Beyond Reporting and Enforcing: Innovating for Higher Medical Director Engagement

A recent study published in JAGS by Goldwein et al. [1], along with an accompanying editorial [2], once again highlights the gaps associated with the role of medical directors in skilled nursing facilities (SNFs). The study underscores key aspects such as the reporting of administrative tasks, the distinction between administrative and clinical responsibilities, and, at best, minimal influence of compliance and regulatory standards. Despite ongoing discourse on this subject, significant gaps remain, particularly concerning the impact of the medical director role, and the critical question persists: will this renewed attention catalyze actionable stakeholders into some action?

As a geriatrician, medical director, fractional chief medical officer for three NH chains, and co-founder of a technology platform designed to operationalize the medical director role across hundreds of SNFs, I offer unique insights, data, and potential solutions to advance this discussion constructively.

Operationalization of the medical director role requires a systematic approach involving strategic recruitment, well-defined contracts delineating expectations, continuous communication and training for medical directors and facility teams, and performance-based data sharing. A digital platform, centered on self-reporting of administrative (non-clinical) tasks by medical directors in accordance with Center for Medicare and Medicaid Services and Post-Acute and Long-term Care Medical Association (PALTmed) recommendations, offers a comprehensive mechanism to visualize and assess medical director engagement. When juxtaposed with the data reported by Goldwein et al., such insights could provide a more nuanced understanding of medical director contributions.

Data collected from our platform in 2024, encompassing 389 NHs across 22 states (Figure 1), indicates that most NHs report more than 10 h per month of administrative time for their medical directors. Review of the tasks illustrated the frequency of reported administrative tasks, with monitoring of clinical quality and metrics emerging as the most frequently cited activity (22%), followed by leadership meetings (14%). Notably, none of the surveyed NHs reported zero medical director hours for the year—a stark contrast to the 36.1% figure reported in PBJ data by Goldwein et al. This discrepancy underscores the pressing need for more accurate and standardized mechanisms for capturing and reporting medical director contributions.

Before addressing solutions for improved reporting and enforcement, a broader discussion on the medical director role itself is warranted. As Goldwein et al. emphasize, this role demands a clear and distinct definition. Unlike attending physicians or nurse practitioners, medical directors are entrusted with systemic responsibilities, including clinical governance, policy oversight, and quality improvement. Without clearly delineating these duties, their contributions risk being undervalued or misrepresented, even within facilities striving for regulatory compliance.

For decades, organizations such as the PALTmed have worked to define and provide training for medical directors, yet widespread impact remains elusive. It is imperative to reconsider expectations, execution, and enforcement related to this role (Table 1). The quality improvement frameworks in SNFs must be re-evaluated, along with the responsibilities assigned to various team members. Some tasks traditionally allocated to medical directors could be delegated to appropriately trained non-physician quality improvement champions. Such a redistribution would enable medical directors to focus on strategic oversight and clinical leadership.

Modernizing quality improvement tools through technology-based infrastructures—including automation and artificial intelligence—can enhance decision-making and drive better outcomes. For example, app-based solutions could enable medical directors to define their roles, track their activities, and receive data-driven nudges for targeted action. AI-powered systems could identify patients at risk of falls who are concurrently prescribed gabapentinoids and opioids, prompting timely interventions. Similarly, historical survey reports could be analyzed to predict potential regulatory deficiencies, allowing proactive engagement from medical directors.

While broader policy and technology-driven solutions will require time for implementation, resource-rich SNF chains can take immediate steps. Partnering with experienced physician leaders can help establish formal systems for medical director conduct, including the recruitment of qualified professionals with clearly defined expectations. Ongoing training initiatives, in collaboration with directors of nursing and administrators, should be prioritized. Furthermore, innovative incentive programs could motivate medical directors to engage meaningfully with facility leadership, fostering high-quality care [3].

In conclusion, while Goldwein et al. emphasize the significance of medical director presence, true progress depends on redefining the role, enhancing education, and leveraging technology to maximize impact. Without addressing these foundational challenges, enforcement efforts risk being superficial, failing to deliver the substantive improvements needed in SNF care.

The corresponding author A. N. was solely responsible for the conception, data collection, analysis, manuscript drafting, critical revisions, and final approval of the manuscript.

The author is the co-founder and has ownership in a digital product, CareAscend.com, that helps medical directors report their administrative time.

This publication is linked to a related article by Goldwein et al. To view this article, visit https://doi.org/10.1111/jgs.19161.