Viewpoint of Subacute Care
There is an increasing movement to provide intensive medical
and rehabilitative services in the skilled nursing setting. Over the past
ten years, this service delivery extension became an identity:
subacute care. Subacute care is an industry term. Since there are no
distinct bed licensure or reimbursement systems in place, subacute is
frequently misunderstood. In the rehabilitation model, subacute is
becoming a viable competitor.
For the medically complex patient, subacute has become the natural
continuum of service delivery. Historically, as far back as 1981,
the staff of the Office of Research at HCFA argued that most stroke
rehabilitation patients should be treated in subacute rehabilitation
programs rather than in community hospitals.
However, it was the managed care payor who established the subacute
provider in the healthcare industry, not the government.
With the recent exponential growth of subacute care, especially within
the skilled nursing facilities, there are many opportunities for
physicians to assume a medical director's position. A physician who
chooses a medical director's role faces both administrative and clinical
challenges. In addition to providing individual patient care, the role of
the medical director also demands that he/she serve as a liaison between
the administration, the governing body, and the entire professional staff.
The medical director's duties include participating in policy making
and long-range planning. The director should supervise the development of
guidelines, rules and regulations for attending physicians, consultants,
dentists, and allied health professionals.
The director should establish standards of medical practice and be able
to supervise and coordinate medical care by peer review. The director
should also be available to provide emergency medical coverage in the
absence of the attending physician or his'J1er designee.
medical director serves on patient care policy, admissions, infection
control, pharmacy, safety, interdisciplinary, and budget committees.
If the director is an employee of the skilled nursing facility, he/she may
not be a member of the utilization review committee, but can serve as a
valuable resource person. As a consultant or independent contractor,
he/she may serve on the utilization review committee.
His/her role is to advise administration regarding the need and
adequacy of medical equipment and supplies such as to ensure quality
medical care. Skilled nursing facilities have certain strict
regulations based on federal and state legislation. The medical director
cannot be considered the chief of the attending physicians. Rather than
direct the attending physicians, the medical director gives them guidance
Attending physicians may strive for autonomy, but the medical director
must direct conformity to patient care policies. This relationship has to
be a negotiated one, characterized by tact, diplomacy, and a professional
mutual understanding. In reality, the medical director represents
administration and has a mission to see that quality care is delivered.
The skilled nursing facility may have an open or closed medical staff.
In an open medical staff, any physician with a state license to
practice medicine is entitled to admit patients to the facility in
accordance with the facility's admission criteria. In an open medical
staff, the medical director should develop written guidelines to delineate
the attending physician's responsibilities.
These policies should be approved by the governing body before they are
implemented. The medical director is responsible in scheduling
regular medical staff meetings in order to provide information and
direction to the entire medical staff.
In a closed medical staff, the governing body appoints physicians on
the recommendations of
the medical staff's credentialing committee. In a closed staff, only
members of the medical staff have admitting and treating privileges. As
few as three physicians may constitute a closed medical staff according to
the joint Commission on Accreditation of Hospitals. In order to have a
closed medical staff, it should be in the policies and bylaws of the
governing body and medical staff.
The advantages of a closed medical staff are that it allows for better
communication between the interdisciplinary teams and greater continuity
of care. These physicians are chosen based on their professional expertise
and their commitment to provide both quality medical and rehabilitative
services for the patients.
Community physicians are frequently invited to continue visiting their
patients within a closed medical staff and can be provided courtesy,
temporary or consulting privileges. Ultimately, it is the closed
medical staff of the facility who has the responsibility for the patient's
care. Regardless of an open or closed medical staff, all physicians
who apply for staff privileges should be of good character, graduated from
an approved School of Medicine, and are currently licensed to practice in
The appointment of physicians must follow a procedure outlined in the
bylaws of the medical staff. Nominations should originate from the
president of the medical staff and should be made in the form of a written
application. This application must be accompanied by a signed statement
that the nominee agrees to abide by the medical staff's bylaws, rules, and
Once approved by the medical staff and the president of the staff, the
application is referred to the governing body for approval. The governing
body appoints and reappoints members of the medical staff annually,
subject to the medical staff's approval.
The medical director must be familiar with federal, state and local
codes, and regulations that are applicable to skilled nursing facilities.
Additionally, the medical director should be familiar with accreditation
bodies such as the Joint Commission on Accreditation of Healthcare
Organization UCAHO) standards for skilled nursing facilities, and the
Commission on Accreditation of Rehabilitation Facilities (CARF) standards
for the subacute medical and rehabilitation programs that became available
in January 1995.
As healthcare reform continues to redefine service delivery systems and
as managed care drives the costs lower, subacute care establishes itself
as a viable alternative for patient care. As the subacute industry grows,
the opportunities for physicians desiring a medical director's position
become more available.
Should you have any further questions
regarding this article, please direct your questions or comments to "Ask
the Doctor" section.
Copyright © 2004 - 2012Taras V.
Kochno, M.D. All Rights Reserved
Board Certified in
Physical Medicine and Rehabilitation