So welcome everybody to talk on educating residents in subacute settings. I'm Sam Mayer, I'm at Johns Hopkins and I'm here with Dominic Vinn, who's also at Johns Hopkins. I'm a associate professor and I'm a former residency program director and currently on the ACGME review committee. Dom, do you wanna introduce yourself? Hi, I'm Dominic Vinn, I'm the director of the skilled nursing facility program here for the Department of Physical Medicine and Rehabilitation at Johns Hopkins. And I'm on the faculty of the School of Medicine, welcome. All right, I'm gonna share our slides. Can everybody see our slides? Okay. So for disclosures, I get royalties for book I publish. And as I said before, I'm on the ACGME RC, but I have to remind people that any opinion I state is my own and not of the ACGME. And I have nothing to declare. Okay, we're gonna start off with the polling questions. Did you know a little bit about who we are? We wanna know a little bit about who you are. So if you could please indicate your role and let us know who you are. Okay, the majority of answers. All right, well let's see the responses. Okay, so we have a lot of residents that's terrific I'm really glad to see that a few people who are attending our consultant in the stiff, and we have a few residency program directors. I'm not sure who the others are. If you want to raise your hand and let me know who you are. So one thing I want everybody to do is please open up your chat box because we're going to be using that as kind of a blackboard. And so, anybody who, who can respond on the blackboard, and we're going to be asking some questions along the way we're going to need you to be able to respond. Okay. So, the objectives of this session are that we want you to learn about what educational opportunities for PM and our residents are out there, and how they can participate in sub acute and why it's important for them to participate in light of the demographic trends in the role of skilled nursing facilities and providing rehab. We're going to define objectives for rotations and sub acute rehab. So what should the residents be learning. Then we're going to identify barriers to resident participation in sub acute. And then describe best practices for overcoming these barriers, and like I said I want to make this as interactive as possible so please help us out and share your opinions and your great knowledge I think many of you have probably more experience than, than some of us do in terms of some of these issues so we'd love to hear from you. So, little bit about demographics. There are 3.2 million people in the US admitted to skilled nursing facilities every year compared to 380,000 going to inpatient rehab facilities, or CIR depending on how they listen to car for CMS terms of letters but. Right, so there's almost 10 times as many people going to sniff. And yet, our residency programs almost exclusively focus on inpatient rehab facilities. And so, when people get out into practice. Many of our, our former residents are going out to practice it's this and have had limited or no exposure to sniff care in most residency programs. So, you know, it's been brought up in a lot of the bold meetings at the academy that we really need to do a better job of training residents in sniff care. And so that's what we're going to talk about today is how we do that. What are some of the problems with doing that. And how we overcome. So let's go on to pull in question number two. Do you think residents should be rotating through sniffs yes or no. All right, can we see the response. All right. One person said no that's kind of surprising. But, okay, and we can talk about that when we get to, particularly with the barriers I think there are some issues that are realistic in terms of why it can be problematic for residents to be instance but. Let's do another polling question. So, during your own residency or if you're a current resident just during your residency will you be rotating through a SNF. Okay, so about a third rotate through a sniff and two thirds don't. So that's the problem in a nutshell. So good to hear. All right, and then polling question number four. So what do you think is the most important objective of rotating through a sniff? So we have a little bit of everything here, but main goal is providing optimal care given the limitations and sniff capabilities. And then also people wanted to talk about the sniff role and scope and rehab. So, excellent. All right. So what we wanna do for this next part is really engage you and kind of thinking about if you were opening up a sniff program for residents rotation, what kind of goals would you have for the residents and writing learning objectives. So those of you that are residency program directors are very familiar with that. Some of the others of you may not be, but to do this, we wanna write SMART goals. Hopefully everybody in rehab is familiar with SMART goals, but they have to be specific, measurable, achievable, relevant and time related. In terms of time related, arbitrarily we'll say that this is a one month rotation. So think about it in that way. But obviously programs may have varying lengths or may do sniff rotations in a lot of different ways rather than just having a pure rotation maybe mixed in with other things. But let's think about it as a one month rotation for the sake of this. And then what we wanna do is relate these to each of the core competencies that ACGME laid out about 15 years ago, which are patient care, medical knowledge, practice-based learning, interpersonal skills, communication, professionalism and system-based practice. So hopefully most of you are familiar with those competencies, having gone through residency or being a current resident or being a program director. But we're gonna go through each one and kind of give you an opportunity to write down what you think are the important things that people should learn in SNF. So we're gonna start off with patient care and I'm gonna turn it over to Dom a little bit. Now monitor the chat box, but please start writing in the chat box what you think the goals are and respond to everyone when you do that. So keep your chat box open, please. So basically the most difficult thing to define in patient care at the nursing home level is what will be the role of a physical medicine and rehabilitation physician? Okay. Yeah. All right, well, let's give people a chance to respond and see. Okay. I'm not seeing responses yet. Is the producer there? It's kind of related to- Okay. Starting to see something, but all right. Okay. So we have a patient care related to rehabilitation plan, pain and spasticity management, bowel and bladder management, payer source determines therapies available, performing a neurologic and musculoskeletal exam, working with staff, want to get more involved with chronic patients, whatever it takes to get the patients participating and progressing, role of PM&R consultant, scope of what they treat, coordinate care and decision placement. You have to assist and carry over functional gains, coordinating care with PTOT, speech, skin, patient family education, the budget can hinder ordering tests, identifying unmet needs, pain management. Excellent. So we got some really good responses there. So Dan, why don't you go over what we have identified as- Yeah. Actually, all of those are really, really good points because it basically covers what I am about to discuss with you. So the secret is I was internal medicine before I changed to PM&R, and I had worked at the nursing homes for a great number of years. And so it's a very, very, very, very different animal from taking care of patient in the hospital. And on top of that, there actually only about a thousand or so physical medicine rehabilitation physician doing SNF right now, I think. And it's still new to this environment. And so many of the internists working at the nursing homes really have no idea what PM&R is all about. And on top of it, those facilities do have PM&R. Usually the agreement is for PM&R to co-manage and just see about every new patient that comes in. And so from an internal medicine perspective, sometimes that sort of throw the attending off a little bit because usually when they consult somebody, it's a specific consultation for a specific reason. Here, they're not used to having people co-manage and seeing the patient along with them. And so that's going to be a little bit of a challenging issue. The other thing is the way that the insurance has changed, and we talked about this a little bit more, the focus is not really rehabilitation anymore. So we're going to have to do something to redefine ourselves why we need it in that environment when the insurance is not really focusing on rehab. And on top of that, this is not a level of care the same as a hospital, because there is a choose wisely campaign where you try to limit testing also at the nursing home. And so when we come in there, we have to be cognizant of which so that we're not going to order too many things that the skilled nursing facility is not equipped to handle. And for example, pain management, they have their particular way of doing it. And some attending would like to take care of the pain management themselves rather than delegate it to a consultant. So it varies from place to place. Yeah. All right, let's move on to medical knowledge. So let's have people type in the chat box what they think are the knowledge. You know, we talked a little bit about the skills that they need, but what are the knowledge base that they need to work in SNF? So please type that in the chat box. We'll give you a few minutes. Okay, so something about the incentives, financial incentives coming familiar with geriatric medicine and polypharmacy, overcoming barriers to progress with function, MSK ultrasound was mentioned. Yeah. And I see beer's list, that is excellent. Identifying patients who may require higher levels of care, hospital transfers, palliative care, hospice-based, general rehab and polypharmacy is mentioned again. Those are really, really, really good points. Yeah, a lot about polypharmacy, limiting nursing care over fall prevention, that's an excellent one. Yeah. You know, the central supply manager to order supplies, determinants of disposition based on social situation, pain management is a big issue that you have to cover in SNF, a big plus that we can add. Coordinating outpatient Botox injections. Diagnosis remains important, yep, absolutely. Splinting and contractures, that's an excellent point. Ensuring interventions, SNF settings as soon as possible when medical decline is noticed because things are often delayed in SNFs, that's a great point. Seating and positioning, quite good. All right. So, Damian, you want to go over what we also have? Yeah. So, you know, the traditional group of patients that skilled nursing facilities will receive will be those patients that were discharged from the hospital that didn't meet criteria to come to, for example, inpatient rehab or LTAC. And so, you know, we see everything, COPD, heart failure, big ones. There's a lot of ortho, joint replacement, some trauma, a lot of general surgical, you know, post-op care. And then obviously we have a lot of strokes and other neurologic conditions. And so when the patient's admitted to the SNF, obviously the medical team is going to traditionally will focus primarily on the medical management, but we try to steer them also to look at things that can identify, especially with neurologic patients and what they can do if they can pick one thing to manage to prevent a lot of other things. So for example, like we talked about spasticity management, because that's going to prevent pain, skin breakdown, you know, et cetera. And so we'll focus on that. And then somebody mentioned Beer's List, which is very, very excellent, because the way that the nursing homes are set up, they're under a lot of regulatory surveillance. And so they really do not want to violate any of that and receive a lot of penalties. And one of which is false and, you know, from the elderly on too many medications. So there's a Beer's List, and that is the list that will list out medications that preferably you do not put the elderly on. And unfortunately, a lot of those medications are those that we use in neurorehabilitation. And so it's always a negotiation with the primary team, and it depends on, you know, how much trust you're able to elicit with the team who's taking care of the patient with you. But to give you some example, benzodiazepine, anticholinergic, antihistamine, you really cannot give a Benadryl, for example, stimulant laxative, muscle relaxants, and that includes all the antispasticity medications, and tricyclic antidepressants. The other thing is, you know, it's good to know also the difference between delirium dementia, because there's a lot of patients who are demented, and they can act out, you know, with symptomatic manifestations. And you want to know whether or not, you know, this is delirium, so that you can treat the reversible causes, like infection, toxic metabolic, and all that, versus somebody who's just acting out because they have dementia. All right. Next, we're going to learn, we're going to talk about practice-based learning, which is often the most confusing one in terms of defining it, but it's basically lifelong learning. So what things do we want residents to get out of this that'll help them be lifelong learners and make sure they're participating in quality improvement as well? So why don't you go ahead and list this? So we have coordinating care, functional bowel and bladder management, nutrition, polypharmacy, therapies, family, and providing services in a whole. Good. Care coordination, they mentioned as an example, anti-coagulation is important, so how to coordinate care in a safe way. Participating in a QI project at the SNF, excellent suggestion, yes. You guys have really, really good ideas. DME, yeah. Better transitions of care when discharged from IRF to SNF, excellent point. Is that, you know, we are often in the IRF complaining about how we receive patients from acute care, but we don't often think about how we're giving patients to subacutes. So, really good point. So here's some of what we've thought of as well. So yeah, before I forget, to the person who wrote better transition of patients discharged from IRF to SNF, I just want to say something because that is such an excellent point. Like Dr. Merritt had just said, we often complain a lot about receiving patients outside to the inpatient rehab unit, but if you're from the skilled nursing facility, a lot of times you will see exactly the same thing that we're doing to the nursing home. And so, you know, I was involved when I first came here with the EPIC template design and people used to complain a lot because in my discharge summary, I included a lot, including past history, social history, and all that. And people would just come to me and say, well, why did we have to do this? You know, they can look at the H&P, but the problem is everything's gonna be printed out on paper. There's no way to know what the nursing home is gonna receive. And you want to help out the team there as much as possible. So when they hold a piece of discharge summary, I like for them to have as much information as possible so that they can take good care of the patients. But, you know, the thing is at the nursing home, obviously we're more of a consultant than attending. And for me, the three rules of being a good consultant is availability, affability, and ability. So one way of doing that is we would like the rehab team to participate in regular meetings with the medical team. You know, when I was internal medicine, we always had to attend what we call risk meeting. They're different names for it, but basically this is where we sit and discuss about patients, you know, those that we sent out and we have to discuss, you know, what we could have prevented. And then we discuss about people that there's a possibility that we're gonna send them out. So what we can do to prevent. And also, of course, there's a lot of meetings on QIs. And so if we get involved and we're gonna be more valuable to the team and we're part of the team, and then you would just make rehab a little bit more relevant and, you know, also visible rather than just somebody who's working in the background all the time. And also, I tried to make the, have the residents sort of present to the nursing team as well as the rehab team, some type of rehab relevant topic. So, you know, we had one resident last year who gave CME type of lecture to the entire SNF organization, not just one SNF, but every SNF under the umbrella on bowels and bladder management of spinal cord injury. And that was an excellent presentation. And so that's how you increase your visibility and your value. So, yeah. Excellent. So interpersonal communication. So what are some of the areas specific to SNF that you think residents should learn when they're at SNF? So obviously we want everybody to be good communicators with the team and with patients, but what are some particular issues you think at SNF? Meeting with the primary team as a consultant. Yes, that's really important. Assess patients with dementia, hearing loss. Oh, good. Excellent communication with the nurses and therapy team. Communication with mid-levels is important too, because they're often mid-levels or the primary caregivers. Yes. Communicating concerns with nursing staff, especially when nursing is handling a huge volume of patients in these facilities. So being cognizant when you're communicating with them that they have a lot of patients you're caring for much more than in a hospital setting. Keep open communications with the primary care team and therapists and nursing staff. Use of empathetic language. Communicating with discharge hospitals. Yeah, prior facilities. Communicating with the families. Communicating with the social work about discharge barriers. Great points. Attending Medicare meetings. I guess it's a similar thing to the risk meetings that Dr. Vinh was talking about. Yeah, there's a lot of different types of meetings at the nursing facilities. Wound care meeting, respiratory meeting. Yeah, insurance meeting also. And having the resident service as a resource for medical knowledge is excellent. That's how we add value, and especially how we add value for the residents being there. All right, and then, okay. Yeah, so before I forget, to the person who had written that we should communicate with the mid-levels, the nurse practitioner, PA, that is such an important point. You know, the attending physician who's internal medicine, you know, he would be there every day, but he would see a patient or so, and then he has to come back to the hospital to see patients. So his mid-level would be the person who's gonna manage all these patients. And often, we're the only other clinician in the facility. And so, you know, often I would, you know, ask the mid-level to round with the rehab team so that we can understand a little bit more about their approach to medical management, and we will give them our opinion on what to do with the rehab part. And it has worked out extremely well. Now, how to communicate effectively at the SNF is a very, very difficult thing to do, because remember that each SNF would have anywhere from 70 to 250 beds. I worked in, you know, a few 250 beds before, and remember that each physician will go to a few of them. And so, you know, when you're on call, you're gonna be on call for several facilities. So when patients have an issue, it can be overwhelming because you have, like, a lot of patients to deal with, and everyone at the skilled nursing facility will complain about something. And so, it takes a little bit of finesse and skills to communicate and address all the patient's concern. And also, you know, it's difficult to write a note in the nursing home, especially when one comes from an inpatient rehab unit, when one is the attending physician, and then when we go to the skilled nursing facility, you know, we're the consultant. So, you know, we have sort of revised the way that we write the note so that we have to expand more on the rehab part of it and minimize the medical issues and make them into comorbidities. And so, it's a little bit more difficult than it sounds, because you have to really be creative with how you define somebody with an impairment that's not very obvious on the chart. And so, just like somebody else had written before, that you have to do a really good exam, you know, an MSK exam, a neurology exam, and have to go through the chart to dig out stuff from the past also. Yeah, I think it's really difficult sometimes for PM&R residents to recognize their specific role in the care of a patient. I think SNF is one setting where they can really have an opportunity to shine in this, is that really understanding, you know, what do we as physiatrists add to the case? And so, rather than focusing as they often do when they're on inpatient rehab, particularly in the early months, they're often focused on the potassium levels or, you know, various other medical issues that they learned in internship. This gives them an opportunity to really behave as a physiatrist and act as a true consultant and explain, you know, what is it that we do? So, focusing on those issues like pain and spasticity and range of motion and all the other issues that we do as physiatrists is critical. And I think documenting that well in the chart so that you're not telling an internist what to do about medical problems, because that will get you nowhere in terms of being able to do that. You know, what I tell my residents is that the skilled nursing facility environment is not a place for them to learn how to manage patient because they all know how to do that. But it's a place for them to develop their PM&R ID to make it flourish as a physiatrist, minus all of the, you know, hardship of having to manage medical stuff. And then you have to be cognizant of the regulatory constraint also. Sometimes, you know, the attending physicians are very aware of certain things. They may or may not decide to treat them because of some of the constraint and some of the, you know, potential, you know, adverse outcome and all that. So, communication with the primary care is good. All right. So, next, thinking about professionalism and what do we want to see our residents, specific professionalism issues that they may run into in a nursing facility. So, Sepia, I'll add to the chat box, please. Working with difficult patients and families. Somebody wants a little more clarification. So professionalism is how do we want our residents to behave in a manner that's professional? And particularly in nursing homes where there may be some issues that raise ethical concerns. So, treat all patients, families, and staff with respect is of course important. Who places your PM&R consult orders and how? I'm not sure what that means, but maybe explain it a little bit more. I can answer that question. Basically, when you go in the skilled nursing facility, you can negotiate with them what kind of patient you want to see and how you'd like to be consulted. And so, we would like to see everyone because you can tease out a lot of rehab issues that have not been identified. But if you don't see the patient, you wouldn't know. There are a few others who only would like to see stroke patients or joint replacement, you can communicate. And then usually there's a system where they would put the consult in. Okay. All right, so. So, you know, the nursing home is not the same thing as, and I say nursing home, just because it's just easier to say, but we're gonna define it a little bit better. But in the hospital, you have a finite number of patients that you see every day that you know. At the nursing home, you don't see patients every day. You have an aggregate panel of patients that you see. And so, punctuality, you know, is extremely important because you have to be very nimble and you have to move very fast depending on what their needs are. And sometimes we go to more than one facility. So if, you know, there's a delay in one that's just gonna affect the rest of the day. And how to advocate for patients in a collaborative manner. This is a very delicate topic because sometimes you sit in the risk management and, you know, a patient being sent out and you strongly feel that the patient should go to the emergency room, but the medical director may not agree with you for whatever reason. And so, it's something that we have to learn how to communicate. So. Can you talk a little bit about the resource issues in nursing facilities and some of the issues in terms of how you advocate for a patient to get a certain piece of equipment or certain medication that the nursing facility may not wanna provide because of cost? Yeah, the nursing home, the majority of them are for-profit and the margin is very thin. How the nursing organizations or the nursing home organizations make the money is, you know, outside of patient care, like the cost of their real estate and stuff like that. But the reality is there's a lack of staff, you know, they don't have money sometimes. It's a real thing to hire, you know, enough and appropriate people. And also there's insurance and everyone has different types of insurance and sometimes it's very difficult to figure out. For example, we injected somebody's shoulder and we found out later that it was denied because this particular HMO did not approve of trimucilone to inject. And so, there's no way for us to know that. It's just a common medication, you know. And so, you know, you just have to, you just have to, you know, figure it out individually. Yeah. Yeah. And, you know, being skilled in negotiating with the facility and with the primary care providers there about doing some of these things, you know, when you think the patient absolutely needs them in spite of the cost and being able to do that in a collaboratory way, as opposed to a contentious way. Yeah. It's really important. Every nursing home is different. There are no two that are exactly alike because they have different philosophy, different leadership and all that. And so, little things like, for example, injection of Botox. There are few facility that, you know, would welcome, you know, that intervention. There are others who won't take the responsibility of proper storage of the medication and all that. And so, you just have to, you know, feel the environment out. Okay. So, next is system-based practice. So, this is, you know, how you figure out your way in navigating the healthcare system, the healthcare economics and everything else. So, what are some objectives here that you can think about? People can type in what they think are some of the system-based issues, how the payment systems and things like that affect things. Transitioning home, yes, that's critical, or in some cases, they transition to long-term care also, so figuring out who can go home. Bundle payments, encourage testing costs low. Ortho bundles, Medicare days and planning according to that. Yeah, that's a really key one. Educating on different levels of care and the requirements and challenges for the new payment system that does not reward functional progress. I hope we can one day work with others to get that changed. Yeah, so we'll talk a little bit about the PDM. Mental health specialist providers, yeah, getting them involved. They're often limited in nursing facilities. It depends on the nursing facility themselves. Like some do have a full complement of specialists coming in, including cardiology. Some of them do have a pulmonary program. Virtually all will have podiatrists and psychologists coming in. We have a few with urology and GI coming in also. Transition to long-term care, especially into assisted living or long-term nursing for the first time can be challenging with the family. So families who are reluctant to admit to that but can't take care of the patient themselves. Really good one. Okay. Yeah, so I just wanna go over a little bit of the definition first so that we don't get confused. So basically, the official name of the hospital is short-term acute care hospital. And then anything after that is post-acute care. And we're not talking about assisted living and all that because that's sort of a different platform altogether. But under post-acute care, you have a LTAC, a long-term acute care hospital. You have IRF, which is inpatient rehabilitation facilities like inpatient rehab. And then you have a skilled nursing facility and home health. Now, long-term care is another platform also, but a lot of time they tend to be lumped together with SNF and long-term care. And the historical perspective is that in old days, nursing homes were nursing homes. People come to live and then they die. And then when there were more patients, especially in their late 80s, early 90s, surviving as we had better medical technologies, a lot of them got discharged to the nursing home and they had no idea what to do with these patients because the level of care is much higher. So many of them will carve out an area within a nursing home and they call it skilled nursing facility. And the nursing home is renamed long-term care. And so this is why we always have nursing home attached to long-term care. And sometimes it's just easier to say nursing home, but we have to be careful about long-term care versus SNF, even though they're in the same area because the reimbursement rules and rates and everything are totally different. But sometimes we refer to them as PLTC, Post-Acute Long-Term Care. So, and the overseer of the operation of SNF is AMDA or Society of Post-Acute Long-Term Care. And they're the one who came up with a certification program for medical directors called the CMD, as well as competency for attending physician, working at a skilled nursing facilities. Because in early days, a lot of time they relied on hospitalists to go and take care of patients' nursing home, which didn't really work out well because the nursing homes are not mini hospitals. So anyhow, what is this PDPM here? In the old days, the payment for the nursing, for rehab and nursing home is called RUC, Prospective Payment System, or Resource Utilization Group Prospective Payment System. And how it worked is just like inpatient rehab. There are different tiers of complexity. And I think there were eight of them and running from 45 minutes a day to two hours and 59 minutes. If they go to three hours, obviously they belong to inpatient rehab. And when the government designed that payment system, they anticipated the majority of people would get the middle level rehab and a few at the bottom, few at the top. But then for the past 35 years, what happened was just about all the buildings were geared towards the top tiers. Like, you probably have read an article in a New England Journal of Medicine a couple of years back, like rehab to death. It will pull people who really shouldn't have any rehab because they're the end of life and they would just start to rehab them. So on the 1st of October, 2019, the government came out with PDPM, which is patient-driven payment model. And it's like a completely, like 180 degrees or reverse. Basically it replaces the RUT system and it de-emphasize rehab. The focus now is more on medicine, on surgical diagnoses or neurologic. And so many of the nursing homes sort of let go of their therapy staff because now rehab is no longer the focus. And then each therapist will have more patients on their panel. And just to make it simple to explain, basically when the patient comes in, they have to have a legitimate ICD-10 code and specific, can be just general hypertension, has to be what type of hypertension, what type of syncope and stuff like that. And then they slot it into different parts. Either it's just pure medical or primarily PT, primarily OT, et cetera. It doesn't mean that they cannot get any other type of rehab, but just that the main focus is PT. And then they eliminate the minute of documentations. And so the therapists do have now the ability to decide who they're gonna see. So what we can, this is not such a negative thing for us in terms of rehab not being needed, because we can turn this around and say that, well, because there's no longer the infinite resources for rehab, we can be the person who can triage the patient better so that appropriate available resources can be applied to the correct people. So the therapist, when they see somebody with an ortho problem, a neural problem, it's very easy to say, ah, they need rehab. But what about somebody who just came out from ICU with post-ICU syndrome, and then they just, you know, general deacon, quote unquote, and then they just don't pay as much attention to them anymore. And then, you know, what if they have critical illness polyneuropathy, for example, and nobody would pick up because now they're not spending like three hours just to exam the patient, and eventually would find out something here. So a cursory exam. And so, you know, we can turn that into something. Yeah, so it's very valuable that the physiatrist can pick up a new diagnosis and they increase their reimbursement. Yeah, and then we have to know to choose wisely also. So we cannot just go in there and recommend, you know, different types of splints and stuff like that, because that's going to come out from their budget. And also it depends on the insurance also. And so you just have to talk to the therapy team first before we order anything. All right, let's go to the next polling question. So you have residents rotating through SNF in your program, yes or no? You can see those results. So majority do not. And why is that? What kind of barriers have you encountered in trying to incorporate residents in your SNF programs? So if you can type that in your chat box, what are some of the barriers? COVID was a barrier, so yes. Hopefully we're getting over that, but that's a huge barrier. Increased outpatient focus in the programs. Misconceptions about SNFs, I think that's a big one too. That says that their program doesn't have anything established yet, and it's hard to get this established. We don't have a teaching facility relationship. Program lost contact to privates, relationships with SNFs, no affiliations. Not included in the GME curriculum. Freestanding rehab, no SNF relationship. So big ones are about relationships. Under-representation of PM&R as primary physicians in the SNFs. So the residents were often too busy with acute care consults to round on the sub-acutes. All right, all excellent things. So some of the barriers to think about are financial. How do you fund the resident time in the SNF? We'll talk a little bit about that. Regulatory issues are a big one too, is that there's all kinds of regulations about being in a SNF. During COVID, there were a lot of regulations about limiting the number of staff visiting the SNF, so that's where some of the people had to put their SNF programs on hold for the residents because they weren't considered essential. Faculty expertise is a big one. So do you have faculty that go to the SNF? And I think for PM&R departments, it's gonna become increasingly necessary that they get faculty involved in that and coordinate with SNF, because the demographics are that. If we're sending all these people off on our acute care consult service and recommending SNF for them, what kind of care are they getting if they're not getting any physiatric input into their care after they go? So this is something that you need to talk to your department chair, and there's money in this too. So it's a money loser for the departments, but they need to start thinking about that. How do you engage residents? A lot of residents are going into pain or sports medicine, they don't wanna spend time in the SNF. And on the other hand, the SNFs may not like the residents very well either in some cases. So how do we get through that? So a little bit about GME funding. So this is an important factor in SNFs is that the way GME is funded is very complicated, but it basically is that Medicare accounts for more than 85% of the funding. And there's some other funding from Medicaid in some states, from the VAs, from Veterans Administration and Department of Defense as well. There's a special fund for children's hospitals that's not really relevant for this population. The GME funding almost exclusively goes to the hospital. So the Medicare funding is given to hospitals based on the number of Medicare patients they have and based on some history about what that hospital had in the way of residents back in the 1990s, it was frozen. There's what's called direct funding, which is their salaries at indirect, which pays for like the residency program director's salary and the residency coordinator's salaries and things like that, and vacations and benefits and so forth. And the IME funding is based solely on the number of hospital inpatient days. So if you're sending a resident out to a SNF, the hospital's not getting paid for that. So how do you get them to agree to have, let's say if you have a residency program of 18 residents, if you have one FTE resident gone to a SNF, how are you gonna get that salary paid for? So what are some of the solutions? So let's go back to funding. So what do people think are some of the solutions for funding? Anybody out there found some alternative funding mechanisms? So residents billing for the services, that's actually limited because of ACGME as well as if they're in training and not really supposed to be billing. Spending less than half a day in the SNF so that they're doing it as part of another rotation. I will say that the billing for the faculty, by the way, could be a reason for having the residents there. So the faculty building may be helping to subsidize this. So they edit it as part of a cancer burn SNF rotation. Reach out to Congress. Yeah, good luck with that. Affiliating with some private physicians who work in SNF, yeah. So for funding, you can use non-Medicare funds. So if you have a VA, VA's almost always have long-term care facilities and SNFs as part of their system, and they're willing to pay for it. So a lot of residency programs that have that option use that. More and more hospitals own SNFs. So with pressure to reduce re-hospitalizations and things like that, a lot of hospital systems have purchased SNFs so that they have more control over where their patients go. And that can be a great option because they very well are probably short-staffed for physicians in the SNFs, and they would welcome having residents go there. So let's talk a little bit about SNF acceptance of residents. So that's another big problem. You want to talk a little bit about that? Yeah. Do we have the next slide? So anyway, for the sake of time, because we're 1225 now, I'm going to summarize what I think about residency at the skilled nursing facility. For me, it's like the way to preserve the inpatient rehab because many residents actually decide to go into sport and all that, partially because they do like it, others because they don't want to have to deal with inpatient medical management and all that. And so the skilled nursing facility is a good compromise also. And then it's good to expand your pure PM&R identity instead of just attaching always to medicine. Now, why some of the nursing homes don't accept medical residents? Not all of them, but a lot of them because they haven't been exposed to. They're a business, they're not an academic center. They're under a lot of rules and regs and penalties. And so they don't have the cushion to absorb some of the mistakes that trainees would make because I had a facility who actually read the notes and then find the facility because of that. And we were basically disinvited. But that's the reality of life that you have to think about. But so, and so this is why learning how to document appropriately at the skilled nursing facility as a consultant is also a good learning experience. For example, don't go and write the patient complain with a medication for pain doesn't come on time. You ask them that when you receive the medication, does it help you? And the patient say, yes, then you can sort of do like a duple entendre, like, you know, the patient reported once he gets the medication, his pain is controlled, something like that, you know, so that you don't incriminate the facility. And to get the residents engaged, you know, emphasize this as part of their future career and future practice opportunities, is that this is something that a lot of them are going to wind up doing when they graduate more and more of them. And so, you know, I have my best friend actually is an interventional spine. And he actually he finally listened to me. And he's looking for a job on the side in a skilled nursing facility, because just day in day out injecting, it drives him crazy. And so, yeah, and so, you know, it's a venue for you to expand. And also, you know, you can have patient return to the outpatient office to follow up with you. So that's great. So it's, it's another venue of career development. All right. So we're getting to the end of our talk, we want to leave some time for questions or comments. So if you can raise your hands if you have a comment or a question, and we'd be happy to respond to you. I have a comment of, I don't know how to raise my hand. Okay, go ahead and... My name's Christian Morris. We met the other day, Dr. Mayer, in the community session. Okay. I have a PM&R resident with me right now and I'm in private practice. And so I've kind of, it's been a two-way street where I've reached out to the University of New Mexico PM&R residency and they've reached out to me. And so it took a while, but we have something set up and I have a PM&R resident with me right now who I'm in the IRF and the SNF and he comes with me to both and gets exposure. And so it is possible. Yeah. And how did you get the residency program to fund it? He's, it's an elective right now for, he's a fourth year. So he has an elective to do it. I'm not taking any money to do it and it's just more an exposure thing for him. Yeah. So I think it's possible. It just, it takes some willpower and some desire to do it. Absolutely. Any other comments? One thing that I wanted to mention for the interventionalists out there is that a lot of these patients in long-term care every three months need a knee, shoulder, hip injection. And so you can set that up fairly nicely and get a lot of ultrasound practice doing knees and hips and shoulders, you know once every three months on these long-term care patients. Yeah. I think it's a great opportunity to teach residents about injections if your facility allows that. So that's great. Yeah. But thank you for your presentation. Thank you. Thank you for all the nice comments. Thank you very much. Yeah. Somebody mentioned they had medical students come. That's even more terrific. So absolutely. All right. All right. Thank you all for listening to us and I hope you enjoyed the presentation and let others know that they can listen to this online afterwards too because it will be recorded and I think available for up to a year after the AAPMNR. So if they weren't able to make it in person. You can reach out to us directly if you have any questions. Yeah. So feel free to email us through the office form or however you'd like to do it. All right. Thank you all. Thank you. Bye-bye.

educating residents

subacute settings

skilled nursing facilities

residency programs

inpatient rehab facilities

educational opportunities

resident participation

rotation objectives

barriers to participation

best practices