Perspectives of Physicians with Experience in Nursing Home Care on Telehealth Use During the COVID-19 Public Health Emergency.

BACKGROUND: Despite expanded access to telehealth services for Medicare beneficiaries in nursing homes (NHs) during the COVID-19 public health emergency, information on physicians' perspectives on the feasibility and challenges of telehealth provision for NH residents is lacking. OBJECTIVE: To examine physicians' perspectives on the appropriateness and challenges of providing telehealth in NHs. PARTICIPANTS: Medical directors or attending physicians in NHs. APPROACH: We conducted 35 semistructured interviews with members of the American Medical Directors Association from January 18 through January 29, 2021. Outcomes of the thematic analysis reflected perspectives of physicians experienced in NH care on telehealth use. MAIN MEASURES: The extent to which participants used telehealth in NHs, the perceived value of telehealth for NH residents, and barriers to telehealth provision. KEY RESULTS: Participants included 7 (20.0%) internists, 8 (22.9%) family physicians, and 18 (51.4%) geriatricians. Five common themes emerged: (1) direct care is needed to adequately care for residents in NHs; (2) telehealth may allow physicians to reach NH residents more flexibly during offsite hours and other scenarios when physicians cannot easily reach patients; (3) NH staff and other organizational resources are critical to the success of telehealth, but staff time is a major barrier to telehealth provision; (4) appropriateness of telehealth in NHs may be limited to certain resident populations and/or services; (5) conflicting views about whether telehealth use will be sustained over time in NHs. Subthemes included the role of resident-physician relationships in facilitating telehealth and the appropriateness of telehealth for residents with cognitive impairment. CONCLUSIONS: Participants had mixed views on the effectiveness of telehealth in NHs. Staff resources to facilitate telehealth and the limitations of telehealth for NH residents were the most raised issues. These findings suggest that physicians in NHs may not view telehealth as a suitable substitute for most in-person services.

Defining the Role and Value of Physicians Who Primarily Practice in Nursing Homes: Perspectives of Nursing Home Physicians.

OBJECTIVE: To identify the perceptions of physicians with expertise in nursing home care on the value of physicians who primarily practice in nursing homes, often referred to as "SNFists," with the goal of enriching our understanding of specialization in nursing home care. DESIGN: Qualitative analysis of semistructured interviews. SETTING AND PARTICIPANTS: Virtual interviews conducted January 18-29, 2021. Participants included 35 physicians across the United States, who currently or previously served as medical directors or attending physicians in nursing homes. METHODS: Interviews were conducted virtually on Zoom and professionally transcribed. Outcomes were themes resulting from thematic analysis. RESULTS: Participants had a mean 19.5 (SD = 11.3) years of experience working in nursing homes; 17 (48.6%) were female; the most common medical specializations were geriatrics (18; 51.4%), family medicine (8; 22.9%), internal medicine (7; 20.0%), physiatry (1; 2.9%), and pulmonology (1; 2.9%). Ten (28.6%) participants were SNFists. We identified 6 themes emphasized by participants: (1) An unclear definition and loose qualifications for SNFists may affect the quality of care; (2) Specific competencies are needed to be a "good SNFist"; (3) SNFists are distinguished by their unique practice approach and often provide services that are unbillable or underreimbursed; (4) SNFists achieve better outcomes, but opinions varied on performance measures; (5) SNFists may contribute to discontinuity of care; (6) SNFists remained in nursing homes during the COVID-19 pandemic. CONCLUSIONS AND IMPLICATIONS: There is a strong consensus among physicians with expertise in nursing home care that SNFists provide higher quality care for residents than other physicians. However, a uniform definition of a SNFist based on competencies in addition to standardized performance measures are needed. Unbillable and underreimbursed services create disincentives to physicians becoming SNFists. Policy makers may consider modifying Medicare reimbursements to incentivize more physicians to specialize in nursing home care.

An international survey of nursing homes.

This article reports the results of an exploratory survey of nursing home care in 30 countries. Most countries used either a social or nursing home model, with a physician model being less common. Resident Assessment Instruments were used in only 35% of countries. Physician visits to the nursing home occurred in 37%. All but 2 countries used advanced practice nurses. Medication use was high, with 82% of countries reporting residents taking 6 or more medicines a day.

An international perspective on long term care: focus on nursing homes.

The world is facing an unprecedented growth of older adults, a sizable number of whom will require nursing home services. Although community-based care delivery systems strive to keep most of those in need at home, nursing homes are increasingly accommodating a more frail population that is straining available resources. This article focuses on common themes evident around the world regarding long-term care of the elderly. Issues related to service delivery, financing, and quality are highlighted.

Academic career development in geriatric fellowship training.

Career development is rarely formalized in the curricula of geriatric fellowship programs, and the training of new generations of academic leaders is challenging in the 1 year of fellowship training. To effectively prepare fellows for academic leadership, the University of Rochester's Division of Geriatrics, in collaboration with the Warner School of Graduate Education, created a yearlong course to achieve excellence in teaching and career development during the 1-year geriatric fellowship. Nine interdisciplinary geriatric medicine, dentistry, and psychiatry fellows completed the course in its initial year (2005/06). As participants, fellows gained the knowledge and experience to successfully develop and implement educational initiatives in various formats. Fellows acquired teaching and leadership skills necessary to succeed as clinician-educators in an academic setting and to communicate effectively with patients, families, and colleagues. Fellows completed a series of individual and group education projects, including academic portfolio development, curriculum vitae revision, abstract submission and poster presentation at national meetings, lay lecture series development, and geriatric grand rounds presentation. One hundred percent of fellows reported that the course positively affected their career development, with six of nine fellows choosing academic careers. The course provided opportunities to teach and assess all six of the Accreditation Council of Graduate Medical Education core competencies. This academic career development course was intended to prepare geriatric fellows as the next generation of academic leaders as clinician-teacher-scholars. It could set a new standard for academic development during fellowship training and provide a model for national dissemination in other geriatric and subspecialty fellowship programs.

Application of assessing care of vulnerable elders-3 quality indicators to patients with advanced dementia and poor prognosis.

OBJECTIVES: To use a formal decision-making strategy to reach clinically appropriate, internally consistent decisions on the application of quality indicators (QIs) to vulnerable elders (VEs) with advanced dementia (AD) or poor prognosis (PP). DESIGN: Using a conceptual model that classifies QIs principally by aim and burden of the care process, 12 clinical experts rated whether each Assessing Care of Vulnerable Elders-3 (ACOVE-3) QI should be applied in evaluating quality of care for older persons with AD or PP. QI exclusions were assessed for each of the 26 conditions and by whether these conditions were mainly medical (e.g., diabetes mellitus), geriatric (e.g., falls), or crosscutting processes of care (e.g., pain management). QI exclusions were also identified for older persons who decided against hospitalization or surgery. RESULTS: Of 392 ACOVE-3 QIs, 140 (36%) were excluded for patients with AD and 135 (34%) for patients with PP; 57% of QIs focusing on medical conditions were excluded from patients with AD and 53% from patients with PP, whereas only 20% of QIs for geriatric conditions were excluded from AD and 15% from PP. All QIs with care processes judged to carry a heavy burden were excluded; 86% of moderate-burden QIs were excluded from AD and 92% from PP. All QIs aimed at long-term goals were excluded; 83% of intermediate-term goal QIs were excluded from AD and 98% from PP. Individuals holding a preference to forgo hospitalization or surgery would be excluded from 7% of potentially applicable QIs. CONCLUSION: Measurement of quality of care for VEs with AD, PP, and less-aggressive care preferences should include only a subset of the ACOVE-3 QIs, largely those whose burden is light and whose goal is continuity or short-term improvement or prevention.

Strengthening the fellowship training experience: findings from a national survey of fellowship trained geriatricians 1990-1998.

Geriatric fellowship training has significantly advanced in the past 2 decades in number, organization, and accreditation of formal fellowship programs. A recent survey examined career decision-making, fellowship training, and current professional activities of fellowship trained geriatricians. This paper focuses upon further desired fellowship training identified by these individuals. The responses reflect skills relevant to four aspects of professional performance: administration, management, clinical geriatrics, research, and education. More than half of the respondents documented the need for increased training in administration, including long-term care medical directorship and Medicare/managed care. Regarding clinical training, 66% recommended additional subspecialty training, particularly in psychiatry, neurology, rehabilitation, and hospice/palliative care. Seventeen percent identified a need for training in research methodology, grant writing, and mentorship. Some 6% indicated a need for further training in education, citing teaching skills and program/faculty development. This article provides examples of opportunities to strengthen each of the four defined areas, including formal training in medical administration by the American Medical Director's Association, model strategies for incorporating subspecialties, hospice/palliative care, programs to pursue graduate level training in research at many universities, and faculty development programs such as those offered by Harvard and Stanford. Accredited geriatric fellowship programs as well as fellows should recognize potential gaps in training, and make available opportunities to strengthen these areas critical to preparing for future careers in geriatric medicine.

The current state of geriatric medicine: a national survey of fellowship-trained geriatricians, 1990 to 1998.

The rapid growth of the older population has focused national attention on the need for physicians trained in geriatric medicine. To gain insight into the evolving status of the field, with particular focus on career decision-making and academic career development of trainees, we conducted a survey of physicians recently completing geriatric fellowships. The 107 accredited extant geriatric fellowship programs in the United States and Puerto Rico were contacted to identify trainees from 1990 to 1998. A mailed survey addressed relevant career development and training issues. Four hundred ninety out of 787 (62%) physicians responded; 20% completed 1 year and 80% 2 or more years of training. Half made the decision to pursue a career in geriatrics during residency, 27% decided before/during medical school, and a mentor influenced 48%. Currently, 80% have a Certificate of Added Qualifications in geriatric medicine, 69% hold academic appointments, 78% teach, 39% participate in research, and 44% author publications. Most are doing predominantly clinical work in multiple settings. Further analysis of the 1996-to-1998 cohort revealed that those completing fellowships of 2 or more years are more likely to identify all geriatrics as their professional focus, conduct and author research, work with multidisciplinary teams, and participate in professional geriatric societies. This national survey documents career decision-making and the academic and clinical profiles of physicians completing geriatric fellowship training in the past decade. Longer fellowship training is associated with academic career development. Although there is a national need to train clinical geriatricians, the additional need to train and fund future geriatric academic leaders requires increased attention.