Welcome, everybody, to our on-demand course here, Physiatric Practice in the Skilled Nursing Facility, What it Takes to be Successful. As you can see, I'm not really in San Diego, and probably neither are you. But we do have a great group of talented people here to present to you in this next hour or so. And we really hope to just impart some of our wisdom to you in terms of what we've learned over the years in being successful practicing in the Skilled Nursing Facility. So without any further ado, let me go ahead and get started. If you don't know who I am, I'm Dr. Steve Nass. I'm Chief Medical Officer for Integrated Rehab Consultants. And my financial disclosure is that, of course, I am employed as the Chief Medical Officer for Integrated Rehab Consultants. So you may already know this already, but significantly more inpatient rehab occurs today in a Skilled Nursing Facility environment than in an IRF setting, an inpatient rehab facility. We all trained and grew up in inpatient rehab facilities across the country. They're generally hospital-based. And a lot of good rehabilitation still goes on in an inpatient rehab facility. But much more inpatient rehabilitation is actually occurring today in America in a Skilled Nursing Facility. Yet, as opposed to the inpatient rehab level of care, physiatrists have no mandate to be involved in SNF-based rehab. You probably may recognize that in an inpatient rehab facility, there needs to be a rehab physician involved in the care. There's no such mandate in a Skilled Nursing Facility environment. So how do we as physiatrists become involved in this important level of rehab care? Well, just to give you a little background on me, essentially about 10 years ago or so, I followed my patients into the Skilled Nursing Facility. I was working in a hospital in a hospital system that had an inpatient rehab facility, of which I was the medical director. And I was doing consults in the hospital. I noticed that more and more of my patients were being discharged to SNF. So I said to myself one day, where are these people going? I think maybe I'll go find out. And I worked with a Skilled Nursing Facility company that was taking a lot of our patients. And I found that their rehab team was very happy to have my expertise. They had not had a physiatrist on staff before. And they really weren't sometimes sure what to do with patients. The primary doctors working in the Skilled Nursing Facility were definitely not rehab experts. The therapy team could not go to them and ask them a question about the rehab because the primary doctors didn't really know the answer. So the therapists were oftentimes put in the position of being the expert. And that sometimes put them in an uncomfortable situation. So they really appreciated having a physiatrist to come along and help them with the rehabilitation aspects of the care that they were getting. And we're seeing more and more of these patients coming from our hospital. However, I mean, will there be times when either the medical director, other physicians in the Skilled Nursing Facility, the advanced practice providers, or even the therapists themselves don't really even understand your role or don't want you to be there? Absolutely, yes. I would say that you'll hear from some of my other speakers that we're somewhat of an unknown quantity sometimes when we walk into a Skilled Nursing Facility. So that can definitely happen. It's not like walking into an IRF where you'll find that everything is very similar. The intensity of rehab is similar. The quality of rehab is similar. If you've seen one sniff, you've seen one sniff. That's what we say because they're all different. So when you walk into a Skilled Nursing Facility, they may not even really be doing much acute short-term rehab. They might be doing more long-term care. They might be doing a great amount of short-term rehab. So I think you have to take that into consideration. What is your Skilled Nursing Facility? What's the environment that you're walking into? And then the next thing that I'll say that I think I learned over the years is that there's a need to standardize. When you go into an inpatient rehab facility anywhere across the country, you'll see that a lot of the protocols, the pathways, they're not always standardized, but they're pretty much consistent from one facility to another. The lengths of stay by diagnosis. I mean, some of that is even set by the payment system that we have now that basically pays a certain amount by inpatient rehabilitation length of stay at an IRF. That's really not the case at all in a sniff. Sniffs do not have the same payment system, and we'll talk a little bit more about that as we go on. But you probably will need to explain what you're doing there, how you can help, why you should be there when you walk into a Skilled Nursing Facility for the first time. Many Skilled Nursing Facilities across the country now have a physiatrist or have a physiatry component, and so they may be very familiar with what you do, but they may not be. So I think some of the keys to success when you're working with Skilled Nursing Facilities... Sorry, grabbing a little bit of water here... Are that we want to maximize the quality of the rehab programs that are going on there, just like anywhere. We want to minimize lengths of stay. Now, your Skilled Nursing Facilities may be in a situation where minimizing length of stay is not one of their primary goals. In fact, because they're paid a daily rate, they may find that they want to maximize length of stay. And so you may get some pushback in some of those areas. I think less these days, as more facilities are doing short-term rehab and they're involved in post-acute networks, and they're getting some push to right-size their length of stay. But back in the day when there was 100-day maximum for patients in a Skilled Nursing Facility, a lot of times the Skilled Nursing Facility was incentivized to go towards a more longer length of stay for patients. But the other thing that we want to do, another key for our success, is to maximize discharges home. Skilled Nursing Facilities also oftentimes have a long-term care function. So they may be sometimes invested in having patients stay there in long-term care. That's not our goal. Our goal is usually to get people home. The other key to success more and more is to avoid unnecessary hospital readmissions. There's been a lot of attention paid to readmissions and how that costs systems money. And so that's clearly gonna be a goal for everybody involved, is avoiding unnecessary hospital readmissions. So how do we do this? Well, we do it by standardizing pathways and protocols. And I'll talk about a couple of those, not in any detail, but just to kind of give you an idea of what I'm talking about. We do it by having a hands-on personalized approach to each case, just like you would in an inpatient rehab facility. You're really not doing anything any different there. It's basically a rehab approach, working with the interdisciplinary team, individualized rounding on the rehab patients. Frequency can be on a case-by-case basis. There's no hard and fast rule in a skilled nursing facility, but usually two or three times a week, maybe less if there's not much going on. One of the nice things about not having a mandate to be there is that you get to pick the frequency of how often you're gonna see your patient. In an inpatient rehab facility, I know it's usually daily. In a skilled nursing facility, it's probably usually two or three times a week. We also participate in the team meetings. There are team meetings in a skilled nursing facility. They may not be called an interdisciplinary team meeting like you have in an inpatient rehab facility, but there's some kind of a meeting where the therapists are talking about, and the social workers and the case managers, talking about each particular case, what it's gonna take to get them home. And we're gonna be really working on minimizing discharge barriers, what does it take to get this person home? What do we have to do to get this person to the next step? All right, let's talk about some pathways. I'm not gonna go into these in any detail, but just to kind of mention here that some of the patients that you will not see in an inpatient rehab facility anymore, back in the day when I was a medical director 20, 30 years ago, we had a lot of cardiopulmonary rehab, CHF, COPD, general deconditioning. That's gone by the wayside. Those patients are pretty much all going to skilled nursing facility now, unless there's really a reason for them to be in the hospital. Because of the 60% rule, you're not gonna see these patients. And so you need to develop some kind of a plan for them. What's it gonna take to get them from point A to point B, some kind of steps that is gonna be necessary. The same thing is true with stroke. A lot of strokes go to skilled nursing facilities. You might make a case, you might hear cases made that stroke rehab is better served in an inpatient rehab facility. There's some evidence to that effect, but I don't think it's 100% true always. And I think that a lot of patients end up in a skilled nursing facility after a stroke. A lot of it is payer choice and they're there. So if you're the physiatrist seeing that patient with a stroke in a skilled nursing facility, you have to have a plan for what you're gonna do to take care of them. And it's very much the same as what you would do in an inpatient rehab facility, but the structure may not be there. You'll see a lot of orthopedic patients in a skilled nursing facility. They're not going to the inpatient rehab facility at all pretty much anymore, unless they meet very strict criterias, such as they're over 85 years old, have a high BMI or bilateral. So for most of your typical total joint replacements, they're gonna be seen by you in a skilled nursing facility, much shorter length of stay, much quicker rehab. You might be seeing these people more frequently, but you need to come up with a plan. What do they do on day one, two, three, four, five to get them home? Hip fracture, again, you come up with a pathway. What's it gonna take to get the patient home? So the skilled nursing facilities are being challenged to provide lower lengths of stay. I think I alluded to that earlier. If they're in a post-acute network, certainly their post-acute network is saying, these post-acute costs are driving our costs up. And so we want lower lengths of stay. We want reduced discharges back to acute. You can't just take this patient who's sick and say, oh, we're gonna send them right back to the ER. That's not gonna work. They're being challenged to provide lower 30-day readmissions. That's something that they're being measured on. So the number of patients that get readmitted to the hospital within 30 days is certainly something that they're gonna be looking at. And they are gonna be looking at quality rehab outcomes, although, unfortunately, there really is no outcome measurement that sticks, so to speak. But clearly, that's our goal, is to have quality rehab outcomes in this patient population. So I wanna give you a little bit of data. I'm not gonna bore you with this too much, but this is a small study that was done by us showing that the effect of a physiatrist, particularly an IRC physiatrist, in a skilled nursing facility reduced the 30-day emergency department visits, reduced the hospital readmissions. You can see that on the far right lower corner. And also, at the same time, reduced the length of stay and increased the acuity of the patient. In this case, it was the rug mix per nursing day. That system has now gone by the wayside in preference to PDPM, which we'll talk about in a minute. But this study, a couple years old, showed that the effect of a physiatrist really fell in line quite a bit with what the skilled nursing facilities were trying to do, particularly those that were existing in a post-acute network. Here's another study. This is actually from our own Northwestern Hospital post-acute network here in the Chicago area that showed that the physiatrists, particularly the IRC physiatrist next to a competitor physiatrist and a control group, we had a reduced average length of stay in the post-acute network and a reduced hospital readmission rate. Nice to be able to show that kind of data. I wanna take just the last couple of minutes here to wrap up and talk about the PDPM model. You may or may not be familiar with that. It's essentially a payment model, a move towards prospective payment in the skilled nursing facility. SNFs are being paid based on patient characteristics now rather than therapy minutes, which was the case in the past. When they were being paid by therapy minutes, the goal of most SNFs in the country was to maximize the minutes of therapy. Now, they're really looking for outcome measures. There's no unified outcome measure, but they're looking for patient characteristics that land these patients into categories that will then pay the skilled nursing facility based on those patient characteristics. So I came up with a couple of theoretical case studies. These are not real patients, but they're similar to real patients that I've seen. Here's a 76-year-old female coming in for basically what is COPD exacerbation, generally deconditioned, weak. She had a prior strokes, got mild residual hemiparesis, poor balance and coordination, cognitive impairment, and some mild dysphagia. So the skilled nursing facility looks at the discharge diagnoses from the hospital, and here they are, COPD and pneumonia. And their PDPM daily rate for this person to come into the skilled nursing facility is based on those hospital discharge diagnoses. But what we do is we start fleshing out, if you will, the more full picture of this patient's characteristics. They're gonna need some additional services because of things like their dependency, their nursing needs, their dysphagia. And so if we start to add those ICD-10 codes into the patient mix for the facility, the facility gets a bigger market basket of their reimbursement goes up based on what those patient needs are. Here's another example. Oh, I'm sorry. So in this case, the PDPM daily rate increased about $84 based on what the physiatrist had added in terms of the characteristics for the PDPM model. Second case is an 87-year-old with a hip fracture and routine healing, also has BPH, but has a history of diabetes, neuropathy, poor balance, coordination, some mild dementia, some urinary retention, and requires intermittent bladder catheterization. So the diagnoses that show up from the hospital when the patient's admitted are a hip fracture and BPH. However, when the physiatrist sees the patient, they start to add some things like poor balance, mild dementia, some therapy issues, wound issues. So these are things, this is not all something that the physiatrist can add. Maybe the dementia was picked up by the speech therapist or the wound care brought in some of these other diagnoses, but we highlight them and we then present a more full picture of what this patient needs in their rehabilitation. So again, the PDPM daily rate based on the hospital discharges alone was 554. When you start adding in these other ICD-10 codes and you more fully flesh out the patient characteristics, you find that, in fact, the facility does better financially in this case. I wanna point your attention to a couple of resources that you can look at. One is the Academy's own position statement, the physiatrist role in skilled nursing facilities. It's available on the Academy website. And I think it's good reading if you're interested in this area of patient care, you probably wanna start with this position statement. There's more information on PDPM that you can get, but the only reason I really bring it up is to kind of fully show you some of the things that add into the value of the physiatrist in the skilled nursing facility. So long story short, what do we do? We're working with our healthcare systems. You're probably associated with a hospital, maybe an ACO, they have a post-acute network. They're trying to get the patient out of the hospital as quick as they possibly can and get them to the next level of care. We want to help them understand and manage that post-acute network. We want to obtain the best outcomes for our patients. We want to utilize less resources along the way and be good stewards of those resources for society and everybody. And we wanna demonstrate the value of physiatry in the skilled nursing facility and in all post-acute settings. I think it's important to recognize that skilled nursing facility rehab really is a transitional phase. There's more of a movement towards home health and outpatient and getting people out of institutions in general, right? Nobody wants to be in an inpatient institution for rehab any longer than they have to. But the advantage of being in an inpatient institution is that you have all the resources there. You have the therapists are all there, the equipment's there. Try to reproduce that sometimes in home health or outpatient environment is much more difficult. So we as physiatrists have to demonstrate our value in all these post-acute levels of care. I don't think it's limited to just acute inpatient rehab or to skilled nursing facility rehab because we really want to help patients become independent and minimize disability. So we want to guide the rehab for our patients in all settings to maximize their functional outcomes and have them live a productive life and a functional life and one that's free of pain where they can do well. And we also want to help guide our health systems and healthcare as a whole so that the post-acute care of people, getting them back to their lives is not terribly expensive, not something that breaks the bank of the healthcare system. And then of course, while we're doing it, we want to have fun and not burn out and just take care of patients. So with that, I'm going to turn this over to my esteemed colleagues and I want to thank you. And that concludes my portion of this conference. Thank you. All right. Well, good morning or afternoon whenever you may be watching this. I'm Charlotte Smith and I'm actually dialing in from sunny Seattle today. We're blessed because it's not smoky or rainy. And so this is a good day to be doing this talk. And I want to thank Steve for allowing me to be part of this really great panel and talk about some of the lessons that I've learned in subacute rehab. And when I say subacute rehab, it means skilled nursing, generally speaking. And I love doing these kinds of talks because most of the really great progress I've made in my career is by taking chances and making mistakes. And I want to emphasize that there's no shame in making mistakes when you're taking on new territories because a lot of what we do in our specialty is we go into unknown frontiers and we develop programs and we develop ways to help people and there's no rules to the game. So we learn from our mistakes and we get better. So I want to share seven of the lessons I've learned today. I limited it to seven. I've made a lot more mistakes than that. But for interest of time, I'm focused on these seven. The disclosures I'd like to make are I'm Chief Clinical Officer for US Physiatry. So I oversee teams of physiatrists that work at all levels of care, including subacute care throughout the country. And a lot of the examples I'm going to give you are things I've seen working with them. And then I also work at University of Washington running one of their spinal cord clinics and doing some of their rehab. And I'm an at-large member currently of the AAP Menorah Board of Governors. So lots of lessons we learn, why? Well, goodness knows there's lots of opportunities to learn lessons and make mistakes in subacute rehab. So, you know, most of us don't get taught about this area of medicine in residency, fellowship or elsewhere. You know, you're fortunate because you're watching a video today and the academy is developing a lot of resources, but, you know, there really haven't been a lot of resources traditionally to teach us. And you learn very quickly if you get into this area that the rules of subacute rehab are completely different than the rules of birth. Teams are different, our roles are different. And as Dr. Nett said, every subacute facility is different. And the great news is once you get into a facility and you feel like you halfway know what's going on, it'll all change. Like for example, the reimbursement with PDPM. So what could possibly go wrong with this scenario? Well, the biggest issue ends up being not being in synergy with the people you're working with. So if you're not on synergy with the facility administration, the medical director and other medical providers there, the nursing team, the rehab team, the referring facilities and the patients and families, well, bad things can happen. And if we get it wrong, it does lead to bad things. You know, the worst would be not getting along with the facility medical director or other medical providers. and I see that happen a lot, just because of lack of understanding, we can stress out the nursing team, we can frustrate the rehab team, we can upset the referring facilities without realizing it, we can lead to poor patient and family satisfaction, and we can be marginalized by the team in the best case scenario, or in the worst case scenario, asked to leave the facility by the administrator. And I've seen both of these scenarios. And I want to emphasize, you can be an outstanding, amazing physiatrist, and be someone who performs extremely well in patient rehab and acute care, but by using the same strategies and same skill sets, it can actually really be problematic in a subacute facility. So why do things go wrong? Well, it really boils down to the five R's. It's a lack of understanding about the rules, the roles and responsibilities of everybody, including us, relationships, reasonableness, and then the reality of the situation. So lesson one, you have to know the rules of the subacute rehab game, because it is a completely different game than inpatient rehab. So the criteria for be accepted very different, who's a good candidate, who's not a good candidate, and what can you do and not do inside a subacute facility. So also your role as you're interacting with all of these differences is quite different than inpatient rehab. So let me give you some examples of rules you have to know. Like for example, ordering diagnostic studies in a subacute facility is actually okay, because the reimbursement in general doesn't come for that out of the daily rate. But doing something like a motor point block inside a facility, unless you have some special circumstances or carve out, it's generally not. Why? Because the cost of the medication comes out of the daily rate. And so that's an example of something where it'd be a great idea to send them to an outpatient facility where it would not hurt the facility if you had that done in subacute rehab. The documentation requirements are completely different. And the reason is because the quality metrics and the hot lesson issues are different than inpatient rehab, but also your strategies and goals are different. And what we have to do to document in a skilled nursing facility is very different than what has to happen inpatient rehab. And the other key thing is that there's some of these misunderstandings. Like how many times will you hear in an acute care facility, oh, you get a hundred days of sniff. Well, it turns out that you usually don't get a hundred days of sniff because there's all these rules and requirements about what you have to do to meet the criteria to be there. But then also just like we've been getting squeezed and directed and our care has been limited based upon insurance companies and reimbursement, it's the same thing with skilled nursing. So we don't want to say things like that. So the other key thing is you've got to know your role. And one of the first decision making points is going to be what will your role be? Are you going to be the consultant or the facility medical director? Now, most of the time, physiatrists tend to be consultants. Although I've seen facilities where the physiatrist is the facility medical director. If so, it's pretty clear what your duties are. Every skilled nursing facility has to have a medical director. They're generally paid for their administrative services. They generally have defined duties that must be performed. And most every skilled nursing facility knows what they are. The administrator knows you. They know they need you and they must have you. So you usually have a very easy access to the administrator. And there's a multitude of administrative tasks that you're responsible for that are clearly defined. But the big thing is you're really ultimately responsible 24-7, 365 for the medical care of the residents. So the buck stops with you. And so, you know, the key thing there is just recognizing the obligation and your commitment to that facility is huge if you're the medical director. Now, let's say that you're not able to do the 24-hour, 365 thing and you elect to be a consultant. And sometimes you can be a consultant, be a medical director. So, for example, one of the facilities that I worked at for five years, I was the medical director for rehabilitation services for the different levels of care for the SNF, the AL, IL long-term care. But you recognize when you walk in, they may not know what you are, what you do, how your skills can help the facility and patients or how to work best with you. And I think Steve touched on some of this. It's up to us to educate them as to what we can bring to the facility. We have to also, I think, try to identify the needs the facility has where we might be useful or hopeful. And that usually involves some research on our part because they may not even know what they need. And then we have to figure out how we can best work with the medical team and the administrator and develop our role. Because over time, as you get more and more involved in a facility, you'll figure out more and more what needs to be done. So, if you're a consultant, you want to ask them, you know, what do you want me to focus on? And, you know, where do they need help? Who's doing what in the facility? Are there specific tasks or duties that you can own? Like, for example, all the work that goes into doing durable medical equipment, the face-to-faces or helping to coordinate the home health care or things like that, you know, or things that a lot of times the medical director is overwhelmed doing all the medical care and they are so appreciative if you take over those tasks. Questions also like, do they want you to write orders or do they want you to make suggestions in your notes? Or do they want you to talk with them? Yeah, I've been in different facilities where it's always, you know, it's like everybody that, you know, I go in, if you don't ask that question, you're not going to meet expectations. Because I've had some facilities were like, please don't write orders. You know, what we'd like you to do is just, you know, put it in a note, or if there's something really urgent or serious, call us. And then if the other ones are like, you know what, just take the ball and run with it. You know, do what you think needs to happen. We trust you. It's all good. So you want to find that out. You also want to find out what kind of patients do they want you to see and how in the world are you supposed to find them and get referrals? Because a lot of the problem in a facility like this is even identifying who you want to see and prioritize. And there are different ways that one can go about that. It may be that you get a census each day, and you can see the diagnoses. It may be that you work with the director of rehabilitation, and they tell you who's on the PTOT speech list. It may be that you focus on new admissions and screen them. So you want to really find out what they want. You want to see what can and cannot be done in the facility. You know, there are some things if you order them, it's just going to create a huge problem because they either don't have the resources or the staffing levels or the expertise to do them. And then how's the best way to communicate? You know, a lot of times in facilities it's meeting driven, but in some facilities it's really more electronically communicating. And then also finding out who is ultimately in charge of the various aspects of the facility. So I want to give you just some examples of what I've seen. This all sounds so simple. It all sounds like, oh gosh, this is common sense. Of course, you know, I would not do any of these things wrong, but it does happen. And just some examples would be, for example, changing payment occasions on a Friday afternoon without telling the primary care team. Well, think about it. You take a geriatric patient, you put them on a little dose of something, you know, for pain or maybe to help with spasticity. For a geriatric patient, that may make them look comatose. I mean, they have adverse consequences and side effects that you may not see in other populations. And the problem is you're not the one that's going to get called most of the time. It's going to be that primary team. And if they're getting phone calls or Saturday or Sunday and they're having to get this person a CAT scan or take them back to the acute care hospital, they don't appreciate that. So you want to, you know, be very thoughtful about writing orders and not changing things that can affect the rest of the team or at least not making it really obvious to them and talking to them ahead of time. The other thing I see is criticizing the medical care provided by the medical director. You know, it's really hard to be a medical director of these facilities because a lot of times the medical directors are working multiple facilities. They are a lot of times part time in these facilities. They may be dealing with extremely complex patients. You know, it's not all straightforward bread and butter patients these days. They're getting oncology patients, complex cardiology, orthopedics, you know, and the thing you have to realize is that, you know, a lot of times they're doing the best they can, but it's a hard job. So that's very important. You don't want to be criticizing them. Also, they have a lot of power and control over who their consultants are. So clearly, if you're having an antagonistic relationship with them, you know, they can vote you out. There's not a problem with that. The other key thing is if we try to do their job, you know, again, this gets back to determining who's doing what. But if we start trying to manage the general medical issues like congestive heart failure, hypertension, and diabetes mellitus concurrently with them, A, there may be issues with reimbursement, but also you get the phenomenon of too many cooks in the kitchen. So the other key thing is if you don't see all the patients they want you to see, or I've actually seen them get upset because they're like, well, this physiatrist is seeing everybody and they don't need to. So you kind of, unless you're a psychic and you can read minds, you really need to talk with them and clarify your role and the expectations before you start. Lesson three, you've got to work with your team. You know, it's critical to find out who your team is, what they're capable of and what they're willing to do. So again, this medical director may be a solo physician who's working part time and is only there, you know, certain days and has a full time day job, or it may actually be someone who's full time at the facility. I've had it both ways. I have one facility where the medical director worked full time at the VA during the day and was only available at nights and weekends. And that was a very different situation than when I had a full blown residential care team with two geriatricians and three nurse practitioners always on site. So different situation and their capabilities are totally different consultants. You know, some facilities have a lot of consultants come to facilities. Others have to send patients to their offices. There are more and more advanced practice providers and developing relationships and getting to know them is critical. Nursing team structure is different. You know, you may have different ratios and credentials of bedside providers, either maybe a lot less RNs and a lot more CNAs. And then the nursing team clearly may have funded knowledge gaps. They may not have ever done any rehab nursing and may not know for the life of them what a bowel and bladder program looks like. The rehab team may have variable disciplines involved. It's not unusual for the services of the rehab team to be contract employees through one of the large agencies. But how often they're actually there and what disciplines are there varies. So there's some facilities I've seen that don't have speech therapy on site unless you specifically request it and they bring someone in. And then there's ones that I've seen that have a complete staff that's employed by the facility in their 24-7. So it's really helpful to kind of know how the rehab team is structured and what they're capable of. And then the same with the admissions team. You may have a nurse or somebody who's a clinician who's screening in the hospitals versus someone who has no clinical background and is essentially a marketing person. And they may or may not be willing to work with you because, you know, what comes in the door affects a lot of times what you're able to do inside the facility. And then last but not least, administration, highly variable credentials. I've worked with some of the very best administrators of my career in some subacute facilities and I've worked with some that were there like a week and had very limited experience and were very brief and differences in terms of their willingness to share their challenges and their goals. So it makes a big difference who the administrator is and what you're able to do. So ways to hurt them, you know, you've got to have your medical directors back. Communication and interacting with the team is everything. Getting to know what they're capable of doing, their expertise, and what tools they have. Like if you order modalities, there are some facilities that don't have modalities. Not going to happen. You may order, you know, manual medicine like myofascial work and they may or may not know how to do that. You've got to learn to work really optimally with your advanced practice providers. They can be your best friends or your worst enemies depending on your relationship. And it's up to us to really, you know, get to know them and set the tone. Not working synergistically with your facility consultants. Like if you have an orthopedic surgeon that comes and rounds there and sees people, but then you're sending patients to another one, that can be a problem. Same with psychologists and plastics. You want to know who's there and work with them because, you know, they're making a trip over and taking the time and that's part of your team. And then things like writing orders for things that aren't possible or that they don't know how to do. Not understanding the pressures that different members of the team face. You know, I've never seen a facility that has enough staffing when it comes to bed size nursing. And I've also realized that the therapists are under huge productivity requirements, especially if they're in a contract situation. And then last but not least is, you know, if you're not the expert resource they need you to be. So the team you have to work with will impact what you're able to do in a facility. And it's all about relationships. You know, it's hard to get people to work in subacute rehab. It's not the sexiest part of medicine. And so it's imperative that you really value the people you have and build relationships. And the key thing to know is that, you know, we can learn from each other and grow as a team. It's easier to provide excellent care when you're working as a team. If people are happy in their jobs, they're not going to leave. And high turnover has been a huge problem at a lot of subacute facilities. But if people love who they're working with, and they feel like they're growing in their job, they're more likely to stay even if it's less money. Patient and family satisfaction is higher when you've got a tight team. But the key thing is that you get the ability to do more with less, you know, in a situation where there is never enough resources for what needs to be accomplished. This is the magic for a good program. So always recognize that every person on the team is valuable. And you know, don't value people only by their credentials, you have to see their potential, they may not be an RN, or a CRM, or a PT, you may be working with a CNA, or a restorative aid. But these are people who can be extremely valuable. And rather than, you know, criticizing them, if they don't have the same skill sets, you build them up, you know, invest to them by providing education. It's also very important never split the team, you know, the whole classic struggle between rehab therapists and nursing isn't basically something that's less a lot of times in subacute. And also just the challenges between clinical staff and administration are always there. And so you really don't want to split the team, you want to help build it. And you can't be negative about your facility, you have to focus on the strengths and get from there. But the key thing to remember is we have the ability to set the tone in a facility by building relationships and having a strong sphere of influence. You have to accept the reality also, that you have to have reasonable expectations. And facilities have things they can and cannot do, as do their providers, you know, they're not the same thing as IRF, they don't have the same reimbursement, the patient population is different, staffing is different, resources are different, length of stay is different, and the pressures are different. But that being said, it's not always worse than IRF. So like, for example, you know, a stroke patient getting, you know, 30 or 60 days, even at a subacute level, it's done well. It's amazing, because you don't get that much time in inpatient rehab. You know, sometimes you get restorative aides who are so on top of their game. I mean, they get these people up and mobilize them like nothing I've ever seen. The thing to recognize is different doesn't always mean worse, sometimes it's better. And a lot of it is largely up to us in our role in the facility. You have to also just recognize that, yeah, patients won't get three hours of therapy a day, most likely, you know, you're not going to get the same interventions you do in a inpatient rehab facility. Call lates may or may not be answered as quickly as in an IRF. Nurses have different expertise, you may not be able to get all the medicines you want. You know, I had to learn very quickly on that I couldn't have, you know, necessarily diclofenac gel, you know, it was over the counter, been gay, you know, you had to learn kind of what was and wasn't available. You also recognize that if you write an order, it may not happen like right away, maybe the next day that things happen. And you may not have a tight schedule, you don't have the three hour rule where everybody knows where everybody's going to be always. And the other key thing is that you're dealing a lot of times with aging patients that are debilitated. And you're not always going to get a perfect outcome every time, you know, sometimes we're dealing with end of life issues, or progressive disease. And so not going home or not being able to community setting doesn't necessarily mean that you failed, that might mean that you're actually just helping them with transitions in their life, and palliation. And that's worthy. And that's helpful if it can't be provided in any other level. So you have to accept reality, each facility and use that to your advantage. And the key thing to remember is that their gaps are your opportunities. And you have to be adaptable. Because like Steve said, the more facilities you go to, the more you realize they're all different. And when you figure them out, they change. And you have to use all of your PMR skill sets, it's really critical that we don't forget our PMR brain, we need to look at the route, the plans of care, don't get lazy and just sign off, you have to step in when patients don't make progress, they're looking to you to see why and to remove barriers, they're going to be difficult patients and families, you know, avoiding them and not getting your hands dirty is not good. And then there's also issues with program development, as Steve said, standardizing things and helping to make things more clear, and more reproducible and helping them have templates and tools improves consistency. And just don't ever make generic recommendations, like, you know, continue PT OT and rehab goals, or pain management, continue nursing and pain meds, you really be thoughtful, because they are looking to you for guidance, and you need to be their expert. So again, the things that can go wrong are usually those five R's. And the overall lessons of things we do every day, you know, communicating well, being a resource being willing to educate and being situationally aware and sensitive needs, especially as they change, seeing deficits and problems as opportunities be useful, don't make things worse. That's half the time my goals, I shall be saying, Okay, please don't let me make anything worse today. You know, be nice and imperturbable, be adaptable, and always challenge yourself to keep learning and improving even if you make mistakes. And that's it. Basically, we can ensure success by using the toolkit that we've learned in PM&R. And I appreciate your attention. I appreciate you guys are interested in this area, and that you're willing to help out in this very needed arena. You know, I ask all of you to do it with excellence, because what we would like to see happen is we want every subacute facility to desire need and want a physiatrist. And that by your being bold and helping to make PM&R essential in every part of healthcare continuum, we're able to have more patients, but we're also able to build our specialty. So with that, thank you very much. And I will close it over and turn it to our next speaker. Thank you for having me on this esteemed panel, Dr. Nats. And I appreciate everything you've done for me throughout my career. And hopefully, in my discussion here, I'll talk more about clinical pearls and things that I've seen over the last eight years of practicing in this setting. So my name is Dr. Aslan Tariq. I'm a board certified physiatrist working in the post-acute setting, mostly across Northwest Indiana and Chicago. My disclosure included, I'm the Chief Clinical Officer for Integrated Rehab Consultants. So hopefully, in this brief talk, I'll be talking about setting up a subacute physiatry practice, defining more the consulting work versus a primary care role, other logistics that go along with this practice, resources that might or might not be available for us, the patient population that I'm normally seeing, certain regulations that come along with this practice, discussion about audits, liability, and also subacute rehab during COVID. So how do you set up a practice in the post-acute setting? I want to give you a background about my current practice and also my background in subacute practices as well. I did my residency outside of Chicago in a freestanding 150-bed rehab hospital with their own subacute unit. As residents, we were very fortunate to have a subacute rotation. All our attendings, I should say, vast majority of our attendings were doing subacute consulting work and primary work for more than a decade, even before I started. So for us, coming out of residency subacute was not unknown. So we were pretty used to working in that setting. Regardless, over time, what I've noticed in my own practice is that the setup of subacute practice is very different now than it used to be before. I'll touch on that later on as well. So obviously, if you are someone who's working in the acute rehab setting and you are aware of the patients that you're discharging to the subacute setting, you might be able to connect with them and discuss taking care of the patient throughout the continuum of care. And that might be one way of doing it. Another way is certain facilities in the area might be interested in having specialty care. They might be interested in having care for their stroke patients, their pain management issues, orthopedic issues, and you might be able to discuss it with them. At the same time, certain facilities want to be different from other facilities and want the specialty care or they might have certain needs. So there could be a number of different ways you can actually approach these sub-acute facilities to get going. You can also work within the hospital system and actually approach them and if they might have certain sub-acutes that they prefer sending their patients to and go to that that route. At the same time you can work in the local or national group, for example, the way that I have it set up. All these have certain advantages and disadvantages but those are things that you have to think about before starting. Now this has been touched on before regarding consultant role versus a primary role. What I want to talk about more is how this can be different from a residency or in practice before becoming attending or even after attending actually. So typically in the hospital setting if I am consulted to see a patient, you know, I am seeing the patient for a short amount of time giving them my recommendations and then at that point signing off. In a sub-acute practice it is a co-management model so I am seeing the patient along with a primary care physician along with the therapist throughout the length of stay. Now the length of stay could be a couple of weeks, could be longer, it really depends on the diagnosis but during this time I am co-managing the patient, taking my role very seriously obviously and defining it along with the primary care physician about what exactly am I taking care of. So there's a clear delineation of the role which again could change depending on your own practice. With me because I have training, fellowship training in intramuscular pain and MSK, my role is primarily to manage those conditions even though I can manage stroke but I am not managing wound care and you know a bowel bladder but again at the same time I can if I want to but at least in my facilities that is a role they've defined for me. Now the relationship with the primary care doctor, the medical director and the team that Dr. Smith had talked about before is extremely important because in the end of the day these are their patients and they want to make life easy for them at the same time provide proper care for their patients. So that relationship has to be open, the communication has to be prompt, at the same time you have to make sure that they are not stepping on their toes and they know exactly what role you have. For example if I am putting a medication in or putting a lab in or putting an imaging order in and they get a phone call in the middle of the night for the results and they're not aware of the fact that I've done this, you know the important part is making sure there's a good relationship with the medical director and the primary care team. Billing and liability are common things that are brought up by the primary care team especially when they're concerned about not getting paid for the services but it is my job and to make sure I let them know that there's you know you can have multiple providers bill for the same patient just like in the hospital setting and this is a co-management model in which you have therapy other primary care physicians or other practitioners seeing the same patient the same day. So if anything you know there's no no concern about billing and liability is also lower than normal because now you have a specialist managing a specific thing that they don't have to manage anymore. At the same time obviously they say that if you are going to be ordering medications that they're not comfortable with and the risk could potentially be on them as well. So it is my job as a consultant to make sure that I explain to them what exactly my role is and how I'll be treating patients and creating a relationship with them. And that also goes on with the administrator, the nursing staff, the rehab team and I have to understand from their perspective why they would need me. The admin has a specific need for me, they want to provide better quality care, reduce readmission rates, the nursing has specific needs in which they might need prompt help, the rehab team has specific needs when they might need something signed off or someone might need a prosthetic or a toddler or there's a wheelchair. So everybody has their own specific needs and I have to as a consultant make sure that I understand their needs and help them as much as I can. Other logistics that most people might not be aware especially when you're starting off, the credentialing is significantly easier in the SNF setting in which it might take weeks versus months to get credentialing in but at the same time there's specific needs for that. Creating rounding lists especially in the subacute setting because you are a consultant, you're not there every day, you know, I expect some help from them but they're not definitely not obligated to help me every day. I'm not an employee of the facility, I'm here to help them at the same time they sometimes they go out of their way to help me out. So they might be able to help me in the therapy team or the nursing team with creating a rounding list of patients that they want me to take care of or if I am taking care of every single patient in the facility with the primary care physician they can create this for me and this also can be created in the EMR system. Other challenges include the EMR system it's definitely not as robust as the EMR system in the hospital setting. It's really more of a nursing EMR, it's not really a physician EMR system or clinical EMR system in that sense so it's not built around that. It is still workable when I started practicing we have paper charts but over time has become EMR so now vast majority of facilities at EMR typically they're cloud-based at the same time they're not very physician friendly so that can be definitely a barrier. Pharmacy can also be a barrier not in the sense that they're gonna prevent you from ordering certain medications but they're not on site so not being on site if I order a medication on Monday for example that might not be completed or the medication might not be delivered until a Tuesday and the medication might not start until Wednesday so there's definitely a delay in that. It could be as fast as within 12 hours but it's not on site and also not having a pharmacist on site can be somewhat challenging but at the same time they are available and I can ask them any questions I want to. Because the type of setting that you're in in the in the subacute setting in the SNF setting it's a high stress environment a lot of regulations and obviously the tough patients as well but at the same time the high staff turnover so by the time you get used to creating a workflow and you have the proper team members who understand what you do you might have change in staff especially in the administration level or the director of nursing level there's a frequent amount of turnover. Typically in the rehab therapy director role that's not a high turnover so that could be challenging by itself. At the same time I use it as an opportunity to learn more about them and also educate them about what I do and help them along the way. Meetings, attending meetings, you know even though we're not obligated to attend meetings but typically it's my preference to attend at least the Medicare meeting or the team conference meeting. Now this meeting can be very short could be about an hour long it could be longer depending on the number of patients they have and also depending on the amount of feedback that you are able to provide them and number of team members so that can be definitely vary but typically it's about a two-hour meeting once a week. They also have morning clinical meetings that again you're not obligated to attend but the more involved you are in the facility the more likely you're gonna be attending meetings. Other meetings include family meetings these are all typically not mandatory they can be voluntary depending on how much you want to be involved with that. With me I'm involved as needed and I'm there for the social worker and the therapy team to help them if their family members have any questions. Assistance for staff like I mentioned before again they're not obligated to help you they are using their own time their you know time that's dedicated the facility to help you out but I really am thankful whenever they do that so that means helping me to find the right information getting medical records getting a patient list getting therapy notes or anything goes along the way they're able to assist me. Other limitations that I didn't talk about was imaging. You don't have an on-site typically you don't have an on-site MRI or CT scan or and even an x-ray usually the third-party companies that come in and provide mobile x-ray or ultrasound and things like that and also the amount of time it takes to get an order in and to get the x-ray or get an ultrasound could could be prolonged it could be up to a day even if you were ordering in stat way. So that can be challenging also being able to look at the images and other modalities like that. At the same time the facility is usually concerned if you're going to order MRIs for patients because it's not almost guaranteed that the Medicare or insurance companies will be paying for that it could also be coming from the facilities pocket as well so it can be very challenging. So at the same time if I am strongly considering getting an MRI or advanced imaging that's a discussion I want to have with the primary care and at that point it's feasible to discharge the patient or do it as an outpatient setting and really based on more clinical diagnosis versus strictly imaging diagnosis. Medications there are certain medications that if you are wary of you know again because the cost of the medications coming from this per diem or lump sum amount of money that the facility the SNF will get I have to be extremely cautious about not ordering extremely expensive medications and this is the cost part of it also be careful with the patient population and because obviously majority of patients are gonna be geriatric so I have to be very cautious with NSAIDs or narcotics and things of that sort. So medications wise you know at the same time you have to be cautious about not ordering so many medications that can be topical or staff intensive intensive for example topical ointments if they're not able to provide the patient bedside ointments or gels things of that sort it can be difficult for the staff to walk around and apply an ointment four times a day on a patient for indefinitely so those are things especially with COVID I could be very careful and cautious about. DME there's an unfortunate rule in which CMS requires that if a DME is provided to a patient it has to be within 48 hours of discharge. Now if a patient was arrives to the facility and they have a stroke and they need an AFO or some other splint like that then you know it's very difficult for the patient not to have an AFO until right before they go home because they really haven't tried it and therapists haven't had a chance to work with them. The other way the way around is that you know I can communicate with my local prosthetic orthotic companies and potentially have them give a trial AFO or trial brace in the meanwhile and they can provide the official brace to them at discharge. At the same time the same law goes with knee braces or neck braces things like that sometimes the facility is able to provide or purchase these and provide the patient before discharge or even early on but that can be challenging. Injections unfortunately neurotoxins are not covered by insurance companies during the stay at the facility. Very very infrequently the facility the SNF can purchase the Botox I should say the neurotoxin injection before during the stay of the rehab but at the same time these are very very expensive and I have to really justify to the facility about why this could be important for the patient. Other injections include ultrasound, a trigger point injection, joint injections, they can be done on in bedside anytime you know anything is medically necessary. Regarding patient population it has definitely changed over the years. When I was in acute rehab in my residency we actually had an inpatient orthopedic floor with patients with knee replacements, hip replacements, hip fractures, things like that. Now that unit while I was in residency was converted into a cancer unit so you can imagine the patient population was changing even when I was at residency. In the subacute setting that has also changed over the last couple of years especially regarding things that Dr. Nats talked about with the PDPM and other managed care plans and things of that sort. Now I'm seeing less and less orthopedic patients. I still have a significant number of patients that are orthopedic care, fractures, spine fusions, things of that sort but that is gradually changing. I'm definitely seeing a lot more stroke, brain injury and other neuromuscular conditions. Now this is a trend that is across the board and it's probably going to continue. The patients are going to get more complex which is why a majority of the time the primary care physician and the facilities are happy to have a specialist come in and help them out because the patient population is getting sicker. A vast majority of my patients have chronic conditions and multiple conditions that usually are multiple medications that can be frail and elderly. At the same time that gives you an opportunity to help them out with the rehab. Chronic pain patients are a small percentage of my practice. They probably less than 10%. Now you know I'm not talking about chronic pain as in they have chronic arthritis. I'm talking about when it's really more complicated in your high-dose narcotics and multiple medications. At the same time you know I am able to help them, maybe potentially guide them, maybe give them injections but as my role as a consultant I'm able to assist them while they are in the rehab setting. At discharge depending on your practice you can see them as an outpatient or you can discharge them or hand them off to an outpatient chronic pain physician for example. You have a number of patients who have dementia, Alzheimer. They can be challenging for a number of reasons. At the same time I know there's always something I can do for them if that means helping with discharge planning, assisting them with polypharmacy, reducing the medication load, seeing if they need some assistive devices, talking to family members and these are all important things for it doesn't matter if you have any patient but especially for dementia patients regarding safety. So it can be challenging especially if they have severe dementia at the same time. I can assist the therapy team to provide new goals for them and to assist the patient with their care. The regulations that are that affect our practice that you know Dr. Natsa talked a little bit about PDPM which is the patient driven payment model model which another regulation is the MIPS which is the merit-based incentive payment model. These are all rapidly changing and it was really hard to predict what's going to happen in the future. You know at the same time you know I am able to still provide care but these are certain barriers that come along the way. If anything you know PDPM has assisted my practice because now my facilities and my therapist are utilize me you know at a better capacity because I'm able to diagnose the patient early on, reduce the length of stay, find different barriers early on the care and then help them versus having them you know not get paid for the services and also providing care for the patient. Other payment models including the ACOs or accountable care organizations and bundle plans they can potentially be a barrier as well you know certain times you might not be part of the ACO or you might not be part of the bundle plan and they might consider you as a cost versus a potential benefit for reducing length of stay and reducing the cost of care. Now these are kind of things that you know they're rapidly changing and you never know what the future is going to hold but they can potentially impact your practice. The same thing with the managed care. Managed care plans and a lot more managed care plans now they were 15 years ago or 10 years ago so that could potentially impact not not necessarily my practice but it's impacting the care that patients receive because length of stay ends up going down and the amount of care they are provided goes down. Peer-to-peer reviews is not a very heavy part of my practice at the same time I am there to assist the patient I'm there as advocate for the patient so if my therapist, my facility, my primary care physicians need any assistance in which I think it is worth it for the patient after discussion with the patient if they length of stay should be extended for them to get adequate therapy before they go home that is part of my role in which I am able to discuss with the other side of the party about why a patient might or might not need rehab. So other challenges that we can face are audits. Now audits is a part of any practice doesn't matter if outpatient or inpatient or subacute typically in the subacute setting the number one reason for audits would be medical necessity. Now it is obviously based on my documentation it's based on the reason for the visit but if my documentation is strong and I really am discussing exactly why I'm seeing a patient versus another physician and able to explain to that and the risk of losing an audit is extremely low. The number of visits a frequency visit also is based on the medical necessity. Now typically in my patient population because the length of stay is really short you know I am seeing patients twice a week sometimes three times a week depending on their needs. Some patients who are less to say doing well in therapy and they don't have any significant issues and a number of these patients gone down significantly over the time that don't have any issues. I might see them once a week just to make sure things are going well, therapy is coming along and they're really hitting their goals. Liability is also part of any practice not significant part of my practice not something I'm thinking about every day. If I am the primary care physician or the primary physician for these patients in a setting then the liability is significantly higher. Typical lawsuits include wrongful death, pressure ulcers, falls, medication errors. Now there is no doubt that a physiatrist or consulting physician can cause some of these issues including falls if you are over medicating someone or there's an error from a medication dose but at the same time the risk is very low. Obviously with this being a geriatric population I'm extremely careful and we should all be very careful with the dosing of medication and start low and go slow. Malpractice coverage and premiums can also be one barrier. Now again it is our responsibility to discuss with the malpractice provider and make sure that they cover a physiatry consulting service or a primary service. Typically this will end up increasing your premiums because this is considered a little more risky than just outpatient for example but at the same time it might not be. So that's a discussion you want to have with your malpractice provider and make sure they're aware that that's what you're trying to do and what your role exactly is. So subacute rehab during COVID we're still in the middle of COVID and this is still impacting our practices. It was extremely challenging early on because there was a lack of awareness of how this will affect the patient population and how this will affect the hospitals and things of that sort. You know but the most challenging thing for providers across the country was there was initial information that was spread that said that you know we were physiatrists or consultants I should say were considered non-essential. When that happened a lot of facilities started limiting the number of times you come into facility you're limiting your you know providers coming to facility period. Some of providers were able to switch over to telemedicine which definitely helped but you know unfortunately a majority of my facilities that I work in they did not have this issue at all and the vast majority of the providers that I've talked to did not have this issue but there were a handful of places where this was an issue. What I had to do myself was transition to less frequent visits or at least not going to multiple facilities the same day so I'm not a carrier of COVID and I'm not spreading it. Obviously this patient population is very vulnerable. From the most recent data that I've seen is 42% of the deaths that are have been around the country due to COVID have been in the long-term setting or this is a living or nursing home setting. So obviously this patient population is extremely vulnerable. Transition to less frequent visits can be detrimental to patients especially if you're doing this to telemedicine you're not able to diagnose a patient or treat them early on but this was at the height of COVID this was definitely a significant issue. Telemedicine has its own challenges including obviously the patient population, they can have a hard time with technology, having staff to assist you during the grounding if that's a therapist doing it or some other person in the facility doing it that can be challenging. Overall there was a 25 to 30 percent reduction in my patient population that has since normalized back to almost 95% of pre-COVID but the reduction number of patients is primarily because of a reduction in elective surgeries. All of a sudden the strokes and the brain injuries, the number of patients from the hospital went down, the length of stay in the hospital went up. Obviously if you add in the patients who end up dying because of COVID so there's a reduction in the number of patients. But you know for me this is an opportunity because I was able to be one of the team leaders and assisting my facilities in getting through this tough time which included many different things but I would just add a few things in here. Reducing the outpatient appointments the patient had to leave the facility so being able to do injections on-site, being able to evaluate patients and helping them minimize the number of outpatient appointments as necessary. Reducing readmission back to the hospital trying to keep everybody in-house and doing what you can especially for things that can be taken care of in the subacute setting. Other things were minimizing the number of patients who had to get therapy in the therapy gym, you know trying to analyze what patients can get therapy in the room and how we can maximize that. Assisting the therapy team and finding new goals for them especially if they run out of different things they can do in the patient's room. You know sorting patients based on their diagnosis, based on their risk for COVID, based on their symptoms. Those are all the things that you know I had to assist my facilities in and they're very thankful for that even though I am not an infectious disease doctor but at the same time I understand you know disease process and rehab obviously. Also other things that we had to do were you know continuing marketing across the other orthopedic surgeons or neurosurgeons or hospitals about you know the type of rehab we're doing in this setting so they continue to send their patients over. The list is longer than this but this is at least a nice summary. So in summary the the work has challenges without a doubt but at the same time is extremely rewarding. I feel like I am very fortunate to be able to help this patient population especially during COVID now with the social isolation that the patients are feeling. They really appreciate the fact that I'm coming in and seeing them in person. I'm able to assist them with their goals, assist them to go home if they need to. The work itself is very flexible. I can work any hours I want. I can take as much time as I want off. There's a significant amount of work-life balance. So thank you again for being bold and making PM&R essential in the whole continuum of care. If you have any questions please please feel free to email me at this address and I'll be happy to talk to you there. Thank you so much.

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