Why nursing homes need more doctors on site

The recent New England Journal of Medicine article, highlighting burdensome healthcare transitions in a subset of nursing home patients, is certainly of documentary value. However, for many of us with real-world experience in the nursing home medical care venue, the article certainly falls short of newsworthy.  Not even mildly surprising really.

Too many of our nation’s nursing home staffs suffer from a lack of onsite MDs for evaluating acute medical conditions of their residents. Additionally, many of our nursing homes also are frequently operating with the minimal number of licensed nursing staff permissible, under state and federal regulations. Making matters worse is that a very large number of these licensed nursing staffs are minimally experienced and minimally skilled, at performing acute clinical evaluations of patients. Equally problematic is that the bulk of the time, of the licensed nursing staff, is taken up by supervisory matters—particularly in regard to care plans, chart documentation and other paper trail maintenance—important to regulatory agencies—and, consequently, of top priority to the facilities’ administrations. In short, our nursing homes’ licensed nursing staffs have become increasingly more proficient and comfortable with their administrative tasks, than they are with clinical tasks.

Thus, the day-in-day-out clinical decision making within our nation’s nursing homes is being significantly influenced by a nursing staff that is struggling with a 4-F syndrome: fear of adverse publicity for the facility, fear of clinical decision making, fear of regulatory surveyors and fear of job loss or subsequent legal repercussions.

As I point out in The Medical Profession Is Dead and the Doctor Is “Critically ill!” nursing home patients will experience more new complaints and more frequent declines from their baseline health status, on any given day, than any other patient population. Paradoxically, the facilities we then place them in, for addressing these daily high-maintenance health care needs, are the very facilities having the least physician-presence of all other health care venues within the medical system. Consequently, most patient medical assessments and medical interventions are carried out by nursing staff.

My personal real-world experience suggests that nursing home residents’ medical interventions begin with phone tag with the attending MD, progress to phone consultation with the attending MD, proceed to trialed phone orders from the MD and, inevitably, end up with the order: “Ship by ambulance to the ER.” It differs from physician to physician, as to how many calls from the nursing home nurse will be required, before the “Ship by ambulance to the ER order comes, but come it will.

What almost never comes, however, is the doctor to the nursing home—for evaluating the patient, documenting his evaluation and treatment plan within the chart—and, by so doing, sharing with the nursing home nurse the responsibility for the outcome of the patient. And so, within our nursing homes, almost any acute or subacute change in a patient’s medical condition—especially if occurring on the eleven to seven shift—generates “the perfect storm” for blowing the patient out of their familiar and secure environment, into the frenzied milieu of the nearest hospital ER.

Of course, the arrival in an already hectic ER simply cries out for expediency, with the result being even more defensive medicine posturing than usual. This generally translates into the patient being admitted to the pricey acute care hospital or the patient undergoing a battery of terribly high-tech (also terribly expensive) tests and imaging, which, all ER doctors know, will be looked upon as surrogate markers for quality care, by any regulatory inspecting agencies—should the chart ever be pulled for their reviewing pleasure. With copies of the results of these pointless tests now safely ensconced within the patient’s permanent medical record, the ambulance can then be called for transporting the hapless patient back to the nursing home—for awaiting his/her next “sinking spell” and their next burdensome ER trip.

In any given twenty-four hours, it is likely that thousands of unwarranted medical interventions, costing hundreds of thousands of dollars, are being ordered within our nursing homes’ populations for the sake of convenience and a host of other self-serving agendas having nothing whatsoever to do with the patients’ needs or best interests.

Alan Cato is the author of The Medical Profession Is Dead and the Doctor Is “Critically Ill!”

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