Medical Direction and the Future of Assisted Living

To the Editor: As President and Executive Director of the American Medical Directors Association (AMDA), we read “Medical Direction and the Future of Assisted Living” 1 and the accompanying commentary by Resnick et al2 with great interest. AMDA is strongly involved in assisted living issues and policymaking because of our members’ deep concerns about the challenges they face when providing appropriate clinical care to their patients in this nonmedical setting. In 2006, AMDA convened stakeholders to begin providing guidance toward assuring a clinical safety net for assisted living residents. Included in the safety net are agreed-upon protocols for physician interactions with the facilities, as well as medication management issues. All stakeholders agreed on the issues and challenges and asked AMDA to take a leading role in providing consensus-based tools on these priority issues. AMDA has no position on requiring medical directors to be in assisted living facilities. However, we do wish to address the authors’ discussions on medical directors in assisted living and who should fulfill that role—a physician or a nurse. There is no question that physician involvement and leadership is needed. Considering that nurse practitioners generally focus on direct care and not on policies and procedures to address the performance of all practitioners across the system, it might be concluded that they are not as well suited to the medical director role as we define it (see The Role and Responsibilities of the Medical Director in the Nursing Home3). The physician has the highest level of skills and knowledge; medical director, as defined in nursing home regulations, is certainly a physician role. As the collaborative model works very well allowing primary care physicians to partner with nurse practitioners, there may also be a cooperative, team model to explore in this setting. Clearly, as Willging notes, the number of nurse practitioners can hardly continue to make significant numbers of visits to nursing homes and serve some 1.6 million assisted living residents as medical directors—it doesn’t wash as a workforce solution. The answer is the primacy of the primary care physician as team leader. Primary care physicians do, and will continue to, provide this care. While they too are in short supply, adding their numbers of 60,000 family practice and 70,000 internal medicine physicians makes a huge difference in meeting workforce needs. Eliminating the barriers that physicians face when admitting their aging patients to nursing homes and assisted living facilities, adding incentives such as appropriate reimbursement, moderating risk of legal action, and acknowledgement of the importance of this care would go a long way to attracting the needed physicians to care for the elderly in any setting. It will be necessary to step away from the traditional fragmented medical specialty model and begin comprehensive geriatric training for primary care physicians and nonphysician practitioners alike to meet the needs of an aging America. One such model, the medical home model, moves the physician to a higher level of clinical performance and focuses on coordination of care. While we at AMDA agree that medicalization is occurring in spite of resistance from the assisted living industry, we also agree that medical leadership is needed, and if done correctly, would improve care without compromising the relative freedom of a social model. Just as the increase of educated and certified medical directors has contributed to improved care in nursing homes, so should appropriately trained practitioners improve the care of those in assisted living. Workforce shortages exist across the board, as validated in the most recent Institute of Medicine (IOM) report. Specialty-trained geriatricians can’t provide all the needed hands-on-care in nursing homes and assisted living facilities. The existing numbers of geriatricians are falling because of the way the specialty has evolved: Now there are less than the number of fellowship slots annually, and the lion’s share of graduates teach, work in university-based clinics, or conduct research. Too few geriatricians actually see adequate numbers of patients in long-term care. The future lies with primary care–based models. The primary care physician/nurse practitioner collaborative practice model has been very successful, and in fact makes it possible for many office-based primary care physicians to have a nursing home practice or visit their patients in assisted living facilities. It’s incredibly exciting and validating to read the works of such respected and knowledgeable leaders acknowledging the need for the assisted living industry to admit the needs for medical leadership and clinical components to their programs. Lorraine Tarnove Executive Director, AMDA Charles Crecelius, MD, CMD President, AMDA

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