If one were looking for an opportunity to shape long-term care, there might be no better time to step into a top advocacy position than days after federal officials launch a major reform effort.
That’s what happened to Suzanne Gillespie, M.D., CMD, who was installed last month as president of AMDA-The Society for Post-Acute and Long-Term Care Medicine. She started her term just as the White House was rolling out its broad list of nursing home initiatives, and as the nation’s providers hoped to put the pandemic behind them at last.
In an interview with McKnight’s Long-Term Care News Tuesday, Gillespie, an associate professor of medicine in the geriatrics and emergency divisions at University of Rochester, outlined how COVID-19 solidified the increasing role medical directors play in the nation’s nursing homes. With increased scrutiny on the sector, AMDA will continue its efforts to make sure nursing homes understand the importance of hiring medical directors trained to do more than just check a regulatory box.
“The president in the State of the Union is talking about nursing home quality and safety. Who’d have thought that was going to happen at any point?” asked Gillespie, who also serves as associate chief of staff for geriatrics, extended care and rehabilitation for the VA Finger Lakes Health Care System and medical director for its two nursing homes. “We’re really focusing on making sure that we collaborate strongly with CMS and with other partners to make sure we do things that will improve care, that our voices, our experience and our skills are present in the conversation.”
(Note: The following has been edited for length and clarity.)
Q: You started participating in AMDA in 2005 as a geriatric medicine fellow. How has being a medical director changed since then?
A: We’ve seen and begun to appreciate more the importance of not only the presence of the medical director, but the engaged medical director, and the important knowledge and skills that they can bring to the space. Certainly, there’s no time that illustrates that more tangibly than the last years of the public health emergency.
Having trained medical directors at the helm has really enabled us to be good dispensers of information, to help our facilities establish good policies and to implement effective healthcare by ensuring appropriate infection prevention, ensuring access to vaccination and other COVID therapeutics. Places that had an engaged medical director were much more capable and ready to do that in what’s been a really difficult time.
Q. Can you elaborate on the value of a strong medical director in non-pandemic times?
A: One of the most tangible ways a medical director can be involved is in the quality assurance and performance improvement process. We’ve seen that in practice in a variety of ways, things like looking at how to prevent healthcare-associated infections or how to decrease or prevent avoidable hospital readmissions. They really hinge on the ability to engage your interdisciplinary team, and in that way, your medical director can be very, very helpful.
Q: How would you like to see the medical director role evolve?
A: We’ve had a requirement in the regulatory manual for some time to have medical directors present, but I think moving that to the next step to having them engaged in the facility and active is really an important quality step. Being an effective medical director requires specific knowledge and skills. Participating in the certification process affords you the opportunity to acquire those skills.
States like California that have endorsed certification as a process, we think it’s great. We’ve seen other states start to take on similar initiatives. More widespread, establishing that expectation would be a great benefit.
Q: How can you tell if a medical director is ‘engaged’?
A: One of the things AMDA has long advocated for is being able to identify the medical directors in nursing facilities. There’s been a lot of talk about transparency in nursing facilities, and we’re still at a place where there’s not even any public registry to see who these medical directors are.
That lack of information brings with it consequences: It’s difficult to know who’s there, to identify their level of engagement, difficult to communicate with them, whether you’re a public health agency trying to improve care or whether you’re a concerned family member or resident. It’s not disclosed, and I think that’s really short-sighted.
Q: Can you quantify engagement?
A: We know that it’s more than minutes in the building. There are some places where the engaged medical director likely is more visible, like engagement in the QAPI process, like engagement in antibiotic stewardship, like participation in some of the initiatives to roll out and assure new programs and clinical services (or) survey processes.
We, like others, are trying to figure out how you quantify “engaged” and link that to quality. We’ve seen the complexity of nursing home care increase with (services including) dialysis, ventilator care or wound vacs.
Having someone overseeing the provision of medical care, the relevant policies and procedures, that interface and transition between other sites of care, it’s critically important.
Q: Does this mean we’re moving toward medical directors serving one nursing home each?
A: No, I don’t think so. It really has to be how a medical director spends their time. How much time in a particular building has to be driven down to align with what the facility needs assessment is. The larger facilities and those with more complex care will require more of a medical director’s time than a smaller facility without as much complexity of care.
But certainly, there are excellent medical directors who are able to serve in the capacity in more than one facility. The question is: Do the facilities have a good understanding of what the time use is and what the contribution should be based upon.
Q: What’s another area you want to focus on this year?
A: You can’t have a conversation about long-term care these days without mentioning workforce. For me, it’s important to think about how we’re engaging new medical providers and medical directors to ensure that the things we do now to improve care, that we have a workforce that’s ready and capable of sustaining that in the future.
I’m really trying to engage the next generation of trainees and newly practicing healthcare professionals in how we work in post-acute care settings. It’s a great place to practice.