The Role of Medical Director in Issues of Pain Control

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The Role of Medical Director in Issues of Pain
Control

• Frederick N Rowland, PhD, MD, CMD

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Objectives

• Review the current regulatory mandate for a
  medical director
• Review the current AMDA roles and
  responsibilities of medical directors
• Review responsibilities of medical director
  pertinent to issues of pain control

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Regulations on Medical Direction

• 1974 Requirement for SNF Medical Director per
  Medicare regulations
• 1987 OBRA requirement for all NFs to have
  Medical Director
• 2005 F 501 rewrite

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Medical Director F 501

• Facility must designate a physician who is
  responsible for implementation of resident care
  policies and overall coordination of medical care

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Resident Care Policies

• Admissions
• Transfers
• Infection Control
• Restraints
• Physician privileges
• Non-physician health workers

• Accidents and Incidents
• Ancillary services
• Medication use
• Release of information
• Overall quality

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Overall coordination of care

• Oversight supervision of physicians
• Ensure care is adequate

• Assure there is consultant support
• Evaluate reports of inadequate care take
  actions to attempt to correct deficiencies

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AMDA roles and responsibilities of the Medical
Director

• Physician Leadership
• Patient Care - Clinical Leadership
• Quality of Care
• Education, Information, and Communication

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Physician Leadership

• Help ensure that patients have appropriate
  physician and health care practitioner coverage
• Assist in the development of a process for
  reviewing physician and health care practitioner
  credentials
• Provide guidance for physician performance
  expectations

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Physician Leadership

• Help ensure that a system is in place to monitor
  performance of health care practitioners
• Facilitate feedback to physicians and other
  health care practitioners on performance and
  practice

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Physician Leadership - Pain

• Attempt to assure that available caregivers are
  knowledgeable and skilled in the provision of
  pain control
• Help the facility develop a system of monitoring
  performance in pain control
• Provide feedback to providers on the pain
  treatment they are providing

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Clinical Leadership

• Participate in administrative decision-making and
  development of policies and procedures related to
  patient care
• Help develop, approve, and implement specific
  clinical practices into policies and procedures,
  including areas required by law and regulation

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Clinical Leadership

• Review, respond to and participate in federal,
  state, local and other external surveys and
  inspections
• Help review policies and procedures concerning -
  protection of patients rights advance care
  planning and other ethical issues

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Clinical Leadership - Pain

• Educate self about the clinical treatment of pain
• Become knowledgeable of the regulations and
  expectations as they relate to pain control
• Assist in the development of policies that
  address the evaluation and treatment of Pain

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Guidelines

• AMDA Clinical Practice Guidelines
• The AGS Guideline on the Management of Persistent
  Pain in Older Persons
• American Pain Society Guidelines
• AAHPM training series on palliative care
• AMA EPEC training program

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Regulations

• CMS regulations
• CMS Quality Initiative
• JCAHO initiatives in pain control

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Policies

• Need to develop policies which address the main
  points of Pain control issues
• Recognition of pain
• Evaluation or assessment of pain
• Treatment
• Monitoring

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Quality of Care

• Help establish methods for reviewing quality and
  appropriateness of clinical care, and provide
  feedback
• Participate in the facilitys quality improvement
  process
• Advise on infection control issues and approve
  specific infection control policies and procedures

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Quality of Care

• Help the facility provide a safe and caring
  environment
• Help promote employee health and safety
• Assist in the development and implementation of
  employee health policies and programs

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Quality Pain Control

• Establish expected goals in pain control
• Policies should include descriptions of elements
  of adequate assessment and quantification of
  pain, and who is expected to do the assessments
• Design of forms to track symptoms

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Quality Pain Control

• Front line providers should have knowledge base
  of good pain control practice
• Frequency of assessment
• When to contact provider
• When to call for help of Supervisor or Medical
  Director

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Quality Pain Control

• System of quality review of patients with pain
• Review with Quality Committee and leadership of
  facility (especially Medical Director and
  Director of Nursing)

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Education, Information, Communication

• Promote a learning culture
• Assist in the development of a medical
  information and communication system
• Represent the facility to the professional and
  lay community
• Help establish appropriate relationships with
  other health care organizations

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Education, Information, Communication

• Maintain knowledge of the changing social,
  regulatory, and economic factors that affect
  health services to long term care patients
• Maintain expertise in the clinical care of long
  term care patients

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Education

• Know that the Medical Director is usually the
  local expert in the care of the long term care
  patient
• Responsibility to help educate the staff
• One provider at a time during ward rounds and
  clinical care
• Specific educational programs for staff nurses

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Topics with which the Medical Director should be
familiar

• State and Federal regulations governing long term
  care
• OBRA 1987
• Minimum Data Set
• Relative Utilization Groups and PPS
• Quality Indicators and CHSRA reports

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Topics with which the Medical Director should be
familiar Resident Assessment Protocols

• Delirium
• Dementia
• Visual function
• Communication
• ADL function
• Urinary incontinence
• Psychosocial
• Mood State
• Behavior Problems

• Activities
• Falls
• Nutritional status
• Feeding tubes
• Dehydration
• Dental care
• Pressure ulcers
• Psychotropic drugs
• Physical restraints

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Resources for the Medical Director

• AMDA at www.amda.com
• Journal of the American Medical Directors
  Association (JAMDA)
• AGS at americangeriatrics.org
• Journal of the American Geriatrics Society (JAGS)
• Annals of Long Term Care (published by the
  American Geriatrics Society)

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Resource for Medical Director

• AMDA Clinical Practice Guideline on Chronic Pain
  Management
• AMDA education programs for the Hospice Medical
  Director
• www.cms.hhs.gov
• www.aahpm.org

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Books on Medical Direction

• Medical Direction in the Nursing Home by James
  Pattee and Orlo Otteson
• Medical Direction in Long Term Care by Steven
  Levenson
• Medical Care in the Nursing Home by Joseph
  Ouslander

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Case of AG

• 63 year old with advanced ovarian cancer
• s/p debulking and multiple attempts at
  chemotherapy to which the tumor no longer is
  responding
• Admitted for care following last round of
  chemotherapy
• Tense ascites and abdominal pain

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AG

• Nurses assessing pain, and treatment ordered by
  patients primary physician
• Monitored by Medical Director via weekly reviews
  of all post-acute patients
• Initial regimen not adequate, and message passed
  to attending by nurses and supervisors

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AG

• Patient remained in pain
• Medical Director intervened with MD
• Patient still remained on inadequate pain control
  regimen
• Medical Director directly intervenes in care to
  provide patient adequate control of symptoms

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Questions?