On October 6, 2021, California Governor Newson signed Assembly Bill No. 749, which, among other things, established minimum training requirements for medical directors of skilled nursing facilities (SNFs). There was bipartisan support for the legislation, which represents a new standard for nursing home medical directors. Notably, there was not a single “no” vote in the California legislature for AB 749.
According to Dr. Michael Wasserman, Immediate Past President and current Chair of the California Association of Long Term Care Medicine’s (CALTCM) Public Policy Committee, “CALTCM is excited that California recognizes the importance of a competent and prepared medical director in improving the quality of care in nursing homes across the state.” Dr. Wasserman further noted, “We hope that this is the beginning of a new era for the state and nursing home industry to fully engage the experts in geriatrics and long term care medicine in efforts to improve quality.”
Among AB-749’s mandates is the requirement that a nursing home may not contract with a medical director unless that physician is – or will be within five years of the date of initial hire as the facility’s medical director – certified by the American Board of Post-Acute and Long-Term Care Medicine (ABPLM) as a Certified Medical Director (CMD). The ABPLM developed its CMD Program in 1991, and there are currently approximately 4,000 medical directors who have achieved the CMD designation. Significantly, the CMD credential is based on clinical competency, which indicates that those physicians who are CMD-certified have demonstrated their clinical acumen in geriatric care.
Dr. Albert Lam, CALTCM President, has noted that, “AB 749 is a critical win for patients, families, and health care providers in California. COVID-19 absolutely devastated our loved ones in nursing homes, and we must provide a higher standard of care to keep our patients safe. With AB 749, nursing homes across California will be able to count on medical directors who are trained and certified.” Dr. Lam further noted that, “This means that for the first time in any state across the US, all of the medical directors in our state will have the foundational education, training and certification needed to guide nursing homes forward to better care.”
CALTCM, which was the sponsor of the legislation, began in 1975 and represents California physicians, medical directors, nurses, pharmacists, administrators, and other professionals who work in long-term care. It is the only statewide organization in California focused solely on clinical quality in nursing homes.
The federal regulations regarding medical directors of Medicare-certified SNFs do not require any special training or certification. The applicable regulation requires that “The medical director is responsible for (i) the implementation of resident care policies; and (ii) the coordination of medical care in the facility.” 42 C.F.R. § 483.70(h). The spectrum of responsibilities of a medical director is extremely broad, and that individual plays a critical role in the quality of care rendered to all residents. Thus, requiring evidence of clinical competency seems to be a pragmatic approach to maintaining and improving the quality of care in SNFs.
There are approximately 15,500 SNFs in the United States, which suggests that more than two-thirds of the nation’s nursing facilities do not have a medical director who has earned the CMD status. Assuring that medical directors of SNFs have attained a demonstrable level of clinical excellence seems like good medicine, especially as the trend continues for SNFs to care for residents with increasingly challenging and complex medical issues often further compromised by multiple conditions of comorbidity.
There is an old adage that observes, “As California goes, so goes the nation.” It will be interesting to see how many states follow California’s lead in requiring certification for SNF medical directors. According to many thought-leaders in the area of long-term care, this is an idea whose time has come.