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The Role of Nursing Home
Prior
to the 20th century, many of sick, needy and elderly were cared anywhere
in country poorhouses.
In Dickensian England, for instance, there
was a need to care for an increasing number of "elderly", who
were generally urban dwellers with no family or friends to serve as caregivers
and no assets to purchase such care.
Hence, "work farms", "poor
houses", "alms houses" arose in Europe and then in the
United States. So that, a structured and more compassionate framework
evolved, generally supported by religious or fraternal organizations.
Only a few Nursing Homes existed before
the enactment of the Social Security Act of 1935, wich was one first important
step in the direction of the change. After World War II, nursing homes
gradually developed.
Over the past five decades, however, the
nursing home has emerged as a prominent component of a broad array
of long-therm care services for older, chronically ill, functionally disabled
people.
Between 1964 and 1985, the number of resident
in nursing home is tripled from 500.000 to 1.5 milion.
This progressive metamorphosis is the result
of converging social, political and economic forces: the increasing number
of people ages 85 and older with functional disabilities, the presence
of legislative incentives (federal system of reimbursement), the expansion
and "medicalization" of the nursing home industry, the recognition
of central position of geriatric medicine in the care of the elderly.
At present a nursing home is an institution
providing nursing 24 h a day, assistance with activities of daily living
and mobility, psycosocial and personal care, such as physioterapy, occupational
therapy.
Nursing homes mainly serve frail elders
with chronic diseases, disabilities, dementia.
Table1 compares institutionalization rates
for some countries. The Table 2 presents the dominant type of nursing
home resident. The key goals of NH care are listed in Table 3.
At
present, residents of Nursing Homes in the USA may be divided into two
groups: a relatively small number of people requiring a short stay, who
are usually transferred from hospitals and require rehabilitative services
or are at the end of life, and a much larger group of individuals needing
long-term care because of impairments in physical functioning and cognition.
About two-thirds of all nursing home residents
are cognitively impaird and have memory, orientation and beaviour or decision-making
problems.
The role of Nursing Home Director
In
1959, the American Medical Association approved a report containing guidelines
for medical care in nursing home and related facilities. The guidelines
were tangible recognition by the AMA that the quality of care in the nursing
home is directly related to the physician's interest and competence in
providing care for patients in these facilities.
In the mid-1960, a group of Maryland phisicians,
who were subcommittee of the Maryland Commission on Aging, visited several
nursing homes.
One important conclusion of the committee
was that the medical care in the Nursing Home was superior when it was
provided by a principal physician as opposed to numerous private
practitioners.
The next major impetus to the growth of
the Nursing Home was enactment of Medicare and Medicaid in 1965. Medicare
regulations and dollars encouraged the use of Nursing Home as a less expensive
alternative to lengthy hospitalization.
The Executive Committee of Maryland Medical
Society approved the concept of Medical Director in August 1970. By 1972,
several professional organizations of lay and religious inspiriration
interested in long-term care accepted the concept of a medical director
as a way of improving the quality of care in nursing homes. In June 1973,
the AMA adopted guidelines for medical directors, listed in Table 4.
In 1977, the AMA published the monograph
"Medical Director in Long-Term Care Facility", which discussed
the aspects of the Nursing home's medical director position.
The importance of the role of the
medical director in Nursing Home was reinforced by the Omnibus Budget
Reconciliation Act (OBRA) of 1987. Based on an Institute of Medicine study,
OBRA mandeted increased attention to quality of life in nursing home,
with requirement for the provision of comprehensive assessment, individual
treatment planning, and delivery of services to allow every resident to
attain or maintain the highest possible mental and physical function status.
According to OBRA '87, the medical director
is responsible for the implementation of resident care policies.
The interpretative guidelines define resident
care policies to include admission, transfers, discarges; infection control;
use restraints; physician practices; and responsabilities of non physician
health care workers (nurses, rehabilitative therapists, dietary services
in resident care), emergency care, and resident assessment and care planning.
The medical director is also responsible
for policies related to accidents and incidents; use of medications, laboratory;
release of clinical information; and overal quality of care.
During this same year (1987) were developed
by AMDA (American Medical Director Association) consensus conference
a list of 9 functions (Table 5). Fallowing the conference, some physicians
were asked to prioritize the identified task within each function.
While
the prevention, identification, and treatment of chronic, subacute, and
acute medical conditions are important, most of these goals focus on the
functional independence, autonomy, quality of life, comfort, and dignity
of residents.
Physicians who care for NH residents must
keep these goals in perspective while adressing the more traditional goals
of medical care.
In Italy, by 1989 with the enactment of
Decreto n. 321 were illustrated general characteristics of RSA (Residenze
Sanitarie Assistenziali), the equivalent of American Nursing Home, but
doesn't exist a uniform set of information on various aspects of residents
and standards, included the medical director's position.
Nursing home is complex system involving
many individuals with different background, various degrees of knowledge,
skills, experience, and motivation.
The process (what is done to patients) involve
several individuals, various disciplenes and professions. In today's enviroment,
determining who and what is accountable for observed quality is as important
as measuring quality.
The medical director should participate
to analyze the effectiveness of current processes, why partecipants do
or do not do what they are supposed to be doing; the medical director
should to define relevant issues to developing and refining policies and
procedures.
The medical director should help identify
the organization's goals and objectives, roles and responsabilities, the
incentives and obstacles throught the caracterization of accurate outcomes.
The passage of the nursing home reforms
incorporated into the 1987 OBRA represent an important milestone in nursing
home regulation. This law and its subsequent regulations have revolutioned
the way to assess structure, process, and outcomes
The basis of an outcomes approach is its
ability to relate the outcome of interest to the care provided.
In a like long-term care area, where has
been still little established about the relationship between process and
outcomes, there is safely enough space for who has will to acquire a profound
quality of care knowledge.
The medical director must provide medical
and nursing leadership for research activities in long-term care. The
ability and desire to attend to long-term care patients is as important
as the respect of the collegues.
Applying research activities can serve as
a planning tool and provide the medical director with the opportunity
to develop and implement studies that increase the effectiveness and efficiency
of resident care. Through the application of research findings, it is
possible to adresspolicies and procedures quality assurance.
The medical director is in a unique position
to offer inservice education programs and conduct teaching rounds. To
be a good physician means to be a good teacher or educator. Education
is always a continuous process, which allows to make progress.
Conclusions
The
future of medical direction in community-based long term care facilities
reflects the future of modern medicine; change is inevitable, but its
exact nature and extent remains to be determined. Historically, it has
been difficult to find well-qualified physicians who were willing to work
in the nursing homes.
Often the medical director was simply the
physician "of last resort" for the nursing home.
Prior to OBRA '87, many nursing home medical
director had role that were predominantly clinical rather administrative
and spent only a few hours per month in their position.
After OBRA'87, the medical director role
has increased in importance in light of the multiple problems that may
be associated with geriatric patients managment: the nursing home residents
have numerous chronic debilitating conditions and frequently experience
acute intercurrent illness.
Particularly in this context, comprehensive
evaluation of an older individual's health status is one of the most challenging
aspects of geriatric medicine. It requires a sensitivity to the concerns
of older people, an ability to interact effectively with a variety of
health professional.
The quality medical care is getting more
important aspect of quality nursing home care for the frail elderly.
The medical director is destined to become
a great point of reference for evalueting the relationship between needs,
care provided and outcomes. His role will depend on every medical director
capacity to expand the opportunities of growth from creative, and proactive
managment in nursing home.
Dott. Fabio Trecate
Direttore Medico del Centro Girola
- RSA della Fondazione Don Carlo Gnocchi di Milano |
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