LONG-TERM CARE PANEL REPORT1

INTRODUCTION

This panel was established in early 1990 to assist the IOM study committee in developing a VA physician requirements methodology that successfully incorporated the long-term care program at VA medical centers. The panel, consisting of five geriatricians, one orthopedic surgeon, and one nonphysician practitioner, met twice during 1990 and participated in other efforts to advise the study committee on appropriate physician staffing for this clinical program. The chairman of the panel was also a member of the study committee; the panel roster is attached. Additional details describing the analysis process followed by this and the other seven specialty and clinical program panels can be found in the “Overview” to this section of Volume II. The panel roster is attached.

This report summarizes the analyses conducted by the panel and its recommendations to the study committee.

EXPERT JUDGMENT APPROACHES TO DETERMINING PHYSICIAN REQUIREMENTS IN LONG-TERM CARE
The Detailed Staffing Exercise (DSE) Approach
Initial Efforts

A central purpose of the panel's first meeting, held in April 1990, was to help determine whether the expert judgment approach to staffing being developed by the study committee could be applied validly to long-term care.

1  

The initial draft of this report was prepared by Judith L.Teich, Staff Officer to the Long-Term Care Panel during the conduct of the study. This final report was prepared by the editors of this Volume.



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Physician Staffing for the VA: VOLUME II LONG-TERM CARE PANEL REPORT1 INTRODUCTION This panel was established in early 1990 to assist the IOM study committee in developing a VA physician requirements methodology that successfully incorporated the long-term care program at VA medical centers. The panel, consisting of five geriatricians, one orthopedic surgeon, and one nonphysician practitioner, met twice during 1990 and participated in other efforts to advise the study committee on appropriate physician staffing for this clinical program. The chairman of the panel was also a member of the study committee; the panel roster is attached. Additional details describing the analysis process followed by this and the other seven specialty and clinical program panels can be found in the “Overview” to this section of Volume II. The panel roster is attached. This report summarizes the analyses conducted by the panel and its recommendations to the study committee. EXPERT JUDGMENT APPROACHES TO DETERMINING PHYSICIAN REQUIREMENTS IN LONG-TERM CARE The Detailed Staffing Exercise (DSE) Approach Initial Efforts A central purpose of the panel's first meeting, held in April 1990, was to help determine whether the expert judgment approach to staffing being developed by the study committee could be applied validly to long-term care. 1   The initial draft of this report was prepared by Judith L.Teich, Staff Officer to the Long-Term Care Panel during the conduct of the study. This final report was prepared by the editors of this Volume.

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Physician Staffing for the VA: VOLUME II The focus of this analysis was the initial draft of a physician staffing instrument, which required the expert to assess the time (and hence FTEE) required by geriatricians to render patient care, work with residents, and perform other tasks at the VA medical center (VAMC). To test this approach, staffing instruments were constructed for three actual VAMCs. Each facility was portrayed as consisting of a set of patient care areas (PCAs), where direct patient care and resident training occur. Among these PCAs were two assumed to be focal points for geriatricians: the nursing home and the intermediate care ward(s). For each PCA, data were presented on the volume of patient workload expected, the number of residents available, and the overall availability of nursing and support staff. The critical question with respect to every PCA was, how much geriatrician time is required, in total, to meet these VA mission-related demands in the course of a typical workday? Each PCA was analyzed, in turn, and total long-term care physician FTEE for the facility was computed. Additional questions at the end of the instrument elicited FTEE requirements for weekend coverage, special procedures, and non-VA physician consultants. In the course of this first meeting, the panel reached several initial conclusions about the assumptions that should underlie the development of subsequent physician staffing instruments: The instrument should be refined to capture more accurately the reality of staffing in the LTC PCAs. In particular, the overall accuracy of physician time assessments could be improved, it was suggested, if the instrument incorporated some type of algorithm for distinguishing among the specific tasks performed in the PCAs: admission work-up, rounds, discharge, etc. More patient-specific information should be provided for each PCA: the average length of stay (LOS), the admission rate, the discharge rate, and the relative proportion of new patients in the total census. Long-term care units should be staffed by numbers of physicians of different specialties; for example, in order to provide comprehensive care, physicians in rehabilitation medicine, surgery, gastroenterology, and psychiatry all should have input into the care of long-term patients. The amount of time contributed on long-term care units by physicians in each of these specialties needs to be addressed. At this first meeting the panel also reviewed and evaluated the initial versions of the empirically based physician staffing model.

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Physician Staffing for the VA: VOLUME II Following the first round of meetings for all eight specialty and clinical program panels, there was convened (in May 1990) Joint Meeting I involving the study committee, the data and methodology panel, and the VA liaison committee. Progress to date on both the expert judgment and empirically based model approaches was evaluated. After reviewing the reports submitted by each panel, the study committee recommended that work proceed on developing a more internally consistent and comprehensive instrument for determining physician requirements by expert judgment. A broadly similar approach should be adopted by each panel, but the instrument for each specialty or program area should be tailored to its specific characteristics. DSE: Overall Rationale For the long-term care panel's second meeting, held in August 1990, three additional VAMCs (denoted here and in the committee report [Volume I] as VAMCs I, II, and III) were analyzed using a revised version of the initial staffing instrument. This new instrument—later termed the Detailed Staffing Exercise (DSE) —was developed on the basis of the panel's critique delivered at the first meeting, plus general instructions from the study committee at the conclusion of Joint Meeting I. As before, each DSE was specific to an actual VAMC. This revised instrument described each PCA in greater detail than before, including more specific information on the VA patient population (e.g., admission rate, length of stay, and DRG mix). In general, the underlying concept behind the DSE is to provide information in sufficient detail about the VAMC that the respondent can assess physician staffing requirements almost as if he/she were reviewing data at the facility. Instructions and Assumptions To illustrate how the DSE works, a completed version of the instrument is presented as Exhibit 1 of the “Overview” to this section of Volume II. This DSE is nearly identical structurally to the one constructed for long-term care. As indicated in Exhibit 1 of the Overview, each DSE has an A and B section. Section A elicits the amount of time, in hours, required to provide quality care for individual PCAs of the VAMC. For each PCA, information is provided on the volume and DRG mix of workload, number of residents by postgraduate year, number of nonphysician practitioners (e.g., nurse practitioners, physician assistants), and general information about the adequacy

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Physician Staffing for the VA: VOLUME II of nursing and support staff. Section B focuses on physician activities not addressed in Section A, such as night and weekend coverage, non-patient-care-related activities off the PCA, and leaves of absence. The Panel Responds Before the second meeting, panelists were mailed DSEs for VAMCs I and II; these were completed independently and returned prior to the meeting. The staff compiled these results on a spreadsheet showing the high, low, mean, and median responses. At the second panel meeting, these DSEs were discussed thoroughly to determine whether panelists were using similar assumptions and to allow members to discuss the underlying reasoning behind these calculations. Following this, the panelists were asked to reassess physician requirements in medicine at VAMCs I and II, again working independently. Subsequently, a third exercise, constructed for VAMC III, was distributed and the panel worked as a group to estimate staffing requirements. Following the assessment, the actual CDR numbers for VAMCs I, II, and III were displayed for comparison. During the group discussion, the panel was asked to reflect on whether certain “rules of thumb ” were used (perhaps implicitly) to help quantify staffing requirements. Interim Assessment of Expert Judgment Staffing Approaches The panel, beginning at its first meeting, discussed alternative and more compact formats for obtaining estimates of the time required by LTC physicians to perform specific tasks in the PCAs. One of the panel's early proposals can be summarized as follows:

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Physician Staffing for the VA: VOLUME II Possible Algorithm for Long-Term Care Physician Staffing   Type of Unit   Nursing Home Care Unit Geriatric Assessment Geriatric Psychiatry Domiciliary I. Direct Patient Care Activity   Admissions/ Evaluation   (For each type of unit and activity combination, the respondent would estimate the required number of physician hours per week.) Discharge Rounds Team Meetings Family Conferences   II. Non-Patient-Care Activity   Teaching/Research Administration   If Medical Director If not Medical Director   Also discussed at the panel meetings were possible questionnaire formats for estimating the amount of physician time from each VA specialty required for consultation on long-term care units. Panel members suggested a matrix (shown below) as one possible means of addressing this issue. It was also recommended that if such expert judgment-based estimates were obtained, they should be compared with the actual FTEE estimates for such consultations, as found in the VA's cost distribution report. In addition, estimates by other specialty panels of the amounts of time which they feel their physicians need to contribute to long-term care units might be usefully compared with what LTC physicians estimate to be the appropriate amount of consultation. Routine input from various specialties to long-term care should be considered an important part of any future model. How this data collection might proceed is illustrated in the following skeletal table:

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Physician Staffing for the VA: VOLUME II Recommended Physician Input from Various Specialties Number of MD Hours per Weekday Required from:   Med. Surg. Psych. Rehab. Med. Neuro. Other1 Illustrative LTC Unit:   Geriatric Medicine Beds=22 ADC=19 LOS=27   Intermediate Care Unit Beds=33 ADC=27 LOS=27   NHCU (I) Beds=78 ADC=74 LOS=109   NHCU (II) Beds=25 ADC=22 LOS=109   1To be specified by the respondent. At its second meeting, the panel also developed a simple topology to help it analyze the time required by LTC physicians in PCAs other than the nursing home and intermediate care: Geriatric consultations for management only Without NPP With NPP

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Physician Staffing for the VA: VOLUME II Assessment/screening for long-term care admissions Without NPP With NPP These activities constitute an important part of the long-term care physician's responsibilities. The amount of time needed for each type of activity should be considered in assessing overall physician requirements for long-term care. In addition, it was emphasized that the nature of an intermediate care PCA may vary markedly from facility to facility. This PCA may consist, alternatively, of: Distinct units where the LTC physician provides primary care; or Distinct units where the LTC physician has a consultative role only; or No distinct units (beds dispersed throughout other services) and the LTC physician has a consultative role. Given these discussions, the LTC panel was subsequently pleased to see the study committee propose an expert judgment format such as SADI, which reflects the spirit of the panel's discussions. The Staffing Algorithm Development Instrument (SADI) Approach SADI: Overall Rationale Following the second round of panel meetings, the study committee initiated a set of postmeeting activities to assist the specialty and clinical program panels in arriving at consensus positions regarding the most appropriate methodology for VA physician staffing. These recommendations would be regarded as advisory to the committee. A central feature of these activities was the introduction of the Staffing Algorithm Development Instrument (SADI). The overall purpose of the SADI was to help test, build upon, and ultimately strengthen the rules of thumb for staffing that emerged from the second meetings of all eight panels. It represents an alternative, more compact means to derive physician requirements, by specialty or program, for any given VAMC.

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Physician Staffing for the VA: VOLUME II Instructions and Assumptions Like the DSE, the SADI has two sections, A and B, which focus on patient care and non-patient-care activities, respectively. In Section A, the respondent is asked to estimate the amount of physician time required to complete a number of patient care functions and tasks under varying assumptions about the availability of residents and nonphysician practitioners. In Section B, the respondent must determine the amount of physician time that should be allocated to research, classroom instruction, continuing education, administration, and leaves of absence. To derive physician requirements for a given VAMC, the estimated physician hours for patient care and non-patient-care activities are summed, then converted to FTEE under the assumption that 40 hours per week translates into one FTEE. Presented in Figure 1 of this report is the long-term care SADI, complete with the panel 's median estimates for physician task times. A detailed and self-contained, illustration of how the SADI can be applied to determine the number of physicians required at a given VAMC is found in Exhibit 3 of the “Overview” to this section of Volume II. This example happens to focus on internist requirements at VAMC I; the application of SADI to determine long-term care FTEE at a given facility proceeds in a virtually identical fashion. A careful study of the example reveals the type of facility-specific data needed to implement any SADI. Although the information requirements of the DSE are greater, both of these expert judgment approaches require data (e.g., on frequency of consults across PCAs) not presently collected in the VA system. EMPIRICALLY BASED APPROACHES TO DETERMINING PHYSICIAN STAFFING FOR THE LONG-TERM CARE PROGRAM Of the 14 patient care areas defined by the study committee, two were specifically designated as “long-term care”: the nursing home and the intermediate care areas of the VAMC. In its two meetings and a follow-up conference call, the panel was presented alternative specifications of production function models estimated for each of these two PCAs. Table 2 shows the final versions of these estimated models, as derived in cooperation with the study's data and methodology panel. Each PF model depicts the workload produced (per time period) in that LTC PCA as a function of the amount of specialty-specific physician FTEE and nonphysician FTEE

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Physician Staffing for the VA: VOLUME II caring for patients in the PCA; in the intermediate care PCA, the VAMC's RAM Group status, reflecting both hospital size and degree of affiliation, is also an important factor in accounting for differences in workload productivity across the sample. Workload in each PF is defined as the total Resource Utilization Group Weighted Work Units (RUGWWUs) generated in the PCA during the fiscal year. This output variable is based, as suggested, on the well-known Resource Utilization Group (RUG) methodology for indexing the expected amount of patient care (largely nursing care) required by a patient. In these statistical models, total RUGWWU is defined as the sum of the medicine, psychiatry, and rehabilitation medicine RUGWWUs generated in the PCA during the fiscal year. As illustrated in chapter 4 of the committee report (Volume I), each PCA-specific model can be used to derive alternative combinations of specialty-specific physician FTEE that are consistent with meeting the patient workload expected in that PCA. However, neither the nursing home nor intermediate care model can be used to derive the amount of FTEE required by long-term care physicians in the VAMC 's 12 other patient care areas. Thus, for example, these PFs do not account for physician involvement in the geriatric evaluation units (which are, in fact, analyzed as part of the inpatient medicine PCA). Nor do they incorporate physician time spent in consultations on inpatient wards or in ambulatory clinics. In sum, the PF models provide an in-depth look at workload production in the nursing home and intermediate care wards, but do not encompass all patient care activities that fall properly under the purview of the long-term care program at the VAMC (e.g., adult day health care). No inverse production functions have been estimated for long-term care. As specified in this study, the IPF is specialty-specific (e.g., medicine, surgery, psychiatry); and the VAMC as a whole, not the PCA (in the VAMC), is the basic unit of observation. On the other hand, the long-term care program is multidisciplinary and concentrated largely in certain PCAs within the VAMC. Nonetheless, the influence of long-term care workload on VA physician requirements is reflected in each IPF—to the extent the independent variable RUGWWU is contained in the equation as a (statistically significant) predictor of physician FTEE required for patient care and resident education in the associated specialty.

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Physician Staffing for the VA: VOLUME II PHYSICIAN STAFFING RESULTS FROM APPLICATION OF EMPIRICALLY BASED AND EXPERT JUDGMENT APPROACHES In Table 1 are alternative estimates of physician requirements for long-term care at VAMCs I, II, and III in FY 1989, as derived from: the VA 's cost distribution report (CDR), the PF variant of the empirically based physician staffing models, the DSE (from the second panel meeting), the SADI (in both its “pure” and modified formats), and a mail survey of panel members conducted just prior to Joint Meeting II (held September 7–9, 1990). In interpreting these results, two important considerations must be kept in mind. First, because the sample of facilities is so small, one must be very cautious in drawing conclusions from the table about the appropriateness of current physician staffing in long-term care across the VA system. The main purpose of studying these VAMCs in detail was not to draw inferences about whether they were appropriately staffed, but to test the feasibility and appropriateness of alternative approaches for calculating physician requirements. Second, the FTEE estimates derived from the CDR and the PF model are for total physician requirements for the two PCAs, nursing home and intermediate care, that the study defined early on as making up “long-term care. ” In particular, these estimates do not include physician FTEE for extended care and geriatric activity not occurring in these two PCAs. On the other hand, the four expert judgment-oriented estimates for each VAMC are for the total amount of FTEE for geriatricians at the facility (across all PCAs). Given the structure of both the long-term care DSE and SADI, these estimates do not include FTEE for consults by nongeriatricians to the nursing home and intermediate care PCAs. Hence, by definition, they are not comparable to those from the CDR and PF model. Both the DSE and the SADI (not modified) yield total physician FTEE estimates that are relatively close to the median of panelist responses to a mail survey conducted in the fall of 1990. In fact, the DSE estimates are closer to these medians than are the SADI results. However, the panel believes that for application across the VA system, an expert judgment process based on the SADI would be less costly and more administratively efficient than one based on the DSE.

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Physician Staffing for the VA: VOLUME II EXTERNAL NORMS Data-Gathering Activities Following the first panel meeting, a memo was sent to members requesting suggestions for specific non-VA long-term care facilities that could provide an appropriate “yardstick” for staffing. Private facilities that were suggested and then contacted by staff included: North Shore University Hospital, Center for Extended Care and Rehabilitation, Manhasset, NY Hebrew Home of Greater Washington, Washington, DC Levindale Hebrew Geriatric Center and Hospital, Baltimore, MD Bethesda Nursing Home, Minneapolis/St. Paul, MN Northridge Nursing Home, Minneapolis/St. Paul, MN Hennepin County Medical Center, Minneapolis/St. Paul, MN Methodist Hospital, Hospital-Based Home Care Unit, Minneapolis/St. Paul, MN Langton Lakes Nursing Home, Dementia Unit, Minneapolis/St. Paul, MN Staff also contacted the American Association of Homes for the Aging, which provided information from the State Operations Manual on Provider Certification (U.S. Department of Health and Human Services, Health Care Financing Administration, September 1989) regarding regulations for Skilled Nursing Facilities (SNFs) and Intermediate Care Facilities (ICFs). With regard to physicians, the Interpretive Guidelines for Nursing Facilities and ICFs state that, “the resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 90 days thereafter.” For SNFs, the Guidelines indicate that, “the resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter.” Several of the facilities provided a comprehensive picture of their services and staffing, which could be used as a comparison with VA long-term care facilities. North Shore Hospital's Center for Extended Care and Rehabilitation, for example, has an average length of stay of 50 days and an average daily census of 186 patients. It is physically adjacent to the hospital, and in this way is more similar to most VA nursing home care units than most private community nursing homes, which are freestanding. The center has a medical director described as being full-time; however, he is also the chief of the

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Physician Staffing for the VA: VOLUME II Chart 3 Nursing Home Ward Average LOS=115 days Assume 1 PGY 4-Level Resident   ADC 1 ADC 10 ADC 20 ADC 30 ADC 40 ADC 50 Daily Rounds High 0.03 0.15 0.30 0.60 0.80 1.00   Low 0.00 0.00 0.08 0.12 0.16 0.20   Mean 0.01 0.07 0.14 0.29 0.33 0.49   Median 0.05 0.08 0.10 0.25 0.33 0.41 Charting, Phone, and Paperwork High 0.01 0.01 0.16 0.30 0.40 0.50   Low 0.00 0.00 0.00 0.00 0.00 0.00   Mean 0.00 0.04 0.07 0.15 0.18 0.03   Median 0.00 0.00 0.08 0.10 0.10 0.17 Patient and Family Contacts plus Teaching High 0.05 0.50 1.00 1.50 2.00 2.50   Low 0.00 0.00 0.05 0.08 0.08 0.17   Mean 0.03 0.13 0.26 0.38 0.50 0.63   Median 0.03 0.04 0.08 0.12 0.16 0.20 Supervision and Teaching (Residents/Staff) High 0.25 0.60 1.21 1.80 2.80 3.00   Low 0.01 0.08 0.16 0.20 0.20 0.20   Mean 0.13 0.27 0.40 0.71 0.28 0.94   Median 0.13 0.20 0.25 0.33 0.33 0.40 TOTALS High 0.28 1.30 2.50 3.90 5.60 6.50   Low 0.00 0.16 0.32 0.48 0.64 0.80   Mean 0.14 0.50 0.93 1.45 2.0 2.30   Median 0.13 0.40 0.55 1.00 1.20 1.40

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Physician Staffing for the VA: VOLUME II Chart 4 Geriatric Evaluation Unit Average LOS=10 days Assume 1 PGY 4-Level Resident   ADC 1 ADC 3 ADC 5 ADC 7 ADC 9 ADC 11 Daily Rounds High 0.60 0.60 0.83 1.16 1.50 1.83   Low 0.08 0.11 0.14 0.17 0.20 0.25   Mean 0.44 0.34 0.44 0.53 0.71 0.79   Median 0.17 0.25 0.33 0.42 0.60 0.60 Charting, Phone, and Paperwork High 0.08 0.11 0.16 0.17 0.25 0.25   Low 0.00 0.00 0.00 0.00 0.00 0.00   Mean 0.04 0.05 0.08 0.08 0.12 0.13   Median 0.02 0.08 0.08 0.08 0.17 0.17 Patient and Family Contacts plus Teaching High 0.25 0.25 0.30 0.30 1.00 1.00   Low 0.00 0.00 0.00 0.00 0.00 0.00   Mean 0.08 0.11 0.13 0.15 0.32 0.34   Median 0.04 0.08 0.12 0.16 0.20 0.25 Supervision and Teaching (Residents/Staff) High 0.50 1.00 1.66 2.32 3.00 3.67   Low 0.08 0.17 0.17 0.17 0.25 0.25   Mean 0.30 0.48 0.69 0.86 1.10 1.26   Median 0.34 0.40 0.48 0.64 0.83 1.00 TOTALS High 1.08 1.55 2.57 3.60 4.65 6.29   Low 0.30 0.52 0.75 0.83 1.00 1.00   Mean 0.65 0.96 1.34 1.60 2.25 2.64   Median 0.53 1.00 1.00 1.14 1.40 1.75

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Physician Staffing for the VA: VOLUME II In some cases, the long-term care program may have the primary responsibility for managing the intermediate bed service. Please complete the following charts, again estimating the number of hours required per day from the long-term care program. Chart 5 Intermediate Ward Average LOS=45 days Assume No Residents   ADC 1 ADC 10 ADC 20 ADC 30 ADC 40 ADC 50 Daily Rounds High 0.07 0.67 1.33 2.00 2.67 3.33   Low 0.03 0.25 0.50 0.50 0.50 1.00   Mean 0.05 0.48 0.96 1.38 1.79 2.33   Median 0.05 0.50 1.00 1.50 2.00 2.50 Charting, Phone, and Paperwork High 0.03 0.50 1.00 1.50 2.00 2.50   Low 0.03 0.25 0.50 0.50 0.50 1.00   Mean 0.03 0.35 0.69 0.98 1.26 1.71   Median 0.03 0.32 0.63 0.95 1.27 1.67 Patient and Family Contacts plus Teaching High 0.67 0.67 1.33 2.00 2.67 3.33   Low 0.02 0.15 0.30 0.45 0.50 0.50   Mean 0.24 0.34 1.18 0.96 1.24 1.70   Median 0.03 0.28 0.55 0.70 0.90 1.21 Supervision and Teaching (Residents/Staff) High 0.33 0.30 0.60 0.90 1.20 1.67   Low 0.02 0.10 0.12 0.16 0.16 0.30   Mean 0.13 0.19 0.26 0.36 0.45 0.69   Median 0.03 0.19 0.16 0.19 0.21 0.40 TOTALS High 0.20 1.79 3.45 5.16 6.83 8.63   Low 0.00 0.83 1.67 1.67 1.67 3.00   Mean 0.11 1.32 2.59 3.67 4.74 6.30   Median 0.12 1.33 2.63 3.93 5.22 6.78

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Physician Staffing for the VA: VOLUME II Chart 6 Intermediate Ward Average LOS=45 days Assume 1 PGY 4-Level Resident   ADC 1 ADC 10 ADC 20 ADC 30 ADC 40 ADC 50 Daily Rounds High 0.03 0.33 0.67 1.00 1.33 1.67   Low 0.00 0.00 0.08 0.08 0.17 0.17   Mean 0.02 0.20 0.39 0.57 0.78 1.00   Median 0.03 0.20 0.40 0.60 0.80 1.09 Charting, Phone, and Paperwork High 0.01 0.10 0.20 0.30 0.40 0.50   Low 0.00 0.00 0.00 0.00 0.00 0.00   Mean 0.00 0.05 0.10 0.15 0.20 0.25   Median 0.00 0.05 0.10 0.15 0.20 0.25 Patient and Family Contacts plus Teaching High 0.05 0.50 1.00 1.50 2.00 2.00   Low 0.00 0.00 0.08 0.08 0.08 0.08   Mean 0.02 0.20 0.40 0.58 0.77 0.83   Median 0.02 0.12 0.25 0.38 0.50 0.63 Supervision and Teaching (Residents/Staff) High 0.67 0.67 1.33 2.00 2.67 3.33   Low 0.02 0.08 0.17 0.17 0.25 0.25   Mean 0.25 0.39 0.78 1.17 1.56 1.80   Median 0.05 0.40 0.80 1.25 1.65 1.80 TOTALS High 0.14 1.40 2.80 4.20 5.60 6.17   Low 0.00 0.08 0.33 0.33 0.50 0.50   Mean 0.07 0.81 1.66 2.47 3.30 3.88   Median 0.07 0.88 1.75 2.68 3.55 4.43

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Physician Staffing for the VA: VOLUME II TIME PER INITIAL CONSULTATION OFF YOUR PCA Fill in the average time in hours required by a staff physician in the long-term care program for each initial (new) consult on another service, noting the presence or absence of a nonphysician practitioner (NPP) in your own service. (When an NPP is present, assume that he/she is performing the consult under the supervision of an attending physician.) Chart 7 Consultation in this PCA Time per Consult without NPP Time per Consult with Long-Term Care NPP   High Low Mean Median High Low Mean Median Neurology 2.00 0.50 1.30 1.50 0.50 0.08 0.38 0.50 Surgery 2.00 0.25 1.25 1.50 0.50 0.08 0.38 0.50 Medicine 2.00 0.25 1.10 1.00 0.50 0.08 0.38 0.50 Rehab. Med. 2.00 0.50 1.15 1.00 0.50 0.08 0.38 0.50 Psychiatry 2.00 0.50 1.25 1.50 0.50 0.08 0.38 0.50 TIME PER FOLLOW-UP VISIT (POST-CONSULTATION) OFF YOUR PCA Fill in the average time in hours required by a staff physician in the long-term care program for each follow-up consultation visit on another service, noting the presence or absence of a nonphysician practitioner (NPP) from your service. Chart 8 Consultation in this PCA Time per Visit without NPP Time per Visit with LTC NPP   High Low Mean Median High Low Mean Median Neurology 0.50 0.08 0.32 0.30 0.25 0.15 0.15 0.17 Surgery 0.50 0.02 0.31 0.30 0.25 0.02 0.15 0.17 Medicine 0.50 0.02 0.29 0.30 0.25 0.02 0.15 0.17 Rehab. Med. 0.50 0.02 0.31 0.30 0.25 0.02 0.15 0.17 Psychiatry 0.50 0.02 0.31 0.30 0.25 0.02 0.15 0.17

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Physician Staffing for the VA: VOLUME II SPECIAL PROGRAMS Fill in the average time, in hours, per week required by a staff physician in the long-term care program for any special program not previously accounted for, noting the presence or absence of a nonphysician practitioner (NPP). Chart 9 Special Program Assume Physician Makes No Home Visits (Supervises NPP) Assume Physician Makes All Home Visits   High Low Mean Median High Low Mean Median HBHC (Hospital-Based Home Care), with 60 Enrolled Patients 5.00 1.00 4.17 3.75 22.00 8.00 13.10 9.20

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Physician Staffing for the VA: VOLUME II SECTION B: NON-PATIENT-CARE TIME Part 1. The activities listed below generally do not occur every day, but may be time consuming when looked at over a longer period, such as a week or month. List the time in hours that you would add to each physician's average workday to allow for the types of non-patient-care-related activities listed below: Chart 10 Assume the amount of research accomplished at this VAMC is: High1 Medium1 Low1 Education of Residents (didactic, classroom, not on the PCA) High 2.00 1.00 0.50   Low 0.10 0.10 0.01   Mean 1.05 0.50 0.20   Median 1.00 0.50 0.30 Administration by Chief (time required to manage your whole program by a Chief and/or Assistant Chief) High 4.00 3.00 3.00   Low 1.00 0.50 0.25   Mean 3.20 1.90 1.50   Median 4.00 2.00 1.00 Administration by Other (non-Chief) Physicians High 4.00 3.00 2.00   Low 0.17 0.10 0.02   Mean 1.40 1.00 0.70   Median 1.00 0.50 0.25 1Examples of research level by total amount of funding (VA plus non-VA) in FY 1988. High: e.g., VAMC I with $8.8 million in total funding; Medium: e.g., VAMC II with $2.75 million in total funding; Low: e.g., VAMC III with about $176,000 in total funding.

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Physician Staffing for the VA: VOLUME II Assume the amount of research accomplished at this VAMC is: High1 Medium1 Low1 Hospital-Related Activities (mortality and morbidity, Q.A., staff meetings) High 1.00 0.50 0.50   Low 0.20 0.10 0.10   Mean 0.64 0.40 0.30   Median 0.50 0.50 0.25 Total Hours per Average Weekday:   For Chief2 High 4.00 3.00 3.00   Low 1.00 0.50 0.25   Mean 3.20 1.90 1.50   Median 4.00 2.00 1.00 For Other (non-Chief) Physicians High 5.50 4.00 2.50   Low 0.50 0.40 0.20   Mean 3.30 1.30 1.20   Median 4.00 1.60 1.00 1Examples of research level by total amount of funding (VA plus non-VA) in FY 1988. High: e.g., VAMC I with $8.8 million in total funding; Medium: e.g., VAMC II with $2.75 million in total funding; Low: e.g., VAMC III with about $176,000 in total funding. 2Assume that Chief does not participate significantly in the Education of Residents and Hospital-Related Activities; SADI users may easily modify this assumption.

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Physician Staffing for the VA: VOLUME II Part 2. In order to determine the actual staffing in this hospital, the number of FTEE must be adjusted to allow for CME, research, and any other requirements. What do you believe to be the appropriate percentage of time the “average” (typical) member of your program should devote to each of the following categories of non-patient-care-related activities? Chart 11 Assume the amount of research accomplished at this VAMC is: High1 Medium1 Low1 Continuing Education High 25 10 10   Low 1 1 2   Mean 13 5 5   Median 13 5 5 Research (off the PCA) High 40 20 10   Low 30 10 3   Mean 33 15 6   Median 30 15 5 Vacation, Administrative Leave, Sick Time, Other High 15 15 15   Low 5 5 5   Mean 11 11 10   Median 13 11 10 Total Percentage of Time High 60 34 25   Low 46 28 15   Mean 52 31 21   Median 50 30 22 1Examples of research level by total amount of funding (VA plus non-VA) in FY 1988. High: e.g., VAMC I with $8.8 million in total funding; Medium: e.g., VAMC II with $2.75 million in total funding; Low: e.g., VAMC III with about $176,000 in total funding.

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Physician Staffing for the VA: VOLUME II INSTITUTE OF MEDICINE Committee to Develop Methods Useful to the Department of Veterans Affairs in Estimating Its Physician Requirements LONG-TERM CARE PANEL CHERYL E.WOODSON (Chair),† Director, Fellowship Program in Geriatric Medicine, Pritzker School of Medicine, University of Chicago, Chicago, Illinois MARGARET GRIFFIN, Assistant Professor, Department of Internal Medicine, Loma Linda University School of Medicine, Loma Linda, California ROBERT W.HUSSEY, Chief, Spinal Cord Injury Service, Richmond VA Medical Center, Richmond, Virginia JOSEPH M.KEENAN, Assistant Professor of Family Medicine and Director of Geriatrics, Department of Family Practice and Community Medicine, University of Minnesota, Minneapolis EDWIN J.OLSEN, Chief, Geriatric Psychiatry, Miami VA Medical Center, Miami, Florida L.GREGORY PAWLSON, Chairman, Department of Health Care Sciences, George Washington University Medical Center, Washington, D.C. ANN L.WHALL, Professor and Specialty Head, Gerontological Nursing, University of Michigan, Ann Arbor Judith L.Teich, Staff Officer †Member of the study committee.

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