Wayne McCormick, MD, MPH
Associate Professor, University of Washington
I have been Medical Director for Visiting Nurse Service of the Pacific Northwest for over a decade. Like many geriatricians who work in long term care settings, I have patients receiving nursing home care as well as home health care, and have held medical directorships in various nursing homes and home health agencies. I have given talks at both the American Medical Directors Association (AMDA) and American Academy of Home Care Physicians (AAHCP) meetings on medical directorships - how they are the same and how they differ between home health and skilled nursing settings. That talk is capsulated in this article.
The roles of medical directors in long-term care settings can be broadly categorized into 8 areas, as outlined in this Table.
| HHA Medical Director |
Nursing Home Medical Director |
| Administrative Oversight of Patient Care Process |
Medical Decision-Making Oversight |
| Community Liaison - Physician Education |
Organize / Coordinate MD Services |
| Quality Assurance / Continuous Quality Improvement / Utilization Management / Utilization Review |
Quality Assurance / Continuous Quality Improvement / Utilization Management / Utilization Review |
| Education of Staff, RN, Patients |
Education of Staff, RN, Patients |
| Employee Health Employee Health |
Employee Health Employee Health |
| Articulate Mission to the Community |
Articulate Mission to the Community |
| Rules & Regulations / Denial & Appeal / Survey |
Rules & Regulations / Payors / Survey |
| Ethics (Patient Advocacy), Research |
Ethics (Patient Advocacy), Research |
At first glance these lists look similar, but there are several important differences. Of course in home care, the family delivers 90% of the care, and in the nursing home, nurses aides do so. Home care occurs on the patient's turf, not on the provider's turf like the nursing home, hospital, or clinic. Consequently, the provider knowledge base is considerably different in the different venues, and educational interactions differ. Quality improvement and utilization management clearly require unique efforts in differing settings as the payor approach and regulatory structure are very different for nursing homes and home health agencies. Consequently, the medical director must have different knowledge sets for different directorships. Education of staff and employee health are similar, with nuances pertinent to the basically nomadic work routine of home health agency staff relative to the 'cooped up' nature of nursing home work. Ethical work and participation in survey also are basically similar from the medical director's viewpoint.
Rewarding Experience of Home Health Agency Medical Directorship
Continued from Page 2
Physician interactions differ as well, and this is where the medical director usually earns their keep - in getting their MD peers to conform to the rules and regulations inherent in caring for patients in different long term care settings. In home care, this commonly involves getting physicians to sign and regularizing the approach to various conditions (e.g., wound care and pain management). In the nursing home, the director must assure that patients are being regularly visited by physicians and that these visits (and concomitant order signing) are documented, as well as assuring that patients have a number of high-quality physicians to chose from for their primary care in the nursing home.
This latter function occupies a considerable amount of my effort as medical director in both settings. I also spend a fair amount of time in quality improvement activities, patient care process oversight, and some small amount of time in ethics and research activities. I make an effort to introduce myself to surveyors when appropriate, offering my availability to answer questions or concerns. In the past I have met with physician and community groups to help educate and articulate the missions of the organizations I represent, although I have not been called upon to do so recently. As it happens, I spend relatively little time on staff education, although I used to do so, and have little to do with employee health. I point this out to highlight that by no means do medical directors of either home health agencies or nursing homes need to feel obligated to participate in or contribute to all 8 functions listed in the Table above. They should take cues from the administration of their organization to participate in functions that would be most useful, and serve to better the operation. This may take the form of only one or two areas in the list above, or more. This should be codified in open discussions with administration and in the contractual relationship. In most situations, the medical director is serving in an advisory or consulting position, and is not in the direct line of administration - they do not usually participate in financial decisions nor in hiring and firing.
For fellows interested in medical directorship in nursing home or home health agency, spending time with a current medical director is highly recommended. Both AMDA and AAHCP offer courses and certification for directorship. Information is available through their websites (www.amda.com and www.aahcp.org).
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