All right, good evening, everyone, and thank you for attending tonight's PM&R BOLD Dialogue on the Opportunities for PM&R and the Rehabilitation Care Continuum under a Value-Based Framework. Before we officially get started, we have just a few housekeeping notes. This activity is being recorded and will be made available on the Academy's online learning portal. For the best attendee experience during this activity, please mute your microphone when you are not speaking. You are invited and encouraged to keep your camera on and to select hide non-video participants. This will ensure that the speakers are prominent on your screen. To ask a question, please use the raise your hand feature and unmute if you're called upon, or you can use the chat feature to type your question. We do have reserved time toward the end of this webinar for Q&A, however, we will note that time may not allow the speakers to field every question, but you are welcome to contact us with any follow-up questions you may have. So with that, I will now hand it over to Dr. Flanagan, who will get us started on tonight's discussion. Welcome, everybody. I'm Steve Flanagan. I'm President of your Academy, and I am delighted to welcome you here today. I've been on the Board of Governors for about six or seven years, and one of my very first meetings on the Board came a discussion of really strategic planning of where we thought the Academy, and more importantly, actually, the field of physical medicine and rehabilitation needed to be in the future. It was a time of immense health care reform. Everything was changing. I think anyone who's been in the field for any length of time knows that was the case, and man, it continues to change like crazy. And we really realized that it was imperative for us, as the primary specialty for physical medicine and rehabilitation, to begin to develop a vision for where we needed to be going forward, and that vision was meant to ensure that we just didn't survive health care changes, but in fact, we thrived. And I talk about that triple aim of medicine, and for those of you who have heard me talk before, I'm sorry I'm repeating myself, but that triple aim of medicine to improve population health, to enhance the patient experience, and to do it more efficiently, which we know is just a government euphemism for less money, you need physiatrists, you need physical medicine and rehabilitation in order to fully achieve that, and we recognize that. We went throughout the entire country talking to physiatrists in major metropolitan centers literally across the country, getting the feedback of our members, literally thousands of physiatry members of the academy, asking them, where do you think we need to be in the future in order to thrive? And we got tremendous feedback. Over the course of the past six to seven years, we've developed five practice areas in which we really think that is necessary to achieve to ensure physiatry plays that vital role in medicine. These practice areas are in pediatric rehabilitation, oncological rehabilitation, spine and pain, musculoskeletal rehabilitation, and the one we're going to be talking about tonight is that rehabilitation continuum of care. That is, physiatrists are necessary through that full continuum of care. When someone comes into the hospital, their first illness, perhaps it's the onset of a disability, and we are vital and necessary in ensuring that their care is the highest quality with the best outcomes, with the best satisfaction at the less cost possible, and that's what we do as physiatrists, and that's really what PMNR BOLD is all about. We think BOLD, it's sort of a gimmicky name. It's not. It is the vision that the academy has for the future of physiatry, which means it's your future. This is your future going forward. I've been in this for three decades. We're really doing this for the younger folks in the audience today. Tonight, we have a great faculty who have been involved with the academy in various levels, and have really put forth tremendous effort, particularly in this rehab continuum of care BOLD discussion. Ed Burnetta, who served as a steering committee rehabilitation continuum of care co-chair, along with Marlise Gonzalez-Fernandez, who's with us as well, who sits on the Board of Governors as a member at large. April Pruski, who contributed to an article that hopefully you've all read in the PMR Journal, serves as a TBI polytrauma medical director at the Phoenix VA. And of course, I just couldn't be prouder because she's also a graduate of the program I chair at Rusk Rehabilitation. So April, no surprise that you are becoming a big wig in the field. And of course, a close friend and colleague who in the past has served on the Board of Governors as a member of large, and who provides so much valuable insight into rehabilitation as it's practiced today and going forward, Charlotte Smith, a senior VP for clinical operations in Madrina. So just quickly on the next slide, I'm just going to share with you something that you have probably seen online or you've read in the Physiatrist, which is PMR vision, which is our BOLD statement. And I would think that everybody in this call agrees with that, that physiatrists are essential medical experts in value-based evaluation, diagnosis, and management of musculoskeletal and disabling conditions, and indispensable leaders in directing rehab and recovery and in preventing injury and disease. And we are vital in optimizing outcomes and function early and throughout the continuum of patient care. And it's that last statement that truly defines what we're going to be talking about tonight, which is that rehabilitation continuum of care. So we're going to go on, and I'm going to turn the baton over to Dr. Morales Gonzalez Fernandez. We're hoping Ed Boneta gets on. I think he may have gotten caught in a snowstorm. There's just crazy weather throughout the country. But Morales, the floor is yours. And again, thank you, everybody, for coming. And Morales, thanks for coming on board and telling us about the RCC continuum of care. Well, thank you. And thankfully, Ed has joined us. But I will be kind of hitting for both of us, and we'll let some time for him to talk at the end. So again, we, as physiatrists, have expertise across the full continuum of care. And part of being recognized as such is having involvement at various levels of the health care experience. So starting in the acute care hospital, again, the focus of what we do is impairment-based and diagnosis-based on those areas that we have specific expertise. And I'll save the details for later so you can enjoy the case presentations that we have prepared for you. But it is important to understand that we are not confined to a particular health care setting, that we can start as soon as a patient is admitted. In some instances, for example, we can be there on day one after a stroke admission, and we can continue to help manage those patients across that continuum of care in a way that is meaningful not only for the patient, but for the health care system, for throughput, and for actually improving outcomes overall and reducing the overall length of care, especially when we take into account the need for post-acute care for some of the patients that have the most impairments. And even those patients that might not need to be in a post-acute setting, we can help manage those conditions and sequelae of disease that are much more difficult for acute care teams. Again, Dr. Pruski will detail some of that. But once a patient is leaving the hospital, there's other opportunities to take care of them. And traditionally, we've done that in acute rehabilitation settings. Our CIRs are the core of rehabilitation practice, but there's also other post-acute care settings that are important as well, and that many people, including Ed, my colleague, have great experience in working in those environments. So with that, I will let him speak a little bit to how the rehab care continuum moves about in the post-acute world, especially in the subacute setting. Yeah. Thank you, Marnice. I think the basic premise and what I have found with this work is that we've kind of expanded our vision to get physiatry involved early. Often as appropriate and to really integrate ourselves in the entire process. I think a big component of this process is the transitions of care and where we can utilize our skill set, and especially the skill set of interdisciplinary team concept, both in the skilled setting, in the IRF setting, and beyond, because I think that's the skill set that we possess. And I think the efficiencies that they're looking for in this environment are many times, I think what they look for is that interdisciplinary team concept, which we have grown up with and could definitely utilize in this new environment. And I think the other thing with PM&R BOLD has been the aspect of, it recognizes the fact that value-based care is becoming much more of an important entity, certainly in the inpatient setting that we work in. And that's another area that obviously it's almost like it makes BOLD make that much more sense in this environment. So, in terms of the Rehabilitation Care Continuum priority goals, part of the work that's been done is exploring again models of acute and post-acute care that ensure that physiatric care can be provided early and often across the care continuum. And a big portion of that is our colleagues learning what we can do and everyone in all these environments understanding that physiatrists have a unique skill set to contribute in different acute and post-acute care settings. And also, it will be important in this context to leverage advanced practice providers that can support physiatrists and expanding the opportunities that we can have and be able to allow us to really extend the work that we do and the impact that we can have through the acute and post-acute care setting. And I'm sorry, just to add to that, on the skilled and long-term care component of that setting, advanced practice providers are very much a part of that care. And I think the more that we get the CRNPs and physician assistants involved in our management of patients and integrate them into our practices, the greater our impact in that area. That said, we'll move on with our live case studies. Thank you. I'm just gonna share my screen over here. Can everyone see that okay? Okay, so hello everyone. My name is Dr. April Kruski and I'll be discussing the enhanced role of physiatry in the acute hospital. The work I will be discussing is from my time as the medical director of the physical medicine and rehab consult service line at Johns Hopkins. Specifically, I grew and developed a specialized program in the acute hospital, such as the enhanced stroke service that I'll be discussing today. I'm no longer at Johns Hopkins and I'm currently the TBI polytrauma medical director at the Phoenix VA. But what I will be discussing today are my own personal views. They're not the views of the government or the VA, but I find the work that I did at Johns Hopkins to be very unique and something that I hope to one day grow at the Phoenix VA. So there are roles in the acute hospital that we're comfortable with as physiatrists. We analyze the criteria to determine what level of care a patient can benefit from after an acute hospital stay. We know the diagnoses, we know the level of support a patient needs for acute rehab. We generally can tell if a patient can tolerate the level of intensity of acute inpatient rehab. And if they're likely to discharge home. So we're well equipped to project the patient's functional level and progress. Beyond that, when we form relationships with other services and offer education on what a physiatrist can help with, we become quickly consulted on certain patient types. In TBI, for example, we can become early engaged on agitated patients, or we can be looked at to help optimize a patient with a disorder of consciousness. In spinal cord injury, we offer assistance with bowel, bladder management, maybe autonomic dysreflexia. For amputee patients, pre-surgically, we can recommend the level of amputation to optimize functional independence. Both pre and post-surgically, we can have conversations with our patients that include how to prevent contracture, even when to expect to receive a prosthesis. We can offer other patients optimal spasticity management, which ranges from doing something conservative to invasive, depending on what the patient needs. We're always best known to our consultative services for our expertise on the back lip and pump management. However, there is an out of the box role for physiatrists, where we can become part of the multidisciplinary team early in a patient's care. It's well-known and frequently discussed that early mobilization can improve patient outcomes, lower 30-day mortality, reduce perioperative complications, and reverse decline in acute hospitalization in very elderly patients. On the right, you see a screenshot from the American Physical Therapy Association from 2020 that highlights 13 articles that advocate for early mobilization. However, there is very little discussion of what a coordinated effort of rehab professionals can do to optimize patient care in the acute hospital. So we're very familiar with the role of a physiatrist in the acute inpatient rehab unit. The physiatrist evaluates patient's medical stability and optimizes the patient's rehab care throughout an inpatient rehab. Stay. We do some medical management, such as looking at a patient's vitals and titrating their blood pressure meds. We address rehab-specific problems, starting by reviewing medications that can be interfering with optimizing the patient. We evaluate a patient's bowel and bladder function and initiate appropriate intervention to optimize independence. We look at patient's spasticity and see if we need to intervene if the spasticity is intervening with function, interfering with function, or causing some sort of pain. We discuss patients frequently with nursing, therapists, care managers, and psychologists, and we lead team meetings looking at the whole patient and setting up length of stay and discharge locations. We are very confident in ourselves and our role in the rehab unit, and it's vital for us to take that model of the rehab unit and apply our strengths early in a patient's hospital stay and not wait till they come to the rehab unit. There are opportunities to create mobile rehab units that span the early continuum of care, starting in the ICU and then go to the medical wards for certain patient populations. Looking at the mobile rehab unit, at Johns Hopkins, I was part of the acute hospital rehab intensive service, what we called ARISE, that offered early coordinated rehab in the acute hospital. So what that meant was a stroke patient could receive up to six sessions per day of physical therapy, occupational therapy, and speech therapy, depending on the needs. For example, if you had a patient with an left MCA stroke who had hemiparesis and aphasia, they could have two sessions of physical therapy, two sessions of occupational therapy, and two sessions of speech language pathology each day, almost three hours a day of therapy in the acute hospital. Therapists focused one session on function and a second session on impairment. In speech, if a patient had more than one impairment, such as having aphasia and dysphagia, one session was spent on dysphagia and a second on aphasia. But if the patient only had one speech impairment, then the patient would revert back to the model of impairment for one session and the other session would be function. But not every patient received six sessions of therapy per day. If a patient came in with a left MCA and only had aphasia, they would only receive speech language pathology services. Upon evaluation, the rehab professionals would participate in a daily huddle at 1145 prior to the second therapy session to harmonize discharge recs, discuss best approaches to patients, such as if a patient is aphasic, what's the best way that we can communicate with them? Is it a communication board? Is it yes, no? So this allowed an opportunity for therapists to have a chance to communicate directly to physiatrists, whether that was in person or over a Zoom huddle. So the physiatrist can discuss with therapists the acuity of a patient's medical condition and maybe why a patient was presenting a certain way. Therapists had the opportunity to mention early concerns of spasticity, patient's difficulty with attention and concentration, perhaps if there was mood disturbances, and to have the physiatrists discuss these concerns with neurologists to intervene either pharmacologically or maybe even consulting a rehab psychologist. Physiatrists in this format are available to discuss care with care managers and families. And this expansion goes beyond the usual focus of mobility and the upper extremity for stroke patients, allowing for a more comprehensive multidisciplinary rehab approach. It brings the acute inpatient rehab model to the acute hospital while patients are being medically optimized, allowing rehab not to be left by the wayside. Physiatrists can work with the patient, acute medical team, and families to discuss stroke rehab, education, rehab goals, and calibrate expectations between therapy, the patient, and the family. So what can this model do for our patients? Having rehab early affords the opportunity for a patient to begin recovery activity early. One stroke study showed that in the early stages post-stroke stroke patients spend a majority of their time in bed alone. A program that allows early rehab can help patients focus on their recovery. Multiple therapy providers checking on the patient through the day can make the team aware of any new neurological changes and offer the patient in-room exercise programs and continuously educate and repeat information that may be difficult for the patient to process. Traditionally in acute rehab, therapy comes to evaluate disposition location and offers little rehab. In a model that focuses on rehabbing patients, patients can progress to a different level of care. Patients perhaps originally thought to need inpatient rehab can progress to an intensive outpatient program. Patients who are thought to not be able to tolerate anything other than a subacute level of rehab can be recommended for a more comprehensive care in an acute inpatient rehab. Additionally, observations about a patient can be shared amongst team members to improve the patient-centered approach. The momentum a patient builds in the acute care environment can then be built on when the patient comes to inpatient rehab. So the patient already had the opportunity to know some of the basics and is ready to build to the next level of care. In a place like the Phoenix VA, where there is no inpatient rehab, if a veteran requires further rehab, they're forced to go to the community. However, if we take a different approach and implement the model as discussed, we can rehab patients on-site and not delay the needed intensity. There is an opportunity of bringing the strengths of the acute inpatient rehab unit to see patients more frequently and coordinate a veteran's care with the physiatrist to potentially transition patients to an outpatient program rather than going to inpatient rehab unit to continue their recovery. This can help improve and streamline care for veterans without adding an outside hospital stay to their care. We evaluated the ARISE program and in a study on feasibility of enhanced model of care for hospitalized stroke patients, we found that it's both safe and feasible to increase the number of therapy sessions during the acute hospital phase of stroke care when implemented by an interdisciplinary team that is specialized in acute stroke care. This study supports that activity during the hospital phase of care can be safely increased to capitalize on the heightened period of spontaneous neural repair. The ARISE model did not change the length of stay nor the percentage of patients discharged home. However, there were fewer hospital readmissions and it reduced the disability as measured by the 90-day modified Rankin scale in the subgroup of patients with the available score. This study shows that an interdisciplinary component in the hospital system after stroke with an introduction of specialized physiatrists and rehab therapists working with patients more frequently can cultivate a restorative focus for the patient. In summary, PM&R physician engagement early in a patient's acute hospital stay can put together the whole picture as rehab doctors speak therapy and medicine. And we serve as a bridge between the rehab team and other physicians. PM&R physicians can oversee the coordination of a patient's care, including therapists, social workers, and other professionals, such as psychologists, which can overall enhance the clinical decisions that can improve a patient care early in the patient's medical course. Thanks so much, April. I think we're going to go on to Dr. Smith is going to give a live case study of her experiences. Dr. Smith. Well, I'm very excited to share a case study that I found very compelling and has actually had impact on just my decision making about my career and what I want to focus on. And I'm going to present a case that's pretty fresh gentleman named Bill. Next slide please. And just to give you some disclosures I'm now working with Madrina as their senior vice president of operations and essentially Madrina is doing is providing bold services across the continuum, which is what I've been essentially doing for the last couple of decades in various roles. I'm also involved in advisory panel forum, I am, which is an insurance type of guidance for best practices and then I just my biggest disclaimer is that on the board of governors I'm absolutely was passionate I think not only is bold critical to survival of our specialty, but I think it's also imperative that we do this for patients and I think this case study is going to provide the information that proves that. Next slide. So Bill is a 62 year old man, and he was coming home from the elections, you were his wife and he were working as in the polls, and he took a wrong turn a ruler it was dark there no lights and hit some ice slid onto the train tracks and got hit brought on right side of the car, boom, and was found pretty quickly. He was Glasgow coma scale three, and they did a really good job, got him to the trauma center within that golden hour had transfused him intubate him and while he's still in the car. And when he got there, it was very clear, he had just devastating brain injury. He had just subarachnoid subdural intervertebral hemorrhages and deep mid brain hemorrhages with diffuse accidental injury and other injuries to skull fracture C2 dense fracture rib fractures pulmonary adhesions liver and spleen and he also had pelvic fracture. So he was in very bad shape, and got admitted very quickly, excellent job in the trauma team to the ICU who very quickly did all the things that you would do in a case like this ventilated intubated managed Ortho got consulted and said, you know, at this point, let's just manage things conservatively. Next slide. And neurosurgery got involved and essentially determined that he was brain dead. They said he had non reactive people's, he had no reflexes, no medullary function that at this point there was nothing they could do in terms of surgical intervention that would appropriate because they felt it's futile care. And then day two he started actually showing some motor activity and he had a gag reflex and a corneal sort of actually breathing off of the ventilator. So that point neurosurgery said well he's not brain dead but he's going to die pretty soon and essentially what the chart said is this is a non survivable injury. He's not going to live more than a day or two and this point we're just keeping him alive, so that his wife can accept that he's going to die. Next slide. And so as a standard. He got tracked and pegged, and this is after he was able to breathe off the ventilator for eight hours, and they progressed to feeds he came in at 150 pounds and had dropped to 132, just by 10 days later. He was having a progression of his two feeds trying to get that up and constant stooling. Of course he got a coccygeal area that was red wound care sought and said oh well it's not broken down yet just turn them side to side, and they signed off. And he had a lot of challenges respiratory rise kept getting pneumonia mucous plugs and recurrent rounds of antibiotics, and which I'm sure did not help the stooling. And he also ended up getting a PT about, and at this point, he was going to be following some commands with this right lower extremity mass extension. But it was a delayed response, and he was opening his eyes spontaneously and intermittently tracking and somewhat responsive and, you know, as usual, he was more responsive to his wife and other people but it was actually documented by other team members that he was indeed responsive. So the goal then was to transform to LTAC, with the goal of being getting off the ventilator and maybe trying some initial coma stem type stuff. Next slide. And the big miracle was Bill's not insured, he, his job did not provide health insurance and so amazingly he was taken to a very excellent LTAC I would say, with Medicaid funding, and it was close proximity which is amazing, because I'm in northern Idaho, that's what they did a really great job and comprehensively evaluated and he was opening his eyes and he was indeed following his wife's like generalized responses when she'd speak to him and at one point he was seen puckering up and trying to kiss her. But what happened is they started him on oxycodone and baclofen thinking that he was in pain and that he was spastic, and he essentially looked comatose again and became non responsive. And so that had to be kind of corrected but he weaned from the ventilator, very quickly, they were hoping it would happen within 28 days he did it within two weeks, but kept having lots of pulmonary issues and needed very aggressive pulmonary toileting and such. And he still was having issues with his skin and the wound was getting bigger and did get appropriate wound care but it was a stage three. So what ended up happening at that point once he's off the ventilator is the funding source said that he's ready to go to skilled nursing and there were two facilities within, like the area that actually would take patients with trachs, and so one of them accepted him. Next slide. And so he goes there, and it was hard, it was really hard for his wife especially because there was less nursing there was less RT. So he went to see a doctor, as you guys are all aware, the requirement for skilled nursing facilities as you don't have to see a doctor for like 30 days, and never met a doctor there. He didn't really get the RT treatments he's getting before and the oxygen was being administered inappropriately. He had more secretions and he ultimately got severely hypoxic was eating 10 liters of oxygen, so they transfer him back to the kid care facility after four days on Christmas. Next slide. He was found of course to be septic and he had bilateral pneumonia, and they also found that the wound was unstageable probably a stage for his weight was 110 came in at 150, and he had a rapid response event at one point he desaturated the 70s and had 50% FiO2, but he got aggressive RT fantastic care, the critical care team IV antibiotics and he got stable, he was still pretty much the same level of responsiveness and versus he got ill, he would be less responsive. So the recommendation that point was for him to go back to the LTAC, but there were two problems one the LTAC wouldn't accept him. And number two, the insurance carrier said no, you know, no more LTAC. So they were going to send him back to the same skilled nursing facility, but the wife refused, and she had toured to the facilities and this was the better of the two that he went to initially, but she was like I don't think he can go to sniff I don't think he's safe, and, but the facility spent a period of time trying to find an accepting facility and found one, and essentially said that if we have an accepting facility and the treatment team says he's medically stable, he has to go whether you like it or not so against his wife's wishes he was transferred. Next slide. And he went to a different sniff and ironically this is a sniff that when she was offered the two different sniffs, she walked to the front door of the lobby and turned around and ran because she was so appalled by what she thought the care would be. So now he's admitted to that one as opposed to the first one. And she was extremely concerned and anxious as you might imagine but the whole goal at that point was just let's get the trach out of him and let's get him home. If possible, but I ironically, she got great care she was happier with the care there. They had had a change in management even though the physical environment didn't look great, the care team was excellent. And they did a really good job and things were moving in the right direction until the 10th five days later, when he is going to have a hemoglobin of 3.4, and gets transferred back to the acute care facility. Next slide. And he looks good. No acute findings and they repeat that the CBC and guess what his hemoglobin was 13.8, and they decided that was probably a lab error, but he did have some capacities in his lungs, but they went ahead and send him back to the same day. Next slide. So, you know, this is a very interesting case just to give you some perspective on this, this is actually my husband's office managers husband, and so he is a good friend of ours who have been in our house and we knew him. And this whole thing was interesting because I was not really working in any of these levels of care I was actually doing a job that was more telemedicine and then you know providing care in Texas and Washington State. And so it was a very interesting thing to be the secret shopper and watch this whole thing happen before my eyes it really was like watching a train wreck, if you can imagine when it was a train wreck. And I'm still involved because he's still there, and things like for example when they said that the hemoglobin his wife pages means as they're taking it back to the ERs hemoglobin 3.4 is like, does he look bad, or is vital signs okay, it's like it's got to be a lab error but yet he still went back. And, you know, what you recognize is, you know, there's so many interesting things that are peculiar to our healthcare system, you know, the trauma responders and the ICU and acute care did absolutely amazing work, especially for rural area, mind blowing. You know the fact that we had an excellent LTAC that accepted this client was amazing this patient, you know, and even sniffs that took trachs can, my experience it's hard to find those levels of care, even in big cities sometimes, but there were so many things that went wrong, you know, the, the worst part I think was early on, once the neurosurgeon said he's gonna die in the next day or two, and told the wife that, you know, all bets were off anything that came out of his mouth she wouldn't listen. And so there really was not any ongoing communication about what does this look like neurologically what is his prognosis and, you know, what are the implications if we take and peg him, because you know that takes us down a different path and if we do And then, not establishing a bowel program, you know they were long sitting him constantly to help his lungs, and because he had two feeds but he was not in a bed that did any protection of sharing. So it was not surprising that those two things happening caused him to get a stage four to cube. The weight loss was extreme, and I think it was, you know, sort of they got behind on that and never caught up. The pain control is interesting too because the time that he got the oxycodone that put him back in the coma. You know that point he really was not having any pain, and it was just an interesting thing they started on baclofen there's no spasticity. And it was just a lot of stuff that on a daily basis as a physiatrist, it would make you want to drink to see these things because these are things that we know that can be done a little bit better and a little more nuanced. It was not challenging I think to see him go to a facility that just flat out did not have the care that they needed the expertise the resources, and it was a complex patient. And it was also hard knowing that you know this is facility where there wouldn't be an empty that would see them maybe for that first 30 days. So it was just hard and the family got very little handholding the wife was kind of seen as a problem, more than a positive because she was really digging her heels in against some of the recommendations. But I think the shocking thing about all this is that there was no PMR physician available throughout this whole situation and I was just like wow, this is an opportunity for improvement. Next slide. Now, what are the thoughts you know PMR to the rescue. I think so, you know, if you look at what trauma facilities require I worked in Austin for 22 years and was part of their trauma team and the American College of Surgeons requires you know that you have a physiatrist available for ideally level two and level one this facility is trying to become a level two. So they're going to need to have a physiatrist, and you can see all the reasons why I think you know you heard earlier just all the ways that we intervene and, you know, being there right there and working with the trauma team and rounding on that patient from the very beginning, when they're in the ICU helps so very much with establishing rapport with the family. I think it also really allows you to have a better view neurologically and a prognostication, because you have more data points, you know there's the opportunity to really tweak and fine tune some things are happening with the care plan from a rehab perspective as they're saving this person's life, which you know they're doing a great job with. And then you look at the LTAC and it's the same sorts of thing the transition between one facility and another was just so hard for the patient and the family, because just there was starting all over again, whole new team and again no physiatrist, they thought he was like completely futile because he was comatose when they put him back on the oxycodone and the baclofen. And so it's just really hard because the wife didn't feel like they were hearing what he was doing before. And then there was no assistance whatsoever with bowel or bladder with the rehab plan of care of pain management. And then it just, you know, from the skilled nursing facility it happened all over again it was like another new team and then we're going back and forth and things aren't happening like we hoped and, you know, the wife was really in a very distrustful place, but really not in a position to demand very much or make many choices. And so it was very hard for everybody involved. Next slide. So, and so I guess the question is, you know, how, how can Pima be to the rescue, how do we do this, you know, and, and I honestly agree with what was said earlier, what Ed said, you know, we really can't do this by ourselves. And we are all about being a team. And I think when I see a situation like this, you know, the first thing I want to do is reach out to every physiatrist in the area, you know, or even in the state, I guess in this case, maybe two states, and see who's And how can we work together. And how can we create systems of care, and I know this can happen because I did this in Seattle, and we had cross menu care were basically as a doctor providing services for us physiatry I worked with the Swedish healthcare system in Washington, and helped coordinate transitions of care, among all these levels, and really shared information and shared patients and did all sorts of things back and forth, and it was amazing. And I think you know very beneficial so it can be done. But the key thing there's several things we can do, you know, I think we have to talk with other people and work with them. I think we have to be on top of our games, you know, gone are the days of doing consult and saying you know not a candidate for inpatient rehab, which literally I saw that there actually was one physiatrist to actually never saw this patient because he didn't think he was a candidate for rehab. And so, you know, I think we've got to broaden our scope and what our usefulness is at every level of care, because that's not the purpose of the consult team at this point, or not the only purpose. So understand that there are differences and best practices for different levels of care so for example, you know, if I played ball, or use the same rules as skilled nursing that I do in an inpatient rehab facility, they're not going to be very happy, because the resources are different. And as a physiatrist, there's many things you have to tweak and do differently in a skilled nursing level versus an acute rehab or LTAC versus even a skilled nursing. So understanding the best practices and really understanding what are the differences and how can you be most effective and different levels of care, I think is imperative for us to learn. And then the third thing, and I think this is so important, I've seen the pluses and minuses of team based care. It is absolutely critical for us to expand the number of physiatrists that are out there, or at least our scope, but the problem is there's just not enough of us. And even if you multiply all of us like four or five times I don't think there'd be enough. The estimate I've heard said is that only 15% of skilled nursing facilities have a physiatrist, which is really sad. But on the other hand, I've also seen nurse practitioners and PAs that try to do this independently. And the honest to goodness truth is it's just not possible, because there's stuff that we learn in the four years, that's really useful and absolutely imperative and critical. And I believe we need each other. And I think that having physiatry led team based care is going to be the answer to meeting all these continuum needs for BOLD. And I think, you know, figuring out how we all do that together, how do we communicate, how do we make sure we're all following these best practices is doable, very doable, and I see it happening in different parts of the country. Next slide. So that's all I had. I just want to thank everybody that's on this call for even being open to the concept of being BOLD, because I do believe this is imperative. I can't tell you how, when I was rounding with Bill, because I got pulled in, she's like, I have this friend, it's a physiatrist, would it be okay if she was here with you guys right now? And they're like, well, what's that? Well, she knows something about brain injury and spinal, she's an MD. And they're like, oh, okay, why not? You know, and it was very interesting, because I would ask questions like, you know, you know, have you guys given any consideration, you know, just because you're trying to be very nice and not pushy, but you're also trying to guide things along. But you know, simple things like just, you know, how do we start our BALD program? You know, how do we position this guy in bed, so that he's not going to break down and things like that. But it's been quite a challenge. And what you realize is that we have incredible expertise, and a lot of tools in our toolbox that can make a profound difference for many of these patients. And, you know, I don't know how it's going to turn out for Bill, but I do know it could have gotten better than it did. So I'm grateful the opportunity to share this case. And if anybody has questions, I'm passionate about this, feel free to reach out to me. You know, we're developing more and more resources, you know, through the Academy for looking at this whole issue of continuum care and team-based care, and it's an exciting time. So thank you very much. Well, thanks so much, Charlotte, for sharing that incredible story. And actually, thank you to all of our panels for really highlighting really this envisioned future that the Academy has for that rehabilitation continuum of care. And I think all the examples here, I think were really fantastic. Dr. Prisky talked about the ability of a system, the Johns Hopkins system, coming together and getting in early, just like that envisioned future is, getting in early, providing that physiatric directed team-based care that improved patient experiences and decreased costs at the end of the day. And that's true for a whole system. Dr. Smith talks about the value that having a physiatrist early on was missed out in that case and how much better that case would have turned out early on and undoubtedly would have saved money, likely decreasing the re-hospitalization, which is something that CMS dings hospitals for on a regular basis. That would have been missed. And that really brings me to what Ed and Marlise were talking about with regards to why we even developed all of this. This PMNR board, it's really for all of us, all physiatrists to go out there and be the champion, be the cheerleader for what we provide. The C-suites at the healthcare systems, the payers need to know that we're not in some luxury, physiatry or in physical medicine and rehabilitation that, gee, isn't it nice when a hospital system or a healthcare system has physiatry. No, we're vital. We are not a luxury, we're vital, indispensable and necessary to achieve that triple aim of medicine. And it's our job as physiatrists to spread the word and to do all the things that you folks all just said. So with that, and the other thing, and it came up twice, and certainly if anyone has questions and needs to stop me from talking, by all means, raise your hands. But we are a small field. There are about anywhere between 10 and 12,000 board certified physiatrists in the country. And if you think of the tremendous variety of disabilities and conditions we treat, that is not nearly enough. I mean, I'm a brain injury specialist. There are probably about anywhere between three and 5 million people with a chronic problem related to traumatic brain injury. I mean, only about a quarter of physiatrists do brain injury medicine. So that's 2,500 for 5 million. That math just doesn't add up. And that's why, and Charlotte spoke to this, having APPs, and Ed can speak to this as well, and I may bring him into the discussion. We're not saying that APPs should be out practicing by themselves. They are part of a rehabilitation team led by a physiatrist that allows the physiatrists to spread their wings and to treat the tremendous number of folks who need our care because they report up to us. They're part of our team. So I know that you can raise your hand if you have questions. Maybe if we take down the slide, we may be able to see everybody. Maybe that'd be a good idea. For those of you who are potentially a little shy and don't wanna be heard, by all means, feel free to type your questions or your comments into the chat box. I'm gonna tell you what, I'm sure you tell all your patients, the only bad question or the bad comment is the one you don't make. So feel free if anyone has any questions. While we're waiting, Ed, I know that probably more than any physiatrist I know in the country, you have probably done a tremendous job in looking at APPs and using them effectively as being a team leader. And I know there's a question here. Actually, let me just read it. Hold on a second. Let me just read, okay. So I know that there, so we have a question here. I disagree that APPs providing care in SNFs. What happened in the case of Bill is what we see happening with APPs. They prescribe everybody Narco or OxyContin or Baclofen. They feel that their role is to prescribe opioids. And I would address that the view that the American Academy of Physical Medicine has is that they should not be practicing independently. And when as part of it, we support them if they are part of a rehabilitation team led by a physiatrist and the Academy now provides education to physiatrists as well as APPs on how to use them appropriately to advance physiatry. But we do not support the independent practice. That is our position. And so I thank you for that. And the Academy agrees that they should not be practicing independently. And you've used APPs so successfully in spreading the wealth of what you do in your healthcare system. I wonder if you could just share some of that. Yeah, and that's one of the areas that I feel like it's a straightforward way. It kind of sits with Charlotte's presentation in that the medications inappropriately prescribed, that's frequently what we pick up on when we go to buildings. And that's how I really train, well, train or educate as best I can in terms of what's appropriate, and really kind of get them focused on what area is causing your pain? Where's your pain? What type of pain is it? What exacerbates it? All those kinds of basic questions that we ask that sometimes don't get asked in this population. And so I feel like just by that, we add value. I've kind of had an interesting interaction with nurse practitioners that I started January 1st as a medical director of an ISNIP, an insurance product for long-term care patients in Pennsylvania. And we have these weekly meetings, one of which is about patients that get transferred to the hospital. And it's nurse practitioners, the insurance products employ nurse practitioners to go out and round on these patients to see them more routinely. And we discuss patients that get discharged to the hospital and perhaps what could we do that would be preventative. And we were discussing a patient that had gone out, just briefly, she, you know, morbidly obese, COPD, with chronic, quote unquote, chronic pain issues. And in the course of our discussion with the nurse practitioner who works with the insurance, she said, yeah, I mean, she's on. And she was on a plethora of narcotics, of muscle relax, et cetera. And I was like, that seems like a kind of patient that would be good for a physiatrist to see. So they actually, because I'm on staff as part of being part of this ISNIP, I went to the building and saw this patient. And I think we subtracted about four or five medications. I injected bilateral knees, you know, and it's still early days. And we'll see how this plays out. But it kind of was an early way of integrating physiatry into an area where we hadn't been before. So it was kind of a neat experience for me. Yeah, and I think that that's a perfect example of how we can use APPs appropriately. And, you know, to a corollary to that question is, you know, how do we safely lead mid-level practitioners and share knowledge without further destabilizing our existence? Right, so, you know, and that's the fear that people have. And I think that's legitimate. I will say that the Academy has developed educational modules for physiatrists on how to effectively use APPs and also to train APPs on what physical medicine and rehabilitation is. Again, the intent is not to have them work as independent practitioners, but as part of that rehabilitation team to spread the wealth. There just isn't enough of us. It's a workforce problem that we recognize in developing BOLD. And this is just one way to help address that need. And I'm delighted, Ayana, that you trained with Dr. Fernandez-Gonzalez and, you know, lead the way and help us advance PM in our BOLD. Steve, can I just jump on a little bit on that idea about models? So I think this is a really great point that's brought up because how you work with an APP is really absolutely imperative in terms of the effectiveness of the APP and the care the patient gets. And I want to also push back that, you know, just letting APPs only be in SNF is probably safe. That's just the opposite. I think you actually need more skills as a physiatrist to practice in a skilled nursing facility environment. So the idea of just handing that over to APPs without physiatry supervision and guidance and involvement at the bedside, in my opinion, is concerning. You know, I've seen it done both ways. A lot of the programs that you see where if you look at the model for the geriatricians or the medical directors of skilled nursing, their model is that the patient's always seen first by them. And then they may have follow-ups and they have team-based care where they go over the patients and discuss them. And I've been involved elbow to elbow with groups like that, and that's highly effective. And then there are certain criteria that, you know, they jump back in if there's something that's not making improvement. And I think that's a very good model. That's one way of doing it. I've seen other models where you maybe just do telephone, touch base. I don't think that works because what I've found in my experience is a lot of times if the APP is telling you what they think they need help with, they may not know what they don't know. And some of the best APPs I've worked with, that's really not their fault. They didn't do a physiatry residency and they understand. They understand, you know, I don't even know what I'm not doing right. So I think getting the model right and, you know, making sure that we're seeing all the pieces of the puzzle and that the physiatrist is ultimately in control of the variables is huge. It's a very, very important aspect of this. And, you know, it scares me to think that, you know, we're just having people that are going out there saying they're providing PMNR services because if they aren't doing it well, and if it's not really being led by someone who knows what they're doing, it really puts a black eye on our specialty. So I mirror and understand everything, the concerns that are being raised. I think this is a big challenge for us. And I think finding that right balance is important, but I think the other key thing is, you know, bottom line is it needs to be physician led. And as we do that, I think we're gonna have better and better outcomes. And I think it will make a big difference in terms of just how we're perceived by other specialties and also by facilities and administrators and patients. All right, Duke. Any other questions about the Rehabilitation Continuum of Care? I think we've had a good discussion. Part of our job as champions of physical medicine and rehabilitation is just to get the word out. The Academy is doing their part, and I'm really hoping that all of you do do the same, whether it's truly supervising APPs or getting out there, talking to the payers, to the C-suites, that, you know, to the payers, to the C-suites, that, man, they need us in order to run their health systems properly, to get patient outcomes that they deserve, and to improve their patient satisfaction, and to do it all more efficiently. And efficiently is what we do. We know, you know, how to get folks through the system, improve their outcomes, and just do it with less money. And that's been shown over and over and over again. Dr. Seaman, I have a comment. This is Ayanna Kersey-McMullen. Just wanted to follow up on my previous comment. So I guess my question is, as it relates to AAPMNR, what legislation are we working to influence as it relates to this? Because Dr. Charlotte made the point about having the geriatricians have been able to position themselves in order to perhaps be the first line of defense, a first evaluator for patients. I think that they're in a much more advantageous position than we are in that they may be the directors of these facilities versus the physiatrist may or may not even be the physiatry director. And so a lot of times when you're having the AAPs, I mean, excuse me, the mid-levels or sometimes in the directorship roles there as well, they're using us as consultants. So they can decide whether or not they're even going to involve us in their care to begin with. That does not give us an opportunity to have that first go round in order to make that evaluation and a lot of that starts with the legislation because these people have been empowered to go into these settings and be in positions of leadership. And I personally think we've kind of missed the mark in terms of our presence more felt and more necessary. It doesn't matter for us to be able to have those conversations amongst one another. I think we understand that very well. I think the problem is that the large society, A, to my point that I made earlier, really does not respect the role of physicians at this point as being further and further destabilized, but more importantly, they don't see the need for bringing us into those environments. And it may be in part because they don't know who we are and maybe in part because of the political environment that's going on right now as it relates to medicine. So what is AAP Menard doing to try to address some of those issues? Because I think it's beyond the individual physician to be able to position themselves in those environments. Thank you so much. Yeah, so I appreciate that. And you're absolutely right. And the Academy has taken a very strong stance on the whole scope of practice, whether it's APPs or chiropractors who call themselves functional care providers or whatever it is that they call themselves. So we advocate on a regular basis every year and throughout the year. We advocate to our colleagues in Washington. We come up with, we meet with people with regards to just like, for example, subacute care. We have a subacute committee that works on how are we going to advance and have healthcare systems, payers, C-suite folks recognize that when you're talking about that full continuum of care, you need that physiatrist, whether it's in the acute care center, in the IRF center, in the subacute, because this is the value that we bring. And it's not just getting legislation passed in the state, in Washington. It's convincing the people who have control of the facilities, who are running the healthcare systems. When you have physiatry on board, that's when you make it more efficient and better. And that's what PM&R BOLD is. That's the vision of the Academy and it's multifaceted. And that's where we're going. But in order to make that happen, what we really need are engaged members to work with us who are going to be the local advocates for their system. We're developing toolkits to help our members be the advocates they need to be in their healthcare system, whether it's a small practice or a big healthcare system like where I am. So it's multifaceted. And I would encourage anyone to get onto our website, be involved more on discussions like this, because that's exactly where we are. And that's what we mean by ensuring that we're not just going to survive healthcare changes. We need to thrive. It's doing those things that you just said. We're just actually, now we're over the hour. This has been a great discussion, but for Arianna and anybody else who is really interested in advancing the PM&R BOLD vision, ensuring that your future as a physiatrist is secure going forward and join us in BOLD. We're always looking for volunteers. And it's that passion that we desperately need in our members that you're showing that's going to help us along the way. So thank you all for participating in this discussion. I want to thank our panel for being part of this and for sharing their perspective and experiences on how physiatrists are essential, vital and necessary going forward. Thanks so much. Stay involved, get involved if you're not. And thanks for joining us tonight on a Tuesday. Be well, everybody.

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