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The Role ofPractitioners andtheMedical Director
on Aging suggested the roles and functions of a medical director and recommended educating physicians on basic roles and responsibilities [15]. By 1974,
skilled nursing facilities (those certied to provide skilled nursing services to
Medicare beneciaries) were required to retain a full- or part-time medical director [16].
The 1987 Omnibus Budget Reconciliation Act (OBRA) and its related regulations expanded the medical director requirements to include residential as well as
skilled portions of nursing facilities. For regulatory purposes, both skilled and nonskilled facilities are referred to as “nursing facilities.” Subsequently, surveyor guidance (as written in 42 CFR 483.75(i) Medical Director [F501] and recently updated
as F841) has claried CMS expectations. Beginning in the late 1980s and early
1990s, physicians serving as medical directors [17, 18] and their representative
organization (AMDA) [19] have reviewed and dened the role and tasks of the
medical director. In 2001, the Institute of Medicine recommended that nursing facility medical directors be given greater authority and that structures and processes be
developed to enable and support and require a more focused and dedicated physician participation [20].
83
Key Medical Director Responsibilities
Over several decades, regulatory agencies and professional organizations have further developed the medical director’s roles and responsibilities. There have been
efforts to try to make these requirements more consistent throughout the USA.For
example, AMDA has developed a program to certify medical directors as having
specic administrative and medical knowledge. In contrast, requirements for medical direction in assisted living facilities vary among states. As of 2022, requirements
for medical directors in assisted living facilities were minimal.
Regulatory Foundation
Federal regulations require every nursing facility in the USA to retain a physician
to serve as its medical director. The primary resource of medical director regula-
tions is OBRA ’87 and the State Operations Manual on surveyor guidance. In addition, there are some individual State regulations regarding medical director
responsibilities [21]. Federal nursing facility regulations divide requirements into
several discrete segments called “F-Tags,” related to one or more specic regulatory
requirements used for State and Federal surveys.
A specic section of federal regulations (F-Tag 841) covers the roles and responsibilities of the medical director. The regulations regarding medical direction require
that the medical director is responsible for (1) implementation of resident care
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S. A. Levenson
policies and (2) coordination of medical care in the facility. Surveyor guidance
provides additional information and instructions on how to survey a facility for
compliance with federal regulations, including that of the medical director (F-Tag
841) (Table3) [22]. A nursing facility can be cited for a deciency if it does not have
a medical director who is fullling these requirements. However, most citations of
F-Tag 841 usually must relate to another F-Tag deciency. Table3 summarizes the
guidance for surveyors to interpret whether facilities meet the requirements of
F-Tag 841.
Other sections of the State Operations Manual review whether care is consis-
tent with current standards of practice. The guidance denes “current standards
of practice” as “approaches to care, procedures, techniques, treatments, etc., that
are based on research and/or expert consensus and that are contained in current
manuals, textbooks, or publications, or that are accepted, adopted or promulgated
by recognized professional organizations or national accrediting bodies” [22].
The facility is expected to obtain the medical director’s input into all clinical
Table 3 Medical director responsibilities based on F-Tag 841
Roles Related functions and tasks
Coordination of
medical care
Implementation of
resident care
policies
• Be knowledgeable about current professional standards of practice in
caring for long-term care residents, and about how to coordinate and
oversee other practitioners
• Organize and coordinate physician services and services provided by
other professionals as they relate to resident care
• Help the facility develop a process to review basic physician and health
care practitioner credentials (e.g., licensure and pertinent background)
• Help the facility develop systems to ensure that other licensed
practitioners (e.g., nurse practitioners) who may perform physiciandelegated tasks act appropriately and consistent with clinical standards
of practice
• Help the facility ensure that residents have adequate primary attending
and backup physician coverage
• Advise on availability, qualications, and clinical performance of staff
necessary to meet resident care needs
• Have meaningful input into the development, review, approval, and
implementation of resident care policies
• Collaborate with facility leadership, staff, and other practitioners and
consultants to help develop and implement resident care policies and
procedures that reect current standards of practice
• Cooperate with facility staff to establish policies for assuring that the
rights of individuals (residents, staff members, and community
members) are respected
• Provide clinical leadership to evaluate and update as needed treatments,
practices, and approaches to care
• Support and promote person-directed care such as the formation of
advance directives, end-of-life care, and provisions that enhance
resident decision making, including choice regarding medical care
options
The Role ofPractitioners andtheMedical Director
Table 3 (continued)
Roles Related functions and tasks
Support for
improving quality
of care
Survey-related
support
• Help coordinate and evaluate the medical and all clinical care within the
facility
• Participate in a meaningful way in the Quality Assessment and
Assurance (QAA) committee or assign and oversee a designee to
represent him/her
• Help the facility evaluate and address issues related to the quality of
care and quality of life of residents
• Collaborate with the facility to develop and implement policies and
procedures related to surveillance and Infection Control
• Identify performance expectations and facilitate feedback to physicians
and other health care practitioners regarding their performance and
practices
• If the medical director is also an attending physician, have a process
to address any concerns with the individual’s performance as a
physician
• Discuss and intervene, as appropriate, with a health care practitioner
regarding medical care that is inconsistent with current standards of care
• Help develop systems to monitor the performance of the health care
practitioners including mechanisms for communicating and resolving
issues related to medical care and ensuring that other licensed
practitioners (e.g., nurse practitioners) who may perform physiciandelegated tasks act within the regulatory requirements and within the
scope of practice as dened by State law
• Help the facility identify, evaluate, and address/resolve medical and
clinical concerns and issues that affect resident care, medical care, or
quality of life and that are related to the provision of services by
physicians and other licensed health care practitioners
• Respond to surveyors on survey-related issues, including individual
resident cases, physician participation, and the facility’s clinical practices
• Help the facility analyze its deciencies and identify areas for
improvement
85
policies and procedures, including services provided by other health care
disciplines.
Professional Organizations andtheMedical Director Role
Medical director responsibilities have been based on recommendations of professional associations. AMDA—The Society for Post-Acute and Long-Term Care
Medicine is a national organization that represents long-term care medical directors
and other practitioners and has written consensus statements on many topics including the medical director role and related functions and tasks (Table4) [23]. These
recommendations include additional aspects of medical direction that go beyond
regulatory requirements.
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Table 4 Medical director responsibilities as identied by AMDA
Role Related functions and tasks
Physician leadership • Help ensure appropriate physician coverage and provision of
medical services
• Help develop a process for reviewing practitioner credentials
• Give the practitioners expectations for performance and practice
• Help develop and implement a system to monitor practitioner
performance and give the practitioners feedback
• Ensure that residents have primary attending and backup
physician coverage
Patient care/clinical
leadership
Quality of care • Review and be available for external surveys and inspections
Education, information,
and communication
• Help develop policies and procedures related to resident care
• Help the facility identify and implement care-related policies
Obtain physician and other health care practitioner services to help
residents attain and maintain their highest practicable level of
functioning, consistent with regulatory requirements
• Help guide staff about interacting with practitioners and the
medical director
• Review and consider consultant recommendations that are related
to resident care
• Help protect resident rights, including advance care planning and
other ethical issues
• Help the facility address issues related to continuity of care and
transfer of medical information and patients between the facility
and other care settings
• Participate in quality improvement processes
• Advise on infection control issues, approve specic infection
control policies, and evaluate infection control practices
• Help the facility provide a safe and caring environment
• Help promote employee health and safety, including
implementation of employee health policies and programs
• Promote a learning culture within the facility
• Guide the facility to provide care consistent with current clinical
standards of practice
• Help develop and optimize medical information and
communication systems
• Represent the facility to the professional and lay community on
medical and resident care issues
• Be aware of social, regulatory, political, and economic factors
that affect medical and health services of long-term care residents
and short-stay patients
• Help establish appropriate relationships with other health care
organizations
S. A. Levenson
Medical Director Relationship withPractitioners
The medical director is responsible for the coordination of medical care in the facility. As identied in the surveyor guidance for F-Tag 841, the medical director helps
the facility provide care that is consistent with current standards of practice, and
helps the facility meet its regulatory requirements” [22].
The Role ofPractitioners andtheMedical Director
87
According to the OBRA’87 surveyor guidance, practitioners are responsible to
the medical director for their performance and practice. As with the medical director, physicians and nonphysician practitioners may also be accountable to others,
such as a program director in academia or an administrator of a group practice. The
medical director must clarify practitioner responsibilities and performance expectations; such as regulatory requirements for frequency of patient visits, facility policies, and clinical standards of practice. In addition to other responsibilities, the
medical director is expected to help the facility develop a process to review basic
physician and health care practitioner credentials (e.g., licensure and pertinent
background) and address and resolve concerns and issues between physicians,
health care practitioners, and facility staff.
Practitioner Responsibilities
As with any supervisory or oversight position, the medical director claries practitioner responsibilities by:
• Setting expectations
• Explaining how to fulll those expectations
• Establishing criteria for satisfactory performance
• Determining whether those expectations are being met
• Giving practitioners feedback on their performance and practice.
The needs of the general population and the specic requirements of each patient
practice setting affect practitioner responsibilities. Long-term care medicine also
includes a hybrid of ambulatory, ofce-based, and hospital-based practice.
Individuals of other disciplines are often intermediaries between the patient and the
physician; e.g., assessment and monitoring, identifying and dening problems, and
conveying concerns to the physician. While residents of Assisted Living may have
comparable clinical and behavioral issues, Assisted Living facilities typically have
a less organized structure and fewer direct care staff than do nursing homes.
The medical director has an obligation to educate practitioners about providing
care in the proper context. Medical care must identify and address risk factors (e.g.,
impaired nutrition, fall risk) and understand clinical decisions that can impact outcomes (e.g., decisions not to hospitalize, choice of medications and treatments).
The medical director can help the facility educate and inform the staff on appropriate clinical practice. Appropriate clinical practices for the long-term care population have been identied and discussed in the literature for several decades [24].
Practitioners should try to minimize complications (secondary and tertiary prevention), including those related to iatrogenic illness [25].
The medical director can guide staff and practitioners to better identify and
address issues such as adverse drug events (ADEs), common causes of acute
changes in condition, falls, altered mental status, and decline in function. The medical director’s clinical knowledge and understanding of a facility’s case mix can help
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the facility develop relevant policies and procedures. Both the medical director and
attending physicians are essential to promoting diagnostic quality in the facility and
to effectively diagnose causes of symptoms in patients [26–28].
The Medical Director’s Relationship withtheFacility
The administrator, director of nursing, and medical director are the key management leadership team in the nursing facility. They are ultimately responsible for the
successful implementation of the facility’s care processes and practices. Unlike a
medical staff president or chief of staff, who primarily represents the physicians in
a facility or organization, a medical director in LTC fullls a pivotal role for the
facility and its practitioners.
A facility’s leadership—principally, the administrator and Director of Nursing—
must know the role of the medical director as based on regulatory requirements and
relevant professional society recommendations. Across the country, medical director performance varies considerably. Many facilities are still challenged to nd
qualied and competent attending physicians and medical directors. Some medical
directors are stymied in trying to assert themselves to improve facility practice and
hold practitioners accountable for the care they provide.
The OBRA ‘87 surveyor guidance does not specify how a nursing facility must
establish medical director services. It requires that the medical director be currently
licensed as a physician in the state where the facility is located, unless an exception
is warranted. The facility may employ or contract directly with the medical director,
or may contract with a company or academic program that employs the physician.
In multi-facility organizations, arrangements for such services may be made by corporate or regional ofces, and policies developed at a corporate level. In these
instances, the medical director still must guide the facility to follow appropriate
clinical policies and procedures.
It is desirable for the medical director and administrator to jointly develop and
update the medical director agreement/contract based on the items discussed herein
and adapted to the facility's needs. For example, some facilities want a medical
director who primarily provides patient care while others accept a medical director
who has little or no patient care responsibilities.
A medical director should consider whether the facility job description is realistic, pertinent, and clearly delineates expectations. The facility should provide the
medical director with adequate support and compensation. Surveyor guidance
related to F-tag 841 acknowledges that various factors can inuence optimal facility
patient outcomes, such as resident characteristics and preferences, individual attending physician actions, and facility support. A facility must maintain an environment
that supports competent clinical practice. For example, before contacting a practitioner, the staff should be trained to:
• Perform proper assessments and coordinate phone calls.
• Provide accurate information to describe a situation in detail.
The Role ofPractitioners andtheMedical Director
89
• Be prepared to answer the physician’s questions about the patient.
• Know what questions to ask the physician.
• Know when to notify the medical director about physician issues and clinical
concerns.
The Medical Director’s Role inFacility Quality
All health care settings are being required to improve quality. This is being done to
improve patient outcomes, improve patient satisfaction and safety, and identify and
focus on providing relevant care that uses resources effectively and possibly at
lower cost (Medicare Triple Aim). In their leadership role to oversee and coordi-
nate medical care, medical directors can help clarify and support the goals and
objectives of care, help the organization articulate and strive to meet its goals, show
the staff and practitioners how to achieve desired performance, help solve and prevent problems, and help improve employee and patient health, safety, and welfare.
Effective problem solving is vital to all aspects of both patient-related and facilityrelated outcomes. The medical director can improve a facility’s problem-solving
processes and practices, and ultimately care quality [29].
The medical director should help the facility identify and address potentially
remediable issues such as the impact of physician and other licensed health care
professional performance and practices. The medical director should guide the
facility in determining whether its practices are consistent with accepted clinical
standards.
The medical director should learn about regulatory expectations for facilities as
well as details about his or her role as medical director by reviewing in the CMS’
State Operations Manual (SOM) for surveyors. This review can help the medical
director determine whether a facility’s care has a clinically sound foundation.
The medical director must also learn about resources that nursing homes can use
to improve quality. One example is the CMS “Nursing Home Compare” website
(https://www.medicare.gov/nursinghomecompare) that reports quality measures
data based on the Minimum Data Set (MDS), as well as stafng and compliance
(i.e., survey deciencies).
The medical director should engage in in-depth case reviews along with other
disciplines, looking for care quality and safety issues that may not have been identied by CMS quality measures [30]. The medical director can provide guidance on
quality and risk management concerns such as adverse drug events, medication
errors, and falls; review accidents and incidents; and advise on infection control
policies and practices. The medical director can assist a facility to evaluate the care
and performance of medical practitioners (physicians, NPs, etc.) and other licensed
health care professionals.
Ultimately, the medical director supports the facility to ensure that its residents
and patients receive adequate and appropriate medical care. When needed, the medical director may intervene directly in the care of other physicians’ patients by examining the patient and reviewing patient orders. For example, a medical director may
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S. A. Levenson
intervene if another practitioner does not respond appropriately or in a timely manner to notication of a signicant acute change of condition,
or is not adequately supervising care provided to a patient by other IDT members.
Pearls for the Practitioner
• Physicians play an important role in long-term care, both in providing direct care
and in providing oversight as medical directors.
• Expectations for performance and practice for both practitioners and medical
directors come from both regulatory and professional sources, and are generally
consistent and widely disseminated.
• Collectively, the physicians and medical director play a vital role in supporting
care quality, including facility-wide approaches to clinical reasoning, problem
solving, and diagnostic quality.
• A facility’s approach to its medical practitioners greatly inuences the success of
practitioner participation and, in turn, many aspects of the facility’s residents/
patient outcomes and satisfaction. This includes—but is not limited to—support
for the medical director and holding practitioners accountable for resident and
patient care.
• Practitioners should view their roles in the context of both the system in which
they practice and to medical decision making for individual residents.
• While clinician performance and participation have varied substantially over the
years, ranging from excellent to highly problematic, expectations for better prac-
tice have grown.
• Changes in the health care system and the increasing provision of post-acute care
as well as the initiatives to reduce avoidable hospitalizations from nursing homes
has required an increased and more dedicated physician involvement.
• The medical director can have a major impact on a facility’s care, inuencing
both the facility’s practices and practitioner performance.
• The medical director is accountable to the facility administrator while licensed
health care practitioners and attending physicians should be accountable to the
medical director.
• The medical director should inform and educate practitioners on expectations
and review and provide feedback on performance.
• Effective medical direction and care given by practitioners can go far toward
attaining and sustaining high quality care.
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The Role ofPractitioners andtheMedical Director
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