The Role of the Medical Director in Long-Term Care Risk Management

In today’s long-term care environment, residents have more complex health conditions, disabilities, and cognitive impairment than in the past and require numerous and complex treatments for various conditions. In addition, public expectations regarding quality and services in long-term care have increased (Levenson). As a result of these and other factors, effective medical directors are needed now more than ever in continuing care facilities, including nursing homes, home health organizations, hospice organizations, and continuing care retirement communities.

A medical director is a licensed physician who oversees some areas of clinical care and services for a healthcare organization (Levenson). While most healthcare settings have physician oversight of some services and operations, “medical director” is the term most often used for this role outside a hospital. In short, medical directors serve as both clinicians and managers in long-term care facilities.

In the 1970s, skilled nursing facilities were required by Medicare regulations to have a physician serving as medical director, and the Omnibus Budget and Reconciliation Act of 1987 expanded the regulation to include nursing facilities. Even after the change in federal regulations, however, interpretation of the extent to which medical directors should be involved in facility operations varied widely. In 2003, a survey conducted by the U.S. Department of Health and Human Services’ Office of Inspector General found that most medical directors visited the nursing facilities they supported only once per week and nearly 90% spent less than eight hours per week at the facilities. In addition, 70% of the 119 medical directors that responded to the survey reported that they dedicated 10% or less of their overall medical practice to their medical director role. (OIG)

In response to these issues, the Centers for Medicare & Medicaid Services (CMS) issued revised guidance in 2005 that expanded the roles and responsibilities of medical directors; however, challenges to effective medical direction still remain. For example, medical directors often have other responsibilities (e.g., running their own private practice, serving as an attending physician, serving as medical director at multiple facilities) and may receive low compensation for their services as medical director, creating difficulties in meeting the complex and demanding care needs of older adults in long-term care. Hesitation among professional liability insurance companies to cover physicians who work in long-term care is also an issue. Despite these challenges, facilities can have significantly involved and effective medical directors and...