Studies Look at Connections Between Physician Time and Quality Care
Patients are coming to nursing homes (NHs) today ‘sicker and sooner’ than ever before. Hospitals are under growing pressure to shorten lengths of stay, and NHs are seeing patients with more comorbid conditions, more serious illnesses, and greater care needs. Two letters in the December issue of JAMDA discuss how much face-to-face practitioner time is necessary to effectively care for patients in the new world where patients are sicker, care goals set the bar higher, and there are penalties for return trips to the hospital and/or emergency department.
In the letter, “Determining the Physician-to-Patient Ratio in Post-Acute/Long-Term Care Using an Economic Model,” Charles Crecelius, MD, PhD, CMD, addresses the challenge practitioners face in light of the pressure to produce income by seeing more patients per day, spending less time with each patient, all while maximizing quality. He used data from the American Medical Association (AMA) Medicare database and from his practice’s own Accountable Care Organization’s experiences with better performing facilities to determine necessary numbers of patients seen by the practitioner. Using the average time of 41 minutes per visit practitioners spent and 14.9 visits per day, Dr. Crecelius says, the average practitioner will spend 10.17 hours per day on direct patient care. “We believe the numbers estimated can provide both adequate revenue and provide for better quality of care.” However, he stresses, “This model is not based on ideal times spent with the patient, but rather the current time spent per coded billing.”
In their letter, “Determining the Optimum Physician-to-Resident Ratio in the Nursing Home,” Paul Katz, MD, CMD, and colleagues present a series of calculations based on what they perceive as good nursing home practice. They concluded that physician encounters ranged from 60 minutes for a new admit to 30 minutes for a discharge. They determined that a full-time physician can effectively care for 10 skilled nursing beds, plus 100 nursing home beds. Their calculations were based on both the clinical and administrative time necessary to deliver care (include nursing time; education; family meetings, consultant calls, etc.). Dr. Katz states, “We do not agree with the premise that administrative tasks are to be completed ‘off hours’ and do not constitute a significant portion of true workload. While the numbers below are based on averages, we believe they present a good approximation of the time needed to effectively care for a cohort of 110 NH residents.”
The authors of both studies urge more research on this topic; and they say that they hope their efforts will encourage a dialogue among practitioners and policymakers about how to define optimum practice in the nursing homes. This is particularly urgent, says Dr. Katz, “given the increasing emphasis on value over volume.”
The first study was conducted by West County Medical Associates. The second was conducted by the College of Medicine, Florida State University.