A regulatory hat will be the latest of many worn by medical directors at nursing homes. They are expected to play an integral role in surveys moving forward, and will be on the hook if documentation is missing or a situation wasn’t handled with new survey requirements in mind.

Medical directors already have significant administrative duties, leadership responsibilities and are expected to stay on top of clinical practices. Now, even more engagement is required, particularly when it comes to regulatory compliance, Quality Assurance and Performance Improvement (QAPI) meetings and clinical decision-making with top-of-mind issues like anti-psychotic use.

While medical directors at rural nursing homes are often already overseeing care in alignment with regulations, many nursing homes still lack this level of involvement. Some say that the expanded responsibilities of the role have been causing hurdles.

For a lot of facilities operated by Good Samaritan, for example, the medical director is seen as a trusted member of the community and serves as the residents’ primary care physician, the operator’s Chief Nursing Officer DeeAndra Sandgren told Skilled Nursing News. 

The essential collaboration on the part of medical directors in rural settings may have given them, and the operators in these areas, a leg up when it comes to how this role will be viewed by government officials in the future.

But rural communities face increasing challenges in finding medical directors in the first place, Sandgren said. Good Samaritan’s parent company Sanford Health has invested in expanding graduate medical education programs to strengthen the pipeline of rural physicians, and uses technology to fill the gaps, like virtual medical director services.

Still, relationships built over time have helped Good Samaritan to have “frequent connection points” and made it easier to prepare for changing regulations and gives everyone a forum to talk at a strategic level about best practices, barriers and opportunities for improvement.

“They develop strong relationships with the administrator, director of nursing and local pharmacist,” added Sandgren. “These close-knit relationships have historically added even more value when the medical director does rounds in the long-term care center and participates in QAPI meetings.”

Overall, existing close relationships between the medical director and wider care team will be seen as a positive to surveyors, states and federal officials.

“They’re going to be looking into the medical director deeper than they ever have,” said Nancy Tuders, assistant director of education, master trainer, with the National Association of Directors of Nursing Administration in Long-Term Care (NADONA).

Medical directors called out in MDS, SOM

Guidance in the State Operations Manual (SOM) and Minimum Data Set (MDS) details interviews with the medical director among other roles if there’s an issue in a survey. The surveyor will question the medical director, asking if they knew about a given situation and what they were doing about it, Tuders said.

“We’ve been trying to let our members know, and people that are on our webinars that they better get together with their medical director and go through what’s in that State Operations Manual, because sometimes [medical directors are] in and out of the building,” noted Tuders.

It all comes down to an effort to get medical directors more involved in the care of the residents – surveyors are looking at their participation and what they’re doing day to day, and what they’re doing in QAPI meetings too.

It’s concerning for some facilities where the medical director isn’t as involved in the day-to-day care of residents. This could be for a number of reasons – maybe they’re stretched thin between multiple buildings, or perhaps there’s another role that an operator has used for monitoring daily care and getting involved when survey issues arise.

In some cases, medical directors started partnering closely with other members of the care team when the Covid vaccine first became available, Sandgren said, providing education and individualized outreach to residents and families about the safety and efficacy of the vaccine.

There’s an intersection now between medical director education and medication management as well, especially around the use of anti-psychotics, added Journey Chief Nursing Officer Jody O’Mara, but it seems to vary from state to state. In Georgia, for example, there’s a higher usage of anti-psychotics in nursing homes, and therefore more of a focus on educating medical directors and other roles like nurse practitioners on how to manage use.

“There is going to be a huge focus on documentation and making sure that your medical record really tells the resident story and explains why we’re doing what we’re doing,” added Michelle Stuercke, chief clinical officer for Transitional Care Management. “It’s not just enough now to sort of check off a box, but we really need to explain why we’re doing what we’re doing.”

When the medical director and nursing staff work side by side to make decisions and engage families on antipsychotics, care teams see success with deprescribing efforts, noted Sandgren.

Advice for operators amid medical director evolution

It might help to do a debrief if a survey was completed after April, Haberhern said, especially if the survey focused on a specific area or raised questions about how the medical director was involved. The goal would be to share insights with sister communities and the roster of medical directors.

“We did meet with our medical director groups, so the head of all of our medical directors in the different states, and just went through the updates with them and made sure that they were aware of it and the direction that we were going with our policy and procedures,” said O’Mara.

Journey ended up making one change with a medical director group that they felt wasn’t on board with changes in role responsibilities, to better align with survey changes, she said.

Surveyors haven’t really focused too much on the medical directors role up until this point, Stuercke continued, so it will be interesting to see how surveyors will respond to medical director explanations. In the meantime, operators can look at trends at their own facilities or in a given area to see how surveyors are interpreting some of the critical element pathways that were part of changes implemented in April.