All right. We'll go ahead and get started just waiting for the slides to load up for a second. All right. Well welcome to our session this afternoon revitalizing in patient rehab next gen physiatrist coverage models for IRFs. Our objectives today will be to identify the benefits and drawbacks of the traditional model of physiatrist coverage in inpatient rehab facilities or IRFs describe alternative approaches currently used by programs to staff their IRFs with rehabilitation physicians and then lastly to discuss key issues to consider in co-management models with another physician. My name is Lauren Shapiro. I will be the session director and also the first speaker today and I'll be discussing the kind of traditional model of the always on physiatrist. I'll be followed by Dr. Evan Zeldin who is an assistant professor at the University of Cincinnati in the Department of Neurology and Rehabilitation Medicine and he'll be discussing a coverage model in which the attending physician serves one week at a time in the IRF setting and then he'll be followed by Dr. Victoria Whitehair an associate professor at Case Western Reserve University School of Medicine who serves as vice chair in the Metro Health Department of PNR and she'll be discussing attending rotation models in IRFs that are slightly longer than Dr. Zeldin's and then our final two speakers will be discussing co-management models with another specialty. Matthew Cowling will discuss a model in which the physiatrist is the consultant in the IRF and Dr. Cowling serves as the chief clinical officer at Madrina and the associate medical director at Encompass Rehabilitation Hospital of Fitchburg Wisconsin and then last but not least we have Dr. Glenda Liz Bosquez who will be discussing the model in which she entrusts medical management to consultants in her case pediatrics. Dr. Bosquez serves as the chief of pediatric rehabilitation medicine at UT Health Austin at Dell Children's and is an associate professor at UT Austin Dell Medical School in the Department of Neurology. We've left plenty of time at the end for Q&A and discussion. We are joined today by a number of people via the live stream but both the audience who is here in San Diego and those at home can please go ahead and send us questions we'll be monitoring them throughout the session and then we'll answer them all at the end. The speakers report having no relevant disclosures. So before we get started I wanted to poll the audience here today and we'll just do it by a show of hands. How often do you cover an inpatient rehab service. Are you someone who covers all year round. So quite a few. Do you cover most of the time. How about a few months of the year. Periodically. And only while on call. All right. So we have a great mix today. And then let's find out who serves as the primary service in your earth program. Is it you as a physiatrist. Most of us. Hospitalist physician. Hospitalist physician. Hospital non-physician practitioner an NPR PA. A pediatrician. Or some other service. All right. So most of us are serving as the primary service. So I'll go ahead and give the first talk as the always on physiatrist. Again my name is Lauren Shapiro. I recently joined Brooks Rehabilitation in Jacksonville Florida as the medical director of a stroke rehabilitation program. But I'm fairly new to that role so I thought it would be helpful for me to start out describing my role at a prior institution and then I'll discuss a little bit about what's different where I am currently because I have found that small changes have made a big difference. So the way things were at my prior job I had an inpatient census of 12 to 14 year round. The patients were admitted under my name even when I was away and I often had to cross cover for other inpatient colleagues when they were out. I could call occasional internal medicine consults but we didn't have a co-management model. We had been trying to work one out but then the covid pandemic hit and they no longer had enough manpower to help us with that. Like many inpatient rehab docs I did two to three half day clinics per week from 1 to 5 p.m. Pretty typically double booked did a lot of talks and procedures. It was an academic setting. My resident would see most admissions that arrived before 5 p.m. and we had a night float resident seeing the late admissions. I could decide if I saw the admissions the day of admission or not but I typically did if they were very complicated and certainly in July and probably August and September as well as our PGY 2s got used to the inpatient rehab setting. Now the hardest part for me was my on call responsibilities. So I was on call for one week at a time. I took call from the resident every night and we were a 72 bed facility. So I got called pretty frequently to 3 a.m. with emergencies at least a few times a week in the average week. I rounded both on Saturday and Sunday on every patient and our census. We had 72 beds. Usually it was about 72 and had no relief day. I worked 12 consecutive days and unless I plan to take a vacation day the following week and I will say that the Friday the week after I was on call was always very tough to get through. Now I don't want to suggest that everything is bad about this model because it's not. Some things worked really really well. We had great consistency of teaching and evaluation of our trainees. Very good continuity of care. I had good familiarity with the primary team members particularly on the floor where most of my patients were and I was better able to control diagnostic work ups and treatments that were not optimally performed in the earth setting and that can be a little bit difficult. I think it was probably very financially beneficial for the institution as well. They ran a fairly lean department without a lot of extra FTE and because I was able to control those diagnostic work ups I imagine there was some financial benefit to them. But what didn't work so well. Often the residents and I spent more time managing medical problems than we did rehab issues and that could I think be a big part of why we didn't have a lot of success in the hospital setting. We spent more time managing medical problems than we did rehab issues and that could at times impact their education. I will say it was spread very thin while cross covering and sometimes had difficulty getting coverage when I needed to take time off. My clinics were very frequently interrupted. I didn't truly have dedicated time for things that I was responsible for outside of my clinical responsibilities and this resulted in a lot of additional night and weekend work. But worst of all was my on call weekends my days on on call were very long very unpredictable and particularly as I got a little bit older working 12 consecutive days with such long hours was very very exhausting so I began to think is this model really sustainable. And I would argue that it can be with good administrative support strong teamwork and probably a lower patient load on weekends. The more I think of it the 72 patients on weekends with them being as sick as they were just way too much. But the problem is is it doesn't leave much of a buffer for when there's a need to respond to something unexpected. So your colleague calls out with Covid and they're gone for a week at my old facility we weren't we weren't allowed to transfer to the emergency room. So we sometimes had to spend many hours trying to stabilize patients on the floor. I see some of my former residents nodding you know so it's not uncommon I'd have to spend three four hours at bedside trying to stabilize a patient before I can move them to the ICU and that really impacted what I could get done that day. Sometimes patients would show up and claim it to clinic insisting they had an appointment but they didn't and you want to be able to accommodate them but you don't have that buffer and then we all have personal and family matters that come up and I'll say practicing in Florida we do face the occasional natural disaster that requires preparation both at work and at home. And I also was giving a lot of thought to burnout in our field which we know is a problem although I hate the term but we know that roughly half of physiatrists meet the definition of burnout and we also know that strategies that are putting into place to try to mitigate rehab physician burnout often don't address the perceived stress points. I found it interesting I read a study it was from the Czech Republic but it was the only one that was relevant to us but in the Czech Republic they did a survey of physiatrists and found that the majority of them have poor sleep quality and met the definition of insomnia and I thought that was really interesting because back when I was a medical student the old joke was that P.M. and R. stood for plenty of money and rest and clearly we're not getting enough rest at least in the inpatient setting and we know there's a tremendous negative impact of sleep of sleep deprivation on physicians. It makes us less vigilant can impact our attention our memory our decision making and comes with a whole multitude of adverse health effects for the physician. It's also associated with increased burnout increased self-reported significant medical errors and decreased professional fulfillment. So it's also important to start thinking about some additional models of coverage because there are simply just a lot of other demands on our time. We have to face a whole lot of regulatory requirements. Many of us are doing more and more peer to peer calls particularly those of us who work at facilities who accept patients without prior authorization and it's just more difficult to stay up to date. There have been a lot of billing and coding changes for the inpatient setting. There's been the evolution of the cover 19 pandemic and there's just been a whole lot of new medications and new devices that have very significant rehabilitation considerations that we've had to stay abreast of. We also have workforce issues. The AMC is anticipating quite the physician shortage by 2036 but interestingly their most recent report mentions an anticipated surplus in PM and our physicians which is quite surprising to those of us trying to hire inpatient physiatrists for sure. There's been a slight growth in the number of earths in recent years but the bigger challenge is that more and more of our colleagues are going into areas within our field that are not inpatient rehab with a growth in interest in pain and sports medicine as a number of articles have come out in the popular press of late younger physicians tend to be more insistent on work life balance as well. So it's important that we pay attention to that and it's not necessarily a bad thing but we are seeing that more and more inpatient rehab facilities are having difficulty recruiting physiatrists as inpatient physicians and an article came out last year where 20 percent of earth medical directors are not physiatrists. Another reason to start considering new models is we're simply taking care of more complex patients in terms of CMI the CMI is rising in inpatient rehab facilities pretty steadily and this slide is already a few years old at my current facility our CMI hovers around one point eight one point nine so quite high and we're taking more cases that are cardiac pulmonary and debility where there may be more justification to involve an internal medicine doctor or some other hospitalist to help manage these conditions. The growth in those cases have outpaced growth in earth patients overall now as I said earlier I recently moved to a new institution and have a new job and the model is pretty similar in that I'm always on on service I don't rotate on and off but small changes that they've implemented there have made a dramatic difference in my ability to get other things done and my level of energy. I actually have a slightly higher census and I don't currently have a resident but I will very soon. But what's very nice is they've hired PRN physicians who provide cross coverage so I'm not constantly covering multiple teams. The patients are just as complex maybe a little less acute because we're totally freestanding and we don't have consultants like constantly saying oh we'll come over and follow the patient over and rehab and then they never do and you have to call them all day. I take calls on all of my own patients at night during the week and I thought that would be a bad thing but I can control that so I order a lot of pure and sleep medicine everyone's on pure and so friend unless they have a contraindication and I very seldomly get called. I don't think I've gotten called past like 830 p.m. in the past few months I've been over there. We do have a medicine consultant for co-management on nearly every case. So they offload a lot of the diabetes hypertension management and so forth while leaving the p.m. and our specific issues to me but probably most importantly we have a larger team on weekends. So my on call responsibilities are far more manageable I'm not like running around trying to see 72 patients. I recently took call I got adequate sleep I went to target and I did a load of laundry so I viewed that very much as a victory. So here are my references I'll be happy to answer questions at the end. And here's my contact information. I'm also frequently on the inpatient rehab forum group so you can also find me there. Thank you. And I will turn things over to Dr. Zeldin Hey everybody. Thank you for that nice introduction. I guess. Yeah. Oh OK. Move it up a little bit. Anyway my name's Evan Zeldin I'm a clinical assistant professor at the University of Cincinnati. I also serve there as the resident associate residency program director and I'm going to be talking about my rotation based schedule that I currently do which is a one week at a time based rotation and I think this is a nice transition because I wasn't always on physiatrist until I took this job about 18 months ago. So definitely some changes. So I have no financial disclosures. The structure of our division is a little bit important to try to understand to go where we're going in the future with this talk but we are in the Department of Neurology under the Department of Neurology. We have the division of PM&R we are roughly divided into two. It's unofficial. We have our sports medicine colleagues. They do a lot of outpatient practice. They do a lot of sports medicine sideline coverage and they help contribute to the call pool for weekends holidays etc. But most of the part what they do is a little bit separate than what we do at the neuro rehab general rehab inpatient stuff so that half of the division which is my half of the division. We have a lot of different responsibilities. We cover all the inpatient care and our freestanding earth. We do consults mostly in our acute level one trauma center which I'll talk about more but also in a sniff and an LTAC and then we have outpatient responsibilities seeing general rehab patients spasticity management spinal cord brain injury etc. So we've divided how we do that into four different services. The first one is one of the inpatient ones and that's what we call the large service that has a service a census of 16 to 24 depending on our inpatient census patients in the inpatient rehab unit. When you're on that service that's all you do from you know eight to five seven to seven whatever your hours are. You just do inpatient for that week. Another week is the small service. So we have a census that's capped at about eight to 10 patients so an intentionally smaller service. And with that though you have some outpatient clinic responsibility. So you have a half day daily depending on administrative responsibilities FTE. When I first started at the University of Cincinnati I had four half days now that I've taken on associate program director role at one half day of clinic and the rest of that time is admin. We also have a consult service so that consult sees consult service mostly sees consults at the University of Cincinnati Medical Center. It is a level one trauma center and a comprehensive stroke center. So those consults are lots of brain injury management spinal cord injury management stroke management trauma management and then disposition planning to see what post acute stay that they should go to. That service exists. things happen but at least productivity wise at the moment it's not quite enough to sustain a full time physician on that for 24 7. So usually you have a couple of clinics that you add on. Again it's flexible so I get to choose when those clinics are on any given week and I'll go into that a little bit more on the next slide. And then the last type of week is an outpatient week. That's a very traditional Monday through Friday 8 to 5. We rotate through all of these services. We're also a residency training program so the inpatient services both services the large and the small are always staffed with two residents. One is a PGY 2 resident serving as a junior resident and the other resident is a PGY 3 or 4 that serves as a senior resident. So usually rounds as the PGY 2 presenting to the PGY 3 or 4 and I kind of stand there and do attending stuff and manage the clinic. And then the last type of week is an outpatient week. I kind of stand there and do attending stuff and manage that. So this is what an example of what your schedule could look like on an average month. So maybe the first week of the month I'm on the consult service. So Monday in the morning I go to the hospital see some consults in that afternoon go to a half day of clinic all day Tuesday see a bunch of consults Wednesday maybe clinic in the morning consults in the afternoon Thursday is my admin half day so maybe I just see consults in the morning and then Friday is a full day of consults. This week is kind of designed to an attendings personal preference so that's how I design my week. But some of my partners have designed their weeks to be a little bit different. I have a little bit more clinic there to give my patients a little bit more clinic space. But this goes above and beyond the FTE that's expected of me at the University of Cincinnati. The next week would be a large inpatient census week. So literally, all I do that week, Monday through Friday, is inpatient coverage. We round on between 16 and 24 patients. We write the residents write the notes. I attest the notes. I do all of the admissions. I do all the pre-screens. It's a very inpatient-focused week. The next week is the small service week. So that's usually the way we do it, is Monday in the morning, we round on the 8 to 10 patients we have. And in the afternoons, you have a half day of clinic. It's really nice because they're in the same building. So you can walk back and forth between the two. The other pro of having the two inpatient types of services is where I was before when I was always on and had like two to three half days of clinic, I was getting constantly pulled in between two spaces. But since there's another attending on the large service that their job is supposed to be managing all of the inpatient 24-7, usually when I'm in clinic, I'm in clinic. And the other attending is managing anything that comes up in the afternoon, like admissions, things like that. And then the last week is the outpatient week. Monday through Friday, 8 to 5, typical outpatient clinic type of schedule. How we divide those four weeks up amongst ourselves is not necessarily equitable. It's what we want. So I'm giving a talk on inpatient schedules. I'm a very inpatient-focused guy. It's what I like doing. I don't love my outpatient weeks as much as my inpatient. So I intentionally have more inpatient weeks. I do more large service, small service, and consults than some of my colleagues because that's literally what I want to do. And we make sure that all of us have all of the inpatient services and the consult service covered 52 weeks a year. And as long as we all come to an equitable arrangement for that, it works out great for everybody. Some of my colleagues like outpatient more, and they do less outpatient. And it all sort of works out in the end. For another good flexibility of this is for vacation and consults. So one, if you're on an outpatient week, you just cancel all your clinic and you go on vacation. You can trade to get into an outpatient week. But if you've got a situation like a Christmas or a New Year's or AAPM&R, and lots of faculty want to go to certain events, what we can do is combine multiple services into one to try to create more flexibility for faculty to leave. Usually the way we do that is combining the small service and the consult service into one week. And that's what you do that week. So you, for example, round on your patients in the morning, eight to 10 patients, and then in the afternoon go see consults in the hospital. And you do that every single day. You don't have any outpatient clinic responsibilities. And this sort of combines two of those services into one service, which frees up more faculty to not be in the hospital. We also equitably divide up all the weekend and the holiday call. Some advantages and disadvantages to this model. So I rotate what I do from week to week to week. So less monotony. Everything I do is different. And hopefully, I feel between the two models that I've been on, it's contributed to less burnout for me personally. We also like that they're built in coverage models, like I talked about. It's very easy to bounce back between the two. It's very easy to combine different services together to make sure that everything is covered 24-7. There's also, it's really good to create a vibrant outpatient clinic model, while still being an inpatient physiatrist primarily. You still have outpatient clinics on most weeks that you do. They're usually protected. And it gives patients that flexibility to get in. And especially if you're doing botulinum toxin injections, and they need to be there every 91 days or so, you actually have an appointment around 91 days out, instead of having to schedule 110 days out, because you don't have clinic for three weeks in a row. And most importantly, it's very flexible. There's some disadvantages, though. I have way less continuity of care than I did before. When I was the always-on, I admitted. I saw them through their inpatient stay, and I discharged them. Now I get them for five days at a time. So it's usually either admitting them, or the middle of their stay, or the end of the stay. Less continuity of care, lots of learning new patients all the time. There's also way less consistency in the day-to-day. Every day is very different for me than the day before. So I usually never know where I am going to be, unless I constantly am looking at my phone. And that sometimes is a problem, and it's also a problem for other people knowing where I am, like my colleagues or my wife, because it just changes from day-to-day-to-day. But yeah, that's my model. And I will now pass off the torch. Hi, so I'm Tori. I don't know if I'm doing this, aren't I? OK, I'm Tori Whitehair. I'm at MetroHealth in Cleveland. And I am Medical Director of Inpatient Rehab. So I'll talk with you a little bit about what it looks like from my perspective as a physician, but also my perspective as a medical director since I do the schedules for this. Yeah. No disclosures. Our structure to begin with, we are a, oh, I liked where you were. I'm coming back over here. All right, our inpatient rehab is technically not a hospital, or it's a hospital unit, but it's freestanding in a way. So we're about a mile south of where our main hospital is, so a little bit of a funky structure there. And then our campus is our primary site for the PM&R department. We have our inpatient rehab units there, our outpatient clinic. It's one of several sites, but where most of our neurorehab physicians practice. And then we have our admin offices and support staff there, as well as our education. We have 24 residents, seven fellows, and then medical students coming through. Our research is primarily located there as well. We have 57 beds, and that's divided in three units. Our units are different in size. It's just one of those things that comes from the way that our, how this hospital was built. And so we have a stroke unit, which is our smallest. There's 14 beds. I'd say the census ranges from about 10 to 14 patients. We have a brain injury unit, which is 19 beds. I'd say that one ranges probably from 15 to 19 patients. And then a spinal cord injury unit, and it's kind of overflow for general rehab patients who are not on one of the other two units. Also, that one has 24 beds. We never get up to 24 there. I'd say that one is usually somewhere between 16 to 20 patients. So they do all vary in size. To tell you a little bit about our department, we have 34 clinical faculty in two clinical divisions. We have our neuro rehab division. We're covering inpatient rehab. We have hospital consults under us, outpatient clinics that are either general or neuro rehab. We have nine physicians as part of this group, one APP who practices only in the outpatient setting, and six rehab psychologists. Six physicians are primary for inpatient rehab, and then we have one primary for consults, and we have two who are more research and admin. But both of them, as well as our consult physician, do assist with some of the inpatient rehab coverage. We also have our musculoskeletal rehab division. We call it MSK, so I wrote that there, should have written that for you. But it's really more of a general also. So that's outpatient clinics only. They are pain, sports, amputee, cancer, EMG, sort of a lot of the other areas there. And that's 11 physicians and seven APPs. The only in-hospital work they do is one of the pain APPs does the inpatient pain consults. Our model is an attending style coverage. So the attending physiatrist rotates on and off the inpatient rehab service. But a little bit different from Evan. Ours are longer rotations. The residents are on units all year round. There's usually two residents per unit. And then the fellows are on intermittently. Four, three of our fellows are neuro-rehab related, the other four are pain. So seven sounds like a lot, but most aren't coming through inpatient. Our on-service time varies between individuals. So we have anywhere from about four months per year up to 10 months per year that different attendings are doing. Rotation length varies. We used to always have four weeks was about the minimum. It would be between four weeks and three months. But just last year, or this year I guess, we went down to having the option for two week rotations as well. The on-service time depends a little bit on people's preference, but also on their assigned clinical FTE and the other duties that they're expected to be doing, whether it's administrative research or teaching. When on-service, most of the physicians will reduce the time they're spending on some of those other duties, and then return to more effort in those areas when on-service, or when off-service. So it's a little bit of a balance that can be challenging, which I'll talk about at the end. Physicians with high clinical FTE, they do add additional clinics during their off-service months. I'll show you what that can look like in a moment. And then many people do plan some of their time off for when they're off-service. That doesn't have to happen this way. We do all cover each other. Vacations come when vacations come. Here's a sample of what some of the rotation schedules might look like. So let's say on our stroke unit, we have two attendings who often work on that area. We might have month-long rotations, so they might just be alternating in there. But on the SCI unit, let's say we have a physician who is 95% clinical, and one who is 30% clinical, we might have something where one of them is on for two to three months at a time, and the other one's coming on for one month in between. But maybe on our brain injury unit, everybody needs two weeks at a time, or that's people's preferences. And so we might see, I think I drew in here that we had three attendings there. So that might be a switch every two weeks. I'd say this is one of my favorite things as a physician, in that we all can have the thing that works for us. This is the hardest part of this for my job in trying to make the schedules. So there's definitely a toss-up there, but it's doable. This is what a weekly schedule might look like for two different physicians. Attending A has 95% clinical time, 5% teaching. When they are on service, they might have four clinics that are in the afternoon, and then the rest of it's inpatient time. For us, we do have some, our clinics are not always in the afternoons. So we do sometimes have these sort of three-hour-long, weirdly short clinics where the attending is on inpatient, goes off to clinic, and then comes back in again to inpatient. It depends a little bit on people's preferences and what kind of clinics. But a few options there, and then I wrote in admin time, but that, honestly, usually when you're on inpatient, it's filled up with inpatient work. Most of our physicians are a little flexible in what their day-to-day looks like. They're probably starting on the unit in the morning, heading off to clinic or not. Maybe they're going back to their office and doing some of the education or admin work during that time, and then coming back up to the unit. So our schedules are very flexible in terms of what that day looks like, and as long as you're getting all those duties done in that day, it's variable for everybody. When that person's off service, though, they're probably gonna have more clinic time. So they'll have their regularly scheduled clinics, and then they'll be adding in. That works best, I'd say, for, we have a physician who does EMGs also, and so if we're backlogged in EMGs, we're just adding an EMG clinic. So it can be a nice plug-in, whatever our need is there. Now, attending B in this example is 50% clinical, 30% admin, 10% research, and 10% teaching. So they have a lot more things that they're trying to do other than inpatient. So when they're on inpatient, it's gonna look pretty similar, but they have only, how many clinics did I give them? Two clinics per week, because they have other things they need to be doing. But then when they're off service, they still have just those two clinics, and that's when they're getting a lot of their other work done. So very, very different looks. I did wanna talk about care transitions and handoff. That is one of the harder parts, obviously, about not having an always-on physiatrist. So we use a lot of different tools in this. The resident continuity is our primary, I'd say, in what we're using, because the residents know their patients, they're expected to know their patients. And our resident and attending transitions are always offset. So we always make sure that whatever day the attending's changing is a few days off from whenever a resident is changing. We use our EMR handoff tool. That one, we use Epic, and we kind of specially designed our own handoff tool that had the right information in there, some things that are auto-populated, some things that we are adding in as well. And then we really use our progress notes for this also. So we have a standardized template that we use as an H&P that gets transitioned into a progress note, and those are detailed. They have a lot of information with a lot of bolding and key information to hand off to the next attending coming on. Optional is to do a written or verbal handoff in addition. Sometimes we use this, sometimes we don't. If it's patients who are pretty standard, we know the residents use them, and we know everything's in the handoff tools and the notes, we might not go out of our way and say something else. But if there's a patient who we wanna make sure the next person coming on knows some key detail, we will find them in whatever way. And I would say, I feel this is sufficient. You know, I do not feel like patients are in unsafe circumstances because of those handoffs. There are so many tools that can be used nowadays that I have no concerns about this. Our call schedule. A resident is actually onsite 24-7. On weekdays, the physician who's covering the unit, they are on call for that unit. I don't get very many calls from that. You know, we have things outlined pretty well in terms of when you do need to call, when you don't need to call. We do send people to the emergency room so they don't need to be doing that emergency management. All the time, they can get them out, they can let us know after the fact. We use a lot of PRNs also, right? There are a lot of things on which I would say helps the residents more so than me, so still a good practice. And then on the weekends, we have a rotation. A rotation includes all of our inpatient attendings as well as most of our outpatient attendings. The ones who have a separate call schedule are mostly not involved in there. And this works nicely because it does share the love a little bit of being on call on the weekends, but I could see this being hard when you're initiating it if it's not something you do right now because you do have to get people on board, but then now it's an expectation that we have set for people when they come in. If they are outpatient, we let them know up front that they will be part of the call schedule. Advantages and disadvantages. For advantages, I really like not always being on, right? It lets me feel like I'm freed up to do my other work and to focus on other things. When I'm on inpatient, I have a lot of trouble kind of turning off that part and focusing elsewhere, so I do like that. The variety in practice is really nice. Just like Evan was saying, I really like having some different things I can do. It is very easy to get coverage even though, I don't know, even though there are six of us, we do run into times where we're like, oh shoot, who's covering what unit? But for the most part, that's really nice and easy. Having just a strong team there can make that really easy to work out. And then very flexible for changes in individual needs. If we have somebody going out on maternity leave for a few months, that's fine, right? We just change around the schedules a little bit. We have the people who are there. Or if we have somebody who takes on a new position within the department and needs to have more time doing something else, that's okay also. We can be flexible there. Also with, to I guess mention for a moment, our trial of the two-week rotations, we had some people who felt very strongly that that was way too short and it's not good for continuity of care. And then we had some others who were like, but I'm drowning by the end of four weeks with the other duties that I have. And so this has really allowed everybody to pick and choose. And this year I just kind of said, all right, how long do you want to be on service? Some people have two-week rotations next year and some people have three-month long rotations next year. And this schedule can allow anything in there. It is flexible for changes in departmental needs. Also, whether that's coverage for somebody or if we need somebody to be covering more inpatient, we have flexibility in there. And for the residents and fellows, I do have in disadvantages that there is less continuity of care for the trainees, right? They're working with a different attending all the time, but they're also getting to learn from a different attending all the time. And many of them have said that that's a thing that they like. They get to learn our different practices. They get to hear our different reasons for doing things and sometimes get to try different treatments on the same patient back-to-back if one's not working. So I think that that is a good and a bad there. Obviously less continuity of care for patients if we are switching off in the shorter periods of time. Although I find that even with the two weeks, you get to see a fair amount of patients through their whole stay or at least most of the way through it. Four weeks, definitely, and anything longer, definitely. Another disadvantage is it can be challenging to maintain your workload when you're on inpatient, just because it's, we have, and I'll say for myself, I have a very low clinical FTE compared to everything else I'm doing, but, you know, my same emails are coming in, I still have to see research patients if I'm involved in research, all the other stuff is still happening, so those weeks can be a little bit more challenging, but I just have to set expectations, I find, for that, and that goes fine. Inconsistent time for completion of non-clinical work goes along with that other one, when meetings get set up, they get set up, right, you can't always control it, and so it can be hard for the non-physicians, the administrators, to sometimes understand that my schedule's a little variable when they're trying to schedule in. Schedule planning and upkeep, I mentioned this earlier, totally fine for all of the physicians who are rotating through, a little hard for me, but that's okay, I think last year I had six versions of the inpatient schedule that happened over the course of the year as things changed, but that's okay, right, that's what lets it be flexible, I'd rather have that flexibility. And then the frequent communications of transitions and changes, not just between each other when we're changing service, but also with everybody who needs to know where we are, whether it's the liaisons knowing who they're trying to communicate with, or if it's our education staff, you know, whoever it is, they don't always know where we are, so that's just on us to make sure we're communicating well, but also doable, so those are some things about us. Okay, I'll hand it off to Dr. Cowling. All right, hey everyone, I'm Dr. Cowling, I'm the chief clinical officer at Madrina, and we're going to talk about the consultant role in the IRF with the physiatrist as the consultant. So, at Madrina we have several providers who do inpatient rehab, and they prefer this model, I also prefer this myself, I'm the associate med director at Encompass Fitchburg, and we use this model here. Prior to this, I was at the rehab hospital of Western Wisconsin covering for them because they needed a medical director, and there we were the primary, and I noticed a lot of us out in the audience are the primary, and when I went back to working with them, I realized quickly that we had a huge load on the primary team, the medicine team would come in and they would see consults, but it was few and far between, and it was a pretty stressful situation, so we at that time had attempted to flip that model where we were consulting, and I put this in here because one thing I think to emphasize with this is if you start with the other models, any of these models in general, if you're going to change the model that your hospital has, that can be incredibly challenging to do, especially because people are used to a certain thing, medicine might be used to a certain thing, so that's something to certainly be prepared for. We had the benefit of starting a new hospital in Encompass Fitchburg from scratch, so when we went into that, we knew we wanted to be consultants, and we really challenged that model of who is the primary in the inpatient rehab, who should be, and we started off as consultants and it's worked out very well for us. We have a freestanding rehab hospital in Fitchburg, Wisconsin, our ADC is 30 to 33, last year at this time I think I flew back early from New Orleans to do our first seven consults, so the census has been building quickly. We have on the rehab team two physicians and two APPs, and then the medicine team has two full-time APPs plus an on-call physician, and they had a lot more physician presence at the start, and the physician still does come in, but mainly they run that on the day-to-day with nurse practitioners. For our weekly schedule with the rehab provider, one rehab provider is working at the hospital, working with the APP. At that time, you're rounding hand-in-hand with the APP, seeing patients, doing education, and then we'll take off and do our team conference, do our review call, and handle any issues we need to. The APP will help us put in the orders, do the notes, handle some of the other issues that come up while we're doing more of the administrative work. The other physician that's not at the IRF that day is out either in a skilled nursing facility or in clinic or doing whatever other activity they want to do, and they're completely removed from the inpatient in terms of call or any responsibilities. On some days while we're in the inpatient, because we're consulting, not responsible for the admissions and discharges, we can go out the second half of the day and either do a clinic or see patients in a skilled nursing facility and continue to work while our APP stays there, and she can kind of handle some of the family meetings and other things that come up. There's full-time medicine coverage from 7 a.m. to 3 every day. That's also when the rehab providers are there, and then when they take off at night, that's when they have an on-call physician that takes care of all the call for them. On the weekends, very similar, except for we don't have a rehab provider there. We just have a rehab APP that's there Saturday and Sunday. The medicine team continues their same schedule. They actually work 7 on, 7 off. This is just a diagram showing the breakdown of the responsibilities. Now, this isn't concrete. This could change depending on the building that you're at, so if you have whatever kind of deal you work out with medicine when you first start or when you change it is kind of how this is going to end up, and there's some nuance in here that I'll talk about that has been kind of a pain point for us. Essentially, the rehab team is responsible for the face-to-face visits, consults, team conference, pre-screen reviews, peer-to-peer evaluations, medical management for rehab diagnosis. We do the pain, bowel, bladder, spasticity, anything really rehab-related we dig in on. The medicine team, they're going to do all the admissions and discharges, acute medical management, acute transfers, chronic medical issues, and then after-hour and weekend call. Then we have this area here in the middle where we kind of split, and that's coordination of care is a big one. If the patient needs outpatient appointments, talking with case management. If it's something that's more rehab-related, and this goes under specialist calls too, you know, we may make the call. If it's a weight-bearing status, an ortho call, or, you know, we're calling neurosurgery. If it's something more related to medicine, a good example would be infectious disease, then they would be responsible for making that call or setting up that coordination of care. Same thing with family meetings. We do do a lot of family meetings because we want to talk about the functional prognosis of the patient, but we do like to have medicine there as well to talk about how they're doing from that standpoint. With our discharge med rec, so the medications is kind of where this gets a little funky. We handle all the pain management on discharge, and that was an agreement we kind of made with the medicine team when we first started. They wanted us to do that because they didn't really feel comfortable with it. So that has hung us up because sometimes when we're not there, they may need us to, you know, put in the orders because they don't want to cover that part of it. There's also the other medications, though, that we don't take care of, but we're managing. So for example, you know, Baclofen, Tizanidine, the spasticity medications. For those things, they look at our recommendation from our progress note and either continue or discontinue at the discharge. So for the patients that are discharging, our sole responsibility, or I should say the thing that would hang the patient up from being discharged is just having the pain medicine done in the med rec, right? So if we didn't have that issue, then that would save us a little bit of time. But overall, this has been a really good setup for us, and that's something that, you know, in hindsight, could we have maybe talked to them a little bit better about that at the start? Sure. But it's sort of been a learning process. With the medications, also who's managing what issue, for example, you know, for orthostasis, we may order the abdominal binder and TEDS, the mitadrine, flagellar cortisone, but then if the patient is having issues with chronic hypertension or hypotension, then they're managing that part of it. We'll manage the neurogenic bowel and bladder, but if you know there's, we suspect that the patient has a urinary tract infection, they're going to be the ones that order the UN culture. And so there's a point with staff education on that, educating everyone at the hospital of what their responsibility is, who handles what. That took a little while at the start, but we've pretty much panned that out now, and it's been really nice. All right. So the strengths of our model, I mean, is we're splitting the work more evenly between providers. So we come in and we handle the rehab stuff. We work with the families. We work with the patients, talk about the prognosis. We spend time with patients. We round with our APPs, and they love that, and they're getting two touches a lot of times from a rehab provider that day, myself and then the APP. And a lot of times we go together, but sometimes we'll go back and forth. We receive the medical director stipend, and we do all the medical director duties and associate medical director. So myself and the other physician, we split those duties so that while we are there, we're acting as the medical directors, doing the team conference, doing the pre-screens, and receiving our stipend for that. The medicine team, though, they're getting compensated for their call, so they get a call stipend, which is very nice for them. So they're doing, you know, you could say more work by doing the admissions and discharges, but they're also receiving a stipend for a call and for that. And we're able to just spend more time in general where we want to be. So we can go into the hospital, we can see a high volume of patients, and then we can go out and see other patients if we want to, go to clinic, or spend time with family. Whatever we decide to do in the second half of that day, it's very flexible because we're not getting called back to the hospital to admit and discharge patients. And overall, I found that this leads to way less burnout. In our delegate meeting yesterday, the big focus was physician burnout. Inpatient came up. We talked about, you know, our training system and, you know, how our providers are burned out and who's responsible for what, and the burden, the administrative burden, plus the burden of the admissions, discharges. It just really wears on you and it becomes unsustainable. This model, I think, is very sustainable, particularly for people who are in private practice and may not have that resident workforce to help them out. This seems to work really well. The drawbacks. So having multiple providers, having their hands in the med rec is not a clean process for us. It's something that's taken a lot of work to tease out what medications are getting continued and which are getting stopped from a rehab standpoint. As I mentioned, the pain medications has been a pain point. This has led to some delays in discharge stuff for the patients where, you know, it's a weekend and they need pain medicine and they want the rehab team to write it, but we might not be there, which is one of the big reasons we pulled on a provider for the weekends. And then we'd have to handle that or other things would come up where they would want to know about continuing or discontinuing a different medication and we weren't there. And your medical care really does, and I think this goes for everything unless you're managing literally every part of the patient. You have to lean on your medical team and have a high-quality medical team to work with. In other situations that I've been in, you can have a medical team that'll come at the end of the day and copy and paste your rehab note, right? And so that's not what we want. We want an engaged medical team. Ideally we want physician-led care in the inpatient rehab, direct oversight of their APPs. And I'm trying to think of any other real drawbacks to this model. I don't really think there are any. The one hangup we do have in inpatient does, you know, working with the APPs, we see the APP. The APP can't see the patients every day on their own without us, right? Because we need to meet the guidelines to get the face-to-face visits. So we do round with them, but then they handle everything else and then we submit the face-to-face. Cool. So that's, I think, all that I have. I know we're live, so if anybody has questions in the, just go ahead and put them in the chat. And thanks for having me. Thank you. Good afternoon. I'm Glenda Lisposkes. I'm a pediatric rehab physician, and maybe a little bit different from what has been presented. However, as speeds rehab physicians, sometimes we might be kind of like recruited to be the sole pediatric rehab physician in a big adult PM&R department to develop a service line. And that was kind of like one of my experiences. So I was recruited as the first pediatric rehab physician in a big adult PM&R department to basically develop a pediatric rehabilitation program that included consults in a level one children's trauma center that was embedded within an adult hospital facility in addition to a clinic and an inpatient rehab program as well. As I mentioned, I was the sole and only pediatric physiatrist that was coming on, and I didn't want my adult colleagues to cover my pediatric patients. I didn't think it was one. My adult colleagues would not appreciate it. I would not want to be covering adult patients either in terms of that kind of like call equity or parity, and it's not completely safe probably to have adult providers or clinicians to be covering pediatric patients either. So from the beginning, I had to come up with a solution, a potential solution or a creative pathway to be able to cover multiple responsibilities, not just clinical but also administrative, in different locations because this was three different locations. So an adult freestanding rehab facility where the clinic was in, freestanding specialty pediatric hospital where the inpatient rehab program for the pediatric rehab population was, and the level one trauma center that was embedded in another hospital in the medical center. So since the beginning, so basically I was going to be 24-7 on 365 a year as the sole pediatric rehab physician. So I had to kind of like come up with a creative solution to provide the safest pathway possible for my patients and for myself in order to try to decrease moral injury as much as possible. I had been exposed to this environment as a trainee, so I knew that I was going to also get very busy very quickly. This was not going to take six, eight months a year for me to develop a practice and have patients in clinic and have time. I knew that as soon as I kind of like opened the doors, I was going to get busy seeing patients. The good thing is that this was an academic position, so we were part of a medical school and the pediatrics department had multiple staff members that had expertise in treating kids. So they already had a pediatric hospitalist group that was developing, was covering the children's hospital. They also had a community pediatricians group and they were open to moonlighting in addition to a multitude of pediatric specialties in the area. So basically we came up with the consideration of enlisting the pediatricians and the pediatrics of specialties to be the primary clinical force in order to sustain myself as a pediatric rehabilitation active consultant. So basically a co-management model, very similar to what was just described, however, I was not in charge of writing orders or that was going, the pediatrician was going to be the primary attending and admitting physician of the record. So they were included in pre-admission discussions in terms of medical coordination, like because we were in a freestanding rehab facility for kids, making sure that we had all the feeding supplementations available, weird uncommon drugs that sometimes I use for like seizure management or antibiotics, checking with pharmacy for formulary, et cetera. So they were in charge of the admissions orders, day-to-day medical management of the patient. They would also assist with consultation coordination and communication. They provide a call-in coverage 24-7 between the pediatricians on site during the day and then on call on weekends as well. So the pediatricians were always going to be first call and yes, if they had a question that needed the brain of a rehab physician, typically constipation at 1130 at night and they didn't know what else to do while I was at Disney World or something like that, then they would kind of like contact me and I would, you know, discuss any additional recommendations. They were also the emergency response leader given that we were in a freestanding facility that did surgeries in addition to having the pediatric rehab unit. And they were in charge of the discharge process. So they were in charge of all of the prescriptions, the summaries, the orders. And I also appreciated that they would actually contact their community pediatrician for the patient in order to provide that sign-off, especially for our very complex discharge patients. How about the physiatrists? So we were physically present every day, but probably, you know, we would for sure try to run for sure the three times a week even though we don't need to follow up truly Medicare guidelines and more often as needed. We are the medical director of the inpatient rehab unit. So we would do the pre-admission screening. We would do the initial consultation, provision of the initial plan of care. All the services required, an estimated length of stay. We were the leader of all the rehab planning meetings, including initial planning meeting, which in the pediatric world, it has different names in different institutions. But basically it's like a prolonged, like face-to-face IPOC with half with the team members and then half it's actually with the family. So in most pediatric rehab inpatient facilities and programs you typically have like a one hour meeting with the family initially on admission. And then we also were in charge of the weekly team round meetings and and then we were just there we have a patient consultant throughout the state. So we will provide recommendations for any rehab related medical issues so identification of potential hydrocephalus after a patient with brain injury comes and they're having difficulties with progression or changes in mental status PSH management A.D. spasticity D.O.C. disorders of consciousness protocols management and you know we have pharmacology bracing equipment etc. For example PM&R will give recommendations for the PSH or neurostorming where the pediatrician would actually be writing the orders and communicating that with the nurses as a rehab physician you're always there to provide additional location as possible. So basically on a day to day how this co-management model would work so communication is super essential on this. So we would have morning rounds with the pediatricians and the sorry the pediatricians will have morning rounds with the nurses and they would basically troubleshoot for any overnight events urging morning events that they were aware of and then we would do a collaborative rounds with each other. It most of the time will be table rounds unless we had a patient that we really needed to see together. So we kind of like discuss and at the end of the collaborative rounds we all had our own to do's to do for the day and then we would do an afternoon checking making sure that all the issues were taken care of any changes or updates had been shared and communicated and all the orders were completed in like I mentioned communication and access is key in terms of like these team members and it is essential to share knowledge. The pediatricians can be trained to meet the primary rehabilitation hospitalist standpoint especially if you have a group of people that you can identify that it's only one or two people that really are interested in being a primary Pete Street Pete's hospitalist for a rehab unit. At the beginning when I started doing this this was like the pediatrician the juror and that was very very difficult because that led to some challenges in terms of continuity of care and by them just thinking that they were just covering you really would lose that primary acute medical management that I really wanted from a pediatrician. So we had to change their model of coverage very quickly. So and then the other thing is kind of like respect each other's expertise as well. So when the be it when I discuss something with a pediatrician even though I'm a P3 physician I'm not a pediatrician so I would kind of like allow them to you know use their knowledge and respect that. And then when I had concerns and we share that they also kind of like respected that. So some highlights you know some people may have questions about how reimbursement works and who bills what and all that stuff. You're both physicians you're both command and command managing so you can bill for individual professional services. I think as needs change in health care sometimes we need to come up with creative solutions and collaborative relationships and look at who's out there that is willing to do that. And I think that's a big part of what we're trying to do here. Look at who's out there that is willing to kind of like help out and then we need to engage and enlist and then leaning into that. And that has that allowed me to have a more rehab focused practice instead of like more I don't know coordination of care and things that could be done by someone else. Thank you. So thank you to all of our panelists. We've gotten a number of questions that I'll read out and post to them. The first question is during on call hours all calls come from the house supervisor at the questioners facility only. The nurses can enter messages via the EMR. This has greatly decreased our call volume and the number of questions we get. We've also seen an increase in the number of questions we get via the EMR. This has greatly decreased our call volume with calls limited to very acute issues. Does anyone else use this model. Sorry. During on call hours at this person's facility all of their calls from the house supervisor only to reduce the on calls that people are receiving at night. Does anyone else use this model so that they're kind of triaging those very acute issues are being posed to the on call physician. Not any. Yes no. Yeah I think so. Right. People can hear me. OK. Not anymore. But at my previous institution yes. The big negative on that was if it wasn't from the primary person and it was being filtered there was a lot of like having to ask a question back and then the person would have no idea because they had never seen the patient. So it was honestly made to like way more involved of a discussion rather than if it was just from the primary nurse it was like a quick fix. It was more calls but they were like shorter and sweeter. And the next question I'll post to Dr. White hair. What calendar system do you each use to track rotating physician schedules. Who is responsible for fielding vacation rotation swap requests and keeping the calendars up to date. So I I'm old school. For our annual schedule. So I just built this for the next year and essentially I build out the entire year when I'm doing this and we fill it in and we figure out how many months people might need. I'm doing it all in one big thing. Everybody's got it. It's easy to send. You can post it wherever you can look at it on your phone. So I use word for that that then though has to get translated into other things right. So that goes to in the in our on call system is probably the most important part for that. That goes to one of our administrative assistants. She then is the one who's responsible for entering our on unit time into our actual EMR the vacation question. Our physicians are they're adults. They are responsible for finding their own coverage for things because there are others of us. That goes back on to them. I know that's different if you if you don't have other physicians in your practice but for us everybody's responsible for finding their own coverage. We tend to send mass emails to people or you can look at the schedule right and figure out who's not on. If it is a challenging thing they come to me. So I'm kind of the last person for it you know like shoot we can't find anybody and my mom's having surgery. OK let's solve this. But for the most part they're able to handle it themselves. That then does come back to me so I can change the schedule and then it goes back out to sort of everybody else who needs to know as well. I think there was another part in there. You're covered. Yeah OK. So our next two questions have to do with the co-management model. So I'll pose those to Dr. Cowling and Dr. Bosquez. First any billing issues arise with the co-management model. Not for me not in the inpatient. Same here. The patient is going to have the hospital based services covered by their bill and then each physician service can still bill for. I think one thing that we just need to make sure is that in terms of I don't know if this impacts or not I try to be very mindful of the primary diagnosis I'm using for the day. So as the rehab physician I may be using like spasticity or neuropathic pain or something for my plan of care while the pediatrician or like the hospitals or something may be using hypertension or something else. I don't know if that's. Yeah that's exactly right. So using the rehab diagnosis I think you could really run into or you may run into an issue with this if you're using mid-level providers frequently. We can avoid some of that because you know we have to have the face to face visits done by a physician. But if they're billing under the same taxonomy then there could potentially be an issue. They have to look at what diagnosis they're managing. So always making sure to triage the rehab diagnosis at the top. Would be the number one move there. While I understand the improvement in quality of life with the physiatrist as a consultant. Have you put any thought into the possibility that the administration eventually doesn't see your value and allows the medicine team to manage completely without you. I love that question. So I think that's a big fear that people have. But you know really as physiatrists we add a ton of value and we shouldn't be afraid of that. We're just letting medicine do what medicine does. They do the admissions they do the discharges we're coming in we're educating the patient on their prognosis managing the rehab medications ordering their equipment everything that they need. I think that comes down to the physiatrist adding value in our belief in ourselves. You know we know what we can add. We know we can do for patients and just being confident in that and we're still managing the team conferences the pre screens you know and all the medical director responsibilities. But at the end of the day it comes down to us believing in our specialty and what we can do for the patients. I'll add that I came in to develop a pediatric rehab program and allowing the pediatricians to cover in patient rehab actually allowed them to learn more about what the role of a rehab physician can be and actually expanded the education of the value of the physiatrist within the health care system. So it actually can work positively instead of negatively in that term. And the last question disappeared but I thought it was a good one so I'm going to paraphrase what I remember reading. Does everyone round on their patients seven days per week including the weekend since it's not a CMS absolute requirement and weekends can be rough on rehab. No we used to have a requirement for the five days a week. Yes we we do see our patients all five days out of the week. They're pretty acute. On the weekends we used to actually require that everybody was seeing the on call person was seeing all the patients. We did back off from that a few years ago and that was partially because of concerns about quality of life and when the question came down to is the is the benefit that we're providing to the patients actually worth what's happening with our physicians and we decided in the end that the answer was no it wasn't worth it. We also did a cost analysis of it and the you know the physician component of your reimbursement is not the biggest part of the payment that you're getting. So every place would have to do their own analysis but we do not on the weekends. We we give an option. It could be anything. You could see all the patients both days if you want to or you could see just the new admissions and the patients who the attending physicians and residents ask you to see. So that's part of our sign out actually as we do have on our sign out who are the patients who I need you to see over the weekend. Why do I need you to see them. And we give that warm handoff and we see a variety. There are people who see all the patients both days and there are the people who see just those bare minimum and I my patients do fine both ways. We have seven day week coverage but the physicians are only there Monday to Friday. We round. So it's the primary physician Monday through Friday Saturday Sunday is weekend coverage. We expect everybody to be seen at least one of those weekend days and then the primary purpose of the weekend days is putting out fires. We also have to admit 24 7. So that's part of the weekend coverage too especially we have a lot of competitors in the area and admitting Saturday Sunday does make a difference. All the pediatric institutions that I work at have a specific role in sponsoring a physician that all the patients in the hospital need to be seen by a clinician either a physician or actually even in the current one and they need to be seen by a physician every day. But that's kind of like why I enlisted the pediatricians to be able to just run quickly on the pediatric patients in our inpatient rehab unit. Our next question is are you concerned that mid level medicine providers can successfully manage patients with some of the high CMI as we discussed. I guess I'll throw that to Dr. Cowling. Yeah that's another good question. So I think one benefit of the earth model with the face to face requirement is that we round with our APP five days a week and we even will sometimes go in especially when training will go in on the weekend. So she's watching what we're doing with the patients you know essentially every day and that really adds to the value of training. You know do I think that if you have somebody that's you know unsupervised and there's not proper training. Yes potentially but with this model where you round hand in hand with the APP I think that's the best way to assure the success and patient safety. And our last question is how do you apply Medicare regulations for hospitalists as primary in an earth. What Medicare regulations apply with an APP for notes rounding admissions etc. I could take that and then if someone else wants to chime in but I think most co-management models will have their rehab physician or the physiatrist serve in the CMS roles that define the responsibilities of the rehabilitation physician. So signing off on the pre-admission screen writing those three face to face notes per week and leading multidisciplinary team conference while letting the other service manage the more medical aspects with regards to NPPs for notes rounding admissions so NPPs can do admissions. CMS has been clear on that they can round in terms of the face to face notes they are allowed to write one of the mandatory three face to face notes per week starting the second week of the patient's stay. I did get clarification from CMS a few years ago. There was some lack of clarity with regards to whether they could write the note on behalf of the rehab physician with whom they are rounding so long as the attending physician provides a nice face to face note attestation and they did clarify that they can in fact do that but it needs to be clear that the rehab physician did see the patient face to face in those notes. I don't know if anyone has anything else to add and that it's the decision maker. You're just not rounding. You're the main decision maker and it needs to be very clear in that the station as a rehab physician that you're the one that is making the decisions as a rehab physician. And then there are split share rules that apply that are probably beyond the scope of this talk but I can plug we have a recorded talk on billing and coding that does cover that in length. Any other questions from the audience. We're just about done. I have one. All right. I have a question for you guys. This has to do with admissions. So if you guys are not the ones who are writing the admission orders do you ever have concerns if it's a very complicated patient there on a lot of sort of rehab medications. How is that handled when the patient's first coming in if you're not the ones putting in the orders. So I would say it's the same you know we have a lot of faith in our medicine team. I think they do a good job of understanding the complex patients early on they would reach out to us and ask us questions about that stuff. You know certainly things like Dex tapers and stuff like that you don't want to miss. So yeah I think it's important. We touch base with the medicine team frequently while we're there and it hasn't been an issue for us. I could potentially see that if there's poor communication but I think being in good communication with the medicine team which is just good care I think that would solve that. We do have lower census in pediatrics most of the time compared to you guys. But one of the things that we would do would be collaborative rounds would be not only rounding for the patients that are admitted but for the potential consoles as well. So we would basically pre-plan for the for the admission. Sorry I said console for the admission that is coming that day and make sure that we have a plan of care and if there is any like spasticity medication or anything that we want to clean or anything that we want to add from the get go to be very clear of what what our recommendations would be. Yeah just to talk a little bit more about that. So during our pre-admission review that's when we're really going through that step when we're accepting the patient and you know really figuring out the needs of the patient then making sure we're communicating that to medicine before the patient gets there. I have one more follow up question about that in terms of the H&P. Is the hospitalist then placing the H&P at least for weekend patients. And then do you guys place another similar sort of thorough note. How do you guys handle that. Yeah so when the patient comes in they're seen by the medicine team within 24 hours and they drop their initial H&P and then if it's a weekday we'll see the patient also within 24 hours we'll see the admissions the next day. If they do come on a weekend we prioritize the Friday admits early Monday morning. But our hospital policy is that and this actually works out pretty well to fit the the face to face visits as well is that we we see them definitely within the first 72 hours more so probably within the first 48 would be more common. Similar with us most PD places won't accept patients over the weekend but the pediatrician would do the H&P and then the rehab consultant a.k.a me would do a very thorough consult including like an iPod type of thing to make sure that we kind of like meet the criterias and discuss all the things that we're recommending moving forward. It's now five o'clock so we will close the session. Thank you everyone for your attention.

physiatrist coverage

inpatient rehabilitation

patient care

provider workload

always-on model

physician burnout

rotational model

hybrid approach

co-management model

pediatric collaboration

work-life balance