. Physicians are also required to evaluate and manage new medical conditions or symptoms. How physicians provide such oversight is not well described in the literature. The few studies available on physician practices in nursing homes suggest that physician presence is limited and that the majority of nursing home visits are made by a limited number of physicians.3 In a 1997 survey completed by the American Medical Association, most physicians reported spending no time in treating nursing home patients (77%); and among physicians who did practice in nursing homes, most reported spending two hours or less per week caring for their nursing home patients.3 This lack of physician presence is reflected in many of the individual resident reports of dissatisfaction. Unattended symptoms, which include the failure to provide physician services for a change in condition, was the tenth most common complaint in 2000, up 44.4% from 1996.18
Against the backdrop of sicker patients needing more physician care is a physician workforce in nursing home care that may be shrinking. In a survey of physicians who provided nursing home care, 50% indicated that they planned to decrease their involvement in the care of nursing home residents.19 Physicians planning to reduce their nursing home caseloads cited poor reimbursement by Medicare Part B for their services; a high volume of telephone calls from the nursing homes; onerous paperwork; and lack of physician authority in nursing homes as reasons for leaving the nursing home environment.19
Section II of this report describes the methods that were used to select facilities and the market areas of interest. The Methods Section also describes the types of stakeholders with whom discussions were held and the type of information that was solicited from these stakeholders. Appendix A includes a copy of the discussion guides used for these discussions.
Section III provides an overview of the findings that emerged from the case study and discusses the three primary issues that arose during discussions with informants. Appendix B summarizes the findings for each facility included in this study.
Section IV of this report discusses the issues and areas for possible future research related to physician practice in nursing homes.
A purposeful sample of nursing facilities in selected markets was targeted to examine various physician practice models. No attempt was made to select a representative sample from which to draw statistical inferences.
Eight facilities were selected for case studies of physician practice models. This section describes methods used to: (1) select market, facility and practice model characteristics, (2) select stakeholders, and (3) create and administer the discussion guides. A summary of the facility and market characteristics of each selected facility can be found in Table 1.
The literature review identified multiple market, facility and practice model characteristics related to access to and quality of nursing home physician care that we considered in selecting facilities and stakeholders. In addition, the Technical Advisory Group (TAG) members reviewed these characteristics and described innovative physician practice models to target.
The following market characteristics were considered in selecting sites:
Managed care penetration -- The literature suggested differences in access to and quality of physician services in nursing homes related to coverage by a managed care or fee-for-service plan. Further, managed care has disparate incentives for nursing homes due to the nature of capitated payments. We examined nursing homes in two different managed care environments. First, a nursing home that was populated primarily with health maintenance organization (HMO) patients. Secondly, a nursing home that had a significant proportion of patient in Evercare, a specialized capitated payment model designed specifically for the institutionalized elderly.
Rural location -- Concerns identified in the literature and raised by the TAG regarding access to care and the availability of specialized nursing home/geriatric physicians led us to consider facilities in rural/semi-rural communities.
Geographic region -- The majority of published literature on physician practice in nursing homes relies on research in two states, New York and California. While these are the most populous states, we intentionally chose facilities spread across the entire United States.
Litigious environment -- Recent literature suggests along with increases in the price of medical malpractice insurance, physicians are more likely to be listed as defendants in lawsuits against nursing homes than previously reported. The availability and cost of malpractice insurance for physicians who practice in nursing homes has been identified as a concern among physicians and so we targeted a facility in Florida, a state with high rates of malpractice claims.
The following facility characteristics were considered in selecting sites:
Ownership -- We intentionally selected facilities to represent the three primary types of nursing home ownership: non-profit, for-profit, and government owned.
Size -- Nursing homes vary widely in the number of residents they house and we attempted to choose nursing homes with disparate bed sizes.
Both the literature and TAG members suggested the potential for a relationship between physician specialization and the quality of nursing home care. Specialization was often defined in different ways. Practice models were identified that represented the primary definitions of specialization. The following types of practice model specialization in nursing home care were considered in selecting sites:
Geriatrics/teaching -- This practice model placed a strong emphasis on teaching and education in geriatrics. Three facilities were selected that use this model.
Nursing home only practice -- This model is one in which the nursing home is served by a physician practice devoted entirely to nursing home care. We included one facility in which the practicing physicians care only for nursing home patients.
Limiting physician practitioners -- A prior research study suggested closed panel facilities (i.e., facilities that generally limit attending physicians to those that are salaried by the facility) provided higher quality care. Alternatively, some facilities limit physician privileges to a small set of community physicians. One facility that employs its own physicians and another facility that limits the number of attending physicians were included in this study.
Other varied physician models -- In this model many physicians practice in the facility and each physician cares for a panel of residents ranging from a few to dozens of residents. No physician practice is devoted entirely to nursing home care.
Participants of the project TAG provided referrals for two of the study sites with the characteristics of interest. Subsequent referrals for study sites with the market, facility and/or practice model characteristics of interest came through LTC practitioner contacts and Internet research on specific models of physician service delivery in nursing homes.
Stakeholder Disciplines
We identified stakeholders in each nursing home representing five specific disciplines and one variable staff member. Based on input from the TAG, each discipline was chosen based upon their participation in or unique view on the physician/patient relationship in nursing homes. Stakeholders included:
A physician with patients in the nursing home.
The nursing home administrator who is responsible for providing privileges for physicians to practice in their nursing home and also has final responsibility for care received by their residents.
Medical directors who, often practice as attending physicians in the nursing home they serve. They may also provide medical care that supplements the care from a patient’s primary physician, or may be responsible for disciplining physicians who do not meet an acceptable level of care.
The director of nursing who observes physician practice and may have the most direct contact with physicians and closest observation of their patient interactions.
Social workers who may receive any complaints patients have regarding their physician care and may act as liaisons between physicians and patients or family members.
A stakeholder for each facility was identified by other respondents as an employee who would add valuable information to the discussions because of their unique perspective on physician care in the facility. These included nurses, nurse practitioners (NPs), a dietitian, an admission coordinator and staff development personnel. The study team designated these respondents as “wild card” employees.
Stakeholder Recruitment
Once investigators were able to confirm a facility’s participation, individual stakeholders were identified and discussions were arranged. Stakeholders were contacted by e-mail, telephone or fax. Limitations to the recruitment process included non-response by several employees and low levels of technology available in facilities. Many facilities did not have e-mail addresses for their employees or voicemail boxes for individual staff members.
In cases where stakeholders in a facility were not available or willing to participate in the discussion, we sought an alternate from the facility. Specifically, in Facility 7, the nurse manager had extensive knowledge about a variety of physician practice patterns within the facility and was substituted for the physician interview in this facility.
In the cases where a suitable replacement was not available within the original facility being studied, we either located a participant who worked in a facility with the characteristics of interest or did not have responses from these respondent groups. Specifically:
In Florida, a physician from the original study facility (Facility 5) was not available. A topic of interest in this facility was how nursing home physician practice patterns are affected by living in state with a high rate of lawsuits directed against nursing homes. As a replacement, we recruited another physician who practices in nursing homes in Florida for the discussion.
In Facility 1 (a facility in North Dakota), attempts to contact the medical director and a physician respondent in this facility were unsuccessful. Thus, a medical director and physician respondent are not included in responses from the Facility 1. Discussions with the remaining respondents are retained in this report because these respondents add important information regarding nursing home physician practices in semi-rural regions.
Creation of Discussion Guides
Discussion guides were devised to gather information pertaining to physician practices in the selected nursing homes (Appendix B). To create the discussion guides, each of the investigators drafted sample questions thought to be relevant to and illustrative of physician practice patterns in nursing homes. The identified issues were then compared to identify major themes, redundancies, and crosscutting themes. Specifically, the discussions sought information in four areas: (1) qualifications and training of the practicing physicians and medical directors; (2) practice models and patterns used by physicians; (3) access to care associated with specific practice models; and (4) the quality of care provided in the practice models used in the facility.
Two types of discussion guides were then created to assist interviewers gather a consistent set of information from each stakeholder. The pre-discussion guide asked stakeholders' about the length of time they had worked in the nursing home industry, the training required to work in their current position and several questions about characteristics of the facility in which they worked. Stakeholders were instructed to complete the pre-discussion guide and fax it back to the investigators.
Discussion guides used during telephone discussions with the selected stakeholders addressed issues relevant to the vocational discipline of the stakeholder. For example, the discussion guide for the director of nursing asked questions that would only be relevant to his/her interactions with physicians as the director of nursing, whereas the discussion guide for a social worker asked a different set of questions relevant to the interactions social workers have with physicians in nursing homes. The wildcard discussion guide was designed after each of the specific discussion guides was designed. Investigators included a variety of issues that were relevant to experience with physician practice patterns. Because the wildcard could be any staff member working at the facility with knowledge of physician practice patterns, no questions were specific to any one discipline.
The discussion guides were pilot tested with each of the selected stakeholder disciplines at a local nursing facility located in Denver, Colorado, and were revised based on recommendations that emerged from the pilot. Some examples of revisions to the stakeholder discussion guides included placing questions regarding credentials and facility description in the discussion guide completed before the actual discussion. This was done to individually tailor each discussion, enable research staff to be more personable with the stakeholders, and ensure that questions were not repeated. Pilot testing resulted in including a statement at the beginning of each discussion to provide study background and, funding information, and a brief summary of anticipated results. Additionally, a clause was added that stated each discussion would be recorded for accuracy of transcription. In addition, some items that were identified as irrelevant or lacking in clarity were deleted or clarified. Staff in ASPE then reviewed the stakeholder discussion questions for approval.
Administration of Discussion Guides
After initial contact with the stakeholders was made, the study abstract was shared along with the pre-discussion guide. Once the stakeholder returned the completed pre-discussion guide, a telephone discussion was scheduled. (Copies of the stakeholder pre-discussion and discussion guides are presented in Appendix A.) Telephone discussions lasted 30-90 minutes. During the discussions, no attempt was made to reconcile conflicting information from different respondents selected for the targeted facility.
The limited number of sites and difficulties encountered in the process of recruiting stakeholders limit the extent to which one can generalize these findings to all nursing homes; however, several consistent themes emerged. As in much qualitative research this was a purposeful sample to examine specific practice models and markets. Thus, the study sites may be systematically different from the average nursing home due to both the sampling criteria and the selection bias between nursing homes that agreed to participate and those that declined. Primary reasons that facilities refuse to participate in the study included time and availability of staff; abundance of paperwork; facility in the middle of the survey process; key staff in training; and the belief that the facility would have little or no beneficial information to add to the study.
| TABLE 1. Facility, Market and Physician Practice Model Characteristics | ||||||||
|---|---|---|---|---|---|---|---|---|
| Nursing Home 1: Minot, ND | Nursing Home 2: Alma, MI | Nursing Home 3: San Diego, CA | Nursing Home 4: Durham, NC | Nursing Home 5: West Palm Beach, FL | Nursing Home 6: New Hope, MN | Nursing Home 7: Rochester, NY | Nursing Home 8: Houston, TX | |
| MARKET CHARACTERISTICS | ||||||||
| High Managed care penetration rate (>50% enrollment) | X | X | ||||||
| Rural | X | X | ||||||
| Geographic Regions (CMS Region) | VIII | V | IX | IV | IV | VI | II | VI |
| Litigious environment | X | |||||||
| FACILITY CHARACTERISTICS | ||||||||
| Ownership | For-profit, Corporation | Non-profit, Private | For-profit, Corporation | Non-profit, Corporation | For-profit, Corporation | Non-profit, Corporation | Government, County | For-profit, Partnership |
| Size (average 100-120) | Average | Above Average | Above Average | Above Average | Average | Very Large | Very Large | Average |
| PHYSICIAN SPECIALIZATION PRACTICE MODELS | ||||||||
| Geriatrics/teaching | X | X | X | |||||
| Nursing home only | X | |||||||
| Closed Panel Model -- Staff Physicians | X | X | ||||||
| Limit Number of Community-Based Physicians | X | |||||||
| A variety of other physician practice models | X | X | X | X | ||||
This project involved discussions with stakeholders from eight nursing facilities representing different physician practice models. The physician practice models reported at each of the targeted facilities appear to be shaped by several factors, including whether the facility is located in an area with a high managed care penetration rate; the facility’s geographic location (i.e., rural/urban); and the pervasiveness of liability concerns in the selected facility. The summary of discussions for each stakeholder as the selected facilities is found in Appendix B.
The case presentations provide examples of facilities with varied physician practice models and the issues related to each of these models. This information can be used when considering ways to promote effective and efficient medical service delivery to nursing home residents; researchers in designing future studies examining physician practices in nursing homes; and by nursing homes and physicians in designing and implementing effective efficient physician practice models in nursing facilities.
Facility Characteristics
The facilities varied in the number of physicians who care for patients, the amount of time each physician spends in the facility and the number of patients followed (Table 2). In the facilities selected for this case study, the number of beds ranged from 106 to 566 and the number of physicians seeing patients at each selected facility ranged from two to 50 physicians. One facility sent laboratory studies and patients who needed X-rays to a hospital located one block from the facility; however, the majority of facilities used a mobile service to perform laboratory studies and X-rays in the facility. None of the facilities reported using a fully integrated electronic medical record. Two of the facilities had relationships with a university training program, and each facility had a unique combination of skilled nursing, custodial, intermediate, and specialized care units (e.g., dementia and palliative care). While only one facility had been involved in a lawsuit, all of the facilities were concerned about the growing number of legal cases against nursing homes. All facilities utilized their medical directors to provide some level of direct physician care, at least in emergencies.
Generally, facilities reported that the medical director's role was primarily as a consultant, but also included quality improvement, quality assurance, training, and acting in a dual role as an attending physician. Four facilities consulted regularly with their medical directors on patients for whom the medical director was not the attending physician. All of the medical directors had an added certificate of qualification in geriatrics, and six of the eight medical directors were also certified medical directors.
Seven facilities reported that mid-level practitioners (such as physician assistants (PAs) and NPs) care for patients in the facility either as salaried employees of the nursing home or in partnerships with physicians. The one facility that did not have a mid-level provider is part of a corporation that is promoting the hire of mid-level providers as full-time employees and is anticipating adding at least one mid-level provider in the near future.
Physician Practice Characteristics
Physician characteristics and practice patterns in the nursing homes were very diverse (Table 3). The percentage of time physicians devote to the care of nursing home residents ranged from 10% to 95% of their medical practice, and the average number of hours the physicians care for nursing home patients each week varied from five to 60 hours per week. The number of nursing homes served by each physician ranged from three to ten and the physicians interviewed care for up to 300 nursing home residents regularly.
The characteristics of the facilities and physician respondents for this study are presented in Table 2 and Table 3.
Three issues emerged across stakeholder discussions regarding physician practice in nursing homes. These issues were the:
These issues are discussed below.
Physician Specialization in Nursing Home Care
The form of physician specialization in nursing homes varied, but most stakeholders clearly valued models of care that permitted physicians to specialize in the care of nursing home residents. The stakeholders did not have precise definitions for nursing home specialists. However, they generally defined physician specialization as physicians who spend a substantial portion of their time in the delivery of medical care to nursing home residents or have the majority of their patient caseload in nursing homes.
The benefits to the physicians who specialize in nursing home care were described as: (1) a reduction in overhead expenses associated with maintaining an office practice; (2) an ability to develop improved knowledge of regulations in nursing homes and effectively meet the needs of the nursing homes; (3) scheduling flexibility; and (4) the opportunity for long-term relationships with nursing home patients and families. Stakeholders felt that if medical students had a greater exposure to nursing home care during medical training, more physicians would select this career path. Based on the literature review, early exposure to the benefits of specializing in nursing home care can increase the number of physicians specializing in nursing home care.1
Other benefits cited by stakeholders regarding specialist nursing home physicians included: (1) accessibility of medical staff to patients, family and nursing home staff; (2) improved knowledge of and sensitivity by physicians to challenges faced by nursing homes (e.g., regulations regarding use of anti-psychotics); and (3) enhanced medical management of common syndromes faced by nursing home residents (e.g., falls, urinary incontinence, agitated behaviors associated with dementia).
Nursing home regulatory requirements are unique and unlike the requirements in other health care arenas. The respondents associated lack of knowledge about these regulations with negative effects on physician communication with the nursing staff, medication ordering practices and compliance with required regulatory visits. Several respondents found the American Medical Directors Association (AMDA) certification program to be a valuable resource for information regarding regulatory requirements such as the use of physical and chemical restraints and required intervals for physician visitations. Sources identified in the literature review supported early exposure during medical training as a strategy to increase physician experience and familiarity with nursing homes.2, 3, 4
The model of physician specialization preferred by stakeholders varied. Some stakeholders favored a model that coupled physicians with mid-level providers (i.e., Evercare), others favored a closed physician practice model and still others preferred a model where physicians practice independently in multiple facilities. The closed models provided a salary to the physicians in contrast to other models in which physicians independently billed Medicare Part B. In the literature review, selected outcomes were superior in mid-level provider and closed models compared to the traditional independent physician practice model.5, 6, 7
Proponents of the salaried-model indicated that this model afforded the physicians more time to devote to the care of the patients, but could be less financially lucrative to physicians in comparison to a model in which physicians independently bill Medicare Part B for their services. Stakeholders also reported that as the number of physicians practicing in a facility increased, communication challenges between the nursing home and attending physicians increased. As the number of physicians increase nursing home staff must remember and use each physician’s preferred method of communicating (e.g., fax, telephone, e-mail, etc.) for different types of medical information (e.g., making available lab results, general medical questions, emergent situations).
Differences in opinion also were evident with regard to the ideal mixture of physician practice across settings of care. For example, one stakeholder felt it was essential for nursing home physicians to practice in outpatient clinics and hospitals and then follow patients from these settings to the nursing home to provide continuity of care. Others felt an office or hospital practice detracted from the physicians' ability to focus on nursing home patients because the physicians were often unavailable for calls during office hours and tended to see their nursing home patients as a last priority in evenings and on weekends. The stakeholders consistently reported difficulty communicating with physicians who care for only a very few nursing home residents because of the competing demands of their clinic and hospital-based practices.
Facility staff members uniformly reported a preference for physician practice models that involve regular and frequent physician presence in the facility. These physicians were described as having a better understanding of the pressures faced by nursing homes and improved relationships with the nursing staff and interdisciplinary teams. Social workers valued models that allowed the physicians to become nursing home specialists and respond quickly to emergency calls. Staff members, and nursing home residents and their families, uniformly were pleased with working with nursing home physician specialists. No patterns in preferences for specific models of care were observed consistently across facility types.
Although the evidence is limited, there is some literature to support that specializing in the care of patients in one care setting improves quality of care and reduces costs. For example, patients who are cared for by physicians who specialize in the hospital setting, have lower mortality rates and reduced hospital costs.2 The literature also suggests that physicians who specialize in nursing home care are on-site at nursing homes more frequently, have quicker response times to emergencies, lower hospitalization rates and reduced use of unnecessary medications.7, 8
Stakeholders also discussed the difficulty researchers may have in determining whether or not specialization results in better care. For example, if one utilizes a higher frequency of lab tests as an indicator of good nursing home care, there may be factors other than clinical acumen guiding the volume of tests. On one hand, a non-nursing home specialist may order more tests because they are not in the facility to perform an assessment and must instead rely heavily on lab tests to substitute for a clinical examination. Alternatively, a nursing home physician may order more tests than non-nursing home specialists, in part, because he/she are concerned about lawsuits if tests are not ordered to support their clinical assessments. Similarly, one stakeholder commented that more visits from practitioners increased the volume of orders but it is unknown whether or not an increase in orders results in improved care. Thus, future investigations regarding the quality of care provided by specialist versus non-specialist nursing home physicians should use caution in the design of outcome variables.
Increasing Use of and Desire to Work with Mid-Level Practitioners
The literature review and most respondents indicated that mid-level practitioners have the potential to increase the quality of care provided to nursing home residents and provide an important service in nursing home physician practice models. Respondents indicated that operating an efficient, large nursing home medical practice is not possible without the use of mid-level practitioners. Mid-level practitioners were described as enabling the delivery of more efficient care because of their ability to respond quickly to urgent care needs. However, a concern expressed by several respondents was that physicians relied too heavily on the mid-level practitioners and participated less in the care of patients when a mid-level practitioner was involved.
An additional concern expressed by respondents and reinforced by the literature was that there are not enough geriatric-trained mid-level practitioners to meet the demand for these practitioners in nursing homes.8 Reasons for this shortage are not well understood, but they may parallel the reasons cited in the literature and offered by respondents regarding the lack of geriatric-trained physicians (e.g., minimal exposure to nursing homes during training).
Information Exchange -- Knowledge About Nursing Home Operations
Stakeholders and the literature review suggest the need for enhanced communications and/or information exchange between physicians, nursing home staff, and across settings and providers of care (e.g., communications among physicians, nursing homes and laboratories).10
Medical service delivery in nursing homes is characterized by issues and requirements that, in some instances, are unique to the nursing home setting and in other instances common across the health care continuum. Persons treated in nursing homes often are severely functionally and cognitively impaired and/or medically complex, requiring intervention by interdisciplinary teams with substantial family/informal caregiver involvement.11, 12, 13 The literature provides evidence that transitions to and from nursing home care are a common occurrence and a major source of medical errors in relation to medication administration, advanced care directives, allergies, and delivery of essential services.14 An AMDA survey of 3,000 sequential admissions to skilled nursing facilities from 25 different hospitals found the following: 22% of transfers had no formal summary of information; legible summaries were available only 56% of the time; secondary diagnoses were missing in 30% of transfers; test results were omitted in 31%-67% of transfers, advance directives and code status were absent in 81% of transfers; and a legible phone number for the transferring physician was present in only 33% of transfers.15
The stakeholders also expressed similar concerns with respect to transitions from hospitals to nursing homes. They noted that transferring medical information from one care setting to another is time-consuming and information exchanged is often inaccurate. This is because physicians often do not follow their patients across care settings. As observed by the stakeholders, nursing homes often are separated geographically from hospitals, diagnostic services, and physician offices, creating communication barriers that contribute to medical errors. In addition, physicians often do not care for patients across care settings, and there is no standardized process or agreed upon set of information to support transfers across care settings.
A common theme that emerged from discussions with stakeholders was the need for physicians to receive accurate and complete information regarding nursing home patients. Information transfer between hospital and nursing home stays was described as cumbersome and wrought with inaccurate and incomplete transfer of information. In most cases, the facilities did not have computerized medical records beyond the software used to record information for the Minimum Data Set (MDS). All stakeholders agreed that electronic medical records would vastly improve quality of care by reducing the inefficiencies involved with tracking down and recording information at times of transfer and discharge.
| TABLE 2. Facility Characteristics | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| #1 -- Semi-rural Location | #2 -- Open Practice | #3 -- Managed Care | #4 -- Limited Physician Pool | #5 -- Litigious Environment | #6 -- Evercare | #7 -- Closed Model | #8 -- Specialist Model | |||||||||
| FACILITY DESCRIPTIVE INFORMATION | ||||||||||||||||
| Number of beds | 106 | 204 | 162 | 130 | 106 | 300 | 566 | 120 | ||||||||
| Source of X-ray services | Hospital | Mobile and within close proximity | Mobile | Mobile | Mobile | Mobile | Mobile | Contract/ Mobile or send to hospital | ||||||||
| Source for laboratory studies | Hospital | In facility | Mobile | Mobile | Mobile | Mobile | Mobile | Accessible from contracting agency within 2 hours | ||||||||
| Electronic medical records | No | Yes, but not using currently | No | No | Currently patient infor-mation sheet, MDS and nursing assistant flow sheets are electronic. Facility is in the process of implement-ing a comput-erized medical record system. | No | No | No | ||||||||
| Non-physician stakeholders consult with medical director regarding patients of other physicians | Occasionally | Yes | Yes | Sometimes | Only in Emergencies | Yes | Yes | Yes, but orders written by primary physician | ||||||||
| Mid-level practitioners (NPs and PAs) | Not currently but plans to add mid-level practitioners | Yes | Yes, employed by physicians | Yes, employed by the facility | Yes, employed by physicians | Yes, employed by physicians | Yes, employed by facility | Yes, employed by physicians | ||||||||
| Medical director credentials | Certificate of Added Qualification in Geriatrics | Certificate of Added Qualification in Geriatrics and Certified Medical Director | Certificate of Added Qualification in Geriatrics and previously a Certified Medical Director (has not renewed certification) | Geriatrics fellowship, Certificate of Added Qualification in Geriatrics since 1994; Certified Medical Director 2003 | Certificate of Added Qualification in Geriatrics; Certified Medical Director; Certified in Hospice and Palliative Medicine | Certificate of Added Qualification in Geriatrics and Certified Medical Director | Certificate of Added Qualification in Geriatrics | Certificate of Added Qualification in Geriatrics; Certified Medical Director; Certified in Hospice and Palliative Medicine | ||||||||
| Special programs/ services provided by facility | Large proportion of patients skilled nursing facility patients (42 SNF of total 106 beds) | Owned by Masons as a fraternal organization and preference given to admission of Masons. Training program to recruit local residents to the nursing home field. | On-site contracted therapy department; busy skilled nursing unit; special wound care contract; accepts high acuity residents with severe wounds and high nursing needs (delirium, tube feeds, multiple wounds) | 4 units independent living, independent assisted living, medical assisted living, intermediate care/skilled nursing care; on-site clinic with 2 NPs on staff and 5 physicians through university | Specialized dementia unit and skilled nursing unit with on-site team of occupational, physical and speech therapist | Specialized dementia and palliative care units | 36 bed skilled nursing facility rehab unit; 72 respiratory care beds; 34 secure unit beds; physicians, and mid-level providers provided through affiliation agreement with university | Specialized dementia unit; skilled and long-term nursing care; respite care; rehab; hospice; and recover care | ||||||||
| Number of patients social worker sees per day | 25 | 8 | 10 | 20 | --- | 7-8 | 3 | 10 | ||||||||
| Physician or facility involved in litigation | No | Increasing in market area | No aware of any suits | Not in last 3.5 years | More lawsuits in Florida than anywhere in country although facility in case study not currently involved in a lawsuit | No | Not physician, but facility has had some | No | ||||||||
| Number of physicians that come to facility | 20 | 9 | 20 | 2 | 20 | 30-50 | 6 | 3 | ||||||||
| Number of years in nursing home care | NHA | 21 | NHA | 20 | NHA | 28 | NHA | 3 | NHA | 5 | NHA | 21 | NHA | 6 | NHA | 7 |
| MD | -- | MD | 17 | MD | 4 | MD | 4 | MD | 19 | MD | 17 | NM | 13 | MD | 6 | |
| MeD | -- | MeD | 28 | MeD | 20 | MeD | 10 | MeD | 18 | MeD | 28 | MeD | 22 | MeD | 6 | |
| SW | 10 | SW | 15 | SW | 9.5 | SW | 9.5 | SW | -- | SW | 10.5 | SW | 25 | SW | 1 | |
| DON | 16 | DON | 38 | DON | 16 | DON | 15 | NP1 | 5 | DON | 25 | DON | 5 | DON | 3 | |
| Other | -- | ADON | 14 | SDC | 13 | NP | 5.5 | NP2 | 15 | RN | 24 | Other | -- | RD | 2 | |
| Number of years at current facility | NHA | 6 | NHA | 11 | NHA | 22 | NHA | 5.5 | NHA | 5 | NHA | 4.5 | NHA | 5 | NHA | 7 |
| MD | -- | MD | 14 | MD | 2 | MD | 2 | MD | 4 | MD | 14 | NM | 5 | MD | 6 | |
| MeD | -- | MeD | 13 | MeD | 20 | MeD | 3.5 | MeD | 4 | MeD | 28 | MeD | 13 | MeD | 6 | |
| SW | 9 | SW | 15 | SW | 9 | SW | 9 | SW | -- | SW | 10.5 | SW | 10 | SW | 1 | |
| DON | 9 | DON | 38 | DON | 16 | DON | 3.5 | NP1 | 4 | DON | 3 | DON | 5 | DON | 3 mos | |
| Other | -- | ADON | 3.5 | SDC | 2 | NP | 5.5 | NP2 | NA | RN | 24 | Other | -- | RD | 2 | |
| PHYSICIAN SPECIALIZATION PRACTICE MODELS | ||||||||||||||||
| Geriatrics/teaching | X | X | X | |||||||||||||
| Nursing home only | X | |||||||||||||||
| Closed Panel Model -- Staff Physicians | X | |||||||||||||||
| Limit Number of Community-Based Physicians | X | |||||||||||||||
| A variety of other physician practice models | X | X | X | X | ||||||||||||
| TABLE 3. Physician Practice Model Characteristics | ||||||||
|---|---|---|---|---|---|---|---|---|
| #1 -- Semi-rural Location | #2 -- Open Practice | #3 -- Managed Care | #4 -- Limited Physician Pool | #5 -- Litigious Environment | #6 -- Evercare | #7 -- Closed Model | #8 -- Specialist Model | |
| PHYSICIAN PRACTICE INFORMATION | ||||||||
| Percentage of time physician cares for nursing home patients | 70% | 40% | 80% | 10% | 40% | 90% | 25-30% | 95% |
| Number of hours physician cares for nursing home patients each week | 30 | 16 | 40-50 | 5-6 | 20 | 40 | 8-10 | 60 |
| Number of patients physician cares for in nursing homes | 200 | 69 | 150 | 75 | 200 | 300 | 120 | 20-250 |
| Number of facilities where physician follows patient | 3 | 8 | 7 | 3 | 4 | 10 | 1 | 4 |
| PHYSICIAN SPECIALIZATION PRACTICE MODELS | ||||||||
| Geriatrics/teaching | X | X | X | |||||
| Nursing home only | X | |||||||
| Closed Panel Model -- Staff Physicians | X | |||||||
| Limit Number of Community-Based Physicians | X | |||||||
| A variety of other physician practice models | X | X | X | X | ||||
The findings from the stakeholder interviews in the context of extant literature suggest several important issues for further consideration as well as some areas for future research. In this section, we first discuss issues in three areas, followed by recommendations related to two specific research activities that would advance our knowledge related to physician practice in nursing homes. The issues to be discussed include: (1) availability of mid-level providers in LTC; (2) physician training in geriatrics and nursing home care; and (3) providing incentives for enhancing physician care through pay-for-performance.
Areas requiring further research where our findings and consensus suggest the potential to improve physician care in nursing homes include: (1) physician specialization in nursing home care and its impact on quality and costs; (2) health information transfer using technology across providers and settings when caring for nursing home patients; and (3) physician pay-for-performance incentives for care in nursing homes. These issues and research topics are discussed below.
Availability of Mid-Level Providers in Long-Term Care
NPs and PAs have been shown to enhance the care of LTC residents,5, 20, 21, 22, 23, 24 which was further supported by our stakeholder interviews. NPs and PAs make urgent resident visits, provide preventive care to long-stay residents, often provide specialty services such as hospice care and wound care, and help educate nursing staff working in nursing homes. Different models exist for involving mid-level practitioners in LTC either as employees of the nursing facilities or employees of physician practices. Current policy permits mid-level practitioners to alternate visits with physicians.
Given the evidence in support of the value of NPs and PAs in LTC, a major issue relates to the barriers that exist to greater involvement of mid-level practitioners in nursing home care. One such obstacle appears to be dissemination of the different types of practice models that are possible for involving NPs and PAs in LTC facilities and obtaining reimbursement for their salaries. Because of the differences in payers, nursing facilities, and markets, a single model is not optimal in all settings. For example, facilities in states with higher Medicaid rates are more able to pay for mid-level practitioners as salaried nursing home staff, whereas managed care programs can hire NPs using Medicare-risk dollars that are offset by a reduction in hospitalization of nursing home residents. Additionally, physician practice groups may be more receptive to providing medical services to nursing home residents if they are more aware of Medicare coverage rules and payment rates for NP service, and the benefits of these NP services to both physician practices and nursing facility residents. Thus, dissemination of practice model and reimbursement information may help to stimulate providers to seek out mid-level practitioners.
Three ongoing initiatives are describing practice models of advanced practice nurses in LTC facilities. These three include: (1) a natio