The recertification visit: maximizing the benefit for the resident.

Each resident in a nursing home must be seen by a physician at regular intervals in most states, according to licensure regulations. While the aim of that requirement is to recertify the need for nursing home care, the benefit for the resident depends upon the assessment and modification of care that are part of the visit. Even though long-term care is a team effort of many professionals, the medical assessment influences the medical-care plan wherein most other services are initiated. The physician then becomes the gatekeeper of most services and treatments that the resident receives. Yet, the physician is an infrequent visitor to the nursing home resident and has the least contact time, generally, of anyone on the care team.

A recent national survey of selected family practice specialists shows that experience in nursing homes is the most highly valued training experience in geriatrics for family physicians.' The implication is that many doctors, who will be entering practice, will be willing to see their patients in the nursing home setting. With the rapid increase in the number of people residing in nursing homes that is projected for the next decade, a sharp increase in physician-patient encounters in nursing homes is to be expected. Whether such encounters result in maximum benefits to the residents, however, depends upon the nature of the visits. Physicians usually work under time constraints. The setting in the nursing home is likely to be perceived by physicians as less efficient than the setting in a physician's office. Nursing home personnel and staff physicians need to work together to create systems that are conducive to efficient and beneficial visits,

There is a sparsity of published literature on how to increase the efficiency and productivity of physicians' visits to nursing homes. Professional roles and relationships of physicians in nursing homes previously have been described. This article addresses specific ways to increase the efficiency of the recertification visit and, hence, the benefit to the resident. The problems discussed and the recommendations for reducing the problems reflect the experience of the professionals in the University of Utah System of Long-Term Care Facilities over a three -year experience of caring for up to 400 residents in six nursing homes (unpublished data). (That does not relate to the survey of selected family practice specialists.)

In this article, several problems are presented, which contribute to lack of efficiency and reduced benefit to nursing home residents. Each problem is followed by a suggested plan for overcoming the problem. The plans, it will be seen, essentially contribute to transferring information about how the resident has fared between physician visits.

Problem 1. Limited communications between nurse and physician often limit the benefit of the visit. It is inefficient for a nurse to call a physician for a nonacute problem at the time that the problem is noted. Frequently, a problem never gets communicated to the physician because the physician's visit does not coincide with the day or the shift of the person perceiving the problem. While the nursing notes and monthly summary may include the problem, those documents tend to be lengthy, and are not carefully read by rounding physicians.

A special, single sheet, kept in the chart, can help overcome that problem. The sheet has three labeled parts-problems to be addressed by the physician, recommendations to the physician, and special considerations. Each entry should be limited to a single sentence, such as, "Mr. ...