I am the first speaker. I am Dr. Steve Natz, and for those of you that don't know me, I am Chief Medical Officer for Integrated Rehab Consultants, the largest group of physiatrists working in the skilled nursing facility environment in the country. And today, we're going to talk about the current state of value-based post-acute care. Now, I have three distinguished speakers that are going to follow me. I'm going to say a couple of introductory comments, and then I'm going to really let my talented colleagues here go and tell you more about this important area. So here comes Dr. Smith. So I think when you're talking about value, maybe we'll go back to kind of the business school definition of value in any service industry, right? Value is always the technical solution plus some kind of interpersonal psychological need fulfillment divided by the monetary costs and any non-monetary transaction costs that are in the situation. And traditionally in medicine, of course, we have focused way too much on the technical solution and not paid enough attention to the other factors in the value equation. There's a well-known graph when you're talking about quality versus resource utilization in healthcare that kind of goes like this. You can see the picture on the slide here where it shows that quality goes up to a certain extent the more resources you pour into the system, right? But in American healthcare, we've kind of gotten to the peak of this and probably gone over the peak so that now as you use more resources, in fact, the quality goes down. And you can think of, you know, lots of examples of this like unnecessary surgeries or too many tests, things like that, that cause the quality to go down even as you increase the amount of resources that you pour into the system. So I think that the other thing that you can think about though is there's a different curve for rehabilitation. And this didn't occur to me for a long time because you always think about the fact that cost or quality versus cost might be the same for rehabilitation as it is for other things. But just to think about it, that you're still trying to get quality over quantity, but the curve is different. Evidence-based practice is often lacking in rehabilitation medicine. Clinical practice guidelines and pathways are often lacking. There are some benchmarks, but they're very few and far between. That sometimes we can put our providers at risk for outcomes, we don't even know what those outcomes are, and we have to overcome socioeconomic inequities. But I think you also have to think about other indicators like quality of life indicators. Sometimes, you know, if you're taking care of a rehabilitation patient, it's not so much whether they live or die, which of course those are important, but what's the quality of their life? Are they able to live a quality lifestyle? Do they feel in their patient-reported outcome measures that they did well? And I think we want to also reduce the burden of care. So some examples of quality in a skilled nursing facility rehab environment are things like reducing or right-sizing the length of stay. As you know, in post-acute care and skilled nursing facilities, historically, you know, skilled nursing facilities wanted to keep everybody 100 days, right? We don't let them do that anymore, and they don't want to do that anymore. In fact, some of them do, but most of them don't want to do that because if they're living in a post-acute network world with their hospital that's going to be sending them patients, they want to right-size their length of stay as well. We want to increase their discharge to home or home-like environment. We want to definitely reduce hospital readmissions. We want to provide good and durable outcomes. We want to reduce the caregiver burden when the person does go home. We want to improve quality of life, and we want to reduce costs to the healthcare system as a whole. Some of the quality models in post-acute care, you're going to hear about some of these today. You're going to not hear about some of the other ones. One of the first ones that, of course, I was aware of was IRF PPS. So the prospective payment system came along for IRF and said, we're going to pay you this much for this case to get to this outcome. In the SNF world, we're starting to get to that because PDPM is a movement towards the patient-driven payment method is a movement towards paying skilled nursing facilities by patient characteristics by ICD-10 codes and moving towards a skilled nursing facility PPS slowly inexorably that CMS is doing. The CMS Quality Payment Program for physicians, MIPS, and soon-to-be MVPs is also a quality model that we can use in post-acute care. The bundled patients holding providers accountable for outcomes, ISNPs we're going to talk more about, but CSNPs and DSNPs and some of these other word salad ones that have to do with special needs for the most vulnerable populations. Managed Medicare, I know I was in another one where someone said disadvantaged Medicare. I think, you know, it's certainly the best you can say about managed Medicare today is that it's managed cost. That's really what managed Medicare is trying to do. And when you're talking about rehabilitation, think back to that curve, you know, that managing cost doesn't necessarily get you a better outcome from a rehabilitation standpoint. It may get you a worse outcome. ACOs and post-acute networks, we'll talk more about those later. And use of physiatrists in a SNF rehab. I mean, I'm up here on the soapbox for that very reason that I think we need more physiatry involvement in skilled nursing facility rehab across the country because that's where you're going to get the quality. So I want to thank you, and I want to turn the podium over to my speakers. Matt Bartell is my first speaker, and he's going to be talking to you about some things in his world. Thank you very much. All right. Let's see if we can move slides. All right. So I'm going to be taking a look a little bit broadly at post-acute care in a health system using our Montefiore Health System over in the lower Hudson Valley as a model for this. But I'm also going to take a look at some other things that we've had with post-acute care overall, and then give you an example of how we actually integrated a hospital into our system and how doing systemness may actually be a really good way to enhance rehabilitation. But I do have to say that a lot of the changes that we've had have been stymied recently by a lot of the changes in healthcare that has gone much more back to more of a fee-for-service model and a lot of the ACO and a lot of the other models that we were going forward with under the original affordable care system has actually kind of been scaled back or kind of frozen. And so there's some editorializing that will be done about that too. I'm not going to go through all of this, but these are a lot of that alphabet soup that we were just talking about. If I use some of these terms and if you actually get back to the slides you can go back and look at what they are. IRF growth, and we know this as a field, I know I've been listening for 10 years at these meetings to people saying that IRFs are dead. IRFs are not dead. They're not dying or on life support, but they're not thriving either. And I can show you a little bit of data that shows that basically IRFs are actually kind of stagnant. We have a service that is really important. We provide expensive care, not as expensive as an LTAC, a long-term acute care hospital, but certainly more expensive than some of the alternatives such as SNF-based rehabilitation or home-based or outpatient. But the thing is there are patients that we all know can benefit from this kind of care and in that diagram of cost versus benefit we are on the higher end, but it is actually something that we can actually utilize. And there have been a lot of things that have been done for cost management, the 60% rule, bundling, Medicare disadvantage, I like that, I'll probably use that from now on, that have actually been a headwind against us being able to provide these services. And it's not only us. I have talked to my colleagues in other departments. Medicare advantage is... They're basically denying everything and it's gotten worse since COVID and it's because they are trying to recoup costs, but they didn't pay for a lot during COVID because nobody got all the expensive care. So I don't know where this perceived need to deny all this care that hadn't been provided before is. But Medicare advantage has been very, very much pressuring on costs and it's actually gotten to the government accountability office if you've been following this. There is now an investigation that it looks like there's systematic under-provision of care. And mind you, Medicare advantage by contract is supposed to provide the same level of care as Medicare fee for service. So they're not doing that. We know it. It's now just got to be proved. So just... This is... I'm not going to linger once again, but this is coming from MedPAC. This is up to 2019 and into 2020, but you can see that the number of actual rehab providers has decreased slightly in 2020 and I think part of that was because of COVID. But if you look overall, it's actually been gradually declining in all areas. Long-term acute care is particularly badly hit. Skilled nursing facilities have remained relatively stable, but they too have actually declined and I think that's because if you're a self-standing skilled nursing facility, it's... As one person who works in the business told me, it's a business of nickels and dimes. There's such a small margin that if there's any kind of an impact like COVID, it really can very severely impact the industry. The spending has been stabilized. I can show you graphs that were prior to 2010 that showed that all of these post-acute care costs were going up. They've actually stabilized and as you can see, these lines are going flat across the screen. Interestingly, the inpatient rehab facility expenditures have actually been up a little bit, which means that we are in the crosshairs. They're looking at us because it's an increase in expenses. We're not the majority of the expenses, but it is, you know, an increase. So there has been a little bit of scrutiny. So with this whole thing, we've moved to the GG codes and all of you guys are familiar. Now we actually, for those of us in inpatient, we've got a much more complex IRF-PAI, part of the alphabet soup, that a lot of people have been saying, this is awful. Why are we having to do this? And I actually am also thinking it is good that we've increased certain instruments there because it does help us to manage and look at the quality of what we provide, but we need to get rid of some things too that are not useful in the IRF-PAI. It seems that they only want to add and never anybody wants to remove. It's kind of like the joint commission, right? You know, more and more regulations, but they never get rid of the old ones. So the thing that this is really being used by the government for is site neutral payment. And site neutral payment has been viewed by a lot of us as a dire life threat because if site neutral payment happens, it means that if a person has a stroke, we're going to get paid the same amount as another location provider, home care or a nursing home or others. That is true, but we can prove our worth and we've always had a problem because in the past the outcome measures were OASIS for outpatient home care. There was RUGS for the system that was being done in nursing homes and then we had our FIM system. Now everybody's being judged on the same thing. So that's part of the reason why a lot of the stuff that's in this new IRF-PAI is useless because it really refers to home care or nursing home care, but it means that we are actually now comparing apples to apples, not apples to oranges to peaches. And that means that we can actually show our value because we can show the better outcomes. We can show the decreased re-hospitalizations. We can show all these benefits. That's why having this system is probably going to work very well, but we do have to worry about making sure we provide quality care and we have to then work on our own internal things. Now since this talk is actually based much more on how do we do the value-based system, it's going to have to talk about money. So it's our existential moment that we need to actually prove our value in dollars and cents and we as physicians don't tend to think in terms of spreadsheets. But I know that Dr. Flanagan gave a talk about how do you appeal to the C-suite and I think the core lesson was you got to appeal to the Excel spreadsheet. Because if it doesn't make dollars and cents, it's not going to get through to the decision makers who often are not basing it upon the quality of care and the fact that your patients love you and the fact that they're walking 50 feet further. They're going to be based upon you saved the system $500,000 and that's an investment we're going to put into. So we have to think to track. We have to improve our quality, but we have to also make sure we have that fiscal thing. So being part of a health system, there is a reason that systems have combined. I was talking to some folks who are here from Baltimore and there's apparently three major health systems and I'm going to fail the quiz because I can't tell you what they are. I know Hopkins is one and Union of Maryland is the second and I can't remember what the third one is. But anyway, what's that? MedStar. So they're competing, but if you're a small independent hospital in this area, you're not going to make it because they have negotiating power with insurance companies, with suppliers, with pharmacy companies. They're going to put you under. So it's either join or die. And health systems also, this is true about our IRFs. Most of the IRFs, and I didn't put the slide up, pulled it out because I can't talk forever. Most IRFs now in the country, most of the beds, like 90% of the beds are in self-standing rehab hospitals. The hospital attached units are a very small percentage. And in our own health system, that's true too. About 10% of our beds are hospital attached and the rest are in a self-standing. And the cost per day per bed is far lower in the self-standing, but we have a value base that we keep that unit. You don't know the fights I've had in the last three years to keep that unit running. Because when they closed it during COVID, they only let me open up not 16, but 12. And I said, 12 is not financially viable. 16, I can make you money. And we finally got back to 16 and now we're showing that we're actually making a lot of money. But the reason we're making money is it's a hospital-based unit. I could take patients on dialysis, patients with ventilators, patients that we would never think and would think they have to go to LTACs, but mind you, New York does not have access to LTACs. So I gotta take those patients or the system's gonna eat them as an expense on the inpatient units. So that's how I can show the spreadsheet value and make a value proposition that now they're even starting to rumor, maybe we can move up to 20 beds. I'm like, wait a minute, I'm gonna have to staff up for that and we can talk about that later. But once you show the value proposition, you can actually increase it. Do I want 100 beds like that? No. Because that's where you put them in the self-standing unit. So coordination of care, you also need to get involved in the whole pathway. Because if you're not involved in that whole pathway, you're going to have a problem where you can't really control the traffic as it has to go. Think of it as you're the air traffic controller. You gotta make sure that the heavy jet lands on the big runway and that little propeller airplane lands on the little runway. And you've got your patients that are the complex ones, they've gotta go into your IRF. You've got the patients who will thrive in an SNF setting. Don't try to populate your IRF with those patients because they're not gonna actually help you with your value-based proposition. Put them in the SNF. And maybe you need to put your physiatrist in that SNF to make sure it works. And then also home-based. You've gotta get involved with your home care agency. And we actually own a home care agency at Montefiore because that helps us to control the cost. So we have patients that we... Well discharge and Medicare is not paying for a certain part of the cost, but it's a certainly better investment for us to have that and eat that cost and keep the patient in the hospital longer or have an outcome that's gonna be adverse. Or send them in a nursing home, which is gonna cost more. So there are very, very important reasons for us to be involved in that whole continuity. Now we had a COVID dividend. One of my challenges with getting the inpatient unit that was attached to the hospital to be much more complex was the nurses were like, we can't handle this. Well having been a COVID unit for two years with ventilated dialysis patients with acorns in every room, the nurses are like, yeah, bring it on. At this point our staff was actually able to. So there was... This is like the only COVID benefit that I can actually think of that we actually turned around a week and actually now take those much more complex patients in. So remember, no money, no mission. So you have to make sure that you have that value base in there and you need to do a lot of cultural change. As you bring in, let's say you bring in a self-standing IRF, you have to do cultural change because the institution is going to actually have to adapt to being part of a larger health system. And one of the things that you want to do is you want to take patients from everywhere. So for example, at both our Burke and inpatient unit, we have about half of our patients from outside the system. But it's a resource that we needed in the system because the system had 3,000 beds and if we didn't have that inpatient rehab hospital, we'd have had 16 inpatient rehab beds. We would definitely not have met our needs. Having 150 beds there plus, so it's 166 total, we have the capacity to actually make pathways and do creative thinking so that we can bring patients through. So we can work with our oncology service to create a pathway. We can work with our cardiothoracic service or our transplant service to create a pathway. And that still means you can be in the 60% rule because remember, for every transplant, I just need two strokes to make up for it. And since our inpatient is running at 90 out of the 150 beds being neurologic diagnoses, I can do this. That gives me, you know, the easy 50 beds that I can probably play with the majority of them non-classic diagnoses and I can work the system. We also had to work culturally to adapt to the fact that we had Montefiore which was coming out of an urban poor environment. The Bronx is the poorest urban county in the United States. We have about 5 to 10% of our people who are undocumented. 15% uninsured and our payer mix is 85% government payer. To Westchester which looks like Manhattan. Westchester's got 85% insured patients, very low amounts of undocumented and uninsured. Try to meld those cultures because it's a very different mindset about how you treat patients. So we'd have social workers who have never had a challenging discharge before. And they're like saying, you can't send this patient home. And we're like, this is an easy discharge. This person's got a home. Yes, I know he's living with three other roommates in a single room rental, but that's a home and he's got people who care about him because his friends came to see him every day he was in the hospital. This is a stable social environment. And they're like, but he doesn't have a house and a car and a job and it's like, hmm. So that's part of that social engagement that you have to work on and bringing together. The people in the Bronx when they see those wealthy patients don't seem to have as much of a culture shock. So the social worker now has the person who says, yeah, I've got the ex-best money. I can pay for the 24. They don't usually have a problem with that discharge. And Medicare's rules. And remember the rules are ever changing in Medicare's favor. They are looking to control costs so they move the goalposts. And the Pioneer ACOs were a great example. We made money on that, they changed the goal. They remade money on it, they changed the goal. So the dream solution, take all your patients that need acute and other rehabilitation, regardless of diagnosis, insurance approvals and bundles, bring them in and make them go through this and come out with the best physical outcome. That's what we want to do. It's not the fiscal thing, but it can be because you can show that you decrease length of stay in your acute hospitals. You can increase your high cost cases that you can bring in. God, do they love transplants. They make a lot of money on those. Oh yeah, they love to have those complex orthopedic reconstructions. They can make a lot of money on those. But only if they can move the patient through the continuum. And they have to have flexible coverage. You need to have the ability to have patients move from one level to the other. And that's where if you also bring in nursing homes into your system, maybe they stay in the nursing home for several weeks to get strong enough to do the acute rehab for 10 days to then go home. Not a common pathway, but it's one that we should often consider because a lot of patients can't wait for 10 days in the acute care hospital to get strong enough to do acute rehab. But you don't want to lock them in the nursing home if they can actually graduate to that level. And vice versa, maybe just buff them up a little bit more and do the recuperation in the subacute, but because of the new changes, not have the patient stay there for 100 days because they can. Get them there, stay there for 10 days, which is all they really need, and then get them home. So we've been working on incorporating all the levels of care in order to make this work. And we have to work with our rehab thing. So what did we do? Talked about the 85. Talked about the 85% government payers. Talked about our challenges. So what did we do? This is kind of like an overview of Montefiore. Once again, I'm not gonna go into the details, but you can see we've got a medical school that's part of the health system. We have multiple hospitals in four counties. There's all sorts of outpatient, inpatient, home care. It's a mess, but it means that there's a lot of potential pathways that we can create. So we wanted to have the rehab's role in all the post-acute care. Rehab isn't just about rehab units. It's not just about consults. It's about post-acute care. So I engage with all of the different people. I've got an ongoing relationship with our director of home care. I've got an ongoing relationship with our nursing home. I've got an ongoing relationship with the directors of these acute care services in order to be able to keep the line of communication moving so that as we get a complex patient, we can figure out the best way to move them. And there's a lot of these one-offs that we have to figure out, but those one-offs can save a lot of money. So early ICU mobilization. We proved about eight years ago that it really saves a lot of money to the system. Only half of our ICUs are doing it. So every ICU director, I introduce them to the topic. We work through it. We actually create the business plan. We go forward. I wish it was much faster, but it isn't, but that's partly due to COVID because that kind of really screwed things up for a couple of years, but it's also because each institution has its own culture. So we have to get through the institutional culture to make sure that they recognize the value of this. So what did we do? We're working on creating a totally integrated PAC network and I think most systems are trying to do this. Our core rehab services are at our rehab facilities for our IRFs, but we're working with our SNF partners and we have a collaborative with 10 nursing homes in Westchester and 10 nursing homes in the Bronx and we have quarterly education sessions and meetings where we actually update them on the latest standards of how to deal with the QBDI or how to prevent C. difficile or how do you mobilize patients. So we work with them and create an educational base, but it also creates and fosters a mutually respected relationship and that allows us to then work with them to create the pathways. So once again, I said we've got 166 total beds. If you look at it, the majority of the beds are in neurologic services and in 2016, Burke officially joined us. Burke was having a real challenge as a self-isolated institution. They were losing a lot of money. We had a view that in four years we could bring them, turn them around financially. We made them turn around and make money in eight months. This works. So how did we do this? We estimated the financial implications and this is a slide from our original presentation in 2014-15 when we were proposing the merger that we thought that there was an incremental contribution of $4 to $12 million to the bottom line if we brought Burke into the system, to Burke's bottom line and we did a couple of things. One of the things is we could create these pathways and get patients for them, because they were having a census challenge, but the other was they never had GME and they were a GME virgin institution. They had no cap. So we, as they came in, immediately established in one year that they became GME institution and they had approval for a residency in one year. I don't know anybody else who's done that, but we just like hammered the paperwork, because that was going to be anywhere from $1 to $5 million to the bottom line once you got that running. GME is a very important part. If your institution has the ability to incorporate it, think about it. It really gives you flexibility. We went from losses of up to $6 million in 2015 that in 2017 they made 3.3, 2018 5.3, 2019 5.2. 2020 we made about 1.2. It was not a great year for a lot of folks and so this is actually something... And we've made about the same. We're a little bit less. The Medicare Advantage has really severely hurt us in the last year or two and it's been an ongoing challenge. But you can see that we've had a tremendous improvement. We've continued to work on length of stay. The length of stay is now under 16 days and this is with a complex brain injury unit and spinal cord unit involved. And our projected profits for the coming year are probably going to be around $1 million. But this is also incorporating that what we did is we were able to install Epic, give 10 to 15% pay raises to all of our staff in order to make the market competitive. It also was done in order to make sure that it's the only non-union institution in the health system. So we wanted to also prevent union accretion. So there was a couple of things that were there that are extra expenses that have actually hit the bottom line a little bit too. But it also meant that Burke became Hospital of the Year in Westchester. So it really was a great turnaround. So this... I'm at the end of my time, but this is kind of an image of... I'm here in the center, but I am talking to people all over the place. I'm talking to our CEO on a regular basis about how do we continue to provide value for the system. I am talking to our practice managers. I'm talking to the director of our faculty practice group. I am talking to all of the different hospitals. And I'm talking to the CEOs of all of them about how we can help improve their bottom line. And this is something that as a leader in rehab, you need to get involved. Otherwise, you're not going to be able to do this. So the conclusions, integrate institutionally, departmentally, administratively, get into the C-suite, talk to them, and you do have value and you can add a significant value to the system. It's incremental value in a lot of ways. Don't talk about savings, because they can't bank savings. Talk about what you can actually generate. And the generation is actually helping to move patients through. So that's actually increasing throughput. So I have the cardiac surgeon saying, yes, the rehab guys can decrease my length of stay by two days. I can bring another 50 cases in. That's bankable. And then we're all held accountable to make sure this happens. So this is actually where I think we actually have to all take a look at, making sure that we're integrated in these systems. I think all of us are now working for or will be working for systems and realize how we can actually put in our value. Thank you, guys. Okay, we're going to have time for questions at the end. I want to introduce, so we stay on time, introduce Dr. Ed Burnetta, who's going to talk to us about ISNPs. For those of you that are virtual, I've got your questions on this little tablet up here. So we're going to get to those at the end, too. I'm Dr. Edward Burnetta. I am a physiatrist who practices in southeastern Pennsylvania. I'm a medical director of an IRF unit at a community hospital in northeast Philadelphia, a 20-bed unit. I am a consultant practice, physiatry practice at nursing homes in the Philadelphia area. My practice goes to 46 nursing homes. I have 11 nurse practitioners that work alongside me. The practices in the last 12 months, I've added more buildings than I think any other 12-month period in terms of my practice. I have two disclosures. One is Steve asked me to talk about ACOs, ISNPs in the nursing home settings. I'm definitely not an expert in this area. I'm a physiatrist. I practice day-to-day. I'm independent. But because this is where I work, I try to stay abreast of what's going on in our buildings. And this is definitely something that's coming our way. The other disclosure is this week I signed a contract with Longevity Health Plan ISNP for Pennsylvania, and I'm going to be the medical director of that ISNP. So that's exciting for me, and I'm hoping that next year perhaps I can talk, you know, a little bit more in depth about how ISNPs are affecting our practices in these buildings. So my practice has grown over the years. I think this year we're going to be over 18,000 encounters in the nursing home environment, and, you know, the practice has been built on the model that exists in the current state is fee-for-service. And I think the basic premise between fee-for-service and value-based care is value versus value. So you can have a productive practice. You can add to the patient satisfaction and quality in a building. But in the value-based model, we really have to demonstrate, as Matt said, we really have to demonstrate fiscal value to the entity. Just to mention the triple aim, a lot of times people talk about that in the gist of value-based care, and, you know, basically it's basically trying to improve quality without increasing cost and or maintaining cost and improving quality. There's various ways you can get to that triple aim of patient satisfaction, and it's one of those areas where they really emphasize in the value-based care model. So payment models in general. This is one of the important points I wanted to make. Medicare, I think oftentimes we talk about Medicare. It's a big player, obviously. It's very important to interact with them. It's where, you know, the innovation model is, et cetera. But from my perspective, I think the more important entity that we have to consider as physiatrists in practicing in these nursing homes is Medicare Advantage. And the reason I say that is, my next slide, I'll talk to you about it more, but Medicare Advantage is 48% of all enrollees this year in Medicare. The overall Medicare program, 48% are Medicare Advantage patients. This time next year when we're talking, it's highly likely that Medicare Advantage will have a plurality of patients under enrollment. So you're actually going from an insurance product that is, was I think 18% of the overall population about seven, eight years ago, to now where next year they probably will have the plurality of patients. There's a couple things fueling that. From my, and again, this is just my opinion. From my perspective, one of those is that the, I feel as though Medicare itself is pushing a lot of their risk away from their management to outside players in terms of trying to get ACOs, trying to get ISNPs or specialty care networks, et cetera, and especially the Medicare Advantage products. And all the major insurance players have Medicare Advantage products. And I read recently where the Medicare Advantage companies, the majority of their profits and revenue come from their Medicare Advantage products, not the products that they sell to corporations, et cetera. So the commercial insurers, these enormous billion-dollar, multi-billion-dollar operations, their biggest profit margin and their biggest revenue source is Medicare Advantage. So it has that momentum of the commercial entities that I think sometimes we are always looking at governmental and Medicare. I think to some degree we have to shift our view as physiatrists at the commercial entities that are definitely going to be playing a bigger role in our lives in the post-acute care setting. So under the Medicare Advantage program, a lot of people don't know a lot about ISNPs. There are specialty programs that are under that umbrella of Medicare Advantage. And the dual-eligible special-needs patient is the biggest group among those special-needs patient entities. The institutional special-needs patients are the ones where have to be in a nursing home for 90 days of the year. So basically, you're long-term care residents in the nursing home. And just to clarify briefly, when you go to a nursing home, it's often there's two kind of demarcations. There's a skilled SNF unit and there's a long-term care component to these buildings. And when I talk about ISNPs, I'm talking about the long-term care component of the building. So many times if you have a 150-bed unit building, you may have 30 beds that are designated as skilled for short-stay patients and you have 120 beds that are for the long-term care patients. When ISNPs come into a building, the patients that they are enrolling are the ones on the long-term care component of the building. So this just reiterates what I just said in terms of Medicare Advantage. If you look at that graph, this is 48 percent in 2022. That's a pretty dramatic increase. And to me, I think it's just going to accelerate with the commercial interest of these major insurance players. So there's going to be more Medicare Advantage in our lives. And whether it's in the guise of an ACO, whether it's in the guise of an ISNP, if you're working in a post-acute care setting, this is the insurance that you're going to have to answer to. This is the insurance that you're going to have to prove our worth. And it's a whole different perspective than a fee-for-service model. So along with this, under the umbrella of Medicare Advantage and the growth of that, the other thing you have to consider, too, there's a silver tsunami in which there's more enrollees going into Medicare. Therefore, there are a greater number of enrollees going into Medicare Advantage. So underneath this, this is a graph of the special needs plans and how they've grown. And to some degree, it mirrors Medicare Advantage advancement, but somewhat stymied early on. And really the interesting thing with some of these programs is there's a government component to this. There's a legislative component to these programs. And with ISNPS there was a balanced Budget Act I think in 2014 that made the special needs plans permanent. So when I talk about special needs plans and when I talk about accountable care organizations they both are enshrined in our laws as permanent fixtures in health care. So they're not prior to 2015 there was like a one-year law and then a two-year and a three-year and no serious businessmen were going to get involved in something that might not be permanent. But now they have the confidence to invest in these entities because they're going to be here. And as you can see the the the top part of that graph the 184 ISNPS in 2011 there was what 60. So you're looking at triple growth in this period of time. And just to explain a little bit with ISNPS. ISNPS are insurance products so they have to go through state insurance processes to be accredited as an insurance company. So that's obviously a very cumbersome and time-consuming process. So not only is this impressive growth based on just looking at you know the numbers it's extremely impressive to me in that they've had to go through a process that's very cumbersome very financially draining. They often develop capital reserves of you know X number of millions of dollars in order to initiate their process in a given state. For instance longevity this Pennsylvania is now their ninth state that they've started their business. So as a subcategory of the of the overall SNPS excuse me of the ISNPS initially a majority of those were you know owner operated. And what you can see in that bottom blue square it's up to 64 this year. That's provider plus owner groups. And again I think that is going to be the fastest growing area for ISNPS. Longevity ISNPS is also a provider plus owner group. So when they come into the state they form partnerships with providers. And for the most part the providers they form partnerships with are the nursing homes. So you have a nursing home where you're going to see a patient. That patient is insured partially by the nursing home. So if you think about that a little bit it's it's it's really you know somewhat of a completely different paradigm over going to a nursing home seeing a patient submitting your billing to Medicare Medicaid getting your billing back in nursing homes not really they're really I guess relatively indifferent as to what's coming back in in to your coffers. With this situation my check comes from I work with I'm contracted now with with both Longevity and PPHP is another ISNP in Pennsylvania. So I have contracts with two of these groups. So my checks come from PPHP. PPHP is in partnership with those nursing homes that I go to in which there are PPHP patients. So they get paid per patient per month for all the patients that are that are enrolled in this program. So they're looking both at their per patient per month. I'm adding to that cost factor by seeing their patients in the building. So they're looking at that and saying is this really worth it to us to have physiatry present if they're costing us money off our quote unquote bonus or incentive payments at the at the end of the quarter because they're in the building. So that's the gist of the major problem or problem and or opportunity that I see for us as physiatrists is we really we have to prove our value in a succinct fashion in order to be attractive to these groups in order to be involved in that type of care in this setting. So with iSNIPS in general the legislative issue I won't bore you with but basically it was a number of temporary measures from the ACA but ultimately became permanent with the Balanced Budget Act and it's grown since. So it has the legislative backing. It's basically a capitated model where again they get a per patient per month payment from Medicare and the thing about this model is if you're a nursing home owner and you're you join in contract with an iSNIP the iSNIP tends to they run the insurance piece you know and it's like a 50-50 type of arrangement but you share you know in savings and so this is actually instead of having patients up on the long-term care part of your building that are primarily Medicaid and where you're making a fairly minimal amount per day you can actually generate higher levels of income per day and then you can also generate savings if those patients are managed correctly. So when when someone becomes insured by an iSNIP the basic goal is the right treatment right place and the real mantra is to maintain treatment in-house as much as possible. So you know any transfer out of the building is costly to the building and costly to the insurer. That's where I feel like that's one area in particular where physiatry can play a very strong role and I take pride in the fact that we go to buildings are able to perform joint injections at bedside with the patient. We save that building the cost of transportation, we save that building the cost of sending a staff member off the unit for two or three hours and we save the the building the or the patient we save them the time of waiting two three weeks for outpatient specialist appointment and you know the other thing would be they're not paying for that specialist appointment outside then either so there's a there's places where I think we can fit in show value show quality of care good outcomes that would allow us to blend in with these with these entities. iSNIP often has a nurse practitioner that they have round on the long-term care patients in the building so it's really a from my perspective a good plan because it's patients that typically don't get seen that often are now seen routinely and regularly and caught early on in terms of issues so you don't have a deep circle to cube that needs you know multiple wound care visits maybe a debridement you catch that the thinking is you catch that earlier because there's someone seeing these patients more routinely and the other flip side of that I think about is when I go into a patient room to see a PPHP patient the patient a lot of rooms are still to bed it the patient beside him is seeing a nurse practitioner rounding on him he's seeing a specialist come in to see him bedside and that Medicaid patient is going to want to be an iSNIP patient the next year so I think that this is going to grow organically within the buildings and I think it's also going to grow because of these major Medicare Advantage products that are you know they're commercial and they're successful and they're I think they're going to actually really kind of push the push the or accelerate this process again I spoke about this a little bit earlier but the arduous process I really think that's the why it hasn't progressed as rapidly as you might think because it's such an arduous process to get that regulatory approval by the state and then even after you get that regulatory approval by the state you have to have a provider network you're an insurance plan so you have to have a provider network that you have to create and you have to have a provider network that you create county by county so it's very arduous for these to get established but once they are established they're able to go you know to the next nursing home down the road they can really expand rapidly once they've established their marketing core and they you know they figured out the landscape hence I feel a certain degree of urgency for physiatry to get involved with these groups early in their lifespan not when they're fully evolved and developed and saying we don't maybe we don't really need you the the other thing with iSNPs is that if you enroll a patient in an iSNP that supersedes all other insurances so episodic care ACOs doesn't matter your patient remains an iSNP patient so if you think about it if a patient goes out which is something you don't like to see happen to say they go to the ER somewhat unstable they stabilize them a bit in the ER transfer them back to the nursing home the iSNP is very keen it's kind of a weird scenario but they're insurance but in the SNF unit they're keen not to keep them on their own SNF for a long time so it's kind of a again a paradigm shift in terms of how nursing homes view the various departments of their building if you know if they have the SNF but to some degree they're paying themselves so it's it's there's a interesting dichotomy there in this model just to go briefly with ACOs and the reason I bring Accountable Care Organizations up is again legislatively they're made permanent the MSSP ACO was part of the Accountable Care Act and that's in permanent legislation so that's going to be here ACOs Accountable Care Organizations are for the most part physician led most part based on primary care and the reason they're important to us is ACOs for the most part want to either avoid skilled stays and or very much limit skilled stays and again from I think a physiatry standpoint we would look at that as a potential negative I think also we could look at that as a potential opportunity for us I'm sure my colleagues that work in the in the skilled nursing facility world have seen where we may have you know suggestions or recommendations that would be helpful and you know they kind of listen to you they kind of don't but now I feel as though the nursing homes need to really heed professional advice regarding hey you know if we tried this with this patient he'll progress more quickly and get out of here sooner with a better outcome and if you're showing that to your local ACOs they'll refer to your nursing home again so I think there is more in some ways they're listening to us more on the SNF front than they have in the past and I've actually had a couple meetings recently with the nursing home chain in the Philadelphia area actually it's more of a like a regional network but they basically see out of kind of out of nowhere they see the value of physiatry I've been in their buildings for a while in the long-term care component but now they're asking me to participate in the skilled component and I'm thinking the reason they're doing that is because they see the value of if they can more efficiently manage patients through this process with our assistance that's a great thing I think it's a skill set that we take for granted we all I think at some point will have been in an IRF and have been part of team meetings and interacted with therapy and family etc and really there's not a it's a natural transition to the skilled facility to do the same thing so just I'm gonna go by that I'm sorry so I'm gonna wrap it up so basically it's important for us in an ISNIP model we really have to look at our impact on payments because they're looking at our impact on payments we can no longer in this model we can no longer say hey I'm not costing your building anything I'm helping out I'm seeing folks for you it's nope nothing out of your wallet it is out of their wallet now so we have to come in with you know our own quality indicators and our own data to show that we are a value to this facility that's just the different ways in which potential role in alignment with the turn of payment models the medical director I'm actually doing now and I am a preferred provider so you can do different models and I'm hopefully I can come back next year and talk a little more depth about how the ISNIP model is working out but thank you so much okay well next up we have dr. Charles Smith I understand that we're having trouble with the live stream so hopefully it's being recorded but we will get to your questions if you have them and dr. Smith all right well good morning everyone I'm Charlotte Smith my main disclosures that I work with Flight Your Health which is an IT company providing PM&R services using a team-based approach and lots and lots of technology and innovations and so I'm going to talk a little bit today about how we prove our value so you know the key thing I think everyone in this room realizes that every level of care can benefit from physiatry but one of the things that we're learning is you're only as good as your value and the question is are we making a difference is there anything we're doing that's changing the metrics in skilled nursing facilities and post-acute care and if so how we prove this and you know key thing is data you're only as good as your data so you guys heard earlier the definition I'm sure there's no one in this room that doesn't understand the basic definition of value about the highest quality lowest cost and you can add all sorts of modifiers to that but what's really important to remember is value is both a noun and a verb so that definition of value is a noun but then there is what do people value and there are stakeholders that we have to work with that are essentially our customers that value different things and the challenges they each have different priorities and these values may actually clash what's good for one entity may be bad for another and guess what we get to reconcile that so let's go to the star rating is everybody here familiar with the star ratings okay so it's kind of a fun thing and these basically are skilled nursing facilities like grades you get from one which is not so good to a five which is just amazing it's based upon the experience of the enrollees who are involved in Medicare and the advantage programs in Part D prescription they read done annually and the sniffs live and die by the star ratings and what you will see there's three categories there's this health inspections which bottom line that boils down to complaints because that's what triggers a lot of health inspections staffing which is in my opinion the hardest and most difficult aspect of skilled care currently since COVID because staffing turnover is horrible and finding people to work is even worse and then quality measures and what's really neat is you can actually go to this website you just nursing home compare and you can pull up a geographic region and you can see and I think these I'm living in northern Idaho I think these are the only two and then 50 miles of where I live and one is a three-star one is surprisingly a five-star which is interesting so the quality measures are broken up into two categories so I call not skill we call it short stay versus long stay so your short stay is your pseudo inpatient rehab but done a skilled nursing level so these are people that if we do well leave there and don't live there but the ones who stay long term are the long term care patients and what you'll see is there's differences in the quality measures between short stay versus long stay so short stay looks similar in many ways to inpatient rehab we're all about functional improvement mobility improvement whether you get home to the community or you get institutionalized all about basically cost which boils down to length of stay and a lot of other factors and it's also about preventing readmissions and ED visits and then also iatrogenic complications like pressure sores long stay is a little different because these are people who may be living there and what you're looking for is that they don't get worse so just like short stay we're trying to avoid hospitalizations and ED visits and falls you're also hoping that they don't develop pressure ulcers UTIs and CAUTIs you're looking at long-term catheter use loss of continence worsening mobility decreased ADL ability weight loss and depression so different measures for different populations that makes sense so here's where we get to the fun part and this is a very busy slide but it I think it helps you know for each of us when we're going in we're trying to prove our value to these stakeholders if we know what's important to these stakeholders and what they value as a verb it gives us an idea of how we can be useful so what do the referral sources need and this is the acute care hospitals well they need people out of their quick is there anybody here that isn't having throughput problems and their acute care systems. In my first email in the morning always in hospitals is, we have 15 people boarded an ED, five in the hallway, just get everybody out. I don't care where they go, they need to go. They also want good outcomes. They want patients to do well and not bounce back to the ER and not bounce back for hospitalization. And they really, really want happy patients and families because they just want everything to go well. Payers want a lot of the same things, like the first, same things that the referral sources wanted but there's two problems. They also want the shortest length of stay possible and efficiency and they want the lowest cost to the payer. Now we get to the patients. The patients, they're not so concerned about those things. They're concerned about getting good medical care. And a patient's biggest fear, a lot of times, like after a stroke or something catastrophic, is they're gonna be put in a skilled nursing facility and they're gonna die in a nursing home and nobody's gonna get them out of bed and nobody's gonna give them rehab and they want good rehab. They also, it's location's very important. Families, there's one of two scenarios. Either you've got a spouse that's elderly and they don't wanna drive very far. They wanna be in a location that's closer to their house because they don't wanna go into the city. It's gotta be free parking as well. And if they don't have a spouse that's older, they may have younger children or people looking after them that are working. They don't wanna be driving all over the place either. So they're concerned also about private rooms. The private room cures a multitude of evils but depending on the skilled nursing center and their ratio of patients and that type of thing, that can be a hard thing to get. It's a very coveted thing. And then last but not least, they don't want a lot of out-of-pocket expenses. Now, what are the SNFs looking for? Well, bottom line is they're into the food chain. They are completely dependent upon the rest of the healthcare system for referrals. So anything that increases referrals, decreases complaints so they get a good star rating, gives them a competitive edge and helps attract and retain staff and improves outcomes, they're all for. Then there's the SNF medical directors, our partners, the people who actually have their name on the chart for short-stay and long-term patients. What do they want? Well, one of the biggest challenges right now is pain management. You guys are probably all aware that the CMS published regulations related to pain management in July of 2019. And of course, COVID came and staffing issues came and I would estimate less than 15% of facilities in the country are able to pull off even half of those requirements. So they need expertise and assistance with pain management. They also need help with complex rehab patients. You know, most of these medical directors are internists or geriatricians or family medicine. They don't know complex rehab things. They don't even really actually know what PT, OT and speech do or where they're indicated sometimes. And then they also need help with assistance, administrative issues because the hassle factor for being a medical director is very high. They have constant paperwork. They have to fill up plans of care. They have to sign off on the rehab notes. They have to fill out face-to-face encounters. So they want that. But the biggest thing I've heard and seen is if a physiatrist comes into their building, they don't want more hassles. So the first rule if we enter a new environment is just not to make things worse. And that sometimes is hard to accomplish. So how can we help improve star ratings? Well, there's so many things. We could do several hours on this. But the bottom line is where PM&R is most helpful is with the complex rehab conditions providing programmatic expertise. You know, also really understanding how to manage common rehab comorbidities like incontinence, skin breakdown, spasticity, how to manage and to prevent those. Pain management, especially non-pharmacologic. These patients don't need a whole lot of opioids. They don't need to be drowsy. They don't need their fall risk to be increased. And so when we can come up with non-pharmacologic ways of managing pain, which a lot of times has been slipped through in the acute care system because the length of stay is so short, people have not really identified the pain generator. But if we spend the time and really do that and manage their pain in a meaningful and appropriate manner, very useful. And then optimizing the rehab plan of care. Thing to recognize is since PDPM came in, many skilled nursing facilities no longer have their own staff. They are leasing or using staff that's agency. And they may not have a speech therapist unless you call one in. They only may have PT, you know, so many days of the week. And they're really not based a lot of times in these facilities so they don't know the patient, which is challenging. And somebody needs to understand and be sure that the rehab plan of care is optimized. This is many of these people's last chance to ever be functional when they get a skilled nursing. So there is no room for error. We have to advocate for them and make sure they get the best that can be gotten in that level of care. The other big things is with the turnover and staffing, and it's not just nursing. It's every level of care right now. It's having problems with therapy, with case management, with social work. Anything we do that decreases the stress to that staff promotes people staying. And I'll give you an example. A lot of these nurses have been in SNF for many years. And they used to get a patient in the 90s that was maybe the slightly debilitated. You know, grandma got pneumonia, got over it. She's a little weak, can't go home yet. You know, now they're getting quadriplegics. They're getting head injuries. They're getting 360 fusions, post-op day three. It's really hard, and that is so overwhelming for these nurses. It's very overwhelming. And I'll give you the analogy. Like, if I get woken up in the middle of the night and they were to say, Dr. Smith, you know, this EKG is horrible, there's something going on, that would freak me out, because I haven't really managed cardiac issues for several decades. I'm not sure I can read an EKG anymore. And so that is not a good thing for me. It would stress me out. I wouldn't be able to go back to sleep. I'd have to run in there. But if someone calls me with a complex autonomic dysreflexia situation, I can do it with my hands tied behind my back. Problem solved, manage it, no problem. Every day, a lot of these nurses and therapists are dealing with that condition they've never seen or never heard of. And their stress just goes through the roof. Having someone who's familiar with these things and can walk them through and support them and grow that team is huge. It's so huge. So that's really important. And then I think also, you know, there's more facility confidence. When an acute care network knows there's a physiatrist, they feel more confident sending their patients there if they have rehab issues. And then there's all these high hassle factor tasks that we can help with, doing those face-to-faces, helping them with the peer-to-peers, doing the rehab plans of care and signing off on them. Those are things we can do to help that poor medical director who's overwhelmed. So is there robust data? The answer's no. It's really kind of sad. Steve and I laugh at it. It's coming, it's coming. But why is there not robust data? Well, the reason is because, number one, PM&R and SNF is new and it's also relatively few. And I think the percentage of skilled nursing facilities that have physiatrists in them is a very small number. Did you say 15%? 15%. So there's a huge need. The other big chings is, you know, if you think that it's hard to get all the different systems talking to each other between IRF and acute care, it's even harder when you start looking at post-acute because they use a multitude of EHRs. They have a lot of paper charts still. And so trying to get interoperability of these IT systems is a major challenge. Then also the other big problem, I think this has been talked about in other sessions, is a lot of the skilled nursing facilities are very concerned about breach of privacy or HIPAA violations. So getting access to their data can be a big problem. They don't want to just give it away. And then last but not least, just the cost that's involved with building data registries. So what do we do? I'll just tell you a little bit about Lightyear. So Lightyear is an IT company. It's got crazy smart data scientists and engineers and computer people that are doing all kinds of really cool things with technology. Some things they do that are fun, like they've created these virtual reality goggles where if the patient used to enjoy hiking, you actually can put them on, the patient sees themselves hiking, which is kind of fun. And they do cool stuff like that, that's kind of fun. But what they have focused on is PM&R services and SNFs. And they've worked with other specialties before and came to the conclusion that PM&R is one of the most critical specialties in our healthcare system. So they are major cheerleaders for us, which I love. And it's great. And like I said, we are MD-led, but we're APP foundational. I'm a very strong believer that we need each other. I don't think there's a chance we're gonna get to the other 85% of facilities without using extenders, nurse practitioners and physician assistants. But I also don't believe that those, I don't think they should work by themselves independently. I think team-based care where doctors are involved is absolutely imperative at this level of care. So one of the things that we've started doing is collecting data on some of our facilities and looking at our patients. And what we found is actually it looks pretty good. We've seen reductions in readmissions. We've seen decreases in pain scores. We've seen deferrals increase. And I think part of that's because it's pretty, it's a status symbol to have a PM&R doctor at your SNF. And then we are seeing that functional scores improve. And some of this is very, this is preliminary data. I will tell you guys, this is not anything ready for publishing yet. You know, we're still doing that. Most of the data I'm showing you is like 3,000 patients from January through July. But it is showing consistent trends and it's reproducible data. And it's, to me, very exciting. So this is an example. I told you pain management is one of the top needs. And one of the things that we've found is that if we have a PM&R team see a patient with pain that's five to six or seven to 10. So we're going to hire half of the pain score. Within two visits, we were seeing a very significant reduction in pain, like 30% on average, which is huge. Why is that? I think part of it is, you know, really evaluating that pain generator. Part of it's changing the way medications are administered. But a lot of it too is teaching education and working with that team and that patient and that family. We are seeing that our facilities that have PM&R services get more referrals. And again, it's very sexy right now to have PM&R in your skilled nursing facility. It's kind of being seen by many of the facilities as a must have. You know, they all want something that's going to improve patient satisfaction, outcomes, and all those things we talked about they value. And it does happen. As PM&R comes to a facility, they tend to attract more referrals. So the other thing, okay, functional trends. So within two visits, we saw functional improvement. And you're going, okay, big deal. Short-term patients, if they're not getting 30%, something's wrong, right? They should be getting better. But what was really intriguing about this is we compared short-term to long-term in functional improvement. And what was kind of mind-blowing is that after two visits, long-term care residents, most of whom have been there at least two years, were showing improvements. That's not what you'd expect. So that was really interesting. I mean, they showed 8.4% improvement in mobility and in basic ADLs after two visits with the PM&R team. And that to me is life-changing because it decreases the burden of care to the staff. It keeps that patient healthier. They have a higher quality of life. They also realize they're not being given up on and they're not being allowed to just comorbidity themselves to death, which I think is huge. So I'm going to stop it there so we have questions. Yeah. Sure. Thank you, Charlotte. Sure. Thank you. Okay. So we do have a little time left on the clock here. It says about eight minutes. If there are any questions, would you please step up to the microphone so that we can capture them? I know that we have one on the, when the live stream was actually working, we got one. So while you guys are thinking about it, I'm going to ask this question. I think it's probably best directed to Dr. Bartels, but it says, it's from Megan. It says, currently available health administration literature on post-acute care integration suggests that hospitals are increasingly likely to partner with, but not necessarily own SNFs in their ACOs, bundle payments and preferred networks. There seems to be a reluctance to invest in IRFs at the system level. What would be your strategy to convince senior leadership that better integration with IRFs to manage their entire continuum as you suggested? Yeah, no. Is this on? No. Come up here. Okay. Yeah, I mean, that's one of the big challenges for any of the large systems to be developed. Now there are models. University of Pittsburgh has, I believe, a model where they own a very large number of skilled nursing facilities and that's a way to go, but it's a very large cash investment and as I had said earlier, it's a very, very low margin business. So it's a good way to lose a lot of money as well. It's kind of like the analogy with wine. You know, the way to make a million is to invest two, but the thing about the way that we are doing it is actually the model that is more common, which is to partner and partnering with the nursing homes works very well because they actually, it's a whole separate industry. They know how to manage it. They know how to do it and just what was said by Dr. Smith. You know, we can actually value add to them and they value add to us. So it's a mutual win-win because by us partnering with them and doing the educational services and helping them to create pathways and then also creating the access to physiatry and we also have our therapy staff who can actually train their therapy staff or it can actually help with the protocols that they're doing so that they can utilize the staff more efficiently. That actually seems to be working better for us than actually owning. We do own several nursing homes, but that has made me very acutely aware of the challenges within that industry, particularly the staffing and trying to make sure that with the low reimbursements that you get, that you can actually still maintain yourself in a positive frame as far as your finances. It's probably better to partner because we have partners that are very successful and they can actually manage the finances and then we can work on the care together. Great. Thanks. So I'll get my answer to that question too before we get to Dr. Tarik who has another question, but I think I would not want to be in the position of walking into the president of the hospital system and trying to beg for more IRF beds today. You know, I think that you'd be swimming upstream sometimes, right, and that, you know, you might want to walk into that conference and say, look, we need to be in all different levels of care and we need to decide which patients that we are, you know, we're going to send to these different levels of care. Where's the value going to be to our organization? That would be a much easier conversation to have, I think, today than to kind of go in and say, oh, you know, stamp your feet and say, oh, we need more IRF beds, right? Dr. Tarik. Dr. Bartels, I think your mic is working, by the way, so you can probably come being close to it. So one is a two-part question. One is, what do you think is the role of APPs especially in your system and, you know, in the future because a lot of us use APPs, and also how do you incorporate this into the training, the residency training in GME? Let me take a stab at that first because I think I showed a slide a few years ago where if we had a physiatrist in every skilled nursing facility for every patient that was doing rehab, it would be, and I'm going to get the number wrong, 3,866 physiatrists, something like that. You're never going to get that number of physiatrists in skilled nursing facilities. Most of the rehab in the country is going on in skilled nursing facilities, right? So, you know, if you're going to have a physiatrist-led skilled nursing facility team and you need 3,866 of them, you've got to have APPs as your extenders in order to be able to ever get anywhere close to that number. But I'm going to let my panelists also address that. Just to add very briefly, the APPs, the nursing home environment is an APP-centric environment. You work with internal medicine APPs. You work with APPs within your practice. You're, to be successful in this environment, we need to have bridges and associations with APPs. Yeah, and I want to add, it's challenging. Like I don't believe APPs should be there by themselves. So it's hard enough for physiatrists who have had not much training often in skilled nursing to go into skilled nursing and understand, it's a completely different job description, a different approach. If you practice in a skilled nursing facility like you do or you're going to be a bull in a china shop and I've gotten many of those phone calls where somebody's brilliant physiatrist comes in and they just disrupt everything. And so there's a learning curve and there's a skill set which all of us can accomplish. There's no physiatrist I know that couldn't learn this and be very valuable to the facility. That being said, you take nurse practitioners and right now it's a horrible situation because many nurse practitioners have gone through COVID and not seen patients. My best friend is a, she oversees a residency program for nurse practitioners and she said some of them are coming out now and they've only worked with cadavers, like they don't know what a CBC is. I mean it's scary, it really, really is. So you take them and then they have not done a residency in PM&R, so what could go wrong, right? You know, and what you tend to see happen is a lot of them have family medicine background. They've done some general medicine rotations. They come in and they duplicate what the primary team is doing and there goes your value. I mean why duplicate something if you're not adding value? So that, they have to have us and I think that we are not doing as well as other specialties in terms of directing team-based care. So you look at family medicine, how it's transformed. They are very successful. Family medicine is the head of it. They have a whole team. They have very delineated job duties. They have quality control. They teach, they mentor, they take the tough patients. They may meet the patient first because there's something different. If an MD comes in and sees a patient first, boy they like that and the facility likes that. But I think we really need to evolve our model and we need to get on top of our game because if we don't do that, number one, there are patients all over America that will not receive our services and the value of PM&R. But number two, I think our viability as a specialty goes down because we have got to learn how to do this. We're just not big enough to do this by ourselves. Do you have a comment Matt or? I was going to say, so I basically agree. This actually goes back, this is not a new problem in our field. I think it was the 1964 or 63 Krusen Lecture that Howard Russ a straightforward carpal tunnel they don't need to see a physiatrist. If it's a complex regional pain with a complex brachial plexus and that, then hell yeah, we need to see them and we need to educate our colleagues about when they need to bring us in. So I actually very much enforce that and this has been going back for at least 50 years. Now the opposite, or actually 60 years if I go back to the 1960s, now the other side too was how do we educate our residents? Yeah this is a really big problem because we have so many requirements for the residents as it is right now that there isn't a lot of time built into the schedule. We have our residents There are extenders. So think of it, you can see more patients and provide more care if you know how to use these people correctly. Good. We're at the end of our time, but I think we can... They told me that they'll cut us off after five minutes, but if you want to ask your question, go ahead. Two things. A quick point to bring up from that discussion. We were talking about rehabilitation, residency, and training, and education. Not enough time, lots of things to train on. Maybe since we're training adult physiatrists, you might consider eliminating the pediatric requirement that's there. Just a thought. It's something I hate doing. You are right next to somebody who's going to like... I don't see the need. I don't see it after 28 years of practice. So there's that, number one. Number two, in our system, a big system and the push for population health and value-based care is coming up. In the state of Michigan, we figured about five years will be 60% value-based. The problem is the value-based team, I would call them relatively immature when you're talking about rehabilitation, and they have the C-suites here looking at 30-day readmission rates. And IRFs look horrible, 30-day readmission, when you're comparing to some other facilities. But it's the 60, 90, 120 days. So how to get in the ear of the C-suites with that kind of data when you're kind of hitting a wall trying to even get that information out there? Well, I think, I mean, Charlotte mentioned some of the data. We have some data from our company, too, saying that we do decrease readmissions in a skilled nursing facility environment. We do decrease, you know, transfers back to the ED. We do, we also reduce length of stay, which helps in that C-suite conversation. It doesn't help so much when you're talking to the nursing home administrator, because they don't necessarily want you to decrease length of stay. But we try to say that we right-size the length of stay. I mean, that's really one of the things that we're pushing. So that, I think that would be my answer to it. Yeah, and IRFs actually, you have to be very mindful of how you're managing your IRF. You don't want high ACTs and you don't want high readmissions. So you need to make sure that you're doing quality care. So you've got to watch your care inside. And there is also an IRF compare. And you want to be the leader in your region and anybody that you partner with, you want those numbers to be good. And if you are looking at it as an aggregate, IRFs generally have lower acute transfers and readmissions. And if the patients are managed well, they also have lower, for that diagnosis, 30-day readmission rates. So, you know, our numbers are actually favorable. So I don't have that problem going into the C-suite presenting our numbers, but I do know that there are institutions that don't have very favorable numbers and those are the ones that either, you know, with the IRFs and with the SNFs, if you're not on the top of that list, you're not going to get the patients anymore. Right. Absolutely. Alright. We're pushing the envelope here on the five minutes, but go ahead and ask a question. Paul, I was more interested in logistically how you're collecting the data from the SNFs since so many don't have robust EMRs. If you could comment a little bit on that. Sure. So the dominant SNF EHR is point-click care. And so we've built it around that. We have a proprietary iOS that we use to connect PCC with... We use Athena, which is what our nurse practitioners are using. So Athena, PCC, married. It's about a one- to two-week project to try a different EHR. You know, it really helps to have a robust team of data scientists and I'm always amazed. I mean, the name of the company is Lightyear, but it should be Lightspeed because they move fast. And so we're actually doing other EHRs as well. And then of course, then there's bringing in, depending on the build out of PCC, there's also bringing in Net Health, RehabOptima, whatever they use. That's the dominant one for them. There are other ones as well. So bringing those three things together is how we got this data. Okay. Thank you. So interoperability is a big issue, as was mentioned. And, you know, I think that it's coming along, though. We have an API with our company that basically shares information with point-click care. And I think, you know, that can be done. So it's coming. Well, the Academy has the registry pilot program. Right. And for ischemic stroke, as a pilot, we chose not to include SNFs just because of the challenges. So this is opening my mind that I think we need to collaborate. Yes. It can be done today. It can be done. The technology is there. Yes. Thank you for your attention. We appreciate you being here. Please fill out your evaluation forms. If you like this educational content and you want to see more of it, I see that our incoming president has left the room, but we'll put the bug in his ear that we need more of this content for next year, please. Thank you.

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