In recent years, seniors are voting with their feet.  We are living longer and becoming more disabled along the way.  These functional declines are often subtle in onset and progression, but eventually cause many to embrace some form of congregate living.  For many, the lower cost social model with more choices has been more attractive than the medical model of nursing homes.  Many ALFs (Assisted Living Facilities), RCFEs (Residential Care Facilities for the Elderly), and Memory Units now care for residents with similar medical complexity, polypharmacy, and functional decline as those living in SNFs. 

During the COVID pandemic, the necessity for improved infection prevention and control measures became obvious as well as the benefit of providing optimal geriatric care in house to reduce the reliance on emergency room care.   AMDA, The Society for PALTC Medicine in recognition of these opportunities, has developed a sub-section for ALFs and sponsored a webinar in May on “Current Issues from Infection Prevention to Clinical Management of Residents”.  Dr. Sarah Howd, MD, CMD presented on the potential role of Medical Director/Consultant/Advisor in these settings of care.  

As of 2016, in the USA, we had 28,900 resident care facilities with 810,000 residents.  26% of these residents had 4-10 chronic conditions (comorbidities) and 52% were > 85 y/o.  About 70% have cognitive impairment and many have medical frailty.  In one year, about 33% of all ALF residents visit the ER and about 24% are hospitalized.  

ALFs (unlike SNFs) are not required to have a Medical Director, but their geriatric expertise may help with infection prevention and control, the development and review of policies and procedures, the improvement of care transitions, the oversight of lab (CLIA Waivers) and immunization coverage, staff education, medical care oversight, and medical representation in the community.  As a consultant for a CCRC and the Medical Director of another CCRC, I’ve assumed the above roles and participated in virtual town hall meetings during the pandemic to provide timely information and address resident’s health care questions.  I’ve screened potential new residents for independent and ALF settings to make sure they are appropriate for our care capacities.  In addition, I’ve been an advocate for 5 “M’s” of Age Friendly Health Care focusing on:  What Matters Most to our patients, the importance of optimal Medication management, promoting safe Mobility, addressing issues of the Mind, and identifying/managing Multiple comorbidities. 

I agree with Drs. Resnick and Dowd that physicians should have a formal relationship with a contract for these services.  I’m also an advocate of monthly written activity reports which inform the administrator about the important contributions you’ve made on behalf of their residents, their families, and their business ecosystem.  Even though these services are not mandated by government agencies, forward thinking ALFs and RCFEs are beginning to embrace enhancing in-house geriatric expertise.  Is it time for you to step into these “new waters”?

Tim Gieseke MD, CMD