FMDA is the official state affiliate and one of the largest chapters of AMDA – The Society for Post-Acute and Long-Term Care Medicine. It is also a Specialty Society of the Florida Medical Association and liaises with the Florida Osteopathic Medical Association, Florida Hospital Association, Florida Health Care Association, LeadingAge Florida, Florida College of Emergency Physicians, Florida Association Directors of Nursing Administration, Florida Chapters of the Gerontological Advanced Practice Nurses Association, and many others.
Nationwide, nursing facility care has transitioned to include not only long-term care of frail residents but also complicated and resource-intensive post-hospital care. The population of people receiving care in nursing facilities is more medically complex as patients are discharged “sicker and quicker” from the hospital to skilled nursing facilities and hospitals are focusing on decreasing readmission rates. However, the majority are still long-term care patients who have increased medical complexity and acuity. Caring for frail and sick patients in long-term care facilities has resulted in a critical need for highly trained and committed health care practitioners willing to provide care on-site to nursing facility residents. 1,3,4,5,6,12
FMDA’s Leveraging Clinical Staff Engagement: A Certificate of Excellence in PALTC is designed to close the knowledge gap related to clinical care in nursing homes by awarding partial tuition scholarships to a maximum of 500 eligible physicians, advanced practice nurses, physician assistants, consultant pharmacists, nurse administrators, registered nurses, and nursing home administrators at certified nursing homes across Florida, as well as full-time students studying throughout the state of Florida.
This certificate program is joint provided by FMDA and AMDA – The Society for PALTC Medicine in collaboration with the National Association Directors of Nursing Administration in LTC, Florida Chapters of the Gerontological Advanced Practice Nurses Association, and Florida Geriatrics Society.
The goal of FMDA’s project is to improve the quality of care given to residents in nursing homes by raising the educational understanding of the complexity of care delivery. We can accomplish this by providing first-class, high-level education that will directly affect the quality of person-centered care provided to Florida’s most frail and fragile citizens living in nursing homes.
Leveraging Clinical Staff Engagement: A Certificate of Excellence in PALTC is designed to educate medical directors, physicians, advanced practice nurses, senior care pharmacists, consultant pharmacists, physician assistants, directors of nursing in long-term care, registered nurses, and long-term care administrators, as well as geriatricians, primary care and home care physicians, physicians considering becoming long-term care medical directors, hospitalists, hospice medical directors, or home care medical directors, residents, fellows, and others with an interest in geriatrics and its continuum of care. The faculty includes national and regional authorities in the fields of medical direction, senior care pharmacology, post-acute and long-term care medicine, and geriatric medicine.
Value of PALTC Medicine to Improve the Training of all Health Care Practitioners
PALTC medicine should be valued by all stakeholders as a unique and specialized area of practice, requiring a defined body of knowledge, skills, and attitudes and serving a distinct population. Residents of nursing homes should receive the highest quality of care, provided by highly trained and credentialed medical directors, attending physicians, and other practitioners. Physician involvement in nursing facilities is essential to the delivery of quality long-term care. Attending physicians should lead the clinical decision-making for patients under their care. They can provide a high level of knowledge, skill, and experience needed in caring for a medically complex population in a climate of high public expectations and stringent regulatory requirements.
FMDA’s Leveraging Clinical Staff Engagement: A Certificate of Excellence in PALTC endorses efforts to improve the training of all health care professionals, including non-physician providers, in the principles and practice of geriatric medicine and other medical disciplines dealing with chronic care conditions; the goal is for practitioners to obtain a sufficient level of knowledge and skills so that care will be provided concomitant with patients’ complex needs.
- Federal regulations governing nursing facilities make physician medical directors responsible for specific duties and functions. Under these regulations, medical directors assume responsibility for coordination of medical care as well as involvement in developing and implementing resident care policies and procedures. FMDA has been providing effective training to medical directors, attending physicians, and other non-physician practitioners in skilled nursing facilities for nearly 30 years. Some of the core responsibilities of medical directors are: coordinating and evaluating the medical care within the facility by reviewing and evaluating aspects of physician care and practitioner services, and helping the facility identify, evaluate, and address health care issues related to the quality of care and quality of life of residents.
- The medical director should establish a framework for physician participation, and physicians should understand they are accountable for their actions and their care.
- The medical director should strive to continuously improve the quality of care in nursing homes by providing ongoing comprehensive education and appropriate training to physicians, nurses, and other health care professionals working in nursing homes.
Role of FMDA – The Florida Society for Post-Acute and Long-Term Care Medicine in Professional Development of Medical Directors
- FMDA believes that medical directors should have a professional career goal to seek and obtain additional training, which is proven to be beneficial to nursing homes.
- FMDA encourages facilities, administrators, owners, and operators to support the medical director in carrying out various professional roles and responsibilities, including providing support, encouragement, and opportunities for medical directors to seek and obtain continuing professional education in medical direction and PALTC medicine.
- FMDA is aware that the problem of insufficient access to qualified physicians in long-term care is best met by increasing the number of qualified physicians in the field.
- FMDA is strongly committed to strengthening the PALTC workforce, including both physician and non-physician practitioners. This includes nurse practitioners and physician assistants and other non-physicians who work collaboratively with attending physicians and medical directors to maximize the value of all members of the interdisciplinary care team. Studies demonstrate that collaboration with mid-level practitioners, particularly in the context of long-term care, may reduce emergency department use and hospitalization of nursing facility residents and potentially improve primary care.15,16 All clinicians should commit to fostering and strengthening this collaboration.
PALTC Clinicians Require Specific Fund of Knowledge and Unique Skill Set
Approximately 10 years ago — due to a variety of factors that included increasing complexity of care delivered to residents in multiple diverse PALTC settings, complex regulatory environment, changes in reimbursement, etc. — AMDA’s leadership began to focus specifically on the nursing home attending physician. Concomitantly, emerging care models (e.g., Accountable Care Organizations) prioritized value over volume. A hypothesis emerged that physicians effectively practicing in this challenging continuum must possess a specific fund of knowledge and unique skill set. 7,8,9,10,11,12
In 2013, an AMDA workgroup published a list of 26 competencies for the nursing home attending physician. In 2016, the ABPLM convened a committee of subject matter experts to perform a job analysis specific to PALTC attending physicians. This resulted in a National Survey (Fall 2016) of a broad cross-section of PALTC attending physicians (nearly 400 responses); results of the 114 task and 73 knowledge statements developed by the steering committee were psychometrically strongly validated (publication pending).
In no specific order, here are some examples of the more popular task and knowledge statements from the survey:
- Be familiar with and adhere to federal and state regulations applicable to PALTC.
- Perform medication reconciliation at the time of admission, discharge, and all care transitions.
- Adhere to principles of ethical conduct and shared decision-making.
- Identify geriatric syndromes prevalent in the PALTC setting (e.g., weight loss, delirium, depression, falls) and use an individual, holistic approach to their evaluation, diagnosis, and treatment.
- Advance care planning
- Infection control targeted to PALTC
- Pain management
- De-prescribing process
According to Dr. Robert Kaplan, former chair of AMDA’s ABPLM and past-president of FMDA, one of the more prominent conclusions from this survey is that a specific body of knowledge and unique skill set is indeed required to effectively practice in the PALTC arena. In addition, many of the same concepts can be applied to mid-level and non-physician clinicians who participate in high-level, quality educational offerings as provided by FMDA’s Leveraging Clinical Staff Engagement Through Education in PALTC – A Certificate Program.
…many of the same concepts can be applied to mid-level and non-physician clinicians who participate in high-level, quality educational offerings as provided by FMDA’s Leveraging Clinical Staff Engagement: A Certificate of Excellence in PALTC.
Similarly, many curricula and core competencies have been developed for teaching trainees to care for older adults. This includes professional societies’ guidelines for care of the older patient, including nursing home care, interprofessional care, geropsychiatry, pharmacy, and home care. Several studies have looked at trainees’ perceptions of providing care to older adults and have identified what these students and residents feel are gaps in their training and potential barriers to delivering best care practices.
Recruiting Interprofessional Students and Trainees – Providing an Affordable, High-Quality Educational Opportunity for the Emerging Geriatric Workforce
Several studies have looked at trainees’ perceptions of providing care to older adults and identified what students and residents feel are gaps in their training and potential barriers to delivering best care practices. Elizabeth Hames, MA, DO, CMD, assistant professor in the Department of Geriatrics at Nova Southeastern University College of Osteopathic Medicine, observed that challenges include addressing complex, multifactorial illness, setting priorities for intervention, and communicating with patients and families (especially when a cognitive disorder is present). Trainees in multiple studies recounted feeling overwhelmed by complex patients and social situations. FMDA’s certificate program seeks to recruit interprofessional trainees (medicine, nursing, pharmacy, allied health) from baccalaureate, graduate, post-graduate, and doctoral educational programs throughout the state of Florida, providing an affordable educational opportunity for the emerging geriatric workforce.13,14,15
In a recently published article, multivariate analyses were performed to compare rates of emergency department (ED), inpatient, and skilled nursing facility use between Institutional Special Needs Plans (ISNPs) members and Medicare fee-for-service (FFS) long-term nursing home residents. The results suggest that mid-level practitioners in skilled nursing facilities were involved in raising the care provided, specifically: In comparison with FFS institutionalized Medicare beneficiaries, ISNP members had 51 percent lower ED use, 38 percent fewer hospitalizations, and 45 percent fewer readmissions, whereas their skilled nursing facility use was 112 percent higher.16
FMDA’s Leveraging Clinical Staff Engagement: A Certificate of Excellence in PALTC features nationally recognized speakers on cutting-edge issues that impact best practices. It includes an excellent range of clinical and administrative topics, a panel discussion with leaders on the critical challenges in PALTC, and access to information and resources. The target audience will earn continuing education credits, certified medical directors may earn credit hours toward CMD certification, and consultant pharmacists may earn general pharmacist and Florida re-certification credit hours.
What Are the Learning Objectives for the Program?
Upon completion of FMDA’s Leveraging Clinical Staff Engagement: A Certificate of Excellence in PALTC, participants should be able to:
- Discuss the professional challenges facing medical directors, attending physicians, advanced practice nurses, consultant pharmacists, physician assistants, directors of nursing, and administrators practicing in the continuum
- Describe the advances in theoretical and clinical knowledge impacting individuals affected by medical issues in the PALTC continuum
- Discuss current and emerging issues and public policy efforts
- Describe examples of evidence-based practice and multidisciplinary approaches to enhance outcomes in various health care settings
- List examples of evidence-based practice as it pertains to PALTC medicine
- Discuss the principles and practice of geriatric medicine, and other pertinent medical disciplines dealing with chronic care conditions
- Review drug prescribing guidelines for older adults and other complex long-term care residents
- Work effectively as part of an interdisciplinary team
- Discuss relevant regulatory requirements (i.e., F-Tags) that are commonly cited in skilled nursing facilities
- Describe the flexibility needed to take on evolving competency-based education
Why Should Current and Future Clinicians Sign up?
FMDA’s Leveraging Clinical Staff Engagement: A Certificate of Excellence in PALTC demonstrates to employers and the public that the practitioner is committed to career development and quality PALTC medicine, as well as the credibility and profile of practitioners working in PALTC settings. The certificate enhances professional reputation, supports continued professional development, exemplifies a high level of commitment and mastery in the field of practice, and increases skills and knowledge.
Why Should SNF Providers Support the Certificate of Excellence Program?
Nursing homes will also benefit from the education provided to health care professionals through the program. Some of the benefits include improved customer satisfaction, higher safety and quality of care, increased competence of employees, future professional development opportunities for employees, ongoing enhancement of knowledge and skills, increased confidence in employees’ abilities, demonstration of employers’ commitment to competence, compliance with industry regulation or government requirements, potential to increase staff satisfaction, and reduced turnover.
Evidence-based literature suggests the presence of a medical director with additional training may improve care quality and the physician is generally more engaged. 1,2,7,8,9,10 A study commissioned by the American Medical Directors Certification Program (now the American Board of Post-Acute and Long-Term Care Medicine, or ABPLM) found that engaging a certified medical director contributes positively to a nursing home’s quality of care. Results of the study described data analysis that represented a 15 percent improvement in quality for facilities with certified medical directors.2
This unique online and on-demand program offers a total of 29 credit hours. To obtain the scholarship, applicants are required to complete at least 20 hours and pass the online final exam, which has no attempt limit. Participants who do not complete the minimum 20 hours will receive the continuing education credits (CEs) they earned.
The goal of FMDA’s Leveraging Clinical Staff Engagement: A Certificate of Excellence in PALTC is to improve the quality of care given to residents in nursing homes by raising the educational understanding of the complexity of care delivery. This is accomplished by providing first-class, high-level education that will directly affect the quality of person-centered care provided to Florida’s most frail and fragile citizens living in nursing homes.
- Nanda A. The roles and functions of medical directors in nursing homes. Rhode Island Medical Journal. March 2015. rimed.org.
- Rowland FN, Cowles M, Dickstein C, Katz PR. Impact of medical director certification on nursing home quality of care. JAMDA. 2009;10:431-435.
- Role of the attending physician in the nursing facility. AMDA. 1991, rev. 2002.
- Medical director role and responsibilities: AMDA Core Curriculum. Columbia, MD.
- Dimant J. (2002). Responsibilities of attending physicians in long-term care facilities. Journal of the American Medical Directors Association (JAMDA). 254-258.
- Dimant J. (2003). Roles and responsibilities of attending physicians in skilled nursing facilities. JAMDA. 4(4): 231-243.
- Levenson SA. The basis for improving and reforming long-term care. Part 1: the foundation. JAMDA. 2009;10: 459-465.
- Levenson SA. The basis for improving and reforming long-term care. Part 2: clinical problem solving and evidence-based care. JAMDA. 2009;10: 520-529.
- Levenson SA. The basis for improving and reforming long-term care. Part 3: essential elements for quality care. JAMDA. 2009;10: 597-606.
- Levenson SA. The basis for improving and reforming long-term care. Part 4: identifying meaningful improvement approaches (segment 1). JAMDA. 2010;11: 84-91.
- Levenson SA. The basis for improving and reforming long-term care. Part 4: identifying meaningful improvement approaches (segment 2). JAMDA. 2010;11: 161-170.
- Levy C, Epstein A, Landry L, Kramer A, Harvell J, Liggins C. U.S. Department of Health and Human Services: physician practices in nursing homes. U.S. Department of Health and Human Services. April 4, 2006.
- Drickamer M, Levy B, Irwin KS, Rohrbaugh RM. Perceived needs for geriatric education by medical students, internal medicine residents and faculty. J Gen Intern Med. 2006;21(12): 1230-1234.
- Counsell SR, Sullivan GM. Curriculum recommendations for resident training in nursing home care. A collaborative effort of the society of general internal medicine task force on geriatric medicine, the Society of Teachers of Family Medicine Geriatrics Task Force, the American Medical Directors Association, and the American Geriatrics Society Education Committee. J Am Geriatr Soc. 1994;42: 1200-1201.
- The Education Committee Writing Group of the American Geriatrics Society. Core competencies for the care of older patients: recommendations of the American Geriatrics Society. Acad Med. 2000;75: 252-255.
- McGarry, Brian E, Grabowski, David, C. Managed care for long-stay nursing home residents: An evaluation of institutional special needs plans. AJMC. 2019;25(9): 400-405)