Role of the Attending Physician in the Nursing Home

March 1, 2003

Introduction

The American Medical Directors Association (AMDA) was founded on the premise that physician involvement in long term care is essential to the delivery of quality long term care. Attending physicians should lead the clinical decision-making for patients under their care. They can provide a high level of knowledge, skill, and experience needed in caring for a medically complex population in a climate of high public expectations and stringent regulatory requirements.

In 1991, the House of Delegates passed Resolution B91, Role of the Attending Physician in the Nursing Home. It reflected AMDA's recognition that the nursing home reforms mandated by OBRA '87 required increased levels of physician participation and medical director oversight in nursing homes.

In 2001, AMDA decided to clarify the principles outlined in its 1991 policy statement and reaffirmed by various reports such as the Institute of Medicine's Improving the Quality of Long Term Care. Like anyone, physicians need clearly stated expectations in order to fulfill their responsibilities. These revisions reflect essential functions and tasks that physicians should perform and cannot readily delegate to others. Although various factors make physician adherence challenging, AMDA believes that attending physicians should work with medical directors to address the obstacles, not cite them as a reason to avoid responsibility.

  1. Responsibility For Initial Patient Care. The attending physician should:
    • Assess a new admission in a timely fashion (based on a joint physician-facility-developed protocol, and depending on the individual's medical stability, recent and previous medical history, presence of significant or previously unidentified medical conditions, or problems that cannot be handled readily by phone);
    • Seek, provide, and analyze needed information regarding a patient's current status, recent history, and medications and treatments, to enable safe, effective continuing care and appropriate regulatory compliance;
    • Provide appropriate information and documentation to support the facility in determining the level of care for a new admission; Authorize admission orders in a timely manner, based on a joint physician-facility-developed protocol, to enable the nursing facility to provide safe, appropriate, and timely care; and
    • For a patient who is to be transferred to the care of another health care practitioner, continue to provide all necessary medical care and services pending transfer until another physician has accepted responsibility for the patient.
  2. Support Patient Discharges and Transfers. The attending physician should:
    • Follow-up with a physician or another health care practitioner at a receiving hospital as needed after the transfer of an acutely ill or unstable patient;
    • Provide whatever documentation or other information may be needed at the time of transfer to enable care continuity at a receiving facility and to allow the nursing facility to meet its legal, regulatory, and clinical responsibilities for a discharged individual; and
    • Provide pertinent medical discharge information within 30 days of discharge or transfer of the patient.
  3. Make Periodic, Pertinent On-Site Visits to Patients. The attending physician should:
    • Visits patients in a timely fashion, based on a joint physician-facility-developed protocol, consistent with applicable state and federal regulations, depending on the patient's medical stability, recent and previous medical history, presence of significant or previously unidentified medical conditions, or problems that cannot be handled readily by phone;
    • Maintain progress notes that cover pertinent aspects of the patient's condition and current status and goals. Periodically, the physician's documentation should review and approve a patient's program of care.
    • Determine progress of each patient's condition at the time of a visit by evaluating the patient, talking with staff as needed, talking with responsible parties/family as indicated, and reviewing relevant information, as needed;
    • Respond to issues requiring a physician's expertise, including the patient's current condition, the status of any acute episodes of illness since the last visit, test results, other actual or high risk potential medical problems that are affecting the individual's functional, physical, or cognitive status, and staff, patient, or family questions regarding the individual's care and treatments; and
    • At each visit, provide a legible progress note in a timely manner for placement on the chart (timely to be defined by a joint physician-facility protocol). Over time, these progress notes should address relevant information about significant ongoing, active, or potential problems, including reasons for changing or maintaining current treatments or medications, and a plan to address relevant medical issues.
  4. Ensure Adequate Ongoing Coverage. The attending physician should:
    • Designate an alternate physician or appropriately supervised midlevel practitioner who will respond in an appropriate, timely manner in case the attending physician is unavailable;
    • Update the facility about his or her current office address, phone, fax, and pager numbers to enable appropriate, timely communications, as well as the current office address, phone, fax and pager numbers of designated alternate physicians or an appropriately supervised midlevel practitioner;
    • Help ensure that alternate covering practitioners provide adequate, timely support while covering and intervene with them when informed of problems regarding such coverage;
    • Adequately notify the facility of extended periods of being unavailable and of coverage arranged during such periods;
    • Adequately inform alternate covering practitioners about patients with active acute conditions or potential problems that may need medical follow-up during their on-call time.
  5. Provide Appropriate Care to Patients. The attending physician should:
    • Perform accurate, timely, relevant medical assessments;
    • Properly define and describe patient symptoms and problems, clarify and verify diagnoses, relate diagnoses to patient problems, and help establish a realistic prognosis and care goals;
    • In consultation with the facility's staff, determine appropriate services and programs for a patient, consistent with diagnoses, condition, prognosis, and patient wishes, focusing on helping patients attain their highest practicable level of functioning in the least restrictive environment;
    • In consultation with facility staff, ensure that treatments, including rehabilitative efforts, are medically necessary and appropriate in accordance with relevant medical principles and regulatory requirements;
    • Respond in an appropriate time frame (based on a joint physician-facility-developed protocol) to emergency and routine notification, to enable the facility to meet its clinical and regulatory obligations;
    • Respond to notification of laboratory and other diagnostic test results in a timely manner, based on a protocol developed jointly by the physicians and the facility, considering the patient's condition and the clinical significance of the results;
    • Analyze the significance of abnormal test results that may reflect important changes in the patient's status and explain the medical rationale for subsequent interventions or decisions not to intervene based on those results when the basis for such decisions is not otherwise readily apparent;
    • Respond promptly to notification of, and assess and manage adequately, reported acute and other significant clinical condition changes in patients;
    • In consultation with the facility staff, manage and document ethics issues consistent with relevant laws and regulations and with patients' wishes, including advising patients and families about formulating advance directives or other care instructions and helping identify individuals for whom aggressive medical interventions may not be indicated; and
    • Provide orders that ensure individuals have appropriate comfort and supportive care measures as needed; for example, when experiencing significant pain or in palliative or end-of-life situations;
    • Periodically review all medications and monitor both for continued need based on validated diagnosis or problems and for possible adverse drug reactions. The medication review should consider observations and concerns offered by nurses, consultant pharmacists and others regarding beneficial and possible adverse impacts of medications on the patient.
  6. Provide Appropriate, Timely Medical Orders and Documentation. The attending physician should:
    • Provide timely medical orders based on an appropriate patient assessment, review of relevant pre- and post-admission information, and age-related and other pertinent risks of various medications and treatments;
    • Provide sufficiently clear, legible written medication orders to avoid misinterpretation and potential medication errors, such orders to include pertinent information such as the medication strength and formulation (if alternate forms available); route of administration; frequency and, if applicable, timing of administration; and the reason for which the medication is being given;
    • Verify the accuracy of verbal orders at the time they are given and authenticate, sign and date them in a timely fashion, no later than the next visit to the patient.
    • Provide documentation required to explain medical decisions, that promotes effective care, and allows a nursing facility to comply with relevant legal and regulatory requirements;
    • Complete death certificates in a timely fashion, including all information required of a physician.
  7. Follow Other Principles of Appropriate Conduct. The attending physician should:
    • Abide by pertinent facility and medical policies and procedures;
    • Maintain a courteous and professional level of interaction with facility staff, patients, family/significant others, facility employees, and management;
    • Work with the medical director to help the facility provide high quality care;
    • Keep the well-being of patients/residents as the principal consideration in all activities and interactions;
    • Be alert to, and report to the medical director - and other appropriate individuals as named through facility protocol - any observed or suspected violations of patient/resident rights, including abuse or neglect, in accordance with facility policies and procedures.