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D. Way
Community-Based Care
Hospital inHome
The VA has been a pioneer in the innovation of health care by discharging inpatients
to return home to complete treatment at home. “ Hospital in Home” is currently
operational in approximately eight VA Medical Centers with ongoing expansion of
this program. Under this program Veterans receive hospital level services that can
provide parenteral infusions. In addition, Veterans receive daily visits from a medical practitioner/clinician and skilled nursing with visit of physical therapists and
nurse aides as needed. In this model, Veterans can even be directly transferred to
home from the Emergency Department avoiding hospitalization. Most programs are
staffed solely by VA employees, although in a “partnership” model, the VA provides
the medical care and DME needs, such as oxygen, while a partner home health
agency and infusion pharmacy provide skilled nursing and infusion services. A
small study has demonstrated a reduction in both the cost of care and the nursing
home 30-day admission rate post hospital discharge [1].
Home-Based Primary Care
Home-Based Primary Care (HBPC) is a comprehensive program that serves veterans
with chronic, disabling conditions and complex psychosocial needs. The goal of
this program is to maximize the Veteran’s independence at home and to reduce
preventable emergency room visits, hospitalizations, and admissions to a long-term
care facility. The success of this program stems from team-based care with attention
to both the medical and psychosocial factors that affect each veteran [2]. The VA
interdisciplinary team (IDT) includes a physician, nurse, social worker, rehabilitation therapist, dietitian, psychologist, and pharmacist. The team may also include
other disciplines such as a nurse practitioner, physician assistant, chaplain, respiratory therapist, and recreational therapist. HBPC provides primary care in the homes
of Veterans for whom clinic-based care has been ineffective [3]. In addition, the
team may also coordinate care, provide palliative care, rehabilitation services, and
disease management.
Veterans receive on average 2–3 “contacts” a month from various team members,
in addition to a primary care visit every 4–6weeks. Frequency of visits and intensity
of care varies according to the needs of the Veteran. If a Veteran lives outside the
coverage area of the team (often designated by driving time) or HBPC is unable to
provide the care needed, the VA may contract with a community-based agency to
provide care [2]. The Veteran may also receive additional skilled services through
Medicare if he/she is a Medicare beneciary. Overall reduction of more than 10%
has been shown in Veterans who are dually eligible for VA and Medicare benets
[2]. Enrollment in HPBC has been associated with decreased hospital bed days of
Department ofVeterans Affairs Options forLong-Term Care
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care, decreased nursing home bed days of care, and a decreased hospital readmission
rates [4].
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Clinical Video Telehealth (CVT)
The VA has a robust telehealth program. In scal 2019, over 909,000 Veterans
received a portion of their VA care through telehealth, and over 60% of VA’s primary and mental health care practitioners provided one or more Clinical Video
Telehealth (CVT) appointments to a Veteran’s home [5].
Telehealth
Telehealth technologies can collect and send a Veteran’s health data, like vital signs,
to the VA care team that can then use this information to remotely manage a
Veteran’s care. A nurse is usually the point of contact. The VA provides veteran
training on the use of the home telehealth system. One study on telehealth has
shown a reduction in hospital length of stay, reduction in cost of care, and an
increase in patient satisfaction [6].
Homemaker Home Health Aide Care
The Homemaker Home Health Aide program provides homemakers and home
health aide services to Veterans who need assistance with basic activities of daily
living (BADLs) and/or instrumental activities of daily living (IADLs). The VA
allows these services to be provided concurrently with other community-based services with the goal to avoid or delay admission to a nursing facility.
Nursing Facility Care
Community Nursing Facilities andCommunity Living Center
The VA contracts with community nursing facilities to provide care to eligible
Veterans. VA funding for care is based on service-connected status, level of disability, and income. If a Veteran does not meet these requirements, then the Veteran
would either private pay or be enrolled in Medicaid if indigent.
Community Living Centers (CLCs) are nursing facilities owned and operated
by the VA. The structure and services are comparable to those in community
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D. Way
NFs. Eligibility for a CLC is also based on service-connected status, level of disability, and income.
End-of-Life Care
VA policy requires the presence of an interdisciplinary Palliative Care consult team
at each VA facility. Hospice and Palliative Care services are part of the Veterans
Health Administration Standard Medical Benets Package. All enrolled Veterans
are eligible for these services if they meet clinical need. The VA collaborates with
community hospice agencies for palliative and hospice services and the Veteran has
the choice between using their VA benet or Medicare benet to fund these services. There is no VA policy at this time that prevents Veterans from receiving hospice services in addition to other care that is palliative in nature (such as whole brain
irradiation, radiation to treat painful or bleeding metastatic disease, or palliative
chemotherapy/immunotherapy) as long as the VA is not funding duplicate care.
Currently, this dual model of care is subject to acceptance by the community-based
hospice.
Pearls for the Practitioner
• Ask your patient if he/she is are a Veteran. They may be entitled to care funded
by the VA.The Military History Checklist will help you gather some of the infor-
mation needed. https://www.wehonorveterans.org/wp- content/uploads/2020/02/
Veterans_Military_History_Checklist.pdf.
• Ask to join the local Veteran Community Partnership. https://www.va.gov/
healthpartnerships/vcp.asp.
• Contact your local VA. www.va.gov/geriatrics/.
Videos
• HBPC. https://www.youtube.com/watch?v=FQxGBb_mxJI.
• Geriatrics HBPC. https://www.youtube.com/watch?v=ZOQ9jTzg4qI.
Websites
• https://www.va.gov/GERIATRICS/pages/Home_Based_Primary_Care.asp.
• https://www.va.gov/health- care/about- va- health- benets/long- term- care/.
• https://www.va.gov/GERIATRICS/pages/Paying_for_Long_Term_Care.asp.
• https://www.va.gov/GERIATRICS/pages/VA_Community_Living_Centers.asp.
References
1. Cai S, Grubbs A, Makineni R, Kinosian B, Phibbs C, Intrator O.Evaluation of the Cincinnati
Veterans Affairs Medical Center hospital-in-home program. J Am Geriatr Soc. 2018;66:1392–8.
2. Edes T, Kinosian B, Vuckovic N, Nichols L, Becker M, Hossain M. Better access, quality,
and cost for clinically complex veterans with home-based primary care. J Am Geriatr Soc.
2014;62:1954–61.
Department ofVeterans Affairs Options forLong-Term Care
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
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3. Home-Based Primary Care Program. Department of Veterans Affairs. Veterans Health
Administration Handbook 1411, Revised 20 Sept. 2017 (online).
4. Leff B, Weston C, Garriguea S, Patel K, Ritchie C. Home based primary care practices in
the United States: current state and quality improvement approaches. J Am Geriatr Soc.
2015;63:963–9.
5. Johnston R, Kobb RF, Marty C, McVeigh P.VA video telehealth and training programs during
the COVID-19 response. Telehealth and Medicine Today. 2021;6(1).
6. Messina W.Decreasing congestive heart failure readmission rates within 30 days at the Tampa
VA.Nurs Admin Q. 2016;40(2):146–52.
The Role ofPractitioners andtheMedical
Director
StevenA.Levenson
Introduction
The role of nursing facilities continues to change within the US health care system.
Traditionally, nursing facilities primarily provided personal and nursing care to the
physically, cognitively and functionally impaired elderly. Today, while nursing
facilities continue to provide residential and custodial care, they now admit medically complex patients, discharged from acute can and specialty hospitals. Both
long-term care residents and post-acute care patients can be medically complex and
have multi- morbidities and risk factors for geriatric syndromes such as pressure
injuries, anorexia, and falls. Managing these patients requires procient clinical reasoning and problem-solving skills. Accordingly, nursing facilities require more
physician and nonphysician practitioner involvement in assessing and managing
patients [1].
Persons who live in nursing facilities are commonly referred to as residents;
while those who are primarily admitted to receive short-term medical and skilled
care are referred to as patients. Long-term residents often need acute care in addition to ongoing chronic medical care. Short-stay patients often have chronic medical conditions as well as the need for both acute and post-acute medical care. Some
post-acute patients may have an extended stay or need to transition to a longterm bed.
S. A. Levenson (*)
Baltimore, MD, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
P. Winn et al. (eds.), Post-Acute and Long-Term Care Medicine, Current Clinical
Practice, https://doi.org/10.1007/978-3-031-28628-5_6
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S. A. Levenson
Physicians and nonphysician practitioners have a vital role in providing nursing
facility care, while medical directors provide a crucial role in organizing, overseeing, and improving the overall care in the facility and assisting with challenging
patient situations. Attending physicians are primarily responsible for managing
individual patient medical care and can facilitate effective collaboration among the
interdisciplinary team [2].
While a medical director can also serve as an attending physician, the roles and
functions of a medical director are separate from those of an attending physician.
The attending physician provides direct resident care; the medical director oversees,
coordinates, and helps improve the facility’s overall medical care and services.
Although concern over physician performance and practice is ongoing, there are
mixed opinions about how to improve performance and practice [3]. In the early
2000s, Maryland implemented substantial state regulations regarding expectation
for the medical director and physicians [4]. Over 20years later, this approach has
had limited success in most other states.
The Role oftheMedical Practitioner
Regulations that originated from the Omnibus Budget Reconciliation Act of 1987
(OBRA ’87), required every nursing facility resident or patient to have an attending
physician to supervise and coordinate medical care [5]. “Supervising the care”
means participating in the assessment and management of patients, monitoring
changes in their medical status, and providing consultation or treatment when
needed. It also includes performing regulatory visits and possibly supervising nurse
practitioners or physician assistants. Table1 describes the basic physician functions
and tasks based on the Federal OBRA ‘87 requirements. Currently nurse practitioners are permitted to serve as the “attending practitioner” for hospice patients.
While many physicians provide high quality care and clinical leadership, others
have little interest in chronic care medicine and been unwilling to attend at LTC
facilities [6]. Some of them may lack the knowledge and skills on the care of chronic
illness, the frail elderly patient, and post-acute and long-term medical care.
Remember that multiple symptoms may have a common cause and multiple causes
can be related to a specic symptom. Others are challenged by the practice environment in nursing homes and may feel overburdened by regulatory requirements.
Increasingly, more intensive physician involvement in long-term and post-acute
care is needed. Active involvement is essential to assess and manage patients, to
avoid unnecessary hospitalization, and to address many issues such as ensuring
accurate diagnosis, management of behavior and psychiatric symptoms, delirium,
and to prevent medication-related adverse effects. AMDA—The Society for PostAcute and Long-Term Care Medicine has developed a curriculum and certication
program for medical directors and a curriculum for attending physicians covering
diverse areas of physician competency, in order to promote a more uniform standard
of practitioner knowledge and skills.
The Role ofPractitioners andtheMedical Director
Table 1 Attending physician functions and tasks in the nursing facility based on Federal OBRA’87
regulations
Roles Related functions and tasks
Supervise
individual resident
care
Make resident
visits
Make timely visits • See a patient at least once every 30days for the rst 90days after
Arrange for
provision of
emergency
services
Delegate tasks
appropriately
• Approve a resident’s admission to the facility, e.g., this may be done by
giving and approving orders upon admission
• Be familiar with, and contribute to, a patient’s assessment and care
planning; e.g., by clarifying their medical history and underlying causes
of impaired function and signicant condition changes
• Take an active role in supervising their patients’ care; i.e., be aware of
the impact of what others are doing medically with their patient and
ensure that it is coordinated and appropriate
• At the time of each visit:
– Review the total program of care, including medications and
treatments rendered by other disciplines
– Write, sign, and date a progress note
– Sign and date all orders except immunization orders that may be
periodic without a new order
– Evaluate the resident’s condition and continued appropriateness of
the current medical regimen
admission, and at least once every 60 thereafter (the next scheduled
regulatory visit date should be determined by the admission date, not by
the actual date that the last visit occurred; a visit is timely if it occurs
not later than 10days after the date it was required). Daily visits are
allowed but must be medically necessary
• Make all required physician visits (required visits after the initial visit
may alternate between visits by the attending physician and visits by a
physician assistant, nurse practitioner, or clinical nurse specialist under
the physician’s supervision)
• Respond appropriately and in a timely manner when notied of an acute
change of condition
• Ensure that there is backup medical coverage (e.g., individual
physician, physician group, or advance practice nurse) if the attending
physician is unavailable. Virtual visits may be allowable
• Delegate tasks to physician assistants, nurse practitioners, or clinical
nurse specialists consistent with OBRA’87 requirements and state
requirements related to licensure and scope of practice
• Be aware of the role of consultants in managing a patient and intervene
when care is inadequate, problematic, or not pertinent (e.g., hospice,
pain management, or prescribing that is causing adverse consequences)
79
As the health care system changes, hospitals are now partnering with long-term
and post-acute care facilities to develop integrated models of care, (see chapters
“Behind the Scenes at Nursing Facilities” and “Preventing Hospital Admissions and
Readmissions” for further discussion). As such, more hospitalists are now paying
attention to these nonhospital settings.
Practitioners must collaborate with the facility’s management, clinical leadership, and direct care staff to provide competent care and to handle conicts or problems that arise. Table 2 identies practitioner responsibilities that are integral to
high quality resident care [7].
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Table 2 Practitioner’s roles and related functions and tasks
Practitioner’s role Related functions and tasks
Accept responsibility for
resident care
• Assess new admissions in a timely fashion
• Seek, provide, and analyze information regarding a patient’s
current status, recent history, medications, and treatments
• Sign monthly orders, interim orders, lab and test results and
review the facility consultant pharmacist recommendations
• Provide information and documentation that helps staff determine
appropriate level of care for a new admission
• Identify and authorize admission orders in a manner that enables
the facility to provide safe, appropriate, and timely care
Support discharges and
transfers
• Guide as needed, transfers of acutely ill or unstable patients from
the facility
• Provide necessary documentation and other information needed
at the time of transfer to enable care continuity
• Provide a pertinent discharge summary within 30days of patient
discharge or transfer from the nursing facility
• If pending transfer to another practitioner, continue to provide all
necessary medical care and services until another physician takes
over the care
Make periodic, pertinent
resident visits
• Make timely patient visits, based on their needs and on regulatory
requirements, including an alternate visit schedule as appropriate
• Provide pertinent progress notes that cover a patient’s condition
(including medical and psychiatric stability), current status,
prognosis, and goals
• Review and validate specic treatments and a patient’s overall
care approaches
• Address relevant clinical issues
• Provide timely. legible, and pertinent progress notes
Provide adequate
ongoing coverage
• Designate alternate coverage
• Inform the facility about communicating with his/her practice
and designated alternate coverage
• Guide alternate coverage as needed to ensure adequate and timely
support
• Notify the facility of any extended absence and related coverage
arrangements
Provide appropriate
resident care
• Perform accurate, timely, and relevant medical assessments
• Dene signicance of resident symptoms and problems, clarify
and verify diagnoses, and help establish prognosis and realistic
care goals
• Help determine appropriate and medically necessary treatments
and services for each patient, consistent with relevant practice
standards and regulatory requirements
• Respond appropriately to emergency and routine notication by
staff
• Analyze and address laboratory and other diagnostic test results
• Assess and promptly manage signicant acute changes in a
patient’s condition
• Guide ethics-related decisions (for example, options for
life-sustaining treatments)
• Order appropriate comfort and supportive measures as needed
• Periodically review continued relevance of all prescribed
medications for patients and identify and address medicationrelated adverse consequences
S. A. Levenson
The Role ofPractitioners andtheMedical Director
Table 2 (continued)
Practitioner’s role Related functions and tasks
Provide appropriate and
timely medical orders
Provide appropriate,
timely, and pertinent
documentation
Perform and act
appropriately
• Provide timely and legible medical orders
• Sign and verify the accuracy of verbal orders
• Document pertinent rationale for medical decisions, consistent
with meeting clinical, legal, and regulatory requirements
• Complete all physician information required on death certicates
in a timely manner
• Abide by pertinent policies and procedures
• Collaborate with the medical director/facility leadership to
support provision of high-quality care
• Notify the medical director/facility leadership about issues and
concerns
• Keep the well-being of patients in mind in all situations
• Be alert to any observed or suspected violations of resident
rights, including abuse or neglect
• Interact in a courteous, professional manner with facility staff,
patients/residents, family/signicant others, facility employees,
and management
• Inform the medical director/facility leadership of disputes or
problems with other parties (e.g., staff, patients, or other
practitioners) that the physician cannot readily resolve
Clinical Reasoning andDiagnostic Quality
81
Practitioners can favorably impact the quality of care in PA and LTC facilities by
means of their clinical performance, practice, and expertise in medical decision
making and problem identication in the facility.
Diverse disciplines (e.g., therapists, nurses, and dieticians) in long-term and
post-acute care must collaborate to address patient and facility problems. However,
decisions are often made elsewhere; e.g., prior to resident admission. Staff, patients,
and families need to review and validate these decisions.
The care delivery process is key to providing safe, effective, efcient, patientcentered, equitable, and timely evidence-based care. Using the care delivery pro-
cess of recognition/assessment, cause identication/diagnosis, management, and
monitoring of response to an intervention is critical. The medical practitioner’s role
is to clarify patient issues and risks that contribute to resident illness and impairment. Patient-centered care require a thorough and thoughtful differential diagnosis
of symptoms.
Key steps in developing and implementing a patient-centered medical plan
include to:
1. Clarify relevant medical issues (including physical and psychiatric conditions as
well as patient prognosis).
2. Determine decision-making capacity of the resident.
3. Identify the primary or proxy/surrogate decision maker.
4. Look at the “big picture.”
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5. Review an individual’s values, wishes, preferences, goals.
6. Reconcile patient goals of life and goals of medical care.
7. Order appropriate interventions, where benet outweighs risk.
8. Monitor and adjust interventions, as indicated.
Facility staff and practitioners must jointly support a culture of effective and consistent care and competent clinical reasoning and problem solving. Diagnostic qual-
ity involves minimizing and recognizing diagnostic errors that contribute to
undesirable outcomes. Facilities and practitioners should review care processes and
identify diagnostic and thinking errors that can result in inappropriate or harmful
treatment [8].
S. A. Levenson
The Role oftheMedical Director
Medical directors often serve in various settings, including hospitals, insurance
companies, specialty programs or services (e.g., dialysis, hospice, wound care,
PACE), and in some assisted living facilities. Medical director practice in nursing
facilities is required by federal regulations, which dene the medical director as “a
physician who oversees the medical care and other designated care and services in
a health care organization or facility” [9].
Medical Director Characteristics
The background, characteristics, and performance expectations of medical directors
has been researched over the years [10, 11] and promulgated by AMDA: The
Society for Post-Acute and Long-Term Care Medicine (formerly known as the
American Medical Directors Association). In nursing homes, most medical directors have an internal medicine or family medicine background, and approximately
one in four are also trained geriatricians [12]. A medical director may cover one or
several facilities. While many medical directors also serve as an attending physician, a signicant number act solely in the role as a medical director with no attending physician responsibilities.
Origins oftheMedical Director Role
The need for a nursing facility medical director evolved out of a government
investigations stemming from a 1970 salmonella outbreak in a Maryland nursing
facility [13, 14]. In the 1970s, the American Medical Association’s Committee
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