Healthcare Providers in Nursing Homes

Residents of nursing homes today are “sicker” and more disabled than nursing home residents were in the past. This emphasizes the importance of quality medical care within nursing homes. The medical healthcare team within nursing homes is made up of physicians, nurse practitioners, physician assistants, and medical directors.

What are the federal requirements regarding medical visits in the nursing home setting?

Medicare requires that a new skilled nursing home resident be seen within 48 hours of admission. If the resident came from the hospital and was seen by the physician within 48 hours, then the physician can wait 30 days before seeing a resident and still be complying with requirements. After the 30-day visit, new residents must be seen at 60 and 90 days as well, and thereafter at least every 60 days. These physician visits may be alternated with a nurse practitioner or physician assistant who is supervised by the nursing home attending physician. Most physicians who give quality nursing home care do not wait 30 days to make the first visit.

What are the roles of the medical providers in the nursing home?

Attending Physicians

The physician manages the overall healthcare of the residents. Ideally, the physician should be a permanent employee of the nursing home, preferably specializing in geriatric medicine (medicine for older patients). This type of permanent staffing arrangement is thought to deliver better quality healthcare because the physician is involved in all aspects of the nursing home. Usually, this improves both staff communication and the treatment of residents. Some evidence also suggests that nursing home residents are hospitalized less often when the nursing home employs a limited number of dedicated physicians. Unfortunately, most nursing home physicians consider nursing home care as secondary to their busy office practices and only spend a few hours per month caring for the needs of nursing home residents.

Nurse Practitioners and Physician Assistants

Nurse practitioners and physician assistants have become more involved in the primary care of nursing home residents. Physician assistants have either a bachelor's or master’s degree in their field of study and can care for the medical needs of residents. Nurse practitioners have master’s degrees in nursing and blend both nursing and medicine to provide medical care to residents. Nurse practitioners and physician assistants can perform 80% of the duties of the physician in diagnosing and treating acute and chronic medical conditions.

Studies suggest that nurse practitioners and physician assistants, acting together with the primary care physician, provide better care, improve resident satisfaction with care, lower rates of hospitalization, and prevent increases in nursing home costs.

Federal regulations require that nurse practitioners or physician assistants be supervised by a qualified physician. The physician provides advice and is available to manage and care for residents with more serious or complicated conditions. In most states, nurse practitioners have more autonomy in their practice than physician assistants.

Medical Directors

The overall quality of medical care in the nursing home is determined by the medical director. The medical director should work closely with the entire staff. He or she must be aware of, and up-to-date on, regulations and organizations that affect nursing homes and long-term care. The medical director should set quality standards for the nursing home through specific policies and procedures. The medical director must make sure the nursing home meets and follows all relevant state and federal regulations and guidelines.

What should I ask the nursing home about the medical care provided?

• Is the medical director certified through the American Medical Directors Association (many are not)?
• Does the physician who will be caring for my loved one (if you do not know the person) have additional specialty training to care for geriatric patients?
• Is the physician board certified, and what is his or her specialty (sad to say many caring for nursing home residents do not have specialty training in geriatric medicine)?
• Does the physician assistant or nurse practitioner have specialized training?
• What is the board certification specialty of the nurse practitioner – adult, geriatric, or family? Most nurse practitioners are board-certified as family nurse practitioners and have less than three hours of geriatric training in their nurse practitioner education. Physician assistants currently have no option to certify in geriatric medicine.

Resources

American Medical Directors Association

National Conference for Gerontological Nurse Practitioners (being renamed the Gerontological Advanced Practice Nurses Association)