The Association Between Nursing Home Medical Directors and Care Quality: Evidence From Certified Medical Director Hires

BACKGROUND: Medical directors are thought to be key determinants of nursing home quality, yet their role is highly variable and evidence of their effects on patient outcomes is limited. This paper examines the relationship between hiring a medical director with a Certified Medical Director (CMD) certification and facility-level quality measures. METHODS: We linked a national roster of physicians who completed CMD certification to facility-level quality data from LTCFocus (2011-2021) and CMS Nursing Home Provider Information files. Using a stacked difference-in-differences event study design, we compared changes in quality outcomes before and after CMD hire with matched facilities that never hired a CMD. Matching was based on state, profit status, and baseline 5-star rating. Outcomes included 30-day rehospitalizations for new admissions, total hospitalizations per 1000 resident-days, pressure ulcers, functional decline, restraint use, and successful community discharge. Models adjusted for staffing levels, resident case-mix, and facility and year fixed effects. RESULTS: The analytic sample included 495 facilities that hired a CMD and 11,823 matched comparators that did not. In the 4 years following a CMD hire, facilities experienced a reduction in 30-day rehospitalization rates of 0.78 percentage points annually (95% CI: -1.26, -0.30) compared to those without a CMD, representing a 4.6% relative decline. Evidence of declines in total hospitalizations was also found: 2 years after CMD hire, facilities experienced -0.081 fewer hospitalizations per 100 resident years (95% CI: -0.161, -0.001) compared to control facilities, a 2.7% relative reduction. No differences in the other quality outcomes were found. CONCLUSION: Hiring a CMD was associated with meaningful reductions in hospitalizations, suggesting that the medical director position is an important determinant of care quality and that individual physicians may vary in their effectiveness in this role. Findings support policy efforts to strengthen medical director engagement and accountability in nursing homes.