Managing a Successful
Nursing Home Practice

 prepared for

Wisconsin Association of Homes and Services for the Aging


 by

Laura Barnard, Director of Marketing
Continuing Care/Senior Health Division
Covenant Healthcare

with contributions by

Brad Fedderly, M.D.
George Lange, M.D.
Rick London, M.D.
Anil Doniparthi, M.D.


Introduction
According to a national physician professional activities census published in 1997, only one in five primary care physicians spends more than two hours per week in a skilled nursing facility (“nursing home”).1 There is speculation about the reasons for physician resistance to nursing home practice - too much work, too little reimbursement, unattractive settings and the inconvenience of seeing patients outside of the office.2 But there are reasons to believe that many PCP’s are now revisiting the idea of caring for patients in the skilled nursing setting. One possible factor is the increasing expectation by managed care/ HMO organizations that physicians follow their patients into the nursing home. In addition, as nursing homes are serving increasingly transitional populations, physicians are less willing to interrupt the care of a patient who may then, following a nursing home stay, move on to the care of the physician who attended in the nursing home.

PCP’s unfamiliar with nursing home practice often hesitate because of the workload. The purpose of this essay is to communicate successful strategies for managing the challenges of nursing home practice.

In preparing this article, we spoke to four Milwaukee area physicians with significant nursing home practices: George Lange, M.D., a board certified geriatrician; Rick London, M.D., a physician who supervises third-year medical residents with nursing home patients; Brad Fedderly, M.D., Medical Director at Franciscan Villa; and Anil Doniparthi, M.D. The physicians shared approaches which have worked for them. All spoke with great passion and conviction about the personal satisfaction which nursing home practice can carry with it: they feel that this setting presents unique opportunities to have a positive impact on individual lives.

The Nursing Home Visit

The cornerstone of nursing home practice is the in-person visit, which typically occurs every 30 days, unless a special condition necessitates more frequent visits.3 The physicians recommend careful planning for these visits, and a structured approach to what will happen during the visit. Tips include:4

  • Make sure the nursing home staff know about your visit ahead of time, will have the time to meet with you, and have the opportunity to gather all relevant data (e.g., lab results) and any ancillary staff you wish to see, in advance of the visit. Ask them to be sure that the medical record is complete and will be available. Ask them to let the family know about your visit, so that they can be present if they wish.

  • The initial assessment visit is very important. The history and physical examination, which lead to the formulation of the patient’s care plan, should include a check of the 19 areas included in Medicare’s Minimum Data Set (MDS) requirement. Discuss advance directives. Define the reason(s) for the nursing home stay.

  • Use a protocol (written or memorized) to structure follow-up visits. Pay close attention to weight, skin integrity, any record of falls, current medication list, current lab values and behavioral issues. Review the plan of care, including medications, treatments and rehabilitative services. Review problem list and vital signs. Always see the patient in person, and communicate with him or her as well as you can. Sign and date all orders. Write and sign progress notes. Consult with nursing home staff and family members, and listen to their suggestions.

  • Learn how the reimbursement works for nursing home patients so that you can optimize payment for your nursing home visits. Master the CPT codes, which now include “typical times” as a guideline. Don’t be afraid to bill at the higher code levels, since most nursing home care is complex and patients usually have multiple, interacting medical conditions which often present atypically. At least once a year, you should be able to bill for a comprehensive assessment at the highest code level (99303). Don’t forget to use the newer discharge day codes when a patient leaves the nursing home. Most important, the success of all coding ultimately depends on complete and accurate supporting documentation.

  • Learn about the nursing home regulations, particularly those that pertain to physician supervision of care. “The regulations are not burdensome,” says Dr. London, but you do need to know them and to understand your obligations as a physician.”

  • Schedule nursing home visits during regular weekday “prime time”, rather than at the end of the day or on the weekend, when you’re likely to feel tired or rushed.

  • Always look around the nursing facility when you visit. Come forward with your suggestions for improving the care or the environment. Good administrators regard physicians as valuable partners in providing quality care.

    • Telephone Calls

    The aspect of nursing home practice most likely to frighten off an otherwise willing primary care physician is telephone calls from NH staff. Left unmanaged, these calls could quickly consume many hours of physician time. And unlike the nursing home visit, the phone call is not reimbursable. However, as Dr. Fedderly says, the telephone volume issue is “completely solvable.” Experienced nursing home practitioners develop practices and protocols which ensure appropriate use of the telephone. These include:

  • Get to know nursing home staff, and establish good, respectful communication. Protocols are helpful, but no substitute for a strong partnership between nurse and physician. Dr. Lange says that nursing home staff function as “my eyes and ears,” ensuring high quality care by sharing their observations of patient progress. Dr. Fedderly adds that, “nursing home staff who feel empowered as partners in patient care are more likely to use good critical thinking skills, which in turn will lead to appropriate decisions about calling the physician.”

  • Establish clear expectations with nursing home staff about when to call (and whom, at what numbers), based on a respectful relationship as well as a knowledge of the regulations. Consider such tactics as: use of the fax, use of voice mail, batching non-emergent calls, use of trusted and easy-to-reach office staff to triage calls, use of a printed “decision tree” algorithm to help nursing home staff make appropriate decisions. Ask nursing home staff to gather all pertinent data before placing the call. Encourage nursing home staff to develop and offer their own recommendations when they relay a situation to you.

  • Have a process in place to ensure that true medical emergencies receive immediate and appropriate response.

  • Be sure that off-hours and vacation coverage arrangements are clear to nursing home staff. Physician colleagues who cover for one another should have mutual knowledge of treatment patterns and philosophies.

  • “Understand and accept that some number of phone calls is necessary,” advises Dr. Lange. Physician contact is, after all, crucial to ensuring good patient care.

    • The Rewards

    Dr. London explains that he recently learned a great deal about the rewards of nursing home patient care by surveying his third-year residents at the beginning and again at the end of a year of nursing home practice. In the first survey, most residents said that taking a history on an nursing home patient is an ordeal, and that they did not find the patients appreciative of their care. By the end of the year, virtually every resident had reversed position: they now enjoyed taking histories and conversing with patients, and they felt that the patients appreciated the care.

    Dr. Lange sums up his feelings this way: “Nursing home patient care can be a challenge, and it can be stressful, particularly when it involves a patient in declining health, but the emotional rewards are very real.” Dr. Fedderly reminds readers that, “Nursing home patients are people, and the better I get to know them, the more rewarding I find this work. I have one nursing home patient who can no longer speak, but even in his eyes I can see his response to my care and attention, and this is very satisfying.”

    Dr. Doniparthi adds: “With nursing home patients there are usually multiple medical problems. Since I enjoy caring for elderly patients, I find this work to be full of interesting challenges.”

    Summary

    Nursing home practice may seem daunting, but there are practical things which can be done to manage even a larger patient load. Visits to the nursing home must be well planned, and appropriate use of the telephone can be ensured by clear protocols and expectations. The real key is the cultivation of trusting professional relationships between the physician and the nursing home staff. When these strategies are in place, there are many fulfilling emotional rewards in this important work.

    Notes

    1. Edmund H. Duthie, Jr., M.D. and Paul R. Katz, M.D., Practice of Geriatrics, 3rd Edition, p. 78.

    2. See Richard S. Kane, M.D., “Factors Affecting Physician Participation in Nursing Home Care,” Journal of the American Geriatrics Society, 41 (1993), 1000-03 and Richard E. Waltman, M.D., “Do Yourself a Favor - Take Care of Nursing-Home Patients,” Medical Economics, February 1999, 110-115.

    3. Medical necessity should determine frequency of visits, and some patients do require (and can be successfully covered by Medicare for) more frequent visits.

    4. For a very structured approach to visits, see Robert and Bonita McCartney, “Nursing Home Visits: An Efficient System for the Busy Physician,” Geriatrics, May 1997, 57-65.





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