Advice from an Emeritus Medical Director

As some of you know, 2019 ended with the closing of my Post-acute & Long-term Care practice.  In the process, I turned over the care of my patients to 3 other physicians and my 2 facility Medical Directorships to 2 of my colleagues.  Having been the Medical Director for over 33 years at my CCRC, I have had some time to reflect on this role, beyond the CMS expectations and AMDA guidelines ((  

This may seem like a checklist, but I’ve found these elements to be important to my success and the success of my colleagues.  These include:

  1. Build respectful and caring relationships with administration, nurses, caregivers, activities personnel, social service workers, and the rehab team.

  2. Be visible in you facility daily and ask if there are any concerns you should be aware of knowing that your expertise & teaching role is best utilized at the bedside.

  3. Dress as a professional.  Your patients, families, & teams will know you take your role seriously and are there for them.

  4. Always wear a photo I.D.  Ideally this idea should have a red tag behind it which is labeled MD, or Doctor (what the local Kaiser team has done).  This is particularly important for women physicians, whom our patients and families commonly assume are nurses or caregivers.  In addition they may not hear you say you are a physician.  

  5. Use an integrated electronic medical record that allows you to draw forward pertinent past information easily into future notes.  This functionality has allowed me to efficiently document encounters and provide the necessary rational for my clinical decisions.  My experience with GehriMed, an EHR that integrates with Point Click Care, has been very favorable. In addition, it allows you to easily document your MIPS activity. 

  6. Work to gain access to the read functionality of your referring hospital EHRs.  I commonly find important clinical details in these records that affect my care plan on new admissions, which I otherwise would miss.  In addition, I get a better idea about who’s the PCP and consultants involved in the care plan of my new patient, which are seldom mentioned in the referral records. 

  7. Commit to identify and call patients’ DPOA or first contact persons at the time of admitting a patient.  Even if your patient is cognitively intact, those persons commonly have a different perspective or important concerns that may affect your care plan.  In addition, this allows you to set expectations and begin to create a therapeutic relationship that’s particularly important if clinical bumps in the road develop.

  8. Don’t delegate advance care planning.  Our nurses and social workers commonly attempt to do so, but seldom have the expertise or time to do it well.  Before you sign the document they create, begin this conversation and you will experience the “Joy” of helping people understand very complex and nuanced issues so they and/or their proxy can make truly informed decisions which can then be documented and trusted. 

  9. Your post-acute patients are much more complex, sicker, and more likely to have incomplete workups and transfer orders.  I have found it medically necessary to see most of these patients at least once a week. This should be a usual care standard for physicians working in your facility.  

  10. Commit to setting up a discharge process that begins on admission and includes you and the physicians in your facilities.  I have found it very helpful to talk to my patient's nurse, CNAs, and a member of the rehab team about my post-acute patients during most post admission visits.  This supports in-person discharges with summaries that can then be faxed to their PCP & consultants. Care transitions are too complex and important to rely on off-site electronically driven discharges.

  11. If an SNF nurse calls and says they are uncomfortable with a clinical situation and a hospital transfer doesn’t appear warranted, you should have a low threshold for seeing that patient ASAP.  This is a good way to assess, teach, and build the expertise of your facility nurses.  

  12. Realize that acute hospitals are your likely referral base and are a part of your success.  Work to build good relationships with them. Attend their medical staff meetings if possible.  Many hospitals now have regular meetings to collaborate with community SNFs. This is a place where you may have the opportunity to constructively share patient care concerns & mutual quality improvement projects.  

  13. Finally, commit to life-long learning.  Geriatrics is an evolving science. There is much to learn from the past, but also from new developments.  Each of us may have different ways of learning. For me, attending medical meetings at AMDA, CALTCM, & CCCC have been inspiring and have become my professional home.  Each has invaluable resources. In addition, the resources of AGS have been very valuable. This expertise, when applied, will bring you great joy and be a blessing to your facility, patients, and families.

Passing the torch,

Tim Gieseke MD, CMD

p.s. This list is not exhaustive.  I hope other experienced physicians and medical directors will add their comments via our blog option.  

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