Hey everyone, good morning. If you don't mind, we're just going to get our session started. So, good morning everyone. I hope everyone is having a happy Saturday, a good morning, and a good conference so far. Thanks for staying for our talk. My name is Evan Zeldin. I'm a physiatrist at the University of Cincinnati. I'm excited to give this talk with some of my panelists who will introduce themselves in good time. But yeah, we're going to hopefully give you some good information on how to improve as a physician leader and also improve your inpatient rehabilitation facility over the next 75 minutes or so. So none of us have any financial disclosures. Our objectives for this session are fourfold. We're hopefully going to look at some acute care transfers and hopefully come up with some strategies to minimize those. We're going to look at some quality measures in an IRF that hopefully we can improve as a group. We're going to work on some strategies that hopefully you can employ to grow an IRF. And then we're also going to have some good leadership tips that hopefully you can take away from this session. So the first portion of the session, my co-presenter, Dr. Falk, unfortunately couldn't be here. He'll be at the last presentation as well. But the first part we'll be talking about looking at acute transfer rates across an IRF, if there are any sort of predictive model that we can come up with to hopefully reduce those rates. So the background about where some of this data was collected, it was collected at ECU Health, which is a rehab facility in rural eastern North Carolina, but it's a pretty large facility. We have 1,700 beds across nine different locations. And last year we admitted over 62,000 patients over the course of the fiscal year. So very large health system, very large diverse patient population. The acute rehab hospital is a 65 bed IRF divided into six subspecialty teams. So there's our general rehab teams that are sort of bread and butter, orthopedics management, polytrauma things. But then we also have some subspecialty teams such as traumatic brain injury, spinal cord, neuro rehab, and pediatrics. And the reason I'm going over all of this, as we'll sort of talk about later, is each team is divided into its own physician, nursing, and therapy services leadership teams. So it allows for the teams to operate independently of one another. So if our spinal cord patients have different needs, different team conferences, different sections that we can help with, they can operate on a different model than the traumatic brain injury team and things like that. And it also allows for physicians, nursing, and therapy services for specific groups to talk to one another and always have the same patient populations. Just some background to hopefully help you better understand some of the information we'll be presenting a little bit later. So on to what we're talking about, which is acute care transfers. So an acute care transfer, what we mean by that is a patient who you admit to your IRF who for whatever reason has to be readmitted to the acute hospital. We're looking at unexpected acute care transfers. There are some expected acute care transfers from time to time. If a patient has a known surgery or a procedure, those patients we admit hopefully know before they come to rehab that they're going to have a procedure and readmit them to the acute hospital. But oftentimes patients decompensate in the IRF and we have to unexpectedly return them to acute. This is important for two reasons. First, it is a metric tracked by CMS. A lot of your facilities might be analyzing this rate because it is tracked by CMS. But also for our patients, the outcomes change on these patients who are unexpectedly returned to acute. There's a lot of good literature out there on this, but the patients who are unexpectedly returned to acute have a worse mortality rate, worse functional outcomes, and are less likely to discharge home than the patients who do not unexpectedly return to acute. So identifying this patient population and seeing if we can do things to fix it will hopefully lead to better patient outcomes and less importantly, but importantly, improve some of the metrics that we look at. So like I mentioned, there's a lot of research already out there on risk factors, lab works, age, past medical history, and their functional status. And then even some prior research that we've published, the time of the day or the day of the week has been shown to correspond with the unexpected return to acute rate. So we are doing a study that's currently ongoing and part of the fun part of preparing a talk for AAPMNR is not being a little bit overly ambitious and not necessarily knowing when you're going to finish collecting data. So we are hoped to have a little bit more data to present to you today, but things got in the way. So we are going to present some of the data that we've collected so far, and we hopefully will have this published a little bit later on in a more of a full comprehensive data set. But what we are in the process of actively doing is a six-year retrospective chart review and looking at the patients who returned to acute and did not return to acute. And we tried to exclude, we're looking for the unexpected ones. So anyone who had a scheduled acute care transfer for a known surgery, known PEG2 placement, known things like that, we excluded from the model. We also excluded those patients when they did return to acute. When they came back to rehab, we didn't look at their second admission, and then we did not look at any pediatric patients. So we tried to look at basically every variable that we could find that we thought might correspond with a return to acute transfer based on past literature and based on things that we hypothesized might cause this. So their demographics, their functional measures, past medical history, how they're currently doing, and then a lot of lab values as well. So we have currently analyzed over 4,000 patients. We ended up excluding 700 of them because we just didn't have enough data to all of those data points. And so far, which the important thing that we don't have yet and we're actively collecting is functional measures. So we can't really say whether their pre-morbid functional status impacts this as well, but we can talk about a lot of the other things that we looked at. And the important thing for a predictive model is the C-statistic, which I didn't really know what that was before undergoing this process. But a C-statistic is a variable that shows the predictive model of a predictive model. 0.8 is the number that you're looking for. So less than 0.8 is good to fair over 0.8 is what you're looking for. If we look at all of our patients, regardless of anything we've gotten to without functional measures, we have a predictive model of 0.74, which is really good, but it's not quite 0.8 yet. But if we break down these groups into individual impairment groups, which I'll go to on the next slide, we can really get improved prediction models in certain impairment groups. So this is looking at, broken down by rehab impairment code, the 1.X all the way through 16. You'll notice that there aren't some impairment codes because, as we all know, there are a lot of patients who come down with specific orthopedic cardiac major multiple traumas and we don't really see, at least in our facility, as much pulmonary impairment codes. So these are our N values and these are our C statistics. Importantly, we have good predictive models in stroke, major multiple trauma, and then orthopedic and brain injury and spinal cord injury. We're getting really close to that. So sort of importantly, what are the predictors of acute care transfer in our facility? These are them. A lot of past medical status things, a lot of invasive devices, pressure ulcers, and a lot of these labs. Which I think the take home points of all of these things is, one, hopefully we are able to, in the future, predict an acute care transfer using a risk model in the future based on these lab values and these patient demographics. And what I hope we can take away from this is, at least right now as a consultant, when I'm going to bring somebody down to rehab, there's a lot, as we all know, these patients are getting more and more medically complex. So it's how do you actively work with your acute care colleagues to find the right patients? Because we know that if we take the wrong patients and they come to rehab and then they go back to the acute care, it's much worse functional outcomes. So for example, we looked at anemia. So I have many times rejected a patient because their CBC is abnormal and their hemoglobin is 7 or 6.8 and say, no, no, no, no. Those patients are too sick. Give them some blood. Let them come. They're going to pass out in rehab. Our data doesn't support that. So maybe those patients, you have a little bit of an easier time bringing them down. Whereas if the patient has an active infection and they have a leukocytosis or they have an active AKI, maybe those are the patients that we talk more with our acute care colleagues and say, this specific patient has an AKI. Please give them fluids. Help control their infection. And that might lead to less acute care transfers, better patient outcomes. So that's what I hope we can take away from all of these things. Yeah. We still need more data. All right. I'll hand it off to Dr. Snover. Thank you, Dr. Zeldin. My name is Michael Snover. I'm the Chief Resident Physician at East Carolina University. And I'd like to thank Dr. Falk for allowing me to be here today. Thank AAPMNR for allowing us to come and talk. And thanks to Dr. Zeldin and Dr. Foster for putting this together as well. So my project was on the standardization of inpatient rehab consults. As a resident physician in the program, we do a 10-week consult rotation service where we work with an attending physician amongst some other colleagues, which I'll get to in the next slide. But basically, I really like the consult service. I wanted to find a way that we could try to improve the efficiency of the meetings and improve some of the metrics that the Center for Medicaid and Medicare Services are looking for in terms of the return to acute rate. So I kind of aimed to tackle that during my rotation. So the Center for Medicaid and Medicare Services, CMS, tracks and monitors the inpatient rehabilitation or IRF return to acute rate or RTA rate as a quality improvement metric. Our academic IRF experienced a significant rise in the number of RTA patients over the past academic year between 2021 and 2022, well above the national average. And I'll get to those statistics. Now, the reason for this increase is what I found to be more multifactorial in nature. So these potential factors include, but not limited to, physician-dependent, increased medical acuity of patients, premature admissions to the inpatient rehab before medical optimization. That's something we found. So when we looked at the data, a lot of times we were taking stroke patients and some other patients before the national average for, compared to some other inpatient rehab facilities. So we think that may have had an impact on some of our return to acutes. As an academic IRF, patient selection was determined by a teaching model where a resident physician would present new IRF consults to a larger multidisciplinary admissions team that I alluded to earlier. Our academic IRF sought to reduce the RTA rate by implementing a standardized template. And that's kind of where the money is in this. I came up with a template to try to better, more concise, and to better present to the attending physician, as well as the other team members, to kind of make everybody better familiar with the patient by only presenting the most important things to evaluate the patient for their admission to inpatient rehab. So our academic IRF proposed that standardizing the presentation format template would lead to admitting only the most medically and functionally optimized patients to the IRF, thereby reducing that RTA rate. So some of the collaborative team members, I kind of pioneered the project on this front. And then Dr. Morales, Abigail Morales, she's our consult attending director. And then Dr. Zeldin also served as well in this project. And then Kimberly Brookbank, she's one of our occupational therapists on our rehab, we call them rehab admission coordinators. Katie Henderson, Jana Andrews, Candice Kluh, and Cass Widgen, they're all nurses that are on our admissions team. So this is pretty much everybody that's on our admissions team that you see here. So we don't have any APPs, it's just a resident physician, attending physician, and an occupational therapist, and some nurses. I think one of the things that's nice about having an occupational therapist on our team is because it's kind of like, you know, they really are, she's really great at looking at the functional status of the patient and kind of help, you know, to, you know, evaluate as well those patients before they come down. So the aim statement of the project is to refine and standardize the quality of a resident physician's new consult presentation as to facilitate a more efficient meeting, as well as to improve the understanding of the relevant aspects of each patient, to make a more appropriate decision on the ultimate level of therapy recommendation, as well as decrease the inpatient rehab return to acute rate. So as far as methods, so a new template was enacted to evaluate each new consult patient that was, you know, going to be presented to the admissions team. Categories were as follows. So the demographic information, name, age, gender, number two, obviously the room number, you got to know how to get there. The brief medical history. So this is only the most important pertinent things, such as what's the reason for admission? Are they TBI? Are they stroke? Are they, you know, general debility or medically complex or something like that? And then the level of functioning with the therapies. So we look at bed level, we look at, you know, how they're doing with bed level therapies. We look also, you know, how they're doing with transfers and are they doing any ambulation? Can they tolerate, you know, a decent level of therapy, a decent amount of time with therapies so that we know that they'll be able to come down to rehab? And then also the therapy discharge recommendations from the therapist can sometimes help support our case when we think there's a patient that's appropriate for admission to the inpatient rehab. And then level of caregiver support after hospital discharge. So some of these patients, you know, we run into problems and, you know, it can increase our length of stay for some patients if they don't have appropriate care when they go home and appropriate supervision. So, you know, we have a T, if we have, you know, for instance, if we have a TBI patient that's young, 30, single, doesn't have the, you know, that expected caregiver support, of course our goal is to get them home independent, but that's not always attainable sometimes and we expect them to have some level of care when they leave. So we try to establish that up front as well and we think that helps to improve our metrics as well. So let's see, we also look at the barriers to rehab admissions. So for instance, if a patient who, he is here with a TBI, but maybe they have a raging AKI, we will bring, that's important to note and the resident physician will bring that up to the team so we can navigate those issues. Also the patient's insurance. And then over a 60-day period, the resident physician presented each patient in the same fashion by following the aforementioned eight-step template. At the end of the 60 days, data was collected on the number of RTAs, number of reconsults, and a subjective questionnaire that I generated was given to each member of the consult team, including the attendings and other team members. And the resident physician as the primary author of the study did not complete the questionnaire given the reason of likely bias. I filled out my own questionnaire. The data analyzed compared the dates of the experimental group for which we're calling the dates that I was on the rotation on that service and then the control group was the dates beforehand, before I took over on the service. So the outcome measures were going to be the questionnaire provided each team member of the admissions team evaluating the efficacy of the new consult format, as well as comparing the return to acute rates and hard data between the two separate 10-week time frames. So the baseline data, our average inpatient rehab facility RTA rate in the control group was 17.125% compared to the national average of 9.96% during that three-month period before I started on the service. And then our average inpatient rehab RTA rate through the dates of the experimental group when I was on the service was 12.47% compared to the national average, which actually rose 10.195%. So even though the national average rose, our particular IRF's RTA rate decreased. So utilizing a new consult template, the RTA rate was decreased by 4.7% with a p-value of 0.06, meaning the national RTA rate, meanwhile, the national RTA rate increased by 0.24. On the satisfaction survey, 83% of participants agreed the experimental format was more efficient and 100% of the team members felt the new format optimally identified a patient's barriers to inpatient rehab admission. So here's a pictographic illustration of the data. So you can see in the purple chart is the national RTA rate, you know, across the nation. And then our yellow there is going to be our rates between those two time periods. So the control is on the left and the experimental is on the right. And you can see a significant reduction in that return to acute rate on our end at ECU. Meanwhile, the national average rose. So just, I'm not going to belabor it, but this is just a few questions that I thought were important to include in this presentation. So, you know, I asked, do you feel the consult meeting is more efficient with the new presentation format? 67% said yes. Are you more fully informed about the patient's medical history? 83% said yes. Does the new format structure add unnecessary time to the presentation? Nobody said yes and everybody said no. Is the new format a good standard to be adopted for future consults? 100% said yes. Does the new format decrease required time to review the follow-up patient's charts after initial consults? 67% said yes. So as a resident, you know, as a physician, we tackle mostly the new consults and then, you know, the ones that we're continuing to follow for admission is for the admissions team. So some challenges encountered. So one of the things is our hospital, like, it seems like it constantly fluctuates between the, we call this red capacity and then internal disaster. So we have, like, you know, when the hospital gets full, maybe we loosen up somewhat, you know, our criteria to admit the patients to rehab. And that, for sure, I'm confident that that had to at some point kind of alter this study that I did here because, you know, it's hard to compare because if 10 weeks was during just normal, like the hospital wasn't slammed, then, you know, you compare that to when the hospital was slammed. I'm sure that data is going to look a little bit different. So I think that skewed in to some degree. So this could have, in turn, increased the, you know, the return to acutes from the inpatient rehab. And a constant changing census also. So we fluctuate too, especially when we go into these periods of internal disaster or, you know, or whatever. We went from, like, 55, we go up to 60. Sometimes we even go to 65, depending on what the hospital upstairs looks like and how we can, you know, help out the hospital and stuff. So let's see here. Let's talk about the internal disaster, yeah. So another challenge was the subjective review of the formatting changes is that, you know, the resident physician or me who conducted the study was one to distribute the questionnaire form. So I don't know, they might have answered it a certain way because I just handed them the papers, you know. So it was, in that way, I guess it was single-blinded, but, you know, it could have impacted the study as well. So next steps. I think, you know, employing this template demonstrates some increased efficiency and team satisfaction, which correlated with an improved RTA rate. Next steps include maintaining this new model with an increased look forward and look back period to assess the effectiveness of the new model. So the new standardized template has been accepted as a standard model and still is being used to date about a year later. So I think it's definitely demonstrated some success. The analysis of the RTA rate has continued to be analyzed and the results look promising. So the p-value that I had there in my data wasn't, I can't say that it is statistically significant, but it's pretty close, and I think if we had a longer period where this study was going along, I think we can prove it's not to chance, and I think we could have proved it's improved things. Yeah. All right, Dr. Zeldin. All right, I'm back. So this next part, we were looking at, so this was a QI project that we worked on trying to get patients out of the hospital at a timely hour, and we'll talk specifically about this, but the framework that I want just to talk about while this was a specific QI project looking at this specific thing, just, you know, with ABPM&R, we have a practice improvement projects we have to work on. We are all trying to constantly, hopefully make, that's why you're all in this session, to make our facilities a little bit better. So while this might not necessarily be a goal of yours specifically, hopefully some of the strategies that we implemented, you could use towards whatever the issue is at your facility, hopefully fixing it. And the main thing I want to get across in this is buy-in. This is a QI project that, as you'll see, sort of worked. We've implemented a lot of QI projects that have just disastrously failed. I'm sure everybody has been a part of those. And I think the main thing that I want to get across in the next 10 minutes or so is I think this one succeeded because we had buy-in from everyone. And we'll talk more about that as we go. So the early discharge, as Dr. Snover alluded to, as I'm sure we all aware, we're admitting more and more patients to the acute hospitals. The acute hospitals are putting pressure on us to admit more patients. And hospital capacity is becoming more and more constrained. COVID caused a lot of healthcare workers to drop out of the system. They caused healthcare budgets to be crunched. So some people didn't drop out of the system. Some people were forced out of the system. And more and more, we're operating in these internal disaster things on a random Thursday in June and not like if there's been an actual disaster going on in the hospital. So delays in discharge from our IRF or sort of at the end of the food chain can really impact everyone. So if we don't get a patient out of our hospital until 3 p.m., the acute care hospital can't get somebody to our facility until 6 p.m., which means they're occupying that acute bed, which means the ED is full of the patients who cannot be admitted to the acute. So it's a whole system that we are at one end of. And if we can get our patients out of the hospital earlier, it will help everyone significantly move along that change. And then, you know, press gaining scores are unfortunately a real thing that we have to deal with. And there has been a lot of data out there showing that when we delay discharges of patients, the press gaining scores will be worse. So that is also an important metric that gets tracked. So at ECU Health, we were pretty bad at getting patients out of the hospital by noon. 21.7% for fiscal year 23, so 80% of patients are leaving after noon, which is pretty late. And we had no idea why. We talked about it a lot as a system. We came up with a lot of ideas that patients weren't getting their equipment on time, or the physicians were doing a bad job signing the orders, or we weren't reconciling our medications quickly enough, or the pharmacist was delayed delivering them, or patients were getting too much therapy on the day of discharge scheduled in the afternoon. And everybody just sort of theorized what the problem was and sort of never really tackled it and figured out why we were having this issue. So we collected some data, and this is two months worth of data collected at everyone in our IRF, and this is obviously specific to us. If you all have this issue, you may have a completely different thing. But honestly, I thought it was DME. I just really thought that patients were not getting their wheelchairs delivered to their room in time, or their hospital beds delivered to their home, so they couldn't go home. And that was not the case. It was pretty much exclusively the fact that therapies were being scheduled on the day of discharge at noon, and patients just didn't leave because they had therapy scheduled for 1 p.m. on the day of their discharge. That was a problem. We didn't really realize it. The second problem, which was a pretty easily fixable problem, is patients' transportation, sometimes family members, sometimes ambulances or medivans or things like that, what we scheduled for them, were just being scheduled really late in the afternoon. Or the family member would show up and was like, oh yeah, I was told to come at 4 p.m. to get this patient. And obviously we didn't say that. I think we didn't say that. But this was the actual data. And knowing the data, we actually could tackle the problems. So like I was talking about a little bit before, we operate six different services at the same time. So I now am no longer with ECU Health, but at the time I was the medical director of the Traumatic Brain Injury Service. So we wanted to do an intervention on one specific service. And the advantage of our model was that I was the medical director. I am very close with our therapy director for the Traumatic Brain Injury Service. I'm very close with our nursing manager for the Traumatic Brain Injury Service. And we all got together, theorized some interventions which we'll talk about. And I think what was the important thing is there's a lot of QI projects that sort of come from above where you have this administrator who you don't even know that's like, you need to be better at this specific metric. And no one has any idea why or we don't really care or those things. And the difference I am theorizing is we sat down with basically every single member of our team multiple times and said, hey, our patients are giving us really bad satisfaction scores and leaving really late in the day, which is causing all of these problems. And this is how and why we're gonna fix it. And do you have any suggestions? And that got a lot of buy-in from our team as to how to hopefully fix the problem. And part of that was restructuring the team conferences to like actually focus on discharging rather than some of the other things we were doing at team conferences. So the intervention, we wanted to focus on each one of those problems sort of simultaneously and see if we could fix it all at once. So therapies on the day of discharge, we worked with the therapy manager and stopped scheduling patients for 2 p.m. in the afternoon. And there were two parts to this. So one, we scheduled patients early in the morning. And two, we talked to family members and sort of tried to combine this into this like nice family education piece that they would have. So, I mean, and this is something we did, but we didn't like regularly do it. So we would say, hey, patient family member, get here early in the day. We'll have your DME that you're gonna go home with. It'll be ready in the room. So instead of using that hospital walker that you rent that we've been using for 30 years, you can use your brand new shiny walker, open it up, make sure it works well and use that in our gyms and make sure it's working okay. And your family member can come and transfer and receive that education. And the nurse will come in and go over all your prescription medicines. And this will just sort of all happen in the morning on the day of discharge. So one, it did help rates. And two, we think it's better for patient care because we're actually like getting family members to have some buy-in on the last day and they can sort of see everything, which unfortunately a lot of times we were just sort of kicking patients out at the end of the day and the family members never show up for education and no one knows what's going on. And then they come to clinic two weeks later and act like, what did you teach me? So these are the interventions that we pretty much did. We worked other things I haven't talked about. We worked with the DME companies to actually store the equipment in our IRF. So there was like a closet of a bunch of wheelchairs, walkers, things like that, tub transfers that they just didn't have to like deliver it. They could just like walk down the hall and give it to patients, which helped them get it quicker. We worked with our inpatient pharmacy. So our hospital has an inpatient pharmacy that like delivers patients with a nice like goodie bag of medications as they walk out the door so they don't have to go somewhere else. We talked with them. We had prescription counseling that would happen right before they left at the end and they would actually get those meds really early in the morning. We did not touch anyone going to a SNF and we did not, because we couldn't really convince the SNFs to like take patients earlier in the day. And then we also didn't mess with anybody's hemodialysis. So these are the results. The big arrow points to where we actually did the intervention. So we collected data for three months before, three months after. And as you can see, I mean, we got from like 20% to 40%, which is statistically significant, but you know, we were still at like, despite all this, only still at 35 to 40%. So much more work to be done, but these interventions with team buy-in, I mean, the other services were at like 15 to 20% discharging on time. We were getting to like 40% with this team approach buy-in. So conclusions, it sort of worked. The important thing I think is like I've been harping on, it was a multidisciplinary approach with a lot of buy-in. The amount of projects I've worked on that management knows something and the people that actually do the work on the ground have no idea what's going on or why we're doing things just leads to failure. And I think just we tried to involve everyone, which I think is why this project mostly worked. So yeah, next steps. If I didn't leave the institution, we'd be continuing to work on that. I hope that it's continuing to work on, but I have taken another job. Anyway, I'm gonna introduce Dr. Foster, who's our next speaker. Thank you. Good morning, everyone. I'm Keith Foster. I'm the Chief Medical Officer of Baptist Health Bethesda Hospital East and West in South Florida. I had the fine ability to work with these young men at East Carolina University where I trained. It's nice to see that some of the same problems I worked on and some of the same research projects we did are still going on. We started the original return to the acute care hospital study back in 2010. Mostly because we were residents and we were sick of admitting patients late at night. We thought it would be funny to see if we could see if there's a correlation between patients bouncing back and we did. And some of these problems still exist. I bring that up because I think, as we talk about the physiatrist as the physician executive and shifting gears a little bit, and Dr. Falk, who couldn't be here, will talk more about the medical directorship. Really looking at these problems and talking and involving the whole team is really what makes us the best physician executive. What other specialty do you know will sit down with a nurse, sit down with a therapist and say, hey, what's wrong? What's the issue? How do we work together and fix it? So I think, in the last talk was about outside non-clinical careers. That's where the physiatrist really shines in teamwork. So we'll talk a little about that. So we have our, talking about the physician executive track, the important of growth opportunities, highlights of physiatry in the C-suite. So I oftentimes get asked, did I get lost? I was a rehab resident. I went on, I did my chief residency and then I actually got my MBA during my residency, mostly because I came from a household that didn't have any money and I had no idea how to manage money. So I was coming into a job as a physician that would certainly put me in a significant bracket change from my family. And I said, gee, I need to learn how to manage money, how to save, how to be a better steward of money. Really liked it. Liked the idea that I was thinking a different way. Liked the idea of really thinking outside the box, learning about money, how important healthcare money was. I had a mentor early on. He used to tell me, no money, no mission. So it was an important piece. You can't ask for things if you're not making money. And then I went on to get my certified physician executive degree course, which is offered by the AAPL, which is a physician leadership group. Really valuable capstone to everything that they had going on. They offer a lot of courses about healthcare finance, healthcare business. And then I went on to get a fellowship in the ACHE, which is American College of Healthcare Executives. It's interesting, that's mostly non-physicians in that group. So it's a nice networking opportunity and you learn a lot from those people. And that was a fun course and actually a very difficult test. Little about me, I started in private practice working for a group that rhymes with U.S. Physiatry for about a year. Had a great time, learned a lot about management, about flow, about how to grow a practice, working mostly at that time in the skilled nursing model. So I learned a lot about post-acute care. South Florida is an interesting post-acute care model. There's a lot of stuff that's very different than the rest of the country. Where I trained in East Carolina, we had some really great nursing homes actually that we rounded in and actually did some great work. South Florida's kind of a mixed bag. At that point, I had a chance to join an employed physician practice, a large hospital system. It was a great opportunity. One of my mentors is sitting in the audience today. I came on board and quickly moved up to the Associate Medical Director of Rehab Services for inpatient and outpatient, and also became the Director of Research there. During that time, I definitely saw a need for us as physiatrists to really get involved in the entire continuum of care. I really inserted myself in a lot of community projects, working with the acute care, working with the ED, how do we move patients quicker, focusing a lot on patient flow. And then we were lucky to be a part of a very large division of neuroscience that really was involved in a lot of hospital associations and hospital committee meetings and everything else. After about six years there, I had an opportunity to join the other public healthcare system in the area as the Chief Medical Officer of the Level II Trauma Centers, a 409-bed hospital with an acute care rehab hospital inside of it. So everywhere I've gone, I've made sure I still have some rehab roots. I think it's really important. One, from a personal standpoint, I'm still a physiatrist. I like to make sure I'm still a physiatrist. But also, it helps to be in a healthcare system that at least knows that you kind of exist. It's already hard enough to tell people what you are as a physiatrist. If you have to start from ground zero, it makes it a lot harder. I left that job about a year ago and joined another neighboring healthcare system. And now with Baptist Health, I'm the Chief Medical Officer of Bethesda East and West, the two hospitals up there. Baptist Health is a 12-hospital healthcare system in South Florida that has basically everything except trauma in our healthcare system. So the physician executive, when you look at the role, there's all sorts of different roles. And the group before me talked a lot about, in the last lecture, about non-clinical jobs. For us, I still consider these clinical jobs. You may not be actively caring for patients, but you're definitely involved in the day-to-day of a hospital. I've always tried to stay involved in a hospital. That's kind of where I like to be. There were certain opportunities that were offered to me, either to work remote or work for an insurance company or work for other people, and it never really fit my personality. But the physician advisor role, which was briefly talked about, really overall responsible for all length of stay in the acute care hospital, highly trained in criteria for observation versus inpatient admissions, which is really, from my standpoint, a made-up conversation that insurances like to pay at different levels based on the patient sleeping in the hospital. But it's super important to the hospital in terms of money and finances. After about 48 hours, if you're an observation patient, the hospital's not making any money. They're losing money. So getting those patients into the appropriate status. For the physician advisor role, physiatry is very rarely a physician advisor. Usually, I had some jobs that I applied for, they wouldn't even consider me because I wasn't an internist and I wasn't a surgeon. So what could you know about patient flow and continuity of care? But as physiatry, we spend our entire lives building medical complexity, right? That's what we do every day. So no one knows how sick a patient is better than the physiatrist and pulling in the anemia is still going on and it looks like they're at high risk for other problems or there's a PE, how do we document that? So I found the physician advisor type role, one that physiatry can really excel at. The chief medical officer role, it's really, every day is a little different. You're basically a chameleon. You're in the C-suite of the hospital. Technically, you're overall physician-related information, medical staff, voluntary, and I call voluntary medical staff your community physicians and then employed physicians. I guess they're kind of non-voluntary, I don't know. So you're over quality, safety, and patient experience, physician growth, and strategy, and you're really the physician voice inside administration. My mentor always told me the CFO's job is to worry about the money. The CNO is to worry about the nurses. The CEO has to make sure the lights are on and everything's going on. You have to worry about the patients. That's your job as CMO, and I take that very seriously, and then I also work on making sure that I'm telling the C-suite what physicians need. Oftentimes, physicians go about their day and they complain about stuff and it never really bubbles to the top. So simple things like EMR not working, IT problems, that's a lot of what I do right now is we're going through a conversion in different EMR, but making sure that voice is really heard. I am a firm believer that physicians have to be advocates in healthcare, and if we don't continue to grow in these physician executive roles, healthcare's not gonna look anything like it should in terms of being able to care for patients, especially as more venture capital firms and other teams take over. Academic leadership is another realm where you can be. DIOs, if you're into academics, you can be over all the different GME programs. I've had the opportunity to be able to open and grow new programs every place I've been. It's fun, it's exciting to see the residents come and do things and grow, and it's also important as we look at a physician shortage, so having that role. And then actually where I'm at at Florida Atlantic University, which we're partners with, the dean's a physiatrist. And he got promoted to dean a couple months ago and I called him, I said, hey, I think you may be the only physiatrist who's a dean across the country. And he's like, I don't know, I thought there was one, we looked, and he's the only dean physiatrist. But his ability to really cross different aisles to talk to different specialties, I think where all of these roles really play a part in physiatry excels. So like I said, looking at what the qualities of a good physician executive should be, you really have to be a team player across multiple hospitals and employees. So when you're looking at nursing, therapy, case management, well that sounds just like a physiatrist. Understanding of patient flow across the continuum, we just heard an hour lecture talking about patient flow and the problems these young gentlemen are having with patient flow and getting early discharges and moving people through the system are the same problems I have as CMO. Talking to my doctor about, hey, can you put the orders in before 12? And then talking to families, do we need a discharge lounge? How do we get these people out? How do we safely have nursing care for them and go over their medications before they leave? Same problems I have every day now. You have to have a broad understanding of healthcare, including surgical subspecialties. And again, who better to understand what happens to the neurosurgical patient and what their recovery is gonna look like other than a physiatrist? We deal with those patients every day or the orthopedic patients. And then the ability to problem solve. I don't think anyone's better at problem solving and thinking outside the box than physiatrists, right? We have a chance to take a step back in our clinical practice and look at the whole picture. If you're a pain management doc, you're not just worried about doing an L4 injection, you're really looking at the mechanics of what's going on with that patient. I think I do the same thing as a physician executive. I take a step back and look at what is the whole problem? It's not just one little thing. And then most physiatrists are cool, calm, and collective. I think that's an important part of the physician executive role. It's very easy to get frustrated. It's very easy to wanna fix problems the second they come up. I think being able to look at things a little bit calmer helps, especially with people like surgeons throwing scalpels in the OR and taking a step back, things like that, which has happened. Opportunities and mentorship. So I think that's really, when you talk about making that transition over from, Dr. Falk will talk a little on audio about the medical directorship for rehab, making that jump into the physician executive role, mentorship is the key. You have to be able to have people who've been through this process. When I was the associate medical director, my medical director had a great opportunity to help me and teach me about what it meant to be a medical director. And then when I was involved in other care, moving up in the CMO role, I had a chance, our system CMO was a really fantastic mentor for me. He had done the role multiple times and really took me under his wing and took a shot on me as someone who had no CMO experience. So I would say to reach out to your local CMOs and hospital leadership, I think you have to be a sponge and learn from the CFO, learn from the COO about what their day is like, learn from the other nursing directors and service line leaders about what they're dealing with and what they're doing. And then hospital-based committees. I always give this advice because I think it's so important for us as physiatrists, if you're gonna make that jump, is to really integrate yourself in the acute care hospital. You don't wanna be pigeonholed as just the rehab doctor. You really wanna be involved in peer review and credentials, which in my opinion, are the two most important committees in the hospital. Credentials is so important to make sure the people coming on staff have the right credentials and you're giving them the right credentials and not giving them the ones they shouldn't have, especially as we get into such subspecialty training now and people should be doing things they're credentialed to do. Peer review, the purpose is really to educate, but oftentimes it's about protecting patients from things that are happening, trends that are going on that may not be what you want them to be. Quality, so starting with quality projects like this, looking at returns to acute, such an important piece of the puzzle, returns to acute are such a high, important process in the hospital and we get penalized as a hospital, no one wins, the patient doesn't win. So starting with projects like that, showing that you understand a little bigger piece of the continuum is so important. And then department meetings, physiatry kind of floats between different departments depending on which hospital system you're in. Sometimes it's neuroscience, sometimes it's neurology, sometimes it's medicine, sometimes it's not anywhere. Trying to make sure you're present in those department meetings, seeing if you can be a part of that leadership, trying to get into those positions, just sitting at the table with people explaining what you do and just helping them problem solve. And like I said, getting out of the physiatry space is so important. You really wanna try to remove that label of post-acute care to really whole hospital understanding. The hospital-wide committees, like I said, the mentorship is huge. The advanced training, I always go back and forth. I really enjoyed my MBA. I think it's an important piece. It definitely opened doors quicker for me, younger than maybe other people would have had that opportunity. I don't think it's absolutely necessary. I teach to the med students about the same thing in the business of medicine. I tell them that your most important degree is your MD. That doesn't matter what else you have. That's the hardest degree you can ever get and it's the most important degree you'll ever have. And no one will be able to replicate that no matter how many other degrees they have after their name. So making sure that you have those other degrees is nice. It's not a necessity. The CPE and AC, there's a whole other bunch of alphabet soup you can collect after your name. I think it's about just being involved in other processes and really networking, I think, is the key. With the ACHE, the degree was nice, the test was hard, like I said, but it was more about networking. I was able to find my most recent job purely through networking. And I found with many of these jobs, they're advertised, but they're not advertised. They're often spoken for before. They're advertised, so being involved in those conversations early is so important and letting people know, hey, I'm looking for a new opportunity. What does your health system have or what are you doing? That's very important. So I will allow us to put on our audio for Dr. Falk, who's another one of my mentors, has been a great leader for me throughout my career and now in his job as chairman of the department, has done a fantastic job. So good of a job that he had to work this weekend because it was so busy, but he's gonna present to us via audio. Hi, good morning. My name is Dr. Clinton Falk. I'm here to present with my group this morning. Thank you for this opportunity to present at the 2023 AAPMNR Conference. I'm here to talk about how to be a successful inpatient medical director. My background includes being the chair and medical director, along with being the Red Sea Training Program Director. We will start with the objectives of this discussion. The first is the academic leadership trajectory. Second is navigating leadership within a major healthcare system. And third is the challenges and successes as a medical director. Academic leadership trajectory. This can take many different forms and paths in becoming a medical director. The ones listed on the screen are just a few that I participated in during my time. And I think they all definitely shaped me becoming a medical director, helping to really know what it is to be a resident in a program that you're serving in. Know what it means to be an inpatient provider on the inpatient units that you're being a medical director of. And then also being highly involved in the medical students and the Red Sea Training Program, I think are very essential because you need to be able to lead not just your nurses and therapists and your physician group, but also your resident physicians too. Also important is that I was the department vice chairman. It gave me a chance to be mentored under the current chairman at that time, which then helped me branch into being not just the medical director, but also the chair and chief of service. So the rehab medical director reporting structure. This can be different at different places that you may work. For me, my team includes the senior administrator for the rehab hospital services, the senior vice president for the allied health system who reports to the office of the president of the hospital, and the attending physicians, which are the faculty members of our department. Your team may be different at different places you are, but it's important to identify your reporting structure, not just for your own benefit, but also to those you serve. These people I work with here are very helpful for me to be successful. We don't report to one another. However, we have a dotted line, as you might say, and we meet very frequently, usually at least once a week, to go over the strategic planning for the inpatient rehab hospital. So then you may say, how is this different compared to the chair or chief of service? These things I also participate in. The executive dean of the medical school and the senior vice president for medical affairs are somebody that I meet with frequently and shows you who they report to. So again, a different reporting structure. All of them are very important in your success as a medical director. However, your team, you need to make sure you establish who you report to and who you need to meet with regularly to be successful. Medical director duties can be a lot. As you can see, some of them listed here are rehab leadership meetings, co-managing with rehab leadership in the operational decisions, obviously things that you are very familiar with, length of stay, case mix index, return to acute, the 60% rule, safety events, but also things you may not think of too often but may be coming more on the radar where you are. They definitely are for me, is our emergency department patient workflow, for patient flow that is. So it's important for length of stay to be monitored closely. However, if the emergency department is full, which ours often is, and there's a delay in length of stay for reasons that could be adjusted to some degree in the main hospital and the rehab hospital, this will affect the flow of patients through the whole center. So even though we're at different spectrums compared to rehab and the emergency department, we still work very closely and what each of us do affects the other one very directly as well. So it's important you keep all these type of metrics in front of your team on a regular basis, including the emergency flow of patients and the backlog that may be there. Because again, even though you may be a rehab hospital that's attached or detached, you're still a part of the same system and your goal is to help patients throughout the whole system every day. Other things that may be affected are things such as cardiac monitors. We added those this year to our inpatient rehab center and although it caused some stress on the front end, it has proven to be a very beneficial thing for our inpatient rehab center and managing patients more appropriately and more effectively. You also need to attend patient and family patient complaints or concerns. These are things that I will do regularly with my rehab administrator dyad partner. Many times these complaints or concerns will first go to the medical director of the unit and nurse manager. However, there are times where the patients are asking for the medical director or administrator to come listen to them, hear their concerns, and then act on things that are more appropriate to make their patient care stay successful. You also need to meet with your rehab leaders regularly. These include your program managers or nurse managers to regard staffing, patient care, resident issues, therapy hours, multiple things. I do this on a weekly to monthly basis to make sure I understand what's going on on the inpatient floor at all times. Other medical director duties include managing people. This can be challenging. Probably the most challenging thing that you will do as a medical director is managing people that you serve. So, the attending physicians, resident physicians, nurses, staff, therapists, we all may have different ways to get to the same goal and this sometimes can lead to disruptions in the workplace and sometimes will take the most time of your day. It can be very unpredictable. However, it's important that you take these things head on, listen to them, provide action plans and ways to improve not just their goals but the patient care goals and the goals of your rehab center. Managing relationships. This includes not just within the rehab center but going beyond. Hospital services, providers, medical directors, they need to understand what your bed capacity, what your length of stay, what your barriers are to get patients into rehab, whether it's insurance reasons and barriers to get patients out of rehab, which could be different reasons as well that they may not be familiar with but if you communicate those more effectively, they will have a better understanding as to what your challenges may be. Public relations for the rehab center, also important. Your outside hospital referrals are necessary for you to keep those communication lines open and to make sure those patients have access to your great quality of care in your rehab center. Mentorship. Resources are extremely important. Your university, medical school and or hospital should have a long list of resources for mentoring, not just your resident physicians, which is important as they are the next leaders, but your junior faculty, even mid-career and senior faculty to mentor people as they get closer to the end of their careers. You need to always be thinking who is your next leader to take over your position. It's not a comfortable thought or decision to make but you should always prepare as to who can take over your position if you are no longer there. The success of a medical director can be a lot of qualities that apply to this. Articulation of your plan clearly. It's easy to think in your mind what you want to do and maybe you told a person or two, but it's important that you get out front of your team on a regular basis and articulate your plan clearly. Well, that's all we have. So yeah, thank you. Thank you all for coming. We finished up a little early. If anyone wants to head out to lunch, if not, we're going to stay for questions if anyone I have a question about, I guess it involves all three of you really, the return to acute hospital issue. We specifically actually had an anemia issue in a 20-bed kind of small community educational hospital system and had seven patients return to the acute hospital in a three-month span of time with severe GI bleeds on Eliquis. So we've elevated that to our risk management, but as we got more careful about making sure that those patients were optimized, got a lot of pushback from case management, from administration on length of stay. And so there are other acute rehabs in the area that will accept the patient sometimes whether they should or not. And so how do we explain that to administration that we're trying to do what's in the best interest of the patient? How do you monetize that with the issues when they return to acute? Yeah. So that's obviously really tricky. I mean, where I was at before we, at ECU, we didn't really have that competition. Does this work? Yeah. I think this works. Anyway, we didn't really have that competition issue where we had multiple IRFs. Now at the University of Cincinnati where I'm at, there's like, I don't know, 50 IRFs in Cincinnati. So it's, like you said, a little bit of a, if you don't take them, somebody else will. And that's a big problem. And so that's not necessarily something I talked about, but that's a hard discussion to have as to if you have those patients that somebody else will take, should you take them first? And I don't know the answer to that. I mean, I think where it comes down to is we have, you know, we've had plenty of patients who have GI bleeds. What I was talking about earlier is at least in the data we have so far, if they're anemic prior to coming to the hospital, that doesn't seem to correspond with a return to acute read. The amount of patients I've had that I've had GI bleeds on Eliquis or something, or, you know, we all have those patients. But yeah, how to, I think it's working with administrators and hopefully at least what I would take away is if you know that there are specific patient populations that are more likely to return to acute, just maybe approaching them and say like, hey, it's going to be bad for the hospital. The hospital's going to get dinged if we keep transferring these patients back and forth. This specific patient for this specific reason is why I'm not admitting them. But if I have data that says that maybe I shouldn't be as worried about this specific patient population, you can be a little bit more aggressive sometimes, and that way you're not that person that's like, oh, I'm never going to admit anyone to rehab because everybody's too sick. You say, no, I can hopefully know by evidence-based medicine that this sick group is sick, but they're likely to do well in inpatient rehab. And this sick group is sick and not likely to do well in inpatient rehab and hopefully having that conversation. Yeah. I mean, I'll piggyback on that too. I think so much of it is relationship, you know, where I was before and everywhere I've been. If you denied a patient, you had to call the physician, physician to physician. I think, you know, as a rehab physician for you to turn to a board certified internist and say, hey, your patient's not stable when they have a discharge order in, I think that's a conversation you have to have and have a normal conversation, physician to physician, and see what you're concerned about, see what they're concerned about. I also think as we really try to do more work around justifying the need for inpatient rehab, we have to get a little uncomfortable with some of these numbers to bring these people to rehab and manage. Maybe it's having, you know, HEMONC or GI follow with you in the inpatient rehab. It's obviously a lot easier if you're attached, and it obviously becomes a catastrophe if you're not attached. But I also think falling on your medical knowledge and helping to improve their understanding of what you need. When you talk about case management and some hospitalists, many of them have never stepped foot in a rehab, never mind a sniff or anything. So trying to teach them about what you do, what you need, why it's important these patients are stable is really important. Thanks. Just a quick question. With your second lecture and your research study that you were kind of talking about, but also both of your guys' studies, did that change in your consult service affect acute hospital length of stay? Did it change? That's one question. So the thing is, did it get to rehab sooner or later or no change in case management, you know, wasn't concerned too much about it? And did it increase or decrease the amount of consults you do per day? And on average, how many consults were you doing per day when you were kind of going through the study? Okay. So that's my first question as far as it pertains to, what was the first question? Oh, length of stay. That's not something, I'm juggling all these questions in my mind. I actually had something I didn't look at in the study. You know, I think it would have been good to look at the length of stay. And I would propose, I at least think that maybe it affects it, but I cannot say for sure. What was the question again? How many consults? Oh, consults a day. No, I would do more than that. 12.8. Yeah. I don't know. It's hard to say. It kind of fluctuates depending on the time, but, you know, I would say any, probably between 12 and 16. It's 12.8. It was 12.8. Exactly. It's a pretty busy consult service at a level one trauma center. It is. Yeah. And, sorry, I'm trying to keep it all straight. What was the third one again? Yeah. So, you know, I practiced in a large standalone and now run the small attached rehab unit. I think the biggest challenge with a lot of the standalones is the lack of support services, consultants and whatnot. Yeah. And a way we found to bridge a lot of that was either telemedicine or just phone communication. Have you guys done any research on that as far as, you know, preventing transfer, reducing length of stay? No, I haven't. I mean, we did this at an attached hospital, and like you said, I trained at an attached hospital. We were like, you know, 400 feet away from the ICU. If somebody coded, like, the ICU team was there in five minutes. I was ACLS certified. Like, we had that. I now, at the University of Cincinnati, we're detached. We have minimal support. We do have help. But, yeah, we don't have those. And telemedicine is actually really interesting in that space. I was actually going to look into trying that. I haven't done any research, but that was sort of something in the back of my mind that we're going to hopefully try to start implementing soon. I don't know if you've had any experience with that. Yeah. I mean, I think it's a great idea because especially when you have low volume, you're going to have a hard time grabbing these specialists. I have a hard time getting them now in the acute hospital just because it's much more profitable for them to stay in their office. People like GI, hemong, things like that, to come and do one consult ruins their whole day. We just started telepsychiatry where I was, and I have to be honest with you, I was really against it because I just feel like we're in a very nice area. We're not in, no offense to, like, middle Idaho, but we're next to, like, 15 other acute care hospitals. How do we not have a psychiatrist? But then you realize for them to come do a consult for a Baker Act on an uninsured patient and make no money versus all cash pay business in their office that's three months booked out. There's never enough money I can pay to offset that. So I think we're going to have to look at more things like that. I think small standalone rehabs, that's the only way they're going to survive is to at least have that phone consultation or a telemedicine visit to kind of help give you guidance. And I also think having a strong hospitalist is really helpful who understands your need. Where I was before, we had basically one hospitalist that was with us that rounded on all of our rehab patients and knew who could do therapy, who couldn't, who was too sick, who was circling the drain. And that helped a lot. Yeah. I think personally I've seen a lot of the specialists at the hospitals they come from, they don't want you to send them back to the ER. If you just call them, they'll give you the opinion there. Whatever they want you to do over the phone, just to avoid having readmitted or not. So communication is a key factor. Absolutely. Yeah. But I agree if there's even a further way, because like we operate financially, if there's a way to financially incentivize that person. I mean, if they're rendering medical services, they should bill further. I mean, when I have a consult, I don't like putting in, what do we call the informal consult thing? Curbside? Curbside. Yeah. I don't curbside consults. If I give medical opinions, I document it and try to bill for my services. So if there's a way that we can create a telemedicine model so they can bill for their services, I think it'll cause people to actually want to do consults. Great talk, guys. Wonderful. So, Dr. Foster, you really did a very nice look at progression to medical executive. A lot of people think about it and they, as you said, do I get an MBA, not get an MBA? I think, could you comment on some of the support you got from different organizations to help get those degrees, because I don't think a lot of people realize they can pursue that avenue. Yeah, absolutely. Of course, one of them was yours, and he was my medical director when I got my CPE, so that helps. But even in residency, I was at a large university, so I went and I was able to get my MBA almost free, which was fantastic. So reaching out, even if you're an adjunct faculty at a medical school, things like that, you never know what's available. So reaching out and doing that is really helpful. You know, look, none of us can survive without the support of others around us. You just have to start asking, you know, and letting people know what you're doing and what you're thinking. Obviously, being careful, you don't want to tell your current employer, I'm out, I'm looking for a way out, but how do you grow together? And you know, we were at a very supportive institution that understood that physician growth was system growth, and the more that we, you know, pay attention to our physicians and help home grow them, the more we're going to have long-term leadership. Hi, I want to compliment you all on great talks as well. So some, there are some models out there where the hospitalist is admitting to the IRF, and then the physiatrist becomes the consultant. So I wanted to see if you have some comments related to that. Is it good? Is it bad? Do we lose some autonomy here? So if you could, I know these systems are around. Yeah, I, I'm definitely biased. I've always been the attending on my case. And I think, you know, as physiatrists, and we look at scope creep, even just from therapists wanting to be the admitting attendings, you know, there's, there's a lot of crazy stuff out there. I think it's super important for us to keep that autonomy. I think, you know, no one can help better direct the totality of care, which is what you're doing as an attending than the rehab doctor. And to have a lot of systems do have internists admit, and then rehab as a consultant. I think we're, we're really shooting ourselves in the foot long term, you know, because eventually it's going to be, well, maybe we don't need the consult on this simple stroke patient. There's nothing the physiatrist is doing. They're just, they're ordering therapeutically. Yeah, that's a risk for sure. Yeah, absolutely. But on the other side of the coin is that you're not getting called for, you know, chest pain in the middle of the night, the hospitalist is, right? And they may be able to deal with that a little bit better than, and sometimes as physiatrists, maybe we're reluctant to reach out to the, if we get that call at 3 a.m., are we a little reluctant to reach out to the hospitalist or can we even get them if they're not as, you know, on the case, you know, for example. Absolutely. And I think that starts with collaboration. That's why I've always found that having a hospitalist that understands rehab is so important. You're not getting a hired gun to come in and just adjust antihypertensive. They really understand that, gee, we got to make sure this patient does therapy. And that partnership is so important. And then they're the ones answering the 2 a.m. chest pain. So that's also very helpful. Yeah. Or you can get residents that answer that first patient. That's always helpful too. Yeah. I have residents now. It's great. But no, I mean, the worry is, I think that as hospitals are crunching numbers, it's, are we still relevant in the system if you have somebody who's primary and we're on top of that? I think, and I don't know if there's any data, and I know AAPMNR is working on defending the role of the physiatrist, which is why we should all continue to pay dues for this organization. But I worry that if we get a little bit into the mindset, I don't want to be called in the middle of the night. Like, I don't want, no one wants to be called in the middle of the night. But if you start, we start saying as a specialty that we're a 9 to 5 specialty or even less than that, then they might replace us with internists, non-physician practitioners who are willing to do those things. Of course. Yeah. Yeah. The thing is though, you know, if we're called and no one's to get called at 2 in the morning, but if you are called at 2 in the morning, what's going to be your decision tree on a complex medical patient? Sure. Yeah. And I think, you know, I, there's nothing I hated. There's only one thing I hated than being more than being woken up at 2 a.m. was walking in at 7 a.m. and found out my patient wasn't there and I didn't know about it. Right. So I think there has to be some ownership in your patient if you want to continue to manage your patient. Right. Yeah. That's the thing. I was, I was telling these guys and I've talked to other people before. I went through like three years of residency without realizing you had to call the attending when you transferred someone. And then my attending one day got really mad. He's like, why didn't you call me? I'm like, I didn't know I had to call you. He's like, of course you have to call me. I'm the attending. You transferred someone without letting me know. So I think there's got to be that ownership. You have to be, you know, aware. So. Yeah. Thank you. Yeah. Yeah. As long as you define your value, I think that's the important part. Absolutely. As long as if you're the consultant, they know why you're there and why you're important. No, I'm not collecting data on it. Yes, it's a problem. It's something that we should look at, but I don't have a good answer to your question of how to fix that particular issue. Ampra and AAP Menard did a look at some of it. I think it was like the average was three and a half days delayed for patients that purely met inpatient rehab. We're not even talking about borderline. We're talking about, you know, they're totally dependent. I am a big fan, you know, of consults being really, helping value our patients in our field and having the ability to do consults on the acute care setting and write that physiatry note to fight the insurance. The reality is that they're getting worse and worse about denying very appropriate patients. I was on a call with Humana state leadership last week, and the guy who's the regional medical director said, well, we all know there's no value in rehab for patients after 85. Looked me square in the eye. By the way, he was a geriatrician. So that's what we're battling. I think the peer-to-peer, it's so important that if you can try to work with your hospitalist, I know it's a pain in the butt. I do it for inpatient versus ops. I do it for acute rehab versus not. We have to be able to say those things that are so important, that, hey, this stroke patient is gonna benefit, and they're gonna go home, and here's what I'm doing. You can't just call and say, hey, they need rehab. You really have to justify why, and hospitals can't do that. They really can't. It's not in their DNA to talk about what they're doing. They're just saying, well, I saw the therapist wrote acute rehab, so I wrote an order to acute rehab, and they're not able to fight that fight. So one thing I will say, I think, what we can improve upon is how we build our case for patients that, when we consult on them, we can build our case by improving our documentation to kind of support why that insurance company should bring our patient down. Because a lot of times, like I've done the peer-to-peers as well, and they ask me, and they go, oh, based on so-and-so's documentation, they said this, this, and this, and I'm like, well, actually, the patient's this, this, and this, and they say, oh, okay, and then it's, I've had cases where it's been overturned that way, so I do think that's one thing we can probably clean up on our end that would strengthen our case for why a patient should come down. Thank you, that was a very insightful presentation. For Dr. Foster, you're a physiatrist first, as you mentioned. Yes. Do you still practice? So, in my current job, I switched about 10 months ago. In my last job, I was doing consults, mostly with the trauma team. I had private practitioner rehab docs, so I did all the uninsured trauma patients, because it didn't make a difference for me, and it helped them out a lot. In my current role, the job where I'm at hasn't been able to figure out how I can be an administrator and a doctor at the same time. I definitely still want to. I think it's really important. Personally, I feel like if I left clinical medicine, it would leave a huge part of me behind. But I also think, I think the last class talked a little bit about the importance of being relevant. You can't really talk to physicians if you're not still a physician. A lot of the guys at my current job joke, well, you're just a suit. You don't want to get that. You really want to be down in the trenches, working with the team, knowing what their struggle is. A lot of the issues we deal with are EMR-related as physicians, and knowing what the click fatigue is, how to remove it, that's really helpful. But yeah, I do plan on still doing, I did mostly inpatient anyway, so in a way, it's kind of easier for me. I don't have to block off time for a clinic. I can round, do some consults. So once we get that kink worked out, we'll figure it out. Okay. So the second part of that question is, right, you want to maintain that street cred, right? So that the docs know. Especially if you have a rehab unit within your hospital, what recommendations do you have so that you kind of maintain the optics of, there isn't any type of nepotism, conflict of interest, especially because if you're CMO, you've got other authorities to deal with. Yeah, I liked the consult role because there was very little question about who was benefiting, right? It was really just the patient, you know? And I would flat out say, oh, this patient's more appropriate for SNF. And I could always point to the fact that I was really deciding a level of care more than really moving bias one way or another, helping fill my rehab with inappropriate patients. And me not following them, I think, helped a little bit too because it wasn't like I was benefiting myself. And you know, I was paid salary anyway, so it wasn't like I was billing separately. But I think you do have to be careful. And I think outpatient helps a little more in that role because there's very little bias that people can see that you're moving people to your benefit. But I just have never really enjoyed the outpatient clinic, so I've made most of my work on the inpatient side. Thank you. Yeah, absolutely. I was just curious with your consult service, if you're getting consults early on before they have that discharge return. Because I find that our facility, a lot of times, our assistant facilities, it's, oh, there's a discharge order, they send a referral, and then they're like, what do you mean we have to wait two, three days? So I was just curious what the timeline is for your facility, and then how you suggest we attack that barrier going forward. Yeah, so we get consults a lot of times almost immediately because we're attached, at ECU, we're attached to the acute hospital. So a lot of times a patient will come in with a stroke, and sometimes we get the consult before the MRI's even there. And it's like part of their order set, and well before that, we're like, week so that they consult us. Those recommendations are like impossible to do. I mean, that's a better timeline than getting it the day of discharge order, so I'd rather have that problem. It was the opposite where we were in Florida. I mean, a lot of the times we were really educating people that we weren't just a dispo, and how do we really help? And I think a lot of it's education. I do a lot of lectures to the case managers on what's appropriate for inpatient rehab, what is inpatient rehab. At one point, I was actually just taking a bus and touring them of our inpatient rehab units so they knew, so that's one way, especially with the hospitals and the case managers. We have built some different alerts in the EMRs in the past about people that I think ECU really works on that very well in Epic, that a patient comes in with a stroke diagnosis, there's a pop-up that says this patient may benefit from inpatient rehab or post-acute care, but it is important that we try to get involved early because I think there are a lot of people that if you had some time to adjust meds or get them more out of bed or work with therapy, you would have a better chance. I think with the stroke teams, it really lends itself to, they're a little more open to that, having you involve stroke and trauma are really the two that I think integrating and rounding with those teams. I used to round with the trauma team on every patient, starting in the ICU, so there were people tubed and sedated that I was like, that guy's gonna be fine for rehab in like three days, and that's important if you have the ability to build that relationship. Thank you, appreciate it. You're welcome. Just one per session, yeah. Only one question, I'm sorry. It's relevant to the question that was just asked. So one of the things is you can embed a consult in some of the power plans for the, like stroke, brain injury, major spine surgery. You can embed the consult. The other thing you could do, depending on your EMR, is you could list the 10 major diagnoses that you would want to be consulted on, and then it could pop up as a cue for that attending physician to say, this patient may benefit from a rehab consult. Would you want to put one in? You could try that. I'm trying to develop a consult service now in our hospital system, and these are things we're looking at. Yeah, I mean, I think for us, coming from a system that had a very robust consult system to now being in a system that has a not very robust consult system that we're working on developing, the things that were the most successful were having the therapists themselves put in the consults if it was a disposition thing. So a lot of times people were getting missed in the system, and it was the attending physician has to sign off on them. They can put the order, it goes in the queue, then the primary can sign off on them. But if they're writing acute inpatient rehab, then that's a sort of a cue to let them know. But also order sets, like you said. If somebody's, the acute stroke order set has CT head, MRI, anticoagulation, aspirin, inpatient rehab consult. And those were the two most successful things we've done to growing the service. And case management, too. Aligning yourself with case management. They drive a lot of what goes on. Absolutely. If you can get to them early, because they want to get their length of stay down. So if you can really work with them as a team. Yeah, no, like, oh, sorry. No, I was just gonna, I mean, you know, it goes back to proving your value and telling people what you do. We know that what we do for patients is great. You want to try to get over that hump of, this is gonna be a delay in my discharge. I hear that all the time. Well, I'm not gonna consult rehab because it's gonna take three days to get the op from a company that rhymes with Humana or others, right? So, but you have, and what I tell the therapists and the hospitalists is, listen, not every patient's gonna be appropriate. And I'm not asking you to delay discharge for every patient. Pick the two or three a week that you're willing to fight for. That you're willing to go peer to peer. The one that has a supportive family. The one that was independent before. And we'll fight together. You can't fight for every patient now. That's just unfortunately the world we live in. And I just brought on two inpatient doctors in a hospital system that did not have a robust consult system. And so we're going service to service and educating. Saying, can we speak at your monthly meeting? Can we give you some PowerPoints that would be relevant so your team understands when to consult us? So we're going service by service. Yeah, and I think it's important too to find out what the barriers to consult are. I've been in places where the hospitalists are graded on their number of consults per case. So, I think knowing that before you get there is important. And kind of triaging which patient really needs one and all that. And we drive the two issues. Length of stay and avoidance of complications as a main driving force for consult. 100%, absolutely. And you know, honestly, after almost completing residency, I can tell you that I think the ideal thing would be if we got consulted early on. I think it could be good because then we can manage some of the things like agitation for TBI patients and spasticity management. I mean, so many people don't really know what PM&R does. And I think that's one of the problems, the barrier in terms of what our field is. I think we can play a large role early on in a patient's hospital admission. And honestly, I think that's the best because we could follow them through. And then if we think that they're medically and functionally appropriate for inpatient rehab, that would be the best. But honestly, I know that's not always feasible. And you know, but I think that would be the ideal scenario. I think it builds your outpatient too, right? How many of these patients just go to rehab versus how many go home? And you're still at least involved in their care. We have a lot of very high functioning strokes now with thrombectomy treatment that aren't coming to rehab, but it doesn't mean they don't need a physiatrist. None of the primaries in the community know how to oversee this care. So if you're building your continuity of clinic and everything else, you have a chance to get involved in those patients and capture them early on. Hey guys, this is a lovely talk and thank you very much. I am a private practice physiatrist and I'm at an acute rehab that's unaffiliated with hospital systems. And a lot of the barriers that I've had, like this talk has been wonderful and I'm just like, well, there's a giant moat. So my question is directed more towards the CMO side of things is for hospital systems that aren't affiliated with, you know, whether it's an academic center or something like that, how are, what are some ways of getting your foot into the door and offering these things? Because that's my issue is access. I mean, it's always easier physician to physician because, you know, you want to capture that doc that has some experience with rehab, whether they trained at a place that had rehab or not, you know, talking to the hospitalists, you know, a lot of times they're just so busy, but it still helps to just talk and like any, anything you're building a consult service, sometimes it's taking people out for drinks, taking them out to dinner to talk and just say, hey, you know, what do you, what do you think? What are you seeing? What can I help with? Here's what I do. You know, it doesn't mean it has to always be a consult. Can I help you with stuff outpatient? You know, are you having trouble with strokes coming back to the ER or amputees? What are you doing for your amputation care? Talking to the vascular surgeons, you know, the surgical subspecialties, if they're not able to get ahold of rehab, they're probably missing it. And it's just a matter of getting in front of them. Most of them know that they don't want to take care of amputees in their clinic. They want you to take care of it. So how do you help that? Thanks. Quick questions for the- You got another three part for me? No, not for you. Yeah, working on your short term memory right there. For the CMO, the big thing is, you know, you're a physiatrist, so you know what a physiatrist is. A lot of us through the cities, we're one physiatrist in a hospital system, right? And it's really hard to find advocates. But the problem is, is when you got a small acute rehab and they're just throughput, throughput, throughput, and you push back. So from an administrative standpoint, how do you, how can we better push back without being offensive and worse in your day because your metrics look horrible because you got somebody who's here. So balancing that because you're sensitive to physiatrists, but ones who aren't, don't know our specialty. And when you say, I can't take this patient, this patient's not appropriate, you know, they have no disposition, they have no guardian, they have nothing, right? And so, and then you, then they make you feel bad and then all that stuff happens. That creates a bad blood with administrators. Yeah, it is tough. I mean, I've been very lucky that I've been affiliated with acute care. So oftentimes we have a chance to take care of patients that maybe are outside the realm of having a safe dispo to really take a shot. And then I had the luxury of moving them back to acute care if I had to. You could certainly talk to your hospital system about if they're open to that, you know, let's do, you know, a two, three week trial. This is a great patient, they're gonna benefit. I don't know if I can get them fully home safely. I just don't know if they're gonna be completely independent, they may need supervision. How can we work together on that? You'll also find that the hospital oftentimes has the ability to help with home health or other things, or oftentimes they'll have contracts with skilled nursing facilities for some of these difficult patients. So I think just starting the conversation, I think a lot of it circles around just them understanding why. Oftentimes we'll get a denial. You don't get to that conversation part until shit hits the fan. And then you're like, well, we need to talk about it. And they're moving on because you've got a fast paced workflow to begin with. So it's really hard to get in early because it's not on their radar. And then when it becomes on their radar, you're a barrier, in essence, you can be a barrier. Yeah, I mean, I would say, you know, trying to get a hold of some of the case management leads, you know, so you can talk to them ahead of time. But, and even, you know, the other thing which we really do a poor job of is getting the good cases back to hospital administration. And, you know, hey, you had a stroke patient that came in total assist and walked out of here. Here's what happened, here's how we helped each other. And look at this patient now, would have sat in your hospital for three months, not having a place to go. So I think that's another angle to attempt to take is the good cases. All right, thank you all very much. Thank you. Appreciate it. Thank you very much. Good job.

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