Annals of Long Term Care

HISTORICAL ASPECTS
In his 1983 textbook Clinical Aspects of Aging, Dr. William Reichel1 outlines the history of the role of the nursing facility medical director, and the early attempts to mandate this role within federal regulation. Dr. Reichel reminds us that in 1970, a Salmonella epidemic in a Baltimore, MD, nursing home caused the deaths of 36 elderly residents. There was no state or federal requirement for nursing facilities to have medical directors at the time. In response to the Salmonella epidemic, the Maryland Medical Society developed an outline of responsibilities for nursing facility medical directors and mailed it out to each facility’s “principal physician,” with a directive implying that if it was not followed, the physician would in effect be guilty of poor medical practice.1 This may have been the first mandated role of a nursing facility medical director in the nation.

In 1971, President Nixon directed the Department of Health, Education, and Welfare (HEW) to implement plans for upgrading substandard nursing facilities.1 As part of this plan, HEW requested that the American Medical Association sponsor seminars on the role of the medical director of skilled nursing facilities. The seminars were held in ten cities around the country, with 558 physicians and almost 1000 other health professionals in attendance. As a result of these seminars, in 1973 the American Medical Association published “Guidelines for a Medical Director in a Long-Term Care Facility,” which listed 15 functions of a medical director in order to help ensure the adequacy and appropriateness of the medical care provided to the residents.1 Also in 1973, HEW proposed a set of common standards for all skilled nursing facilities under Medicare and Medicaid. There was no requirement for a medical director within these standards. The American Medical Association was very vocal in its advocacy for a federal requirement mandating nursing facility medical directors. In 1974, regulations were approved, which required, as a condition of participation, that each skilled nursing facility retain a physician to serve as a medical director on at least a part-time basis.1

Once again in 1982, with new proposed regulations, the medical director mandate was deleted. The American Medical Association, the American Geriatrics Society, and a relatively new organization, the American Medical Directors Association, along with 34 other national organizations, protested the absence of a medical director role in the proposed regulations. It was felt that without a clear federal requirement for physician administrative input, that many, if not most, nursing facilities would not voluntarily hire a physician for this role, and that the residents would suffer from this absence. As a result, the medical director mandate was once again restored in federal regulation for skilled nursing facilities.1

In the 1980s, Drs. James Pattee and Thomas Altemeier of the University of Minnesota School of Medicine, began conducting research on the role of the nursing facility medical director, and also began a continuing medical education course offered in several cities around the country for training nursing home medical directors. In 1991, they convened an expert panel to develop a core curriculum for nursing facility medical directors.2 This curriculum served as the foundation for the American Medical Directors Association core curriculum program for nursing facility medical directors.

The current era of nursing facility regulation was ushered in by the passage of the nursing home reform amendments of the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87).