Physicians providing care to nursing home residents assume a com¬plex responsibility that requires time, energy, and commitment if it is to succeed. They must assess and advocate appropriate interventions. As¬sessing the need for rehabilitative therapy is especially important but not well understood by most physicians and, therefore, is almost rou¬tinely delegated to therapists (see Ch. 29).
Physicians must see patients as often as medically necessary but not less than every 60 days. Regulations require that certain patients, such as those with dementia and delirium, undergo further evaluation using standardized Resident Assessment Protocols. These guidelines were established by the Health Care Financing Administration (HCKA) to help identify the causes of common problems and ensure that interven¬tions are specific and appropriate. Visits, even if routine, should not be perfunctory; patients should be examined, medication status assessed, and laboratory tests ordered as needed. Findings should be docu¬mented in the patient’s chart to keep other staff members informed about any problems. If possible, the physician who cares for the resi¬dent in the nursing home should also treat the person’s acute illness if hospitalization becomes necessary.
Caring for a nursing home patient often involves considerable inter¬action with the family. Rapport can be established at the outset if the patient ami family are made to feel that someone in authority is listen¬ing and trying to address their concerns. Physicians can alleviate fears of abandonment by engaging in positive discussions of what can be done, even if it is only palliative, rather than stressing the withholding or stopping of treatment (which relatives may perceive as subtle in¬stances of abuse and neglect—see Ethical Considerations, below). An interdisciplinary team can more easily address problems and advocate good geriatric care, particularly if residents and families are included in the decision-making process. Organized family meetings, in which the physician, social worker, and nurse participate, can be particularly helpful.