Improve Physician Staffing in Nursing Homes

With more and more patients quickly discharged from acute care hospitals to skilled nursing facilities (SNFs), SNF residents are more clinically complex than ever. Despite the fact that residents have greater health care needs, federal standards for professional staffing at SNFs have not changed in more than 30 years. The consequences are dire. The Inspector General reported that one-third of residents using Medicare suffered adverse events or other harm, many avoidable, within 15.5 days of admission. This awful situation is due, at least in part to inadequate staffing and the failure of minimal staff to recognize and respond promptly and appropriately to residents’ increasingly complex needs.[1]

Studies over the decades demonstrate the value of registered nurses in preventing poor outcomes for residents. Studies also look at the need for greater physician involvement in long-term care facilities. A recent CMA Alert reported that residents who do not see a physician or advanced practitioner after admission are more likely to be rehospitalized, to die, or to fail a successful return to the community.

A new study looks at the differences in resident care and outcomes depending on whether the physicians practice in the nursing facility or in the community. The study of 91 newly-admitted residents to a single California nursing facility between November 2011 and February 2015 found that, one year after admission, residents seen by a physician who practices in the SNF (as opposed to the community) received fewer medications and were less likely to be rehospitalized.[2]

Physician	Number of prescriptions	Rehospitalization
Staff physicians	15	28% (20 of 71 residents)
Community physicians	21	60% (12 of 20 residents)

The Medical Executive Committee of the California nursing facility referred the quality improvement study to the facility’s Quality Assurance and Performance Improvement[3] Committee, to “launch a new performance improvement plan based on the conclusions of the study.”

More than 40 years ago, Congress recognized the absence of physicians in SNFs as a “failure in public policy.”[4]  The time has long since passed to recognize – and mandate – better physician staffing in nursing facilities.

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[1] HHS Office of Inspector General, Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries, OEI-06-11-00370 (Feb. 27, 2014).
[2] Edward L. Schneider, Jung Ki Kim, Diana Hyun, Anjali Lobana, Rick Smith, Robert Shmaeff, Janice Hoffman, Aida Oganesyan, Kimberly Appleby, “A Prospective 12-Month Study of Prescriptions in Long-Term Care Nursing Facility Residents,” The Senior Care Pharmacist, pp. 206-214 (Mar. 2019).
[3] As required by §6102 of the Affordable Care, 42 U.S.C. §1128I(c), nursing facilities are required to have Quality Assurance and Performance Improvement programs.  See 42 C.F.R. §483.75.
[4] Senate Special Committee on Aging, Subcommittee on Long-Term Care, “Nursing Home Care in the United States: Failure in Public Policy,” Supporting Paper No. 9, “Doctors in Nursing Homes: The Shunned Responsibility,” 94^th Congress, 1^st Sess. (Feb. 1975).