Medical direction in long-term care continues to evolve. Trends over the last several years show a slow influx of younger physicians who only work part-time in nursing homes. They usually dedicate themselves to several sites of service, including nursing facilities, assisted living, and hospice. The “occasional” doctor unfamiliar with the nuances of the LTC spectrum may be fading. Instead, a medical director/attending physician committed to working across the long-term care continuum and with the interdisciplinary team seems to be emerging. This trend may conflict with the proposed medical home model, whereby non-nursing home patients with chronic illness are provided coordinated care by a much larger cadre of physicians, without definitive integration of skilled or chronic nursing home care services.

This view of the physician's evolving role in long-term care is provided as commentary on discipline-specific survey topics related to medical directors, but it also is a fitting introduction to a physician-centric look at the results of the 2008 Senior Care Digest Interdisciplinary Report: A Survey of Long-Term Care Health Professionals, part of the Sanofi-Aventis Managed Care Digest Series^®.

The 2008 report contains the results of a national survey of long-term care health professionals, including medical directors, pharmacists, directors of nursing, and nurse practitioners, who care for elderly patients residing in nursing facilities, assisted living facilities, and other senior care settings. The survey results paint a portrait of these health care professionals and their work, practices, and attitudes in regard to issues in long-term care. (ALSO SEE, Long-term care: A test bed for coming health care reform.)

Geriatrics readers include more than 9,000 medical directors who provide care for the elderly residing in nursing facilities and assisted living facilities¹ and the results of this most recent survey make for interesting comparisons with results of the 2007 survey which have been featured on the journal's web site, www.geri.com, for the past year. Some of the shifts include:

• Concerned about the safety and efficacy of atypical antipsychotics, medical directors are prescribing even fewer of them. (2008 vs. 2007)

• More than half of medical directors still reported ordering the varicella zoster vaccine either never or rarely. (2008 vs. 2007)

• The percentage of medical directors who had earned the certified medical director (CMD) credential was down to 29% from 36%. (2008 vs. 2007)

• The average number of attending physicians per facility is down relative to the number reported in the previous year. (2008 vs. 2007)

Discipline-specific questions
The 2008 survey focused on several questions for each discipline, including for medical directors: Tag F501, medication regimen review, clinical issues, and medication errors.

On medication errors, medical directors were surveyed to determine whether they are involved in assessing medication errors in their facilities and to identify the most likely reasons these problems occur. A large majority (85%) of medical directors reported that they are involved in assessing medication errors.

Medical directors indicated that the most common reason for medication errors in nursing facilities (41%) involves ineffective policies and procedures designed to prevent these problems. Poor communication between attending physicians and staff was the second most common reason identified (38%), followed by failure to review specific errors as part of a quality improvement process (28%). One-third (32%) of medical directors also identified reasons other than those mentioned in the survey instrument. (reasons charted)

The open-ended responses to the question can be grouped into two basic categories: (1) “human errors” caused by nursing, and (2) errors caused by inadequate staffing or “too many medicines, too few nurses,” according to the survey’s accompanying commentary, and while these categories accurately reflect medical directors’ perceptions, they do not address the root cause of the error, such as inadequate policies or failure to adopt approaches to reduce the likelihood of repeat errors.

On clinical issues, the 2008 survey returned to the two ongoing and controversial topics which were also covered in the 2007 survey: prescribing of atypical antipsychotics and immunization to prevent varicella zoster infections (shingles).

Atypical antipsychotics
Behaviors associated with Alzheimer’s disease (AD) and other forms of dementia, including psychosis, aggression, and agitation, often are managed with off-label use of antipsychotic medications. Recently, published studies have questioned the safety and efficacy of the newer “atypical” antipsychotic agents (atypicals) in patients with AD or other dementia. To examine this issue further, the survey asked medical directors whether this information has influenced their prescribing of these medications and, if so, how.

Slightly less than one-half (47%) of respondents reported that they now prescribe atypicals less frequently than they have in the past.

This compares with 28% who indicated that they have not changed their prescribing behaviors with respect to atypicals. Sixteen percent indicated that they always obtain consults from a psychiatrist or psychologist before prescribing these agents, and 24% said they continue to prescribe them, but at lower doses compared to the previous year.

Recent studies have questioned the safety and efficacy of atypical antipsychotic medications when used to treat dementia-related behavioral issues.² For example, one reported that outpatients with dementia who were taking atypical antipsychotic drugs were 3.2 times more likely (95% confidence interval, 2.77-3.68) to develop any serious event during 30 days of follow-up. The pattern of serious events was similar but less pronounced among older adults living in a nursing home.³

The survey data strongly suggest that such studies have influenced the medical director’s perception and prescribing of atypicals in nursing facility residents with Alzheimer’s dementia. One-half indicated that they prescribe atypicals less frequently than they did in the past, while significant numbers indicated that they prescribe them at lower doses and more frequently obtain—or even require—a psychiatry/psychology consult before prescribing these agents.

Management of behaviors associated with dementia through either drug therapy or nonpharmacologic interventions remains a challenge. Medical directors and attending physicians must weigh the risks and benefits of any intervention used to address these behavioral issues. This could include strategies such as developing facility-wide policies overseeing the use of drug therapy or the use of consults from specialists. Until a safe and effective pharmacologic agent or nondrug intervention is developed specifically for that indication, prescribers will continue to face the challenge of finding agents that produce the best possible outcomes with the fewest and least serious side effects.

Varicella zoster
A vaccination for the prevention of varicella zoster infection (shingles) has been available for use in adults over age 60 since early 2007. In May 2008, the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices released a detailed report entitled “The Prevention of Herpes Zoster,” which included the recommendation that all adults over the age of 60 receive one dose of the zoster vaccine, even if they have had a previous episode of the condition. Persons with chronic medical conditions (e.g., chronic renal failure, diabetes mellitus, rheumatoid arthritis, and chronic pulmonary disease) can be vaccinated unless those conditions are contraindications or precautions. The recommendations further state that the vaccination is not indicated to treat acute zoster, to prevent persons with acute zoster from developing postherpetic neuralgia (PHN), or to treat ongoing PHN.⁴

To gain insight into the use—or lack thereof—of this vaccine in long-term care settings, the survey asked medical directors to report how frequently they prescribe this product in each of four age cohorts.

Medical directors reported ordering the vaccine either never or rarely, with a frequency that increased with age—65% for those aged 60 to 69 years and 83% for those aged 90 or older. A small percentage (3% to 5%) of medical directors indicated that they always administer the vaccine, and slightly higher percentages reported that they administer it usually or occasionally in all age cohorts.

The varicella zoster vaccine is of special interest in long-term care as the elderly patient with chronic illness is at particularly high risk for this problem, partly because of advanced age and age-related reduction in cell-mediated immunity. Other comorbid conditions may contribute to increased risk.⁵

Yet, the survey results indicate that use of this vaccine in the nursing facility is the exception rather than the rule. Additionally, when facilities do use it, there is an apparent trend to vaccinate older residents less frequently than their younger cohorts. This reflects the existing data that efficacy decreases with age.

There is little reason to expect the vaccine to be more dangerous or more effective in the frail elderly. There also is scant evidence that the vaccine is as effective in the long-term care population as in the general population. However, the stakes are higher in this group because of their many comorbidities and general frailty. Clearly, there is much to be learned about the efficacy of the vaccine in the frail elderly. However, a large randomized, prospective zoster vaccine trial involving this population is not likely to happen soon, so physicians will have to rely on observational data regarding the effectiveness of this vaccine for their residents.⁵

The National Council on Aging, the American Pain Foundation, and other organizations are partnering on an awareness campaign called “Spotlight on Shingles.”⁶ And the American Medical Directors Association has included information on the vaccination in its “Immunization Toolkit.”⁷ These efforts are likely to increase attention on this issue, and as awareness of the benefits of varicella zoster vaccination increases, its use may grow in nursing facilities.

Medical director credentials and specialization
Twenty-nine percent of medical directors reported having obtained certified medical director (CMD) status through the American Medical Directors Association (AMDA).

Forty-seven percent reported that they are board certified in family medicine. Nearly one-half (42%) are board certified in internal medicine, and 17% completed fellowship training in geriatric medicine.

Approximately one-third (37%) have earned a certificate of added qualifications in geriatrics. More than one in 10 possess other credentials, including board certification in specialties such as hospice and palliative care, hematology, and psychiatry.

Twenty-eight percent of medical directors indicated that they have served in this capacity for between 10 and 20 years, while 16% have worked as a medical director for less than three years.

Twelve percent reported being a medical director for more than 20 years.

Employment model
Approximately one-third (38%) of medical directors reported that they are self-employed on a full-time basis.

One-fourth (23%) of medical directors are employed by a group practice, and 12% are employed by a practice site such as a nursing home.

A total of 6% of self-employed medical directors reported not seeing any patients in an office setting, but rather seeing patients only in a nursing facility and/or assisted living facility (ALF).

Practice description
When asked to identify where they spend their time, medical directors indicated that they devote an average of slightly more than half (55%) of their time to office-based practice.

Essentially all medical directors (98%) serve in nursing facilities in that capacity, and 91% also serve as nursing facility attending physicians. One-third (35%) serve as AL medical director and 16% serve as hospice medical director.

Medical directors in nursing facilities
The majority of medical directors (65%) serve in that capacity in one facility, while 20% reported serving in two facilities. Fourteen percent said they serve in three or more facilities, while 2% indicated they do not serve in a nursing facility.

When asked to report the average size of their medical staffs per facility, one-half of medical directors reported that they have between one and five attending physicians per facility.

Five percent reported that they have more than 25 attending physicians.

Medical directors as attending physicians in nursing facilities
Ninety-one percent of respondents reported serving as a nursing facility attending physician. Approximately one-third (34%) serve as an attending physician in only one facility, while 20% serve in two nursing facilities.

Thirteen percent reported serving as an attending physician in six or more nursing facilities.

When asked to report the number of residents they serve at any one time as an attending physician, respondents reported an average of 110, with a range of 8 to 850.

Sixty-nine percent reported responsibility for 100 or fewer residents, while 18% reported serving more than 200 residents.

Medical directors in assisted living facilities
Of those serving in assisted living facilities as medical director or medical advisor, a large majority (29%) reported serving in one facility only. None serve in more than four ALFs.

More than one-half (56%) of medical directors serving in assisted living facilities reported that their facility is connected to or on the campus of a nursing facility, such as is the case with a continuing care retirement community (CCRC).

When asked to identify the location where they see their assisted living patients, the majority (62%) of respondents indicated seeing these individuals in their office, but more than half (53%) also reported seeing them in the patient’s personal residence within the ALF.

Twenty percent reported seeing patients in an office or examination room within the ALF.

Home visits
Survey participants were asked to indicate how many patients they see in their respective private residences, defined as living at home (not in assisted living) either alone or with family or caregiver. Forty-four percent of respondents indicated that they make one or more home visits per month, with a range of 1 to 100.

Of those who provide home visits, the majority (71%) make 10 or fewer visits per month, but a small percentage (7%) of respondents indicated that they make 25 or more such visits per month. The average number of home visits reported was 5.82 per month.

Commentary
Survey results reveal that most medical directors are board certified and/or credentialed as a certified medical director. While the survey data are not powered for statistical analysis, certain trends can be observed. In the 2008 survey it was found that the percentage of medical directors who had earned the CMD credential was down to 29% from 36% in 2007.¹ This is likely due to the fact that in 2008 a greater percentage of respondents had less than 10 years’ experience as a medical director—59% versus 40% in 2007.¹ A more detailed analysis of survey data revealed a trend of increasing prevalence of the CMD credential with experience. None of those with less than three years of experience were CMDs (a minimum of two years’ experience is required before a medical director can apply to qualify for the CMD credential), compared with 13% of those with three to five years of experience and 54% of those with 20 or more years of experience.

A “typical” medical director could be described as self-employed, either part-time or full-time, serving as a medical director in one facility and spending most of his or her time in an office-based practice. However, the typical medical director also spends considerable time in the nursing facility and a portion of time in hospital practice. The average medical director also typically serves as an attending physician for a large number of residents in his or her facility and, in some cases, other facilities where he or she may not be medical director.

Interestingly, the average number of attending physicians per facility is down relative to the number reported in the 2007 survey: 79% of facilities now have 10 or fewer attendings compared with 67% in 2007.¹ This could be explained by a decreasing number of “occasional physicians” in nursing facilities due to a variety of possible reasons, including insufficient reimbursement, regulations, concerns about malpractice, and an increase in the number of physicians who focus on providing long-term care. The last reason would support what appears to be a bimodal distribution of the number of patients cared for by medical directors serving as attending physicians. While most serve 100 or fewer residents as attending physician (with one-third of those serving 30 or fewer residents), another group serves 200 or more nursing facility residents. Interestingly, the physicians working in the field generally are enthusiastic about their work with this patient population, and organizations such as AMDA are promoting the many pluses of long-term care as a career choice. For example, the AMDA Foundation sponsors a Futures Program to educate fellows and residents about long-term care and introduce them to medical directorship.

A more detailed analysis of survey data revealed that, while the number of physicians responsible for 100 or fewer residents in the capacity of attending physician far exceeded the number of those responsible for more than 200 residents (69% versus 18%, respectively), the total number of residents served by the latter cohort was almost twice that of those physicians responsible for fewer residents.

It is likely that those medical directors with attending physician responsibilities for large numbers of residents are working full-time in that capacity. It may also be that these individuals have a minimal or no office-based practice and serve only long-term care facilities, either in a self-employed capacity or with a group practice that specializes in long-term care facilities.

With regard to assisted living facilities, it was common for physicians to report seeing patients in their personal residence within the facility or in an office or examination room within the ALF. This could be due to a number of reasons, including increasing involvement of medical directors in assisted living, or it could be due to the physician’s desire to provide person-centered care in which the physician can see the environment and interact with the ALF staff to better serve the resident. Physician visits in the facility may also be necessary to care for sicker residents who may have difficulty visiting the physician’s office.

While, on average, medical directors reported spending only a small portion of their time in assisted living facilities, the proportion of medical directors who reported serving in that capacity is noteworthy.

Approximately one-half of assisted living medical directors/advisors reported that their facilities are connected to nursing facilities, where it is likely that they serve as medical director for the entire campus (e.g., a CCRC). This differs considerably from the results reported in the 2007 survey,¹ in which one-fourth of medical directors indicated that the facilities were freestanding. While the survey data are not powered for statistical analysis, this difference might point to a trend of an increasing presence of medical directors/advisors in freestanding facilities even though this is not required by law. This trend, if valid, might be driven by the facilities’ recognition of the risk management role that a medical director can play, or it could reflect an increasingly complex resident population with multiple comorbidities and need for medical care.

The growing involvement of physicians in assisted living is likely due—at least in part—to the evolution of this care setting from primarily a social model to more of a medical model. Increasingly, assisted living facilities are becoming home to residents who 20 years ago would have gone into a nursing facility. These individuals typically have multiple comorbidities and take several medications. So it is not surprising that, despite lack of regulations or government mandates, these facilities are seeking the involvement of physicians.

Methodology
Approximately 15,000 nursing facility medical directors, pharmacists active in practice with the elderly, nursing facility directors of nursing, and geriatric nurse practitioners were selected to participate in a national survey between March and May 2008. The total number of respondents was 638, and after eliminating undeliverable invitations the following response rates were calculated: medical directors, 2.3%; pharmacists, 8.4%; directors of nursing, 4.7%; and nurse practitioners, 5.2%.

References
1. Simonson W, ed. Senior Care Digest Interdisciplinary Report: A Survey of Long-Term Care Health Professionals. Managed Care Digest Series® 2007. Bridgewater, NJ: sanofi-aventis, 2007.
2. Sultzer DL, Davis SM, Tariot PN, et al, and the CATIE-AD Study Group. Clinical symptom responses to atypical antipsychotic medications in Alzheim•er’s disease: phase 1 outcomes from the CATIE-AD effectiveness trial. Am J Psychiatry 2008;165:844–854.
3. Rochon PA, Normand SL, Gomes T, et al. Antipsychotic therapy and short-term serious events in older adults with dementia. Arch Intern Med 2008;168:1090–1096.
4. Harpaz R, Ortega-Sanchez I, Seward J. Prevention of herpes zoster: recom•mendations of the Advisory Com•mittee on Immunization Practices (ACIP). MMWR 2008;57(5):1–30. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm?s_cid=rr5705a1_e. Accessed June 6, 2008.
5. Evans JM. Vaccination to prevent her•pes zoster and postherpetic neuralgia in the nursing home? Caring for the Ages 2007;8(9):12.
6. NCOA Week, May 20, 2008. Avail•able at: www.ncoa.org. Accessed June 5, 2008.
7. Lindstrom A. Shingles study confirms benefits of vaccine. Caring for the Ages 2006;7(12):26–27.