Working in an assisted living facility can have many benefits to a medical provider such as a doctor, advanced registered nurse practitioner, or physician assistant. It depends on which role you will provide to the facility.
Life in an assisted living facility can be fun, stressful, yet rewarding.
Working in this setting is usually an enriching experience for medical providers. You will have opportunities to practice medicine the way you feel is best for the patient and your lifestyle.
Physician life in Assisted living
Doctors usually work part-time in an assisted living setting. The doctor will often evaluate patients when they first arrive at the facility. Most facilities require an MD evaluation before moving into the facility or soon after move-in day.
Patients will be pleased and welcoming when the provider admits them to the facility with a medical examination. If you don’t want to be the one who evaluates the patient, you could always defer to an APRN or Physician assistant.
You will be treated with respect and be appreciated by the staff and patients at the facility if you show them the same common courtesy.
Medical visits completed in the resident’s apartment/home utilize the assisted living CPT codes which are very similar in structure to office visits but pay more!
APRN’s
Advanced nurse practitioners often are assigned to assisted living facilities. Most APRN’s that I know appreciate the autonomy of working in this setting.
Similar in structure to a doctor visit, they will round on the patients usually seeing them in their apartments. The APRN will sometimes see the patients in the facility “office.”
They become friends with the nurses and staff developing into an integral component in the care team.
Physicians Assistants
The assisted living facility is usually considered an extension of the physician assistant office practice. Many are taking time out of their day to round and evaluate residents assigned to their office doctor.
This break in their day helps to add variety and a change in pace to the regular office visits. This isn’t to say that a PA cannot focus on just assisted living, but I have found the blended model is more the norm.
The PA can do very well in this setting, providing medical care. It is a natural extension of the role they were trained to manage.
Home visit in Assisted Living Facility
Most patients prefer an evaluation in their apartment/home as opposed to the facility office setting. We find that the convenience home visits provide to the resident is much appreciated.
Home visits at the assisted living facility will mean the patient doesn’t have to wait for a provider in the waiting room or hallway. They will also be more relaxed in there own home setting.
Many residents will use their home phone to call their loved ones so that they can be a part of the visit. Having the family member on the phone will allow you to ask questions and make sure you address all issues.
Office Visit in Assisted Living
Some assisted living facilities will modify an area of campus to look like a primary care office. The E&M visit done in the ALF primary care office should be billed using the office visit CPT codes.
Most offices in the assisted living will have an exam table with seating. There will also be an area for the provider to chart and write out prescriptions.
The office may have mounted blood pressure cuffs and otoscopes in the rooms. If not, then they will have portable equipment to make your life easier.
Most exam rooms in the ALF will be basic, so don’t expect to see advanced medical equipment. The common supplies typically found in an exam room will rarely be seen, such as tongue depressors, glucometers, alcohol swabs, and other supplies. Many providers will bring their supplies and store them in the office.
If you see patients in the facility office setting, you will feel like your back at your office. Evaluating patients in their office allows you to have all the tools within your reach. You will have a place to sit and document on the resident.
Waiting room
If there is a waiting room for patients near the facility office, it will usually be small. You may be able to fit one or two residents.
Having one office with a small waiting room could potentially slow your visit time as you wait for new residents to arrive and get set up in the office. Having the patients complete evaluation paperwork and forms while they wait can speed up times.
Medical Assistant assigned to the provider
You can improve the quality of life by having a medical assistant working with you. The MA can help bring patients from their rooms to the medical office.
The MA obtains vital signs, starts progress notes, collects paperwork, files notes, makes followup calls, assists with scheduling specialty appointments, and more.
If trained correctly, the MA can take on the role of scribe. The more you train them in the use of EHR, the more useful this staff member can become.
Utilized correctly, a medical assistant can improve the provider’s efficiency and allow them to evaluate patients quicker, with potentially less stress.
Medical Directorships
There isn’t a requirement that the assisted living facility has a medical director. Most doctors either follow their patients from their office setting or get assigned to them at the facility.
By having one or two doctors assigned to the patients, the assisted living facility can focus their attention on them. They work together to maintain a safe environment for the patients and staff.
Having the pseudo-medical director role can lead to an enjoyable, mutually beneficial relationship. There will be a better collaboration of care between the staff, patients, other providers, and the doctor.
Unlike nursing homes, facilities paying a financial stipend to be a medical director is much rarer. They will often market the services of the doctor in the facility. In return, the provider builds up a panel of patients they provide with medical care.
Medical model ALF
Assisted living facilities that operate with a “medical model” take on much sicker patients than your average assisted living home. Therefore they need more medical oversite and care.
Medical model ALF may elect to bring in a medical doctor who acts as a medical director. They will be paid a small stipend for their services due to the need for more medical oversite.
“Medical model” homes benefit from having the doctor, APRN, and physicians assistants at their facility. The increased presence of medical providers helps avoid “readmits” to the hospital.
These types of assisted living facilities are quickly becoming a
step-down unit” for nursing homes. Most patients are being discharged quicker to the community still requiring sick care from Aids, Nurses, and medical providers.
Paperwork in the Assisted Living Facility
Unfortunately, paperwork is something all medical personal cannot avoid. Just like in the primary care offices, there will be labs to review, orders to sign, refills of medications, and more.
Facilities that provide medical management of their residents will have service plans or orders that need signatures from a medical provider. These are straight forward order sheets that list the medications that the resident is currently taking.
These medication plans will usually have a statement indicating that the resident is stable for the assisted living setting. They will often want you to document this in a note once a year or more if having a change in the condition of the resident.
Unlike nursing homes, medical providers cannot give verbal orders to patients. They will need to either write a prescription or write out instructions of care and deliver to the facility to implement.
The families will sometimes request additional forms such as veteran benefits forms, statements of disability, FMLA paperwork for family members, and prior authorizations for medications.
Medication Management
There are three types of medication management in the assisted living setting.
1. Self-management:
The patient can manage medications themselves with minimal assistance from support staff. They will set up their schedules for taking the meds. The visiting nurses who do not have an affiliation with the ALF can set up pillboxes that identify the days of the week or take the pills out of the bottles.
Many of these same residents will eventually need assistance with medication management, and their age or disease state progresses.
The medical provider will need to send refills to the pharmacy when residents request or during visits to the facility.
2. Family support:
This can be a bit more challenging requiring the families to obtain the meds from the pharmacy, dispense the pills and followup on refills. The family will usually try to participate in medical visits when they are visiting.
When the family is managing the medications, it can be challenging for the facility and resident. When medication changes occur before the family visits, the family member will have to make an unplanned trip to the pharmacy.
The nurses will need up to date medication lists from the family to assist with care. Residents will often ask for medication assistance, but the facility will need to be contracted for this service to provide help.
3. Long term care contracted pharmacy:
This is usually the easiest way for the resident because the facility and pharmacy handle the medications.
The facility will attempt to get refills in a timely fashion. If there exist problems with medications, it is easier for staff to communicate the problem with the pharmacy, provider, and family.
Typically, the facility has a contract with a long term care specialty pharmacy that will provide the medication in blister packs. Blister packs make it easier for nurses to dispense the medicines. The patients can sometimes have access to blister packs, making personal med management easier.
When the patient uses the local pharmacy as opposed to the facility pharmacy, the medication list isn’t always up to date with the staff. Therefore it will require medication reconciliation by the provider at each visit.
Progress notes
Documentation in this setting is very similar to the office setting. However, one difference is the need to document the reason for seeing patients in this setting.
Visits in the assisted-living setting can be documented using an electronic health record or paper progress notes. It is usually best to use electronic health records due to the ability to look up previous progress notes at a later date.
The assisted living facilities are not always good at filing your notes in the chart. You may want to keep a copy of your paper notes as a backup and file them yourself.
You can scan them with a portable scanner or file them at your office. Having a copy will prevent issues down the road if you get audited or someone requests your visit note.
Use of Electronic Health Records in an Assisted living facility
Utilizing an electronic health record will improve your ability to make clinical decisions at a later date. The EHR allows you to access the patient’s medication list from the recent med reconciliation.
You can check their allergies and review their diagnosis list. The EHR is helpful when you receive calls when not at the facility. The nurses don’t always have the patient information allowing you to prescribe correctly.
The actual documentation of the note should progress much smoother and capture more data using an EHR. We find it very limiting using paper, obtaining all the data components of the visit. The facility also appreciates neatly typed notes for their records.
The physician provides sick care E&M visits for the patients on an as-needed basis. These visits are very similar to medical appointments performed in-office setting.
In Conclusion
Life in an assisted living facility is very similar to working in nursing homes with less support from staff. However, you will be paid more per visit for providing the extra services, but you will need to take care of more busywork.
The work you perform in this setting is usually appreciated. However, there will still be the challenge of families wanting to be involved even when they are not at the facility for visits.
You will need to set boundaries with staff, residents, and families to allow you to perform your role as a doctor, APRN, or PA in the facility. With time, this setting can be rewarding, and you will enjoy working as a medical provider in this setting.
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