“How many nursing home administrators have you met who think they know clinical better than physicians?” This is one of my favorite questions that I’ve put to colleagues over the past year. It is actually common to see a nursing home administrator opine on a resident’s clinical condition and care needs. Under what basis do they have the knowledge to understand an incredibly complex patient population? What are their goals and how do those goals mesh with the delivery of high quality care? The major goal of a nursing home administrator is to keep occupancy high, which means filling beds and keeping them filled. Similarly, they must endeavor to maintain a profit, balancing the expenses needed to care for highly complex patients with the revenue received from the government. Furthermore, the mix of employees run the gamut of nurses, who are well educated and devoted to caring, to housekeepers and nursing assistants who have limited education but have hearts of gold. The front line staff, with its limited educational background, provides the bulk of direct care to the most frail and complex group of individuals ever seen. And yet, nursing home administrators often think that they know clinical better than physicians.
The nursing home industry, for all practical purposes, is a real estate play. The incentive for the owners of the nursing home real estate to hire high quality administrators is questionable. At the very least, the most important attribute of an administrator will be their ability to fill beds and bring about a profit. The investment in having administrators with excellent leadership and management skills has a limited return on investment, not because it’s not possible, but because ownership doesn’t believe it can happen, nor do they think it matters. This may sound cynical, and while it doesn’t represent all nursing home owners, it does represent the norm. Why does society put up with this? Ageism, pure and simple. We don’t put the same value on a frail older adult with cognitive dysfunction as we place on others. We also don’t know what to do. And we go back to the fact that many nursing home administrators think they do know what’s best for their residents. Which, by all logic, is nonsense.
Geriatricians spend their entire career working with frail older adults. We also work in a team environment, melding knowledge from various disciplines into one cohesive view of each individual that we care for. Geriatricians pay attention to input from social workers, nursing assistants, nurses, therapists and family alike. To ignore all of the data at our disposal goes against the core principal of person centered care. Geriatricians are the experts in the care of older adults. Where are they in the nursing home hierarchy? Unfortunately, many nursing homes don’t have geriatricians as attending physicians, much less as medical directors. So the default for the administrator is to assume that they know what’s best for the patient. What other business would we allow to run like this? I believe that the only reason that we allow this to happen is that at the end of the day it’s really only the real estate that matters. And, because grandma really doesn’t have significant perceived value.
No comments:
Post a Comment