Physician Staffing for the VA Volume II, Supplementary Papers (1992) / Chapter Skim
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Long-Term Care Panel Report
Long-Term Care Panel Report
Pages 351-392
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From page 351... ...
EXPERT JUDGMENT APPROACHES TO DETERMINING PlIYSICIAN REQUIREMENTS IN LONG-TERM CARE The Detailed Staffing Exercise (DSE) Approach Initial Efforts A central purpose of the panel's first meeting, held in April 1990, was to help determine whether the expert judgment approach to staffing being developed by the study committee could be applied validly to long-term care.
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From page 352... ...
The amount of time contributed on long-term care units by physicians in each of these specialties needs to be addressed. At this first meeting the panel also reviewed and evaluated the initial versions of the empirically based physician staffing model.
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From page 353... ...
Progress to date on both the expert judgment and empirically based model approaches was evaluated. After reviewing the reports submitted by each panel, the study committee recommended that work proceed on developing a more internally consistent and comprehensive instrument for determining physician requirements by expert judgment.
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From page 354... ...
Interim Assessment of Expert Judlpnent Staffing Approaches The panel, beginning at its first meeting, discussed alternative and more compact formats for obtaining estimates of the time required by LTC physicians to perform specific tasks in the PCAs. One of the panel's early proposals can be summarized as follows:
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From page 355... ...
It was also recommended Hat if such expert judgment-based estimates were obtained, they should be compared with the actual FIRE estimates for such consultations, as found in the VA's cost distribution report. In addition, estimate by other specialty panels of the amounts of time which they feel Heir physicians need to contribute to long-term care units might be usefully compared with what LTC physicians estimate to be the appropriate amount of consultation.
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From page 356... ...
Other At its second meeting, the panel also developed a simple topology to help it analyze the time required by LTC physicians in PCAs other than the nursing home and intermediate care: a. Geriatric consultations for management only 1.
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From page 357... ...
Given these discussions, the LTC panel was subsequently pleased to see the study committee propose an expert judgment format such as SADI, which reflects the spirit of the panel's discussions. The Staffing Algonthn Development ~strmnent (SADD Approach SADI: Overall Rationale Following the second round of panel meetings, the study committee initiated a set of postmeeting activities to assist the specialty and clinical program panels in arriving at consensus positions regarding the most appropriate methodology for VA physician staffing.
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From page 358... ...
the respondent must determine the amount of physician time mat Should be alloca" to research, classroom insbuction, continuing education, administration, and leaves of absence. To derive physician requirements for a given VAMC, the estimated physician hours for patient care and non-patient~are activities are summed, then converted to -ME under the assumption that 40 hours per wed translates into one THEE.
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From page 359... ...
In sum, the PF models provide an in-depth look at worldoad production ~ the nursing home and intermediate care wards, but do not encompass all patient care activities that fall properly under the purview of the long-term care program at the VAMC (e.g., adult day health Carey. No inverse production functions have been estimated for long-term care.
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From page 360... ...
Second, the P-1EE estimates derived from the CDR and the PF model are for total physician requirements for the two PCAs, nursing home and intermediate care, that the study defined early on as making up Long-term care.. In particular, these estimates do not include physician F1EE for extended care and geriatric activity not occurring in these two PCAs.
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From page 361... ...
North Shore Hospital's Center for Extended Care and Rehabilitation, for example, has an average length of stay of 50 days and an average daily census of 186 patients. It is physically adjacent to tile hospital, and in this way is more similar to most VA nursing home care units than most private community nursing homes, which are freestanding.
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From page 362... ...
The extended care department of mat hospital has no beds of its own, but is responsible for managing the care of approximately 1200 nursing home patients who reside in approximately 45 private nursing homes in the community. Contacts with these facilities did not, therefore, yield meaningful comparisons.
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From page 363... ...
completed by panel members in conjunction win the two meetings of the long-term care panel served to highlight the fact that, in addition to possible differences in staffing patterns between the VA and private sector extended care facilities, there may be differences among VA facilities with regard to their long-term care physician staffing. For example, the following results emerged from a simple comparison of patients per total physician P-1EE allocated to LTC ~ He nursing home care units, geriatric evaluation units, and intermediate medicine units, respectively, for the three facilities used in the staffing exercises at the second panel meeting:
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From page 364... ...
Inpts per LTC FIEE = 36.0 7.0 29.0 2.0 = 18.0 = 142.0 = 46.0 = 96.0 = 3.0 = 47.3 = 114.0 = 73.0 = 41.0 = 2.0 = 57.0 Panel members had also suggested Mat staff contact VAMCs (indicated here as VAMC A and B) Mat are generally recognized within the system to be well organized and well staffed with regard to their extended care services.
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From page 365... ...
The VA's own staffing guidelines from 1965 use the figure of 100 beds per physician as an explicit standard for nursing home care units. Comparisons of Nursing Home Staffing in VA and non-VA Facilities Table 4 shows the its from applying the staffing ratios cited above (for North Shore, the Hebrew Home, Levindale, VAMC A, and the 1965 VA
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From page 366... ...
CONCLUSIONS As a framework for determining VA physician requirements in long-term care, Me panel endorses a specification of the Reconciliation Strategy that can assess the [-lL;E needed for all extended care and geriatric services, not simply for nursing home and intermediate care beds. Regarding He components of the strategy, He panel recommends He following:
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From page 367... ...
[However, the effect of nursing home and intermediate care workload on physician requirements is recognize in each IPF through the independent variable RUGWWU (Resource Utilization Group Weighted Wow Units3.] Third, an expert judgment model built around the SADI offers a flexible approach for evaluating physician FREE requirements for all extended care and geriatric services.
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From page 368... ...
The panel notes, however, that these non-VA physicians can serve to improve the quality of patient care. External Nouns For three VAMCs the panel computed what physician Al EE would have been had each been staffed with the same intensity, in turn, as three private sector nursing homes, another VA nursing service, and as suggested by Me VA,s own rough guidelines published in 1965.
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From page 369... ...
1. Physician staffing requirements were not reviewed for HBHC because, under the current VA system, the program is implemented by nursing with little direct physician involvement for patient care.
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From page 370... ...
screening for enrollment into HBHC, (b) patient care planning, (c3 multidisciplinary care management, (d)
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From page 371... ...
7. One final and major point: Further iterations of the LTC SADI should have the capability of assessing physician time requirements for all of the following activities, defined by the VA,s Office of Geriatrics and Extended Care as falling within its purview: Nursing home care (VA, community, state homey Domiciliary care (VA, state homey State home hospital care Hospital-based home care Community residential care Adult day health care Hospice/paUiative care Reppite care Geriatric Research, Education and Clinical Centers
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From page 372... ...
Final Remarks The panel urges the VA to adopt a form of Reconciliation Strategy that uses expert judgment rather "n statistical models to determine the amount of physician -ME required for patient care, resident education, and administration within the LTC program of a VAMC. The remaining components of F-1EE discussed above should be determined through a combination of empirically based and expert judgment based approaches, as indicated.
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From page 373... ...
2Does not include Glue for consults by nongeriatncians to nursing home and intermediate care PCAs. Derived by replacing the SADI-based estimates for non-patient~e activities untib estimates based on the DSE; all P-lEE for patient care and resident Paining in the PCAs continue to be derived from the SADI.
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From page 374... ...
(-6.798) with R2 = 0.702 and N = 118 where W = He gal logarithm of total RUGWWUs, plus 1, produced in the nursing home PCA during the fiscal year; MED_MD = VA staff physician FlEE from the medicine service allocated to direct care in this PCA; RMS_MD = VA staff physician t-lEE from the rehabilitation medicine service allocated to direct care in this PCA; SllR_MD = VA staff physician t-lEE from the surgery service allocated to direct care in this PCA; 0THER_MD = total FlEE allocated to this PCA by VA staff physicians not in medicine, surgery, psychiatry, neurology, and rehabilita tion medicine; SOCW = social worker P-lEE allocated to this PCA; and
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From page 375... ...
(3.754) where W = with R2 = 0.803 and N = 129 the natural logarithm of tota1 RUGWWUs' plus 1, produced in ~e intermediate care PCA dur~g the fiscal year; INI MD = VA staff physician t-lLE from intermediate medicine (i.e., recorded in the intermediate medicine cost center)
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From page 376... ...
376 P~Y51CIAN SI.HFFI~G FOR ME Vat-VOLUME HGROUP(4+5) = categorical variable ammun,g a value of 1 if the facility is in RAM Group 4 (midsize general umffili~ed VAMC)
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From page 377... ...
Beds/ Physician Belle= 81.0 Hospital Unit: Beds = 40 2 physician Al plus 1 PA Beds/physician Melee = 20.0 Physicians also have responsibilities on the hospital inpatient's geriatrics service.
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From page 378... ...
IBased on FY 1989 CDR data; by definitions does not include FTEE allocated to intermediate care.
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From page 379... ...
Section B seeks responses to a series of questions for the time spent in activities over Can direct patient care. Instructions: In Section A, for each cell of each table, please estimate the number of physician hours required from the long-term care program at the VAMC to deliver good~uality care under the specified circumstances.
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From page 380... ...
level below, please fill in the average number of physician hours required from the long-term care program. Keep in mind that the daily rounds do not include new a - fission work-ups, since they are covered ~ Chart 1.
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From page 381... ...
LONGT~l GiRE PENAL REPOkT Chart 2 (continued) 381 Assent No Residents Nursing Home Ward ADC ADC ADC ADC ADC ADC Average LOS = 115 days 1 10 20 30 40 50 Charting, Phone, High 0.50 0.30 0.60 1.00 1.30 1.60 and Paperwork Low 0.01 0.80 0.16 0.24 0.32 0.40 Mean 0.20 0.17 0.38 0.58 0.73 0.90 Median 0.20 0.17 0.40 0.60 0.75 1.00 Patient and Family High 0.05 0.50 1.00 1.50 2.00 2.50 Contacts plus Low 0.01 0.08 0.16 0.17 0.32 0.33 Teaching Mean 0.03 0.16 0.40 0.58 0.75 0.93 Median 0.04 0.08 0.17 0.25 0.33 0.41 Supervision High 0.20 0.50 1.30 2.70 3.20 4.20 and Teaching Low 0.01 0.01 0.01 0.03 0.03 0.05 (Residents/Staff)
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From page 382... ...
382 Chart 3 P~YSICUN SIDING FOR To Vat-VOLUME Assume 1 PGY 4-Level Resident Nursing Home Ward ADC ADC ADC ADC ADC ADC Average LOS = 115 days 1 10 20 30 40 50 Daily Rounds High 0.03 0.15 0.30 0.60 0.80 1.00 Low 0.00 0.00 0.08 0.12 0.16 0.20 Mean 0.01 0.07 0.14 0.29 0.33 0.49 Median 0.05 0.08 0.10 0.25 0.33 0.41 Charting, Phone, High 0.01 0.01 0.16 0.30 0.40 0.50 and Paperwork Low 0.00 0.00 0.00 0.00 0.00 0.00 Mean 0.00 0.04 0.07 0.15 0.18 0.03 Median 0.00 0.00 0.08 0.10 0.10 0.17 Patient and Family High 0.05 0.50 1.00 1.50 2.00 2.50 Contacts plus Low 0.00 0.00 0.05 0.08 0.08 0.17 Teaching Mean 0.03 0.13 0.26 0.38 0.50 0.63 Median 0.03 0.04 0.08 0.12 0.16 0.20 Supervision High 0.25 0.60 1.21 1.80 2.80 3.00 and Teaching Low 0.01 0.08 0.16 0.20 0.20 0.20 (Residents/Staff) Mean 0.13 0.27 0.40 0.71 0.28 0.94 Median 0.13 0.20 0.25 0.33 0.33 0.40 TOTALS High 0.28 1.30 2.50 3.90 5.60 6.S0 Low 0.00 0.16 0.32 0.48 0.64 0.80 Mean 0.14 0.50 0.93 1.45 2.0 2.30 Median 0.13 0.40 0.55 1.00 1.20 1.40
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From page 383... ...
LON~1~W GORE PAIL REPORT Chart 4 383 Assume 1 PGY 4-Level Resident Geriatric Evaluation Unit Average LOS = 10 days ADC ADC ADC 1 3 5 ADC ADC ADC 7 9 11 Daily Rounds High 0.60 0.60 0.83 1.16 1.50 1.83 Low 0.08 0.11 0.14 0.17 0.20 0.25 Mean 0.44 0.34 0.44 0.S3 0.71 0.79 Median 0.17 0.25 0.33 0.42 0.60 0.60 Charting, Phone, High 0.08 0.11 0.16 0.17 0.25 0.25 and Paperwork Low 0.00 0.00 0.00 0.00 0.00 0.00 Mean 0.04 0.05 0.08 0.08 0.12 0.13 Median 0.02 0.08 0.08 0.08 0.17 0.17 Patient and Family High 0.25 0.25 0.30 0.30 1.00 1.00 Contacts plus Low 0.00 0.00 0.00 0.00 0.00 0.00 Teaching Mean 0.08 0.11 0.13 0.15 0.32 0.34 Median 0.04 0.08 0.12 0.16 0.20 0.25 Supervision High 0.50 1.00 1.66 2.32 3.00 3.67 and Teaching Low 0.08 0.17 0.17 0.17 0.25 0.25 (Residents/Staff) Mean 0.30 0.48 0.69 0.86 1.10 1.26 Median 0.34 0.40 0.48 0.64 0.83 1.00 TOTALS High 1.08 1.55 2.57 3.60 4.65 6.29 Low 0.30 0.52 0.75 0.83 1.00 1.00 Mean 0.65 0.96 1.34 1.60 2.25 2.64 Median 0.53 1.00 1.00 1.14 1.40 1.75
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From page 384... ...
384 P~YSl~UN S1HFFING FOR TO VA-VOLUME n In some cases, the long-tenn care program may have the primary responsibility for managing the intermediate bed service. Please complete the following charts, again estimating the number of hours required per day Mom the long-tenn care program.
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From page 385... ...
LONG~lE'W CdRE PANEL REPORT Chatt 6 385 Assume 1 PGY 4-Level Resident Intermediate Ward Average LOS = 45 days ADC ADC ADC ADC ADC ADC 1 10 20 30 40 50 . Daily Rounds High 0.03 0.33 0.67 1.00 1.33 1.67 Low 0.00 0.00 0.08 0.08 0.17 0.17 Mean 0.02 0.20 0.39 0.57 0.78 1.00 Median 0.03 0.20 0.40 0.60 0.80 1.09 Charting, Phone, High 0.01 0.10 0.20 0.30 0.40 0.50 and Paperwork Low 0.00 0.00 0.00 0.00 0.00 0.00 Mean 0.00 0.05 0.10 0.15 0.20 0.25 Median 0.00 0.0S 0.10 0.15 0.20 0.25 Patient and Family High 0.05 0.50 1.00 1.50 2.00 2.00 Contacts plus Low 0.00 0.00 0.08 0.08 0.08 0.08 Teaching Mean 0.02 0.20 0.40 0.58 0.77 0.83 Median 0.02 0.12 0.25 0.38 0.50 0.63 Supervision High 0.67 0.67 1.33 2.00 2.67 3.33 and Teaching Low 0.02 0.08 0.17 0.17 0.25 0.25 (Residents/Staff)
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From page 386... ...
OFF YOUR PCA Fill in the average time in hours required by a staff physician in the long-term care program for each follow-up consultation visit on another service, noting He presence or absence of a nonphysician practitioner (NPP) from your service.
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From page 387... ...
All Home Visits High Low Mean Median High Low Mean Median HBHC (Hospital- 5.00 1.00 4.17 3.75 22.00 8.00 13.10 9.20 Based Home Carey, with 60 Einrolled Patients
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From page 388... ...
388 PHYSICUN SIXFFlNG FOR ARE Vie-VOLUME SECTION B: NON-PATIENT~ARE TIME Part 1. The activities listed below generally do not occur every day, but may be time consuming when looked at over a longer period, such as a week or month.
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From page 389... ...
LON~1ERU CdRlE PI REPORT Chart 10 (continued) 389 Assume the amount of research accomplished at this VAMC is: Highl Mediuml Low Hoppital-Related High 1.00 0.50 0.50 Activities (mortality Low 0.20 0.10 0.10 and morbidity, Q.A., Mean 0.64 0.40 0.30 staff meetings)
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From page 390... ...
member of your program should devote to each of the following categories of non-patient~related activities? Chart 11 Assume He amount of research accomplished at this VAMC is: Highi Mediumt Lows Continuing Education High 25 10 10 Low 1 1 2 Mean 13 5 5 Median 13 5 5 Research (ofIthe PCA)
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From page 391... ...
OLSEN, Chief, Geriatric Psychiatry, Miami VA Medical C - ter, Miami, Florida L GREGORY PAWLSON, Chairman, D - rtment of Health Care Sciences, George Washington University Medical Center, Washington, D.C.
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