New study highlights lack of nursing home medical director presence

More than one-third of nursing homes had no on-site medical directors present during the first quarter of 2023, despite requirements to do so, according to a new study. Researchers say the findings raise serious questions about the oversight of resident care in these facilities.

Medical directors provide federally-mandated and necessary oversight of resident health and ensure that every resident receives care that provides the best possible physical, mental and psychosocial well being. They develop, implement and evaluate resident care policies and procedures that reflect current standards of practice.

But these regulations are only effective if a medical director actually spends time at a facility, evaluating residents and developing their plans of care. That's too often not the case, the study found.

The analysis revealed significant differences based on ownership type. For-profit nursing homes were less likely to report any medical director time (61.4%) compared to non-profit (71.3%) or government-owned facilities (66.5%).

There were also considerable variations between states, with some reporting just 45% of nursing homes having any medical director time. Just as concerning, among nursing homes having a medical director, the time spent on-site was just 36 minutes per day, or 4.2 hours per week. For an average-sized nursing home, that's less than one minute of medical director time per resident day.

This new study comes as many nursing homes are pushing back against recent Centers for Medicare and Medicare requirements for minimum nurse staffing, including an RN on-site 24/7. This rule has been excoriated by the industry and the American Hospital Association, although as AHCJ previously reported, patient advocates don't think it goes far enough.

The study was published Sept. 2 in the journal of the American Geriatrics Society.

Why this matters

Medical directors ensure that residents receive high quality care based on their specific health needs, preferences and abilities. Inadequate care and oversight can lead to poorer outcomes, including loss of function, increased fall risk, increased hospitalizations, and even premature death.

"Our findings highlight a significant gap in the presence and involvement of medical directors, particularly in for-profit facilities, which raises serious concerns about the adequacy of care provided to residents," Richard Mollot, executive director of Long Term Care Community Coalition (LTCCC) and co-author of the study said in a statement. The LTCCC is an advocacy, education and policy organization focused on improving quality of care for long-term care residents.

Medical directors play an essential role in ensuring the overall quality of care in a facility as well as addressing problems that arise, from infection control protocols to unnecessary anti-psychotic drugging, according to Mollot. The study findings confirm what he has heard anecdotally for years - that many residents rarely or never see a doctor, and that many problems like infection control violations, pressure ulcers, and substandard dementia care are avoidable.

Journalists can use the LTCCC's staffing database to track staffing levels in facilities in their state or community, and help hold owners accountable.

Mollot and colleagues from the University of California, San Francisco, and the California Association of Long Term Care Medicine looked at staffing data from 2017-2023 for all nursing homes from every U.S. state and the District of Columbia. It excluded other non-director physicians, physician assistants, nurse practitioners, and clinical nurse specialists.

Researchers analyzed the presence or absence of and the amount of time spent by medical directors at facilities; the presence and time by ownership type; variations in presence and time across states; and overall CMS deficiencies for violations of medical director regulations, using federal Payroll-Based Journal (PBJ) data on staffing positions for that period, along with federal nursing home ownership data and deficiencies data for 2023.

Pushback

The head of the Post-Acute and Long-Term Care Medical Association, Rajeev Kumar, M.D., strongly disagreed with the study's findings, according to a story in McKnight's Long Term Care News. He told the publication he thinks there were discrepancies in how the data was reported by nursing homes to CMS, due to how medical directors report their time. Often, these professionals split their time between administrative work, which is reported to the PBJ, and clinical work, which is covered by insurance reimbursements and not reported the same way. Kumar called the PBJ system "flawed."

Mollot pushed back on Kumar's assessment. In a follow-up email to McKnight's, Mollot said he thought it was clear that critics hadn't read the complete, paywalled study.

"It is disturbing to hear that they are drawing such conclusions," Mollot said. "This is not an opinion piece."

Resources

• Medical director role and requirements, The Society for Post-Acute and Long Term Care Medicine.
• State data and information, The Long Term Care Community Coalition.
• A Closer Look at the Final Nursing Facility Rule and Which Facilities Might Meet New Staffing Requirements, KFF.
• Why Nursing Home Residents Still Suffer Despite Tough State Laws, The New York Times.
• Nursing Homes Increasingly Rely On Staffing Agencies For Direct Care Nursing, Health Affairs (use the login provided with your AHCJ membership benefits to access).