How your colleagues ease the hassle of nursing home care

November 22, 1999

Few physicians love the work. But our poll turned up valuable advice on making the best of it.

How your colleagues ease the hassle of nursing home care

Few physicians love the work. But our poll turned up valuableadvice on making the best of it.

By Deborah Grandinetti, Senior Associate Editor

What makes caring for nursing home patients easier? According to yourcolleagues, the most useful strategy is limiting yourself to a few facilities.That's the answer we got from more than 60 percent of the physicians whoresponded to a Medical Economics poll asking, "Where do youstand on nursing home care?"

Next in order of helpfulness were scheduling visits in advance, so thatpatients and staff are ready; establishing treatment protocols; and assigningsome visits to nurse practitioners or physician assistants.

The majority of our respondents do see nursing home patients, and a feweven said they genuinely enjoy it. One went so far as to claim this is his"favorite part of practice." Another, who no longer does hospitalwork, said that nursing home care "keeps my skills at a higher levelthan I can achieve in the outpatient setting." Yet another couldn'tunderstand why so many physicians consider it a big deal to drive "amile to see a patient they've cared for for 15 years."

But physicians also told us about the problems. At the top of the list:low reimbursement, followed by paperwork hassles. Said one doctor: "Iusually get $18 to treat patents with congestive heart failure or chronicobstructive pulmonary disease." Another complained that he makes lessper hour than a home health nurse.

Low pay isn't a problem for all physicians, however. One reported that"nursing home revenue has been a good source of income for our group.There's little overhead, and reimbursements have improved in recent years."

Another often-cited annoyance: frequent phone calls. One respondent complainedof getting four calls per patient per month. Another simply labeled thecalls "excessive," underlining the word three times.

But the unnecessary calls, and even the paperwork, can be kept to a minimum,according to Tacoma, WA, family physician Richard E. Waltman, author ofthe article that prompted our poll. He's pictured above. (See "Do yourselfa favor--take care of nursing home patients," Feb. 8, 1999, availableat www.memag.com.) One of Waltman'sstrategies is to have his office staff write down all nonemergency questionsor requests. Then he reviews them all at once, gives his answers, and hasa staffer call back with the information.

Waltman also makes it clear to each facility that he doesn't want tobe called at home on nights or weekends on non-emergency matters. And atnursing homes where he's confident in the facility and the staff, he tellsthe nurses they can write routine orders per his guidelines, and he'll supportthem. For instance, he communicates that he wants all new stroke patientsto have their heads elevated in bed. So the staff at these facilities canfollow through without having to call Waltman and wait for his order.

What makes doctors avoid nursing homes entirely? One survey respondentsaid his biggest concern was litigation from the patient's family. Another,who sees these patients in his office only, made a similar point. "Everynursing home does its own thing, and almost never follows acute care guidelines,"he said. "That creates a big liability problem."

Waltman sympathizes, having been on the end of one such lawsuit himselfas a nursing home medical director. Now he protects himself by documentingthoroughly and avoiding cases and conditions he's not comfortable treating."The bottom line is that everything you do has to meet the communitystandard."

When a nursing home pushes for a particular intervention that Waltmanthinks is unwarranted, he asks the facility to fax him an analysis of thetreatment's benefits, risks, and cost. He also asks for several alternatives."Writing it up forces the staff to think it through," he says.

To make nursing home visits more efficient, survey respondent RonaldA. Gilson, an FP/geriatrician in Oregon, books an appointment beforehandwith the resident care managers, when possible.

"They're the ones who know the patients and can give you an overview,"he says. And making rounds with the care manager saves time he'd otherwisespend trying to figure out what the patients need. It can also prevent himfrom missing problems--especially those important enough to require an unplannedreturn visit.

One of our respondents keeps things running smoothly by scheduling amonthly meeting with the facility's director of nursing, and a quarterlymeeting with its administrator.

Another tries to have ambulatory patients brought to his office. "Thisis particularly good for annual exams. It's also good for patients to getout of the nursing home," he explains.

It's clear from our survey that some physicians will never consider nursinghome care their cup of tea. One discontinued it because he enjoys officeand hospital practice much more. "I don't want to replace what I likewith what I don't like," he said. "I think nursing home care ispracticed most efficiently by the nursing home medical director."

. How your colleagues ease the hassle of nursing home care. Medical Economics 1999;22:81.