A Day in the Life of a Medical Director Cari Levy, MD, CMD Eastern Colorado Healthcare System, Denver VA and the University of Colorado Denver

Overview of Seemingly Boring Topics

• Federal and State Regulations • Infection Control • Ethics • Resident Rights • Working with Families • Quality Management

Overview of More Seemingly Boring Topics

• Medical Care Delivery Systems • Risk Management • Medical Information Management • Employee Health and Safety • Governance • Management Functions • Organizing the Medical Staff

Who are the Major Players?

• Administration • Nursing • Therapists (OT/PT/ST) • Pharmacists • Social Workers • Dietary • Medical Director • Physicians/Pas/NPs • Consultants • And yes, the state surveyors

Wednesday Morning

• 5:10am: Wake to happy thoughts It’s QA Day!

• And what, you ask, is QA day and why are you so excited?

Federal and State Regulations

Federal Regulations

• Physician medical director in nursing facilities mandated by law in 1975 • OBRA ’87 • Responsible for implementation of resident care policies • Ahhh and then there is the expanded F tag 501!

Federal Regulations

• Recognize drugs designated as “unnecessary” and determine alternative methods of treatment or evaluate and document need for using an unnecessary drug for a particular resident.

• Recognize abuse and neglect as they relate to principles of immediate jeopardy in situations of noncompliance in a nursing facility.

• Participate in quality indicator review process.

Federal Regulations

• Physician must supervise medical care of each resident • A physician must be available at all times • Residents have right to be physical or chemical restraint-free unless required to treat medical condition • Facility must ensure that resident’s ADL abilities do not diminish unless unavoidable due to clinical condition

Immediate Jeopardy

“A situation where the provider’s noncompliance with one or more requirements of participation has caused or is likely to cause harm, impairment, or death to a resident.” --Guidelines for Determining Immediate Jeopardy, State Operations Manual

6:30am: Arrive at facility to be greeted by our social worker who says….

Good, morning Dr. Levy. We are having some serious behavior management issues. Alan hit Lenny, Shirley thinks we are giving her poison Vitamin C and Bill has been singing constantly for 3 days. We’re losing it around here!

Quality Indicators

 24 QIs in these domains:  Accidents   Behavioral/Emotional patterns Clinical management   Cognitive patterns Elimination/Incontinence

Quality Indicators

      Infection control Nutrition/eating Physical functioning Psychotropic drug use Quality of life Skin care

Infection Control

• Influenza, MRSA, VRE • Tracking patterns • Responding to outbreaks • Cohorting • Getting to know your Department of Public Health

7:00am: The activities director calls you into her office.

Maddie keeps falling asleep during activities because she is so sedated. We have our AMDA painting to work on and she keeps falling asleep in the fresh paint. What are we to do?

Residents have the Right to…

• Be free of restraints • Refuse any treatment • Be informed • Formulate advance directives • Choose a personal physician • Participate in care planning • Privacy, confidentiality • Medication self-administration • Be protected against abuse

8:03am: The cell phone rings…

Doctor, this is Opal’s daughter. I’m worried about my mom. She just seems to be getting weaker, is losing weight and fell last night. Is there something more we can do before I call the state?

Working with Families

• Be available to communicate with family members • Encourage families to designate a contact person • Empower family to take an active role • Expect the attending physicians to communicate plan of care and be available • Participate in family council meetings

Medical Care Delivery Systems

• Compliance with regulatory visits • Availability for urgent visits • Appropriate oversight of medical care delivery

Some Important Considerations  Many negative things can happen to frail elderly individuals  Many negative outcomes are unavoidable  Treatments do varying degrees of good, harm

Ethical Considerations

• Is the family acting in the best interest of the resident?

• Is the treatment appropriate for the stage of disease?

• Is the resident a danger to self or staff?

• Can the resident’s needs be met in your facility?

10:48am: As you walk by the salon you see Mary Lou is not there today.

8:22am: Nurse C.J. comes to tell you…

Mrs. Talbot’s INR was 4.5 and her doc is out of town.

Quality Management

• Oversight of Medical Care – Medication Management: LMWH stop dates, Coumadin flow sheets; polypharmacy – Response to clinical decline – Unnecessary hospitalizations – After death chart reviews

• Accidents

Risk Management

• Physical restraints and side rails • Chemical restraints • Pressure ulcers

Clinical Areas of Risk

• Nutrition and hydration • Malnutrition • Dehydration • Falls • Tube feeding and alternatives • Wandering/elopement

Reducing Risk

“

P

recision of communication is important, more important than ever, in our era of hair trigger balances, when a false or misunderstood word may create as much disaster as a sudden thoughtless act." — James Thurber

9:35am: Alas, the consultant pharmacist asks to see you. The use of psychoactive meds is sky rocketing. Is Bob pumping funny air in here?

Medical Information Management

• New admission screening • Completion of initial assessments • Confidentiality • Timeliness of physicians signatures • Chart audits • Hospital transfer documents

10:06am: A page overhead asks you to come to come to medical records.

Dr. Sobusy is not up to date on his visits. What do you suggest we do?

Management Functions and Organizing the Medical Staff

• Provide information to staff and assist in allocating medical resources effectively • Understand the appropriate use of consultants within nursing facilities (prophylaxis for staff) • Communicate with attending physicians and mid-level practitioners.

• Educate physicians about regulations and care practice standards

Certification and Recertification Physician certifications must include: • INITIAL: • Skilled care need or RUG certification • SNF services related to condition • Current skilled care need arose in SNF • RE-CERTIFICATION: • Reason for continued skilled care • Estimated time patient will require • Plan for home care, if appropriate

Certification and Recertification Therapy certification requirements: • PT, OT, and ST require signed evaluation, treatment orders • Evaluation must be signed, dated • Recertification needed every 30 days

Employee Health and Safety

• Immunizations • TB Testing • Infections – influenza, conjunctivitis, varicella • Injuries • Advice • Prescribing

12:30pm: It’s time for QA!!!

Our Quality Indicators

 Behavioral/Emotional patterns- increased behavioral problems  Cognitive patterns – declines in cognition  Nutrition/eating – weight loss  Psychotropic drug use – increased  Falls - increased

What is going on here??

 Physician retired and a new practice took over care of his patients     MDs, NPs, PAs seeing patients 3x/week Volume of orders quadrupled More transcription errors Psychotropic drug use due providers who are not familiar with residents and non-pharmocological strategies  Use of Detrol LA in demented residents = declines in cognition, increased falls

Quality Indicators: Steps in Facility QI Review Process STEP 1: Review QI reports and select a group of QIs to review STEP 2: Select a separate sample of residents for each QI that will be reviewed for potential problems STEP 3: Review the care for each sampled resident related to the QI being reviewed STEP 4: Make conclusions about the quality of care for each resident for each QI being reviewed

Quality Indicators: Steps in Facility QI Review Process STEP 5: Decide if there is a facility-wide problem with the QI after reviewing the care for each resident in the sample STEP 6: Discuss the conclusions of the QI investigation with the Quality Assurance Committee and plan improvement interventions.

STEP 7: Evaluate the effectiveness of the improvement plan based on subsequent QI reports after determining if the resident population is the same.

Governance

• Understanding hierarchy so you can obtain a response when you need one. – Board of Directors – Corporate entities • Medical • Business • Try not to mix the two!!!

1:00pm: The corporate medical director appears on the scene…..

How can I help you with this new group?

5pm: Great day!

What makes you return to do it again tomorrow?

Opportunity to Impact Care Delivery and Change Lives