Physician

Key Duties and Responsibilities

• Provide physician coverage for a dynamic service area.
• Determine and conduct an appropriate rounding schedule to accommodate skilled and custodial patient visit requirements.
• Conduct and appropriately document timely patient visits in compliance with clinical need and regulatory requirements.
• Efficiently manage long-term care (custodial) patients, including ACO REACH patients in nursing facilities.
• Participate in brief daily rounds for ACO REACH patients – discuss the change in status, condition with ACO REACH medical director.
• Manage medical care of patients on skilled days; ensure adequate visits according to contract requirements and medical necessity; effect safe and timely discharge from skilled level of care.
• Respond to direct phone calls and pages from 7:00 AM to 6:00 PM, Monday through Friday, according to CCMD policy.
• Initiate adequate daily communication with Call Center for review and follow-up of non-critical calls, pages, requests for orders, lab results, etc.
• Provide clear direction for nurse callbacks.
• Thorough and accurate medical documentation of all visits using SOAP format in group EMR.
• Dictate timely discharge summary for skilled patients returned to care of PCP.
• Participate equally in shared daytime weekend call with option to participate in overnight and weekend call for additional pay.
• Participate in QI program and Peer Review.
• Participate in utilization management program.
• Attend medical staff meetings.
• Active, ongoing patient/family communication.
• Appropriate CPT and ICD10 coding and daily submission of billing forms to office.
• Timely completion of all medical records and signing of telephone orders and charts in accordance with facility and other applicable requirements and regulations.

Rounding

The Supervising Physician is responsible for coordinating rounding schedules and team-specific work processes in collaboration with the clinical team. Patient visits are prioritized based on new admissions, whether patients are skilled or custodial, acuity of skilled patients, any changes in patient condition, follow-up of on-call phone log activity, family requests and routine (for subsequent custodial visits). Generally, Nurse Practitioners will be available to perform the admission history and physical, alternate routine custodial visits, and regular skilled and medically necessary visits as appropriate. They will also support the physician by handling laboratory results and responding to family and facility calls regarding patient care. These activities need to be coordinated between team members so that expectations are clear. Urgent pages require response within 15 minutes and routine pages within 60 minutes. In any case where clinical concerns or risk or quality issues exist, the NP is responsible for addressing these with the supervising physician. (See Figure 2.1)

Visit Requirements

• Both physicians and nurse practitioners perform patient visits. Requirements for various types of visits are defined in accordance with the Federal Omnibus Reconciliation Act of 1987 (OBRA), Title 22, Physician Responsibility Standards, applicable state law (see Appendix D, Legal and Regulatory) and individual facility policies.
• Nurse Practitioners will perform authorized medical services utilizing approved standardized procedures as contained in the Nurse Practitioner Standardized Procedures Manual (Appendix F, Nurse Practitioner Standardized Procedures).
• New Admissions: Either the physician or nurse practitioner may perform the admitting History and Physical (H&P) within the nursing facility unless the patient has traditional Medicare insurance. In this case, the NP may do the initial visit, however the physician is required to complete the History and Physical within 72 hours of admission. The supervising physician will countersign any nurse practitioner H&P and will see the patient as medically necessary.
• Skilled Visits: Skilled patients must be seen at least twice weekly. These visits may be performed by the physician or nurse practitioner, at the discretion of the supervising physician. Complexity of the case or any change in condition should be considered in making this judgment.
• REACH ACO Visits: Long-term care (custodial) patients that are part of our ACIO REACH High Needs program should have 2 provider visits a month. One of every 3 visits should be by the physician and the other 3 can be performed by either the physician or nurse practitioner as clinically indicated.
• Custodial Visits: Under California’s Title 22, custodial visits are required every thirty days. The physician and NP may perform alternate routine monthly visits to custodial residents.
• Medically Necessary Visits: The physician or nurse practitioner may see a patient for a repeat visit based on medical necessity, such as a change in condition or at the request of the family or patient. Any serious or significant clinical issue or change in status encountered by the NP requires notification of the supervising physician (see Title 22, Appendix D, Legal and Regulatory).
• Transfers to Acute Facilities/ER Evaluation: It is CCMD policy to notify the accepting physician when a skilled nursing patient is sent to an acute hospital or ER for an unplanned event or acute change in condition to ensure continuity of care. All unplanned transfers to acute level of care will be recorded on the Team Monthly Report.
• Planned Discharges: A dictated Discharge Summary needs to be completed for all planned discharges of patients who leave a facility for a lower level of care, including home, Board and Care and Assisted Living. A copy of the Discharge Summary is provided to the Primary Care Physician (PCP) of contracted medical groups for continuity of care. Patients who expire, return to an acute hospital, are transferred to another skilled nursing facility or transition over to custodial residents in the same facility do not require a discharge summary although it is reasonable to perform one for continuity’s sake.