JAMDA 14 (2013) 157e160

JAMDA

journal homepage: www.jamda.com

Special Article

Developing Future Nursing Home Medical Directors: A Curriculum for GeriatricMedicine Fellows

Masaya Higuchi MD, Aida Wen MD*, Kamal Masaki MDThe John A. Hartford Foundation Center of Excellence in Geriatrics, Department of Geriatric Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, HI

Keywords:Medical directornursing homecurriculumgeriatric medicine fellow

None of the authors reports conflicts of interest w* Address correspondence to Aida Wen, MD, John

University of Hawaii, Department of Geriatric Medicin9, Honolulu, HI 96817.

E-mail address: aidawen@hawaiiantel.net (A. Wen

1525-8610/$ - see front matter Published by Elsevierhttp://dx.doi.org/10.1016/j.jamda.2012.10.008

a b s t r a c t

Long term care facilities are important sites of care for elderly adults. Despite a growing need and interestin medical direction in nursing homes, there have been limited educational opportunities in this area forgeriatric medicine fellows. This article describes a novel medical director’s curriculum for first-yeargeriatric medicine fellows to prepare them for the role of nursing home medical director. This novelcurriculum has been integrated into the Department of Geriatric Medicine’s Fellowship training programat the John A. Burns School of Medicine, University of Hawaii. The curriculum consists of seven seminarsthat have been integrated into the didactic sessions during the first year of fellowship. Core content areasinclude: (1) roles and responsibilities of the medical director, (2) infection control, (3) physician docu-mentation, (4) federal regulations and state surveys, (5) quality improvement, (6) culture change innursing homes, and (7) transitions in care. All topics were discussed using the framework described bythe American Medical Directors Association’s position statement on the roles and responsibilities of thenursing home medical director. To our knowledge, this is the first curriculum in the medical literaturethat is designed to prepare geriatric medicine fellows for roles as medical directors in nursing homes.

Published by Elsevier Inc. on behalf of the American Medical Directors Association, Inc.

It is not uncommon for a recently graduated geriatric medicinefellow to be asked to take on the role of a medical director ata community nursing home. The fellow will be asked to attendmonthly meetings for input regarding multiple aspects of nursinghome care. However, although the geriatric medicine fellowshiptraining may adequately prepare the fellow for the clinical care of frailelders in nursing homes, the physician may actually be quite unpre-pared to address regulatory, safety, quality, and administrativeconcerns. This article describes an innovative curriculum for first-yeargeriatric medicine fellows to help meet this need.

Background

Long term care (LTC) facilities, also known as nursing homes, areimportant sites of care for older persons within a complex medicalsystem. It is estimated that about 42% of elder adults who live to theage of 70 will experience care in a nursing home at some point intheir life.1 Since 1974, when Medicare regulation required skillednursing facilities to have a medical director, there has been a growing

ith commercial enterprises.A. Burns School of Medicine,e, 347 N. Kuakini Street HPM-

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Inc. on behalf of the American Me

need and interest in medical direction. Despite the increasing needfor developing medical directors at LTC facilities, limited opportuni-ties are available for fellows to gain competency in this area. Althoughthe Accreditation Council for Graduate Medical Education accredita-tion requires teaching in the competency of systems-based learning,there are minimal requirements for education specifically aboutnursing home medical direction, despite this being a common careerpath for geriatric medicine fellows after training.2 There are signifi-cant differences in the knowledge and skill sets necessary for beingan excellent medical director compared with the skills required asa practicing physician.3 Therefore, many practitioners and fellowshipgraduates have found themselves unprepared for medical directing atthese facilities.

Currently, the geriatric medicine fellows at the University ofHawaii acquire their clinical skills at a variety of settings. Their LTCexperience includes 3 months in community nursing homes and3 months at the Community Living Center of the Department ofVeterans Affairs. Fellows are also responsible for providing year-longcontinuity care for a small number of residents at an assigned nursinghome. The fellows are responsible for direct patient care and tele-phone coverage at their nursing homes. Attending physicians areassigned to each nursing home to supervise the fellows’ clinicalactivities. For medical directorship training, the fellows have theopportunity to shadow a medical director at various communitynursing homes for one half day per month for 3 months, during the

dical Directors Association, Inc.

Table 1Needs Assessment: A Structured Interview for Geriatric Medicine Fellows

Structured Questions Answers

1. If your knowledge or performance inthis area is less than ideal, what doyou think are some of the reasons?

“It is difficult to stay updated, and tocatch up on new regulations andpolicy changes, as well as insurancecoverage.”

“I don’t knowwhere to go or whom toask for information and resources.”“There is a lack of structuredlearning opportunities.”

M. Higuchi et al. / JAMDA 14 (2013) 157e160158

1-year fellowship period. Depending on the issues at hand, thefellows may attend quality-assurance meetings or review incidentreports with the medical director.

To supplement their clinical experience, our fellowship programhas developed a curriculum called “Primer on Medical Directorship inthe Nursing Home” over the last 5 years to better prepare fellows fortheir future roles and responsibilities as a medical director at LTCfacilities. The purpose of this article is to describe this novel curric-ulum for first-year geriatric medicine fellows at the University ofHawaii.

“We don’t have enough exposure tolearning about the medicaldirector’s role in LTC facility.”

“We have a lack of exposure tomedical director role models.”

2.What might some of the solutions be? “I want to be able to see the bigpicture first.”

“I want to knowwhy it is important tome and other physicians.”

“I need to have one person/source topull together, digest, andsummarize the information for busyphysicians/fellows.”

“A formal curriculum about theexpectations and responsibilities ofthe medical director would behelpful.”

“I’d like to attend a conference, forexample, American MedicalDirectors Association.”

“I wish I had the opportunity to seewhat medical directors are doing intheir role at an LTC facility.”

“I want to shadow a medical directorduring rounds at an LTC facility.”

3. How would you enjoy learning aboutmedical directorship?

“Lectures should start at the level fordummies.”

“I would like a more case-basedlearning approach rather thanlecture style or teaching ofconcepts.”

“I would like to learn by a problem-based learning approach with realcases encountered by medicaldirectors.”

“I am interested in the realities of lifeework balance and scheduleflexibility. What does a medicaldirector’s schedule look like?”

Needs Assessment

Before revising and updating this year’s version of the curriculum,we performed a needs assessment with four geriatric medicinefellows at the University of Hawaii who had completed their first yearof fellowship during the academic year 2010e2011. No previousneeds assessments had been performed. This needs assessment hadboth quantitative and qualitative components for the first time sincecurriculum development. The purpose of the needs assessment wasto guide curricular revisions. The quantitative survey demonstratedthat geriatric medicine fellows understood the importance of themedical directorship role (Likert scale: mean score ¼ 5; 1 ¼ stronglydisagree and 5 ¼ strongly agree), but felt a lower level of prepared-ness in fulfilling these responsibilities (mean score ¼ 3.25; 1 ¼strongly disagree and 5 ¼ strongly agree). During the structuredinterview, the fellow was given the opportunity to explain why he orshe felt that his or her knowledge or performance in this area was lessthan ideal.

The results of the structured interview are summarized in Table 1.The fellows said that there was insufficient exposure to medicaldirector role models, and that they needed more specific informationregarding important regulatory and legal aspects of nursing homecare. They felt that having a formal curriculum describing theexpectations and responsibilities, including a summary of the basics,and an understanding of the “big picture”would help. They expresseda desire to have the curriculum describe common scenarios, provideopportunities for problem-based learning, and include daily practicalaspects of medical direction (eg, tips on schedules, balancing ofresponsibilities). They also wanted the curriculum to review boardexamination type questions.

“I would like time for Q&A, especiallycovering topics that appear on thegeriatric board exam.”

LTC, long term care; Q&A, questions and answers.

Curriculum

Description

The novel curriculum for medical directorship (“Primer onMedical Directorship in the Nursing Home”) was developed bya faculty member in the Department of Geriatric Medicine at the JohnA. Burns School of Medicine, University of Hawaii in the 2006e2007academic year. The curriculum has been revised and updated annu-ally. The medical director curriculumwas originally in a more didacticor lecture format. However, based on the 2010e2011 needs assess-ment, the curriculum underwent significant revisions with greateremphasis on problem-based learning and application. This seminarseries is part of the mandatory geriatric medicine fellowship’sdidactic curriculum in the first year of training. Seven 1-hour sessionsare delivered over a 3-month period. The seminar series is scheduledin the middle of the first year of the fellowship. Scheduling thiscurriculum in the middle of the academic year ensures that fellowsalready have sufficient clinical experience, a strong foundation innursing home care, and an appreciation of the role of LTC facilitieswithin the complex medical care system.

Specific Learning Objectives of the Curriculum

The primary goal of the curriculum is to equip fellows with skillsand knowledge that are uniquely applied to the role of medicaldirection in nursing homes. Specific learning objectives include: (1)The fellow will be able to describe the roles of the medical director ina LTC facility according to American Medical Directors Association(AMDA)’s position statement; (2) the fellow should be comfortableapplying what he or she has learned in fulfilling the responsibilities ofthe medical director role; and (3) the fellowwill understand the valueof teamwork as a critical aspect in effective medical direction.

Curriculum Content and Instructional Methods

The curriculum was based on AMDA’s description of the roles andresponsibilities of the medical director as outlined in their positionstatement and was delivered by the geriatrics faculty member who is

M. Higuchi et al. / JAMDA 14 (2013) 157e160 159

a certified medical director. These roles and responsibilities weredivided into four categories: (1) physician leadership; (2) patientcareeclinical leadership; (3) quality of care; and (4) education,information, and communication.4 All topics were taught using thisframework, with an emphasis on understanding the importance ofleadership, partnership, and culture change in fulfilling theseresponsibilities.3 Figure 1 illustrates this framework and providesgeneral examples of each. Fellows are guided through this frameworkin developing strategies to address issues specific to each topic.Throughout these sessions, we ask the fellows to describe examplesof cases they have seen during their clinical rotations in the LTCfacilities. This leads to richer learning and application during thedidactic sessions. We conclude with a summary of the key points, andemphasize leadership, partnership, and culture change. The coretopics for these seven sessions were: (1) roles and responsibilities ofthe medical director, (2) infection control, (3) physician documenta-tion, (4) federal regulations and state surveys, (5) quality improve-ment, (6) culture change in nursing homes, and (7) transitions in care.

Each session also had a reference and resource list to providefellows with access to original information and to further theirlearning opportunities. Because lifelong learning is an important partof medical education and medical direction, we also provided manyonline resources and Web sites. We believed this was particularlyimportant as nursing home care continues to change and evolve. Allmaterials were included in a handbook that the fellows could keepfor future reference.

Session 1 begins with an overview of AMDA’s revised positionstatement. During this session, the medical directorship framework isintroduced to enable the fellows to use a systematic approach towardproblem solving as a medical director. This is followed by discussing

Fig. 1. Example of medical director’s roles and responsibilities regarding infectioncontrol. IDT, interdisciplinary team.

a reflective article outlining the three components that are necessaryfor becoming a successful medical director and effecting lastingchange: leadership, partnership, and culture change.3 We emphasizethis approach as an important strategy in the successful transitionfrom physician to medical director.

Session 2 introduces the medical director’s role in infection controland managing infection outbreaks in the LTC facility. The mainteaching points emphasize the unique character of infection control,multidrug-resistant organisms, and health careeassociated infectionsin LTC facilities. The latter part of the session introduces the approachto infection outbreak in LTC facilities, including seasonal influenza,scabies, norovirus, and tuberculosis.

Session 3 introduces the basic regulatory requirements of physi-cian documentation in LTC facilities, inappropriate documentation,and ways that documentation can limit litigation. In a frail populationthat is frequently declining in health, the potential for litigation ishigh. The case discussion focuses on how person-centered care andgood documentation can limit litigation and minimize survey defi-ciencies from the perspective of medical director. Fellows discussstrategies they can use to help facilities improve their documentation.

Session 4 focuses on federal regulations and the state surveyprocess for LTC facilities. This session also introduces fellows to themedical director requirements of state surveys, specifically describingthe two main expectations: (1) The facility must have a licensedphysician designated to serve as a medical director, and (2) themedical director must coordinate medical care and provide clinicalguidance and oversight of the facility’s resident care policies.5

Session 5 discusses quality improvement in nursing homes. Thissession begins with an introduction to the Minimum Data Set (MDS),which is a standardized, comprehensive assessment system that ismandatory in all Medicare/Medicaid facilities. The data collectedusing this instrument have ramifications in quality assurance andreimbursement. Fellows learn how the MDS is used by nursingfacilities and discuss ways to use the MDS for quality-improvementinitiatives during the monthly quality-assurance meetings held atall LTC facilities. We also provide online resources for them to drawon as they help the facility with quality improvement efforts.

Session 6 describes the culture change movement in LTC. In thepast, nursing home care was more nursing centered and based onrehabilitation, but it is now evolving to become more person-centered and focused on quality of life. Discussion is generatedfrom videos, case examples, and articles regarding how the concept ofperson-directed care can be achieved.

Session 7 focuses on transitions in care. Nursing home and hospitaltransfers can be potentially harmful for elders. We use sample casescenarios to trigger discussions. To improve transitions and preventavoidable hospital transfers, the fellows realize that the facility mustconsider systems-based strategies. Various tools used by othernursing homes are introduced.6

Measuring Outcomes and Curriculum Evaluation

This curriculum is being evaluated in two ways. An evaluation ofknowledge, attitudes, skills, and abilities was conducted before andafter this educational series to assess efficacy of the curriculum. Inaddition, we conducted a structured individual feedback interviewwith each fellow who completed the curriculum.

Discussion

Nursing homes residents are among the sickest and frailestchronically ill patients in the medical system. Physicians who practicein this setting must have a sound knowledge of general and geriatricmedicine. However, as Dr. Steven A. Levenson7 pointed out in his first

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book for medical directors, Medical Direction in Long-Term Care,physician input into improving the operation and management of theLTC system is also essential. Defining the medical director’s role basedon nursing home needs was an important first step.8 The concept andthe role of the nursing home medical director have continued toevolve since 1974, when it became a federal requirement for allnursing homes to have a medical director.9e12 These concepts wererecognized by AMDA and served as a foundation for the reviseddelineation of medical director duties that was published as a posi-tion statement in 2003 by AMDA.4 The concepts presented in theAMDA position statement were considered by the Centers for Medi-care & Medicaid Services when they revised the Surveyor Guidancerelated to F-Tag 501 in 2005.5

To meet the growing need for effective medical directors, AMDAbegan offering ongoing educational opportunities with the goal ofequipping physicians for this role. AMDA then developed the CertifiedMedical Director program to equip and recognize the dual clinical andmanagerial roles of the medical director. Not surprisingly, multiplestudies have demonstrated an improvement in the quality of care inthe nursing homes managed by certified medical directors.13,14 Since2001, AMDA created a “Futures Program” that provides scholarshipsand a special educational track for a limited number of interestedresidents and fellows to attend the AMDA annual conference.However, many other geriatric medicine fellows do not have theopportunity or resources needed to prepare them for this role. Ourcurriculum provides them with the basic foundation and framework.It is particularly important to prepare our current geriatric medicinefellows for future roles as medical directors in nursing homes becauseof the significant and rapid changes in LTC. These include highercomplexity of patients, changes in demographics, reimbursementimplications arising from health care reform, requirements for qualityimprovement, legal concerns, and the shift for more person-centeredcare in LTC. In addition, there is increased accountability and higherexpectations for medical directors to have an important role in theoversight of these issues.

To our knowledge, this is the first curriculum described in theliterature that is designed to prepare geriatric medicine fellows forthe role of medical director in nursing homes. This curriculum isunique and has strengths in many aspects. First, the curriculumformat was redesigned to mirror AMDA’s position statementregarding the roles and responsibilities of the medical director in LTCfacilities. We also increased the emphasis on culture change and theinterdisciplinary approach. Second, the content covered in thecurriculum includes common issues that often need to be addressedby the medical director. It also addresses the need for fellows tounderstand the “big picture” context, as well as learn about the“basics” of nursing home operations. Third, the instructional methodsused in this curriculum provide more case- based, interactive learningand application, and the opportunity to share experiences. Ampletime is provided for questions, answers, and discussion to reviewboard examination type questions.

We also recognize some limitations of our curriculum. Accredi-tation Council for Graduate Medical Educationeaccredited geriatricmedicine fellowship programs have other requirements, and onlya limited amount of time can be spent on medical direction in LTC.Therefore, the curriculum has to be taught in a time-efficient manner.Second, fellows have many diverse interests within the broad field ofgeriatric medicine, and specific interest in medical directorship maybe limited. However, our geriatric faculty felt that for fellows to be

able to take on a leadership role in transforming medical care andquality of life in LTC facilities in the future, it was necessary to providebasic education, expectations, and resources in medical directorship.Finally, this curriculum does not provide the hands-on role modelingdesired by fellows, but it is complemented by opportunities forfellows to shadow a faculty medical director at various facilities. Thiscurriculum provides basic knowledge in LTC medical direction andmakes the shadowing experience much more meaningful.

Future Directions

We have received extremely positive feedback from the fellows sofar, and this curriculum seems to meet the needs of both the fellowsand the LTC facilities. However, we are in the process of conductinga full analysis of the quantitative and qualitative evaluations of thisunique curriculum. Based on the analysis, we plan to revise, update,and modify this curriculum annually to optimize its effectiveness. Weplan to share our findings and lessons learned through publication ina peer-reviewed journal. One year after the fellows graduate, we planto conduct a survey that will include questions about whether theyeventually pursued a career in medical directorship, pursued CertifiedMedical Director certification, and were able to apply any of theconcepts and knowledge learned during fellowship. In addition, wemay also consider performing needs assessments for other potentiallearners such as internal medicine and family medicine residents. Wealso plan to share this curriculum with others by including it ina medical education Web site where it will be available to othertraining programs on a national level.

References

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3. Ferrini R. Making the successful transition from Physician to Medical Director.Ann Long-Term Care; 2009:25e26.

4. American Medical Directors Association. Roles and responsibilities of themedical director in the nursing home: Position statement A03. J Am Med DirAssoc 2005;6:411e412.

5. State Operations Manual: Appendix PP - Guidance to surveyors for long termcare facilities (pp. 623e639; F501 S 483.75(i) Medical Director). 2012. Avail-able at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf. Accessed November 9, 2012.

6. Ouslander JG, Lamb G, Tappen R, et al. Interventions to reduce hospitalizationsfrom nursing homes: Evaluation of the INTERACT II collaborative qualityimprovement project. J Am Geriatr Soc 2011;59:745e753.

7. Levenson S, editor. Medical Direction in Long-Term Care. Owing Mills, MD:National Health Publishing; 1988.

8. Pattee JJ. Update on the medical director concept. Am Fam Physician 1983;28:129e133.

9. Dimant J. The role of the consultant in long-term care facilities. J Am Med DirAssoc 2003;4:274e280.

10. Katz PR. A silver lining. J Am Med Dir Assoc 2003;4:222.11. Levenson SA. The nursing home medical director: A new era. J Long Term Care

Adm 1989;17:6e9.12. Pattee JJ. History and evolution of the role of the medical director. Clin Geriatr

Med 1995;11:331e341.13. Boyce BF, Bob H, Levenson SA. The preliminary impact of Maryland’s medical

director and attending physician regulations. J Am Med Dir Assoc 2003;4:157e163.

14. Rowland FN, Cowles M, Dickstein C, Katz PR. Impact of medical directorcertification on nursing home quality of care. J Am Med Dir Assoc 2009;10:431e435.