Escalating Needs of Doctors in Nursing Homes

The fresh article from New England Journal of Medicine, emphasizing troublesome healthcare change in a section of nursing home patients, certainly is a worthy documentary. But, for those of us with experience in the real-world of nursing home medical care venue, the article isn’t really that surprising.

A lot of our country’s nursing home personnel have to put up with a lack of MDs on the site for assessing acute medical conditions of the patients. Moreover, several of our nursing homes usually function with the least amount of licensed nursing staff allowed, under both state and federal regulations. What’s worse is that a lot of these registered nursing staff are less experienced and less skilled, at doing acute clinical assessments of patients. Aside from that, the amount of time is being eaten up by supervisory issues, particularly about chart documentation, care plans,  and all other paper works needs that are crucial to regulatory agencies, and as a result, on top of the priorities to the establishment’s administrations. To cut the long story short, the registered nursing staffs of our nursing homes have become more and more skilled and contented with their administrative duties as opposed to their clinical responsibilities.

So, the daily clinical decision making in most of our country’s nursing homes is greatly affected by a nursing personnel that has to battle with a 4-F syndrome: fear of clinical decision making, fear of unpleasant exposure for the facility, fear of loss of work or ensuing legal consequences, and fear of regulatory surveyors.

As pointed out in The Medical Profession is Dead and the Doctor Is “Critically ill!” nursing home residents will go through more fresh complaints and still more common drops from their baseline health condition as opposed to other patient population. Ironically, the establishments we put them in to meet everyday high-maintenance requirements, are the same establishments with lowest presence of physician of every other health care areas inside the medical system. As a result, most medical evaluations of patients as well as medical interventions are done by nursing staff.

Based on a personal real-world experience, nursing home patients’ medical interventions should start with phone tag with the attending physician, grow to phone consultation with the attending physician, the move on to trailed phone order from MD to MD, and end up with the order: take to ER via ambulance. It varies per physician on the amount of calls from the nursing home required prior to the order but it should come.

What is almost always never there is the doctor in the nursing home – for assessing the patient, charting his assessment and treatment plan in the chart – and, by doing such, giving out his part with the nursing home nurse the duty for the result of the patient. So, in most nursing homes, virtually any subacute or acute change in the medical condition of a patient can create the perfect recipe for getting the patient out of their comforting and familiar environment into the madness of the ER in the nearest hospital.

Upon arriving in an already busy ER, order is badly needed and consequently, more defensive medicine is given than usual. This means that the patient will be admitted to the more expensive acute care hospital or he could go through a series of very high-tech, not to mention very expensive, imaging and tests, which most every ER doctor knows, will be viewed as replacement markers for quality care, through any regulatory surveying agencies, if the chart should be pulled out for review. With these several copies of series of tests placed on the patient’s permanent medical record, the patient can now be transported back again to the nursing home, just waiting for the next event to happen and then yet another trip back to the ER.

In any day, it is possible that several unnecessary medical interventions that are no cheap ones are being ordered in the population of our nursing homes in the name of ease and a host of several other self-serving plans that have nothing to do with the patient’s requirements or best interests.

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