Physician Evaluation and Management of Nursing Home Residents

Physician evaluation of nursing home residents at admission and regularly thereafter is an important part of caring for this rapidly increasing segment of society. The diverse goals of nursing home care, the heterogeneity of nursing home residents, and the varied circumstances under which physicians evaluate them make a single set of recommendations for evaluating all nursing home residents inappropriate. For example, the goals of care and foci of evaluation and management for a nursing home resident admitted for rehabilitation after a hip fracture are very different from those for a resident admitted for terminal care of end-stage cancer or dementia. Similarly, the nature and extent of patient evaluation at admission or at an annual examination are different from those at a routine monthly visit. The general goals of nursing home care are 1) to provide a safe and supportive environment for chronically ill and dependent persons; 2) to maximize individual autonomy, functional capabilities, and quality of life; 3) to stabilize and delay, if possible, the progression of chronic illnesses; and 4) to prevent subacute and acute illnesses and recognize and manage them rapidly when they do occur [1]. Because nursing home residents are heterogeneous, the goals for caring for specific residents vary. This heterogeneity can be illustrated by categorizing nursing home residents into several types. Examples of subgroups and components of their medical evaluation that need particular emphasis are listed in Table 1. Although not all nursing home residents fit neatly into one of these categories, and residents may change from one type to another as their conditions change, this general nosology can help physicians target their evaluations and management for each type of nursing home resident. Table 1. Points of Emphasis in the Medical Evaluation of Different Types of Nursing Home Residents As in other comprehensive assessments of geriatric patients in other settings, the timing and purposes for evaluating nursing home residents are important in determining the scope and areas of emphasis for evaluation. Physicians evaluate nursing home residents at the time of admission, at periodic visits every 30 to 90 days, when acute problems occur, and at the time of annual review for residents who stay longer than 1 year. The objectives and elements of evaluation at these different times depend on the clinical status of the resident and goals for care. Finally, physician evaluation of nursing home residents must be viewed as only one component of a multidisciplinary process that produces an overall care plan for each resident. The goals and context of nursing home care require that a broad range of health professionals participate in care planning and overall management for nursing home residents. In addition, recently implemented federal nursing home regulations mandate comprehensive, multifaceted assessment with interdisciplinary communication and participation. Specific components of the physician evaluation are presented below. However, the relevant federal rules and the role of the interdisciplinary team are reviewed first. The specific recommendations made in this article are based on literature review and experience, not on a meta-analysis of research. In fact, no research on the most cost-effective strategies to evaluate and care for subgroups of nursing home residents exists. We hope the recommendations described stimulate discussion and research on these issues. These recommendations may be difficult to achieve given the nature of the nursing home environment, the need to spend more time in the nursing home, and inadequate Medicare reimbursement for physician care in nursing homes. Despite recent increases in the relative value of nursing home visit codes achieved by the American Medical Directors Association and the American Geriatric Society, creative and efficient strategies and close cooperation among the interdisciplinary team and physician extenders (where available) are needed to fulfill our recommendations. Federal Rules and the Role of the Interdisciplinary Team The Omnibus Budget Reconciliation Act (OBRA) of 1987 contained new federal rules for nursing home care. After considerable public comment, debate, and revision, the new rules became effective in 1991 [2]. Although these rules address a broad range of general and administrative aspects of nursing home care, the process and quality of clinical care are heavily emphasized [3]. With this act, the goal of care is achieving the highest practicable level of functioning (as opposed to custodial care). The act also requires that when a resident's condition deteriorates or complications develop, documentation must show why such situations were medically unavoidable. Although many physicians, nurses, and other health professionals believe OBRA 1987 represents unnecessary governmental intrusion into the clinical care of nursing home residents, the rules were developed in response to an Institute of Medicine report [4]. When read carefully, the rules provide a sound basic paradigm for improving the process and outcomes of nursing home care. Federal and state nursing home inspectors have interpretive guidelines for these new regulations and will focus increasingly on compliance with OBRA 1987 in the next several years. One of the central elements of OBRA 1987 is the mandate for a comprehensive, reproducible assessment of all nursing home residents within 14 days of admission, including the Minimum Data Set, a standard 4-page form composed of 16 sections [5]. Selected areas of the Minimum Data Set must be updated quarterly, and the entire assessment must be updated whenever an important change in patient condition occurs (Table 2). Table 2. Areas Covered by the Minimum Data Set and Resident Assessment Protocols* On a national level, the Minimum Data Set will be used to compile standardized data on nursing home residents, as a tool for quality assurance, and eventually as a component of a prospective reimbursement system. For the individual nursing home, the Minimum Data Set provides health professionals a tool to identify clinical problems and to develop a comprehensive care plan for each resident. Selected items from the Minimum Data Set, called triggers, are designed to alert the interdisciplinary team that a particular problem or set of problems should be evaluated further. A standard set of assessment protocols (the Resident Assessment Protocols) address 18 common problems in nursing home residents [6] (Table 2). The Resident Assessment Protocols were developed by experts in geriatric medicine, gerontologic nurses, and other gerontologists through a contract with the Health Care Financing Administration. The Resident Assessment Protocols provide recommendations on critical elements of the history, physical examination, and diagnostic testing useful in identifying potentially treatable conditions that may underlie the clinical problem. Most nursing homes have not adequately developed the interdisciplinary cooperation and communication required to make full use of the Minimum Data Set and Resident Assessment Protocols, and the reliability and validity of the data recorded on the Minimum Data Set by typical nursing home staff need further study. In fact, based on our experience and on discussions with other nursing home professionals across the country, the Minimum Data Set is often viewed as just another component of the onerous paperwork required of nursing home staff. Yet, these tools can help physicians and members of the interdisciplinary team to identify important problems in their nursing home residents and to incorporate evaluations from multiple disciplines into the overall care plan. Table 2 lists the disciplines generally responsible for completing specific sections of the Minimum Data Set and the Resident Assessment Protocols. This is usually accomplished at care plan meetings, in which the interdisciplinary team establishes a comprehensive care plan for each resident and updates it quarterly. Because physicians generally do not attend these quarterly meetings, medical aspects of the Minimum Data Set, Resident Assessment Protocols, and care plan must be discussed regularly on routine rounds with the nurses, social service providers, rehabilitation therapists, and other members of the interdisciplinary team. When available, nurse practitioners and physician assistants may play an important role in communicating with the interdisciplinary team and implementing the care plan. Admission Evaluation Physicians evaluate nursing home residents within three admission contexts: direct admission from home, admission from an acute care hospital after an acute illness that requires nursing home care, and readmission of a nursing home resident after hospitalization for an acute illness. Often, the primary physician changes during these transitions. Thus, adequate and timely transfer of information critical to patient care among nursing homes, hospitals, and physicians' offices is important. Explicit policies and procedures should be developed to address information exchange, and simplified, comprehensive, and standardized documents should be used during these transfers. Table 3 lists the key elements of the physician evaluation during nursing home admission. Some elements require greater emphasis than others, depending on the circumstances of the admission. In addition, an interdisciplinary team can conduct several of the recommended assessments because they are requirements of the Minimum Data Set (see Table 2). Standardized assessment instruments besides the Minimum Data Set are available to assist in selected areas of the evaluation, including hearing [7, 8], mobility [9, 10], cognitive function [11, 12], affective status [13-15], and overall function [16, 17]. To screen for hearing impairment, hand-held audioscopes are available that provide frequency sounds at several d