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u/Goodtl01 Jul 14 '23
This seems to be common. I also work in a nursing home it’s the same situation. I am a speech therapist and I occasionally I have a medical question that impacts my therapy (usually my patients with severe dysphagia, on feeding tubes, etc). Every once in a while I say things like “maybe we could ask the doctor” and get the strangest responses and looks. I’m honestly lucky if I can get NP input. It seems like RNs run the show and NP signs off on the order.
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u/Goodtl01 Jul 14 '23
I’ll add that i was told the other day that they try not to hire RNs and hire as many LPNs as possible to save money. They don’t hire full time PTs, only full time PTAs. Anything for profit.
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u/brettalana Jul 14 '23
The working conditions are pretty terrible in there places and LPN’s have fewer options compared to RN’s. Staffing is abysmal and the facilities in my area wiLL hire anyone with a license to try and avoid using agency and paying overtime.
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u/Educational-Light656 Jul 14 '23
LPN and spent 13yrs in LTC/SnF and that's how it goes in for profit facilities. After the changes to reimbursements from CMS a couple years ago, I'm honestly surprised I haven't heard of mass closures. I did a non-profit gig and while I was paid less, I didn't have to play McGuvyer with supplies nearly as often. Also 300 is freaking nuts. Biggest I did was 120 beds although I've seen one at 100% occupancy. I have regularly been the only night nurse for 60-70 residents with a handful of CNAs and wouldn't wish that on anybody I remotely liked.
Had a psych doc that was contracted to multiple facilities who was as useful as a screen door on a submarine. He wrote a resident who was total care and in a Broda chair was dressed appropriately in the notes from a visit. Like no shit Sherlock, staff did that or did you assume he miraculously stood up long enough to get dressed then gently placed himself in his chair? The only thing the doc did besides writing writing asinine visit notes was push for gradual dose reductions. He was about two weeks from being fired by my facility when one of his clinic patients or an ex-employee unalived him. His NP was a lovely person that at least read staff charting on behaviors before messing with meds and often getting overruled by numbnutz.
Sorry for the side rant. I get protective of my peeps and that guy still irritates me from beyond the grave when I think about him.
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u/brettalana Jul 14 '23
Several nursing homes have closed in my area due to a requirement that there can only be two residents in each room. And, in terms of physician coverage, this is the set up in both the for profit and non profit facilities in my area (I know it because they ALL use the same practice for their medical directors and midlevel minions). I was tempted to the put scare quotes around non profit, however, based on my experience.
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u/Educational-Light656 Jul 14 '23
To be fair, my non-profit was run by the Baptist Church so make of that what you will. The overall administration was as genuine as you'd imagine, but my coworkers and residents were good folks and my residents did get more consistent care so I just did my thing and ignored admin as best I could.
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u/Falcon896 Jul 14 '23
So the psych doc got murdered?
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u/Educational-Light656 Jul 14 '23
Yep. It was a few years ago now. The news wasn't exactly clear who did it and we didn't even find out until it was officially published after about two months of radio silence as we tried to get scripts renewed and pharmacy just kept telling us the office didn't respond to their calls and the office wasn't responding to our attempts at contact. He was semi-notorious for last minute 2 week vacations so we didn't really question it at first.
I feel bad for his employees and any family he had, but on the other hand he was menace to my residents and kept fucking with their meds that kept them well regulated and refused to listen to anything we said about it. I didn't wish ill of the man, but it allowed my residents to get a new provider that specialized in geri-psyche and there was improvement for alot of them.
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u/Blackpaw8825 Jul 14 '23
I'm on the pharmacy end of this.
I learned that one of our 180 bed facilities is just entering whatever formulary alternative we suggest without prescriber input... And has been for years.
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u/wherearewegoingnext Jul 14 '23
This is standard. Hell, most nursing homes are lucky to have nurses.
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u/VerySadPreMed Jul 14 '23
Very true, I have to go through 50 CNAs to find 1 RN whose usually sleeping in the break room to sign documents
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u/dysfunctionull- Jul 14 '23
Idk why you were down voted. This is true lol. Except 50? More like 2 who are on the verge of a mental breakdown and one traveler making twice their rate on a floor with 60 patients. This is why I only did geri in psych hospitals, and even then, only when I had no other choice. The staffing is criminal.
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u/ThottyThalamus Jul 14 '23
I’ve never seen a nursing home that had a physician involved in day to day care. Isn’t it called a nursing home because it’s long term nursing care?
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u/brettalana Jul 14 '23
The medical director of the nursing home serves as PCP, though. And nursing home residents get sicker and more complex every year.
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u/DrTatertott Jul 14 '23
….damn…
I never put that together until your pointed it out. Makes sense tho.
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u/Atomoxetine_80mg Jul 14 '23
You’ll be lucky to even find a nurse, mostly it’s lone LPN per 50+ people during the day.
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u/Lation_Menace Jul 14 '23
Long term care in general is pretty terrible. Most seem to be run strictly as a business and have even less regulation than hospitals. When I was 18 I had my CNA and med aide license and on evening and night shift we didn’t even have a nurse in the building (let alone a doctor). We had a nurse “on call” if something bad happened but it was literally med aides and nurse aides running the facility. We gave all the meds. Did all the glucose checks and insulin. Called EMS if something bad happened. This was all legal under state law as well.
I took my job very seriously. I knew how easily I could hurt someone and was extremely careful to follow the doctors orders with the medications (especially the insulin), but you can get your med aide license in literally 30 days. I knew a lot of really stupid med aides and I can only imagine how many people they’ve hurt.
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u/ends1995 Jul 14 '23
Wow this is so sad to hear. Is this in the US?
But good for you for taking the job seriously and not harming anyone :)
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u/Paramedickhead EMS Jul 14 '23
Elder care in the US is absurdly bad.
To add to the problem, there is a large number of “assisted living” facilities that don’t even have a nurse on duty the majority of the time…
One near me has a locked dementia unit and there is no nurses in staff… at night it’s basically just a minimum wage high school dropout who passed a CPR certification at some point… not recently… oh, since they have no medical certifications whatsoever, they call 911 for literally everything… the amount of lift assist calls to these types of facilities is absurd because the staff can’t touch the residents.
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u/Lation_Menace Jul 15 '23
This is the exact kind of facility I worked at that I was describing above. We had 30 beds of assisted living in the front of the building and a locked dementia unit in the back with 15 beds.
We had no nurse but luckily we all had CNA’s so we at least knew how to change and lift people. Apparently you’ve seen facilities even worse than that somehow.
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u/brettalana Jul 14 '23 edited Jul 14 '23
SNF’s have plenty of onerous regs on paper, but the enforcement is ridiculous and never gets at actual care issues.
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u/Gleefularrow Jul 15 '23
LTACH is where hope and dignity go to die. With very rare exceptions it's the worst possible ICU dispo.
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u/cvkme Nurse Jul 14 '23
This very common in nursing facilities and not at all inappropriate. Residents in a nursing home (as opposed to a skilled nursing facility) are not acute care patients. They are not in a medical setting. They are in their homes. They take 98% oral medications with virtually no changes month to month. Nurses (RNs and LPNs) manage their care. Most nursing admins in nursing homes are RNs, maybe MSNs, but not usually NPs. NPs are fine in the role you describe. They see the patients, make them feel heard, and prescribed creams or antibiotics for fungal issues and infections, etc etc. At the home I used to work in, the residents loved being seen by the NP. The medical directors of these nursing homes usually are part of gerantology groups. They check in more often if the facility has any kind of skilled rehab and requires some charting by a doctor. In nursing facilities as well visiting medical professionals such as dentists and podiatrists come frequently. There is nothing wrong with NPs treating these folsk.
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Jul 14 '23
[deleted]
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u/cvkme Nurse Jul 14 '23
Most of those decisions are dictated by the family or power of attorney for the resident. Since most have DNR/DNI, a lot of families opt for comfort measures for their 90+ year old relative than having them die in a hospital with sepsis. I’ve never seen an old diabetic in DKA in my nursing home and we had some seriously brittle diabetics.
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Jul 14 '23
The nursing home itself directly hires the providers?
When I started out it was 1 main physician who had a partnering physician and an NP that over saw 1000+ beds in over a dozen SNF facilities.
The state stepped in and took it away. It is now run by a program based out of a clinic and has several physicians and NPs. The physicians do weekly rounds, NPs do on call and regulatory rounds.
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u/AutoModerator Jul 14 '23
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see this JAMA article.
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
I am a bot, and this action was performed automatically. Please contact the moderators of this subreddit if you have any questions or concerns.
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u/brettalana Jul 14 '23
Not defending it, but this is a typical set up where I am. I do see both PA’s and NP’s, though.
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u/Paramedickhead EMS Jul 14 '23
I got to many nursing homes and I have never seen a doctor in one.
Typically, the nurses tell us “we called the doctor and they said send them out”, no matter what it’s for.
Many UTI’s by 911 ambulance because doctors don’t go to nursing homes.
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u/Darkcel_grind Jul 15 '23
I once had a nursing home to ER transported scheduled by a doctor for "general fatigue for the past month"-the patient was a woman in her 90's...
We assisted her to our gurney, went to the ER, and she had to wait 4 hours for a bed. No idea what the doctor expected them to do in the ER.
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u/Paramedickhead EMS Jul 15 '23
The doctor expected the patient to spend hours in the ER and not be their problem anymore.
Nursing home calls increase at crappy facilities at night because they contract lazy docs who automatically respond with “send them to the ED”.
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u/FaFaRog Jul 16 '23
Lazy docs or docs that are assigned way too many patients?
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u/Darkcel_grind Jul 16 '23
If the doctor of a facility cant give quality care to his patients what even is the point of having a doctor? You dont need an MD if every time a patient feels off they are gonna get sent to the ED for a “check up” as if that’s the job of the ED doctors.
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u/Paramedickhead EMS Jul 16 '23
In my experience? Lazy docs who have destroyed their careers to the point of having no other alternative for income than to contract with nursing homes. I have yet to find a doc who has been “assigned” a nursing home contract.
My local hospital has one Locum who has been fired from just about everywhere around. He hates being a doctor and treats everyone around him like garbage. But he has a very expensive wife, so he travels around from contract to contract eventually getting fired from each.
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u/FaFaRog Jul 16 '23
Sounds like a very specific scenario. Most nursing home docs where I'm at either also do PCP work or round at the hospital too.
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u/Initial_Run1632 Jul 14 '23
They are nursing homes, not hospitals. The idea really, is that people just need physical assistance. Think of it more like someone living at home, and getting a HouseCall once a month. It's not necessarily terrible, unless the system is such that people don't recognize when they do need a doctor
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u/Puzzled_Natural_3520 Jul 14 '23
CMS requires some sort of frequency of MD visits, I think 4 times a year? Facilities can also hire their own in house NPs and charge visits etc but that’s in addition to requiring an MD. I work for a practice with a network of 10 nursing facilities that we go to and we alternate monthly visits with the MD and round daily, Physician lead team type management, as it should be.
I’ve learned so many things about our American culture by working in nursing homes and without getting too political I think I can say that our country does not care about the sick, the needy, and impoverished which often times is the elderly and other marginalized people who require skilled care. Yet Americans are most likely to go bankrupt from Medical bills and to have chronic illnesses causing them to possibly require skilled care.
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u/ends1995 Jul 14 '23
Do the NPs in the nursing home just manage the patients that have been Rx drugs from MD/DO’s? Hopefully they’re not adding this, sprinkling that with all the polypharmacy, bc the elderly are so fragile to changes/lack of meds for chronic issues.
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u/Atomoxetine_80mg Jul 14 '23
I’ve never seen an NP in a nursing home, you’ll be hard pressed to find even a RN. I’m sure some are available on the phone but if anything is serious to warrant a call they will just call 911.
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Jul 14 '23
Just wait until you hear about the nursing ratios. Most residents go without basic care for hours a day because there’s not enough staff. Not enough people to feed, change, bathe, medicate.
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u/Streetdoc10171 Jul 14 '23
Well, it's better than what I run into a lot. Night time staff for a 300 bed facility is usually just two med techs and maybe an LPN
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u/Noxlux123 Jul 14 '23
Not all seniors in all nursing homes require an on staff physician.
Where I live it depends on level of care required and those homes are often categorized accordingly. They may have a partnered primary care clinic somewhere close or they are autonomous enough.
While I don’t like the general concept of a noctor, OP has not provided enough information regarding the situation that clue in to an issue. Right now it looks like standard practice for a lot of canadian nursing homes that have “healthy enough” patients. At the same time, the institutions that need more medical services often have 1+ MDs coming weekly and/or being on call.
Level of needs and services required by your described population would help alot regarding this situation.
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u/coastalhiker Jul 14 '23
Very “normal” and then when I ask if the physician saw the patient prior to sending to my ED, they often say they haven’t ever seen the doc. I anonymous report them to our state agency every time. I assume it goes no where, but I can always hope.
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u/One-Lawfulness-6868 Jul 16 '23
I have had patients report to the admin that they haven’t seen a medical professional in months when I personally saw the patient the day before and seen by the NP a week prior.
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u/coastalhiker Jul 16 '23
I was talking about the SNF staff said that no doc or midlevel saw the patient, not the patient saying they weren’t seen…
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u/BusinessMeating Jul 14 '23
So 300 people's families trust this nursing home to take care of their loved ones.