All right, welcome everybody. Thanks for joining us on a Monday afternoon. We'll wait a few minutes before we start. I'll give a quick intro as well. We have some amazing speakers today and a really interesting topic, especially for us in the field and for anybody else who's joining who's not really aware of what subacute physiatry or SNF physiatry is, hopefully this will enlighten you and tell you more about the future of physiatry in this setting. So we'll wait about three or four minutes, actually probably less than that, and we'll get going because we have a total of four speakers and we'll have a Q&A after that as well. If you have any questions, please feel free to ask in the chat box and we'll be happy to answer them as the conversation is going or even afterwards. So we'll keep it informal. So before we start, I think maybe I'll give a quick intro about subacute physiatry from my perspective. So I completed my residency here in Chicago at Mary and Joy Rehab Hospital, it's a freestanding rehab hospital. We actually had a subacute unit in our hospital, it was I think a 40 bed unit. We're very fortunate in residency that we got to moonlight in that unit. We also had a dedicated two month rotation in subacute. Majority of our attendees were doing subacute. So for me, including Dr. Patel, who's going to talk later, we were doing subacute at a pretty early stage in our career, but that has become our career. So hopefully we'll talk more about that. I'm going to start sharing my screen, so we'll start in a second. And if anybody can't see it, please let me know in the chat box. Okay, we'll get going. So hopefully at the beginning, at least my part of the talk, and we'll have a lot to talk about, will be an introduction to physiatry practice in the CIF setting. My goal is to hopefully discuss some of the history and what is happening now and potentially what the future entails for us. My disclosure will include I'm the Chief Clinical Officer for Integrated Rehab Consultants. Hopefully in this discussion, I'll be talking about post-acute care, IRF versus SNF, the history of physiatry in this setting, the role of physiatry in this setting, and then some different practice models that are out there. Because I figured, and I've had a lot of students reach out to me, medical students and residents and attendees as well who are interested in this type of practice, I wanted to make sure that it was broad as well and discussing things, including IRF, and some of these things obviously are very apparent for a lot of us, but I think it's important that we keep it more general initially and we'll talk about it as time goes on. So in the post-acute care setting, you have different settings, and we're going to focus mostly on the skilled nursing facility, but for those who don't know, there's long-term care hospitals, inpatient rehab, there's skilled nursing, obviously home health, and you also have unskilled home care. Physiatrists can be present in all these different settings, and I think we honestly need to be in all these different settings because you want to manage the rehab. We are the specialists and experts at knowing what type of therapy someone might need and rehab someone might need. So I think it's important that we're aware of these different settings, but we'll talk more about the skilled setting. Sorry about that. So there's obviously certain advantages that IRFs have over SNF, but this is a nice chart that I found. The source of this is the Medicare Payment Advisory Commission that talks about the main differences between subacute and inpatient rehab, and briefly I was talking about how I was lucky enough to have access or exposure to subacute or SNF work even in residency, but a lot of residency programs don't have that access, a lot of students don't have that type of access. So it's important that they understand, we all understand what the difference could be. The main thing that I think about in the SNF setting would be the multidisciplinary team approach is not really required in this setting, in the SNF setting. A lot of times historically you only have the primary care physician, maybe nurse practitioners, nurses, and therapists managing it, might not be a lot of coordination in them. The intensity of rehab is obviously very different. We'll talk about that in the future slides. So the approval that the physician might have to give for pre-admission, the discharge rate is significantly higher in the IRF setting versus the SNF setting, but the cost-wise a significant amount more money is spent by Medicare for SNF care versus for inpatient rehab care, but this is kind of the broad picture of that. It's important to know where inpatient rehab is headed. Some of these key points here that I want to point out is in 2004, there was 1,221 inpatient rehab units, and that went down to 1,161, and since then it's gone up to a little bit to 1,180, and I think it's almost stabilizing at that point, but this is not just the number of units. We'll talk about the number of patients being taken care of this, but a number of trends are happening that are pushing the patients towards the SNF side, and I'll touch on these later. One of the interesting things that I found in this data point from the MedPAC is the freestanding hospitals were about 217 in 2004, and that went up to 243, and non-for-profit, there were 768 of those, and now they're down to 677. There's certain trends that are happening. Things are becoming more towards the profit side, and the freestanding is going up a tiny bit. In 2017, Medicare spent $7.9 billion on IRF care provided for fee-for-service beneficiaries, because it had 1,180 IRFs, and there were 340,000 beneficiaries, and they had about 380,000 IRF stays, and we'll talk about how that compares to the SNF setting. The number of fee-for-service is holding steady, even though there's a significant decline that happened from 2004 to 2013, from almost close to 500,000 cases now to 372,000, but over the last four or five years, the number of fee-for-service cases have stayed pretty consistent. At the same time, you can notice here down with payment per cases that has gone up from about $13,000 to about $18,000, so more expensive, obviously, over time with the cost of care and this inflation. The number of licensed beds in the United States from 1994 to 2015, and you can notice the chart here. It went up a slight amount in the early 2000s, then it stabilized, and it went up and down, but overall, it's staying pretty consistent. Now, this does not mean that all of these beds are filled. The number of beds that are staying filled actually is going down as time has gone on, but at the same time, it's staying pretty consistent. The most recent data that we have is 2014, about 15,000 skilled nursing facilities provided skilled care, and there are 1.7 million patients providing 2.4 million Medicare fee-for-service coverage days. The important thing from my perspective for everybody who's watching this is five times more rehab is done in the SNF setting than the IRF setting, but there's not five times more physiatrists working in the SNF setting versus the IRF setting. Now, that does not necessarily mean that has to be the case, but at the same time, there's not a lot of physiatrists doing this. So what is filling the movement of rehab patients in subacute settings? There's obviously a number of different reasons, but I want to jot down at least five of them. One of the most important ones, 60% rule has restricted some of the non-compliant patients from going to IRF. They might be the diagnosis, maybe it's the prognosis, different things, or discharge planning, they can be limited from that. In the LCDs, the local coverage determination specifies subacute rehab for certain diagnosis. That is changing as well with the different bundle plans and accountable care organizations. Medicare Advantage managed care has been significantly increasing as time has gone out and private insurance companies may direct care to where the patient might go and usually is typically based on the cost of the care. Subacute rehab also has been shown to be less costly for certain diagnosis and there's data that proves that and they look at that data. One thing that is wishful thinking that does happen is subacute providers recognize the need for physiatry-directed short-term rehab in a stiff environment. That's what we want maybe in the future for them to base the care on where the specialty care is, where the best care is provided. So cost-wise, comparing apple to oranges, let's look at some of the data points here. For the different diagnosis, that could be a trach with a vent, it could be respiratory with vent, joint replacement, hip fractures, strokes, but look at the average cost of some of these things. You can see there's a significant difference in patient rehab, long-term care, and subacute care. Now this does not necessarily mean it's better care, but a lot of times these are certain things that MedPAC and other organizations are looking at to make certain judgments. Now history of physiatry in this subacute setting, likely since the 80s, it's really hard to kind of pinpoint exactly when physiatrists started working in this setting. I have met physiatrists who worked from the mid-80s to early 80s in the setting, but at the same time obviously it's a lot more popular now and there's a number of reasons for that. But back at least from what I have talked to some of the physiatrists, they had a mixed practice. They were doing inpatient rehab, outpatient clinic, but also would do subacute rounds. But as far as I could tell from my research, my own individual research, I have not found a physiatrist doing nothing but SNF work in the 80s. I think maybe mostly late 90s and then things kind of start changing. At this point there are a lot of physiatrists, including myself, who primarily worked in the SNF setting and we have a lot of my colleagues who do the exact same thing. Another limitation is obviously the limited exposure and residency. Like I said before, I was fortunate enough to get access, but a lot of programs now they're opening up to more the whole continuum of care and the residents are able to access the subacute and round in those facilities, but there's historically been very limited exposure. There's no dedicated rotation, a lot of the attendees might not even do subacute. So that has obviously limited the amount of physicians who do this. Also the volume limitation. Historically a lot of patients were not getting subacute rehab or you might have pockets of facilities that have 5, 10, 15 patients, but that has changed. The trend of that has changed. Now you have much larger facilities with nothing but the focus on subacute rehab. So the volume is changing, the type of patients are changing, and obviously the role is changing. Historically from, again, from mostly the people that I've talked to, a lot of times they were the primary care physician for the patients versus being the consulting physiatrist and that role has started to change over time as the patient complexity has been changing as well. So I did some search and research and I found that there's an article in the Physical Medicine Rehabilitation Clinics of North America. This is in 1996, even before I started medical school, and the article basically talked about physiatry and subacute rehab. I want to just read a few lines from that article. It's really important because 25 years later, we're still talking about the exact same thing. So subacute rehab programs increase opportunities for physiatrists to be involved in several categories of rehabilitation care and to establish a continuum of rehabilitation care that delivers service to the patient at a lower intensity than in conventional rehab. So this article is phenomenal. I've read through it many times over the years and really tells you what some of the authors were talking about way back before it even became a popular thing to discussing how the changes in rehab are happening as time goes on and how we need to be involved in all the different levels of care. So as far as the number of physiatrists working in the setting, at least from the data that we have been able to collect, and with that I mean IRC, there's approximately 1,000 physiatrists in the country working in the subacute setting. Some of them might be seeing patients once a week, maybe it's once a month. It's really hard to know exactly what the data is for that. But overall, there's close to 1,000 physiatrists working in this setting. And you can see historic numbers from 2004 to 2019 with an estimate, I see a significant trend in more patients being seen or more encounters being done in the SNF setting from less than a million to now almost 2 million approximately. And in acute setting, you have from close to 6.2 million. So the trend is happening, the changes are definitely happening, and you can see that across the board. So what are some of the challenges? And I know the other speakers will talk about some of these as well, but I want to give you a quick oversight of this. Before physiatry being involved in my practice, I worked at eight different facilities. I have some advanced practitioners that work with me, and a majority of the facilities did not have a physiatrist before that. And these are the kind of things that I had to talk to them to tell them about my role and to help improve their outcomes and things of that sort. But there was inconsistent primary care physician visits and oversight. So you might have a physician round once a month, maybe it's in a weekend, and they just weren't as involved with the rehab and the patient care. Because historically, patients weren't as sick, at the same time, these doctors usually had other practices, but that was inconsistent. The primary physicians, nurses, staff were lacking rehab knowledge, not knowing about contractures or stroke or bowel, bladder, and things of that sort. So that was something that I frequently encountered. Overprescription of medications, including NSAIDs, narcotics, hypnotics, obviously we understand these patients are a lot of times geriatric, and we've got to be very careful about this. Inappropriate excessive testing and imaging, lack of cohesiveness between families and therapists and primary care physicians and even specialists, or delay in providing specialist care. So if, for example, someone has knee pain, by the time they were evaluated by an outpatient orthopedic surgeon or a physiatrist, it would take weeks at a time, versus having a physiatrist in-house who can figure out and fine-tune different things and may potentially do injections, prescribe medications, order braces that can actually help the patient out earlier than later. Other challenges were inappropriate discharge to the hospital for things that can be managed in-house, increased length of stay, increased pain scores, increased readmission rates, low Medicare rating. Rating is a big part of what the facilities are striving for because that can end up making them part of a network of preferred providers for the hospital, so they always strive for that. Lower discharge rates to the home, audits, health inspections, all the different challenges that facilities have. And all of these things are part of the physiatrist knowledge base that we can help out with. Lack of specialized rehab, not having fall programs or bowel-bladder programs or pain protocols, and inconsistent poor outcomes with peer-to-peer. Peer-to-peer is unfortunately becoming a big part of our practice, and a lot of times, if the primary care physician is the one doing the peer-to-peer, they cannot speak the same language as we can that are talking about prognosis and diagnosis. So in 2016, we have a position statement that came out talking about physiatrist role in the specialty setting, and there's some of these things that I really want to just read out, and there's a link here for reference, and please read this. This is very important, and I think worth reading. So physiatrists by virtue of their training, experience, and knowledge of rehabilitation, impairment, and function have the unique qualification and expertise to be the leader of the SNF rehab team, and that's what we strive for. We want to be the leader of the rehab team. In the ideal situation, a physiatrist in the specific setting will serve as the consulting or co-treating physician model, and visit the patients two to three times a week depending on the need. So really that need is based on medical necessity. And lastly, the physiatrist management of patient in the SNF setting will lead to greater functional gains by the patient, earlier discharge, and cost-saving for the health system. So we want to keep on promoting ourself as being value-based, cost-efficient, cost-saving, and for the betterment of the patient. There are many different models of working in the setting. So you could be an employee. You could be an independent contractor. You could be a consulting physician. You can be actively involved in anybody undergoing subacute rehab or be a consultant to manage a specific patient population, maybe it's pain, maybe it's stroke, maybe it's orthopedic. You could be overseeing patients undergoing therapy, med B therapy. You could be a primary care physician as well. You can have advanced practitioners. You could be a medical director. You could be a rehab medical director. There really is different pathways of helping the facility. It really depends on what they need and what you can provide for them. So what is the new model? And I was looking at the slides of my esteemed colleagues, and I really didn't find anything about the different set up, the settings that we work in. Now when I show some of these pictures, these are actually real pictures of my facilities. And some of my colleagues might say, well, I've never seen a place that looks like that or my facilities definitely don't have this kind of resources, which is definitely true. A lot of the facilities don't have this, but this is what they're striving for. This is where they're going to work. You want to be the preferred place for insurance companies to say, I want to send my patients here because they provide good care or things of that sort, or families who decide on where they want to go. A lot of times families might be the ones helping the patient out and looking online and looking at reviews, things of that sort to decide on where someone needs to go. So facilities are going above and beyond to feel like home or feel like a resort. So if you look at some of these names here, Symphony, Thrive, Elevate, Ignite, I mean, these are some good branding names too. And a lot of times they're not even called a nursing home, they're called a medical resort. So the idea behind that is to make this more of a home environment, more of a rehab environment. So a lot of these facilities have spent a lot of money getting state-of-the-art equipment. They're affiliated with different hospitals, they might be owned by a hospital, they're staffed seven days a week, they have a full-time therapist, that you might have independent living in the same place. So you get your rehab, you go to assisted living, all in the same location. You have discharge planning, home visits, you have physician availability, a lot of facilities I work in, they have a full-time nurse practitioner who's there, the primary care physician is extremely involved, you have multiple providers in the same facility. Now obviously this does not mean all the facilities have this, but the ones that have this will probably end up surviving longer because they can provide that level of care. The private rooms with the en suite, bathroom, four-star hotel feel, spa, I mean, all the stuff that you can imagine that a hotel might have, outings and chef-catered meals and movie theater. Two of my facilities have a Starbucks on site, and again, I understand that a lot of facilities might not be like this, but these are the kind of facilities that really are looking to partner with us and help provide the care that patients need. Now my patient mix is very similar to what it was during my residency and potentially prior to going forward, but you have about 40% in the IRF setting, you have 30 to 40% in orthopedic, and even that is shifting now more towards non-orthopedic care. I still see fracture patients, still see some complicated hip replacements, but a lot of the joint replacements are actually heading straight home. You have stroke patients, cardiopulmonary cancer, but regardless of all the things that I said, at least in my role, because I'm primarily a consultant, I'm mostly managing musculoskeletal, neurological, and things of that sort. It really depends on your practice and what you want to do. I think really a physiatrist can do so many things for these patients. It doesn't matter if it's cognition or bowel, bladder, or wound care, and the list goes on and on. We can help these patients out because we do historically help these patients out in the acute setting. Thank you again for being bold and making PM&R essential in the whole continuum of care. There's a whole lot of amazing talks coming up after this, so I will leave my email up here. Please feel free to ask me any questions at any time, and I'll hand this off to Dr. Natz. Hello, guys. Can you hear me? I hope so. I am going to see why that happened. Okay. All right. So my role in this, thank you for having me, Aslan, is to tell you a little bit about how the SNF fits into the rehab continuum. So for those of you that don't know me, I know many of you do. I looked at the list of some of the attendees for our community session. Thank you for being here. I'm Dr. Steve Nads. I'm the Chief Medical Officer for Integrated Rehab Consultants. And my financial disclosure is that, of course, I'm employed as the Chief Medical Officer for IRC. So where does subacute rehab fit in the continuum of care? You heard a little bit about this from Aslan. I would say that we all grew up in the paradigm of acute hospitalization, hospital care, IRF care. But I think that we also need to realize that post-acute institutionalized care could mean IRF, could mean SNF, could mean LTCH, could mean a long-term care facility. And then you also have, this actually is a slide from the academy, you have home health and other outpatient types of parts of the continuum as well. So as Aslan mentioned, significantly more inpatient rehab occurs in the SNF today than in an IRF setting, yet physiatrists don't have a mandate. CMS does not mandate that a physiatrist be, or even a rehab physician, as they call it in their parlance, needs to be involved in SNF-based rehab. So how do we get into the SNF? Well, I'll tell you, in my own personal experience, I followed my patients into the SNF. I found that I was doing councils in the hospital, my patients were being sent to a skilled nursing facility. I went there and they were very happy to have my expertise following these patients. And most primary doctors in the SNF are not really rehab experts. They're going to, they may not know what a rehab physiatrist is, but they may, and they may be threatened by you sometimes, but they, a lot of times, most of the time, I found, will defer because they're not really the expert in it. They've usually been put in a position of having to say sign therapy orders and those types of things without really knowing exactly what they're doing. One of the things that I noted early on was that all IRFs are very similar. You have very similar environment, the intensity of therapy, the quality of therapy. But as you'll see, if you do any of this, that if you've seen one SNF, you've seen one SNF. They're all very different. There's really a need for there to be standardization. Aslan touched on this, so things like protocols, pathways. I'm going to talk a little bit about that in a few minutes. Nance, can you, sorry, good job. Can you share your screen? I don't think we can see it. Oh, you can't see it. I'm sorry. Yeah, that's okay. Hang on one second. How about now? Thank you. Can you see it? Yes, I can. Yep, thanks Steve. Okay. I'm sorry. I thought I was sharing my screen. So keys to success. So working with SNFs, we want to maximize the quality of the rehab programs. We want to minimize lengths of stay. Now, sometimes that may be working against what the facilities are looking for. You know that sometimes facilities, if they're paid on a daily rate, want to maximize their length of stay. But I think as rehab physicians, we need to work with those facilities to make sure that they understand the dynamics of the post-acute networks and the need to minimize lengths of stay. We want to maximize discharges home and we want to avoid unnecessary hospital readmissions. Now, I've got to see if I can go forward here. There we go. So physiatrists manage rehab patients using standardized rehab pathways, standardized rehab protocols, a hands-on personalized approach to each case, individual rounding on each case, and then frequency. You know, this is kind of, we go back and forth about this. Generally, when you're seeing patients in an IRF setting, you're going to see patients pretty much daily. But in a SNF setting, because maybe because it's a little bit lower acuity, maybe just because it's a slower pace, usually two to three times a week. If you look at the Academy's position statement, we kind of, that was actually highlighted in there as well. And we're going to manage our patients through team meetings. It may not be called, you know, interdisciplinary team meeting like you have in the IRF, but there are going to be some kind of a team meeting that you can participate in. And we're going to try to minimize barriers to discharge. All right, we're going to try this one more time. There we go. In terms of pathways, and I'm not going to go into much detail on these because we don't have a lot of time, but there are pathways that you can look up that have been developed that are out there basically for different types of clinical diagnoses. And they'll usually be something like this, a pathway or a protocol that will have assessments along the way, and then some kind of a roadmap that you're going to follow. And we have them for various different, these are actually IRC pathways, but you know, they're readily available on the internet or in other places. But these are really going to be helpful to your skill. And you're going to be able to use them in your clinical nursing facility because they probably don't have these types of pathways that they've really ever developed, at least not multidisciplinary ones. You know, the physical therapist might have a pathway, the OT might have a pathway, but they've never really coordinated them. So SNFs are challenged to provide lower lengths of stay, as Aslan mentioned, reduced discharges to acute care, lower 30 day readmissions and quality rehab outcomes. Some data for you, for those guys that like data, is that we did a study, was actually published as an abstract in JAMDA a couple of years ago, showing that this was a nationwide study of physiatrists, actually, particularly IRC physiatrists versus non-physiatrists or just non-IRC in general, with 30 day admission to emergency department visits, risk adjusted lengths of stay, resource utilization, rug mix versus nursing days, and 30 day hospital readmissions. So bottom line is that having a physiatrist involved in the team moved the needle in all the right directions. We had lower ED readmissions, we had lower lengths of stay, we had lower hospital readmissions, we had higher utilization of, higher acuity of our patients. And similarly, this is locally, it was shown that we had lower average length of stay and lower hospital readmission rates. I wanna just spend a minute talking about the payment system. The payment systems are different for IRF versus SNF, and I think it does behoove us to be a little bit aware of how things are working there. In the SNF, it's still not a prepaid model, but it's moving toward more of a prospective payment system model with the patient-driven payment system or PDPM that came into effect last year. With that, patients are basically paid for based on their characteristics rather than on therapy minutes. Prior to that, they had been paid for on the acuity of therapy. So all facilities were driven towards trying to maximize the number of minutes of therapy for patients, whereas now they're actually looking at more fuller patient characteristic. I think we can help out these facilities with PDPM as well. I developed a couple of short case studies. Because of our lack of time, I'm not gonna spend too much time on these, but essentially what the PDPM model does is it takes the hospital discharge diagnoses, and that's the starting point for your skilled nursing facility payment rate. If you can see that these are a couple of hospital diagnoses in this particular case, when the physiatrist evaluated the patient, they fleshed out those diagnoses much more significantly looking at the functional status of the patient, things like dysphagia, the nursing needs. And so essentially by adding those ICD-10 codes to the case, the facility got paid a more appropriate rate for taking care of that patient. Here's the bottom line. It was about $84 a day more based on the additional diagnosis codes. And these are public knowledge. You can look these up. You can see what CMS is gonna reimburse based on the PDPM model for any of these codes. Here's another one, a hip fracture routine healing. Essentially, if you add the additional codes that come with the territory when you're a physiatrist, you end up with a situation where the facility makes, I think appropriately, more reimbursement based on the fact that you fleshed out the characteristics of the patient. So as I already mentioned this, there's the physiatrist role in skilled nursing facilities position statement. There's also some additional PDPM information. And I think in summary, let me just say that I think it's important for us as physiatrists to be working with our facilities, obviously, but then also with our healthcare systems. You're probably, if you're gonna get hired by a system hospital or an accountable care organization, ACO, they're gonna have some kind of a post-acute network. Whether they know it or not, they have a post-acute network, and it's helpful for you to help them understand and manage their post-acute network so that they reduce costs and have better outcomes for the patient, use lower resources. So I think that we can demonstrate the value of physiatry in the SNF, as well as all post-acute settings. Also important to recognize that SNF rehab is kind of a transitional phase. We've seen, even in the last 10 years that I've been involved in it, much less orthopedic patients, much less of the traditional orthopedic patient, the joint replacement. A lot of them are going home now, and that's probably appropriate. If you can go home after joint replacement, go home. You can get your rehab there. But we should be able to demonstrate value in all levels of care and help our patients become independent and minimize their disability. So we become the guide for our patients in all the rehab settings and help guide our health systems and also have fun. This is the community. So I think it's important for us to realize that we don't want to burn out. We want to take care of our patients and have fun while doing it. So thank you very much. And with that, I will stop sharing my screen and turn it back over to you guys. Hi, guys. I think I'm next. Thanks, Steve. Let me pull up my screen here and start playing. So Dr. Amish Patel. I'm with Integrated Rehab Consultants as well. Got a couple of our little disclosure things to get out of the way. So I was a founder, chief executive officer for Integrated Rehab. I'm going to do a couple of case studies. My colleagues are on the board. Dr. Tariq, you've already listened to, and just now Dr. Nats, chief clinical officer, and Dr. Nats is our CMO. And I will try to stay close to on time here and turn it over to Charlotte Smith from U.S. Physiatry afterwards. IRC, our group, many of you are familiar with us. We're the largest group of physiatrists in the post-acute slash skilled nursing setting. We do quite a bit of work in inpatient rehab facilities as well these days, although probably not as much as U.S. Physiatry. It is becoming more of a point of focus on us. As far as our cases, I'm going to get a little bit into the peer-to-peer reviews on the first case. Full disclosure, one of the ways in which I was able to pick the cases that I wanted to go over was I just Googled peer-to-peer in my Gmail search box. And guess what? I found a lot of the more interesting cases and found a few of those. Out of those, I picked the one peer-to-peer that makes the most sense. I initially had a bundled patient as well. In between my two cases, I will talk about bundled patient care as well because it's important. I know Dr. Nats hit on it a little bit in terms of the ways in which we can work with different systems, ACOs, hospitals, and how some of them don't even know they're working with you. So I'll touch on that a little bit. And then the second case is actually Dr. Tariq's case. So if you would like to hop in, we'll allow it. Sorry, are you sharing your screen? Because I don't think it's- Hold on one second. I'm on the first slide. Let me share. Okay. One second. I don't know, I might've hit it too quickly for when Dr. Nats was still sharing it. Can you see it now? Yes. Okay, perfect. Okay, don't worry, no one missed anything. So just going on to the two types of my two cases. In between the two cases, I'll talk about the bundled patients with peer-to-peer leading this off. So 62-year-old female. By the way, I didn't fill the slides up with a lot of information. I'm probably too good at talking and talk too much. So I'll try to stay on track and talk through more of this rather than read the slides. Initial case, 62-year-old female. A stroke patient, prior level of function, totally independent at home in the community, was driving, working, et cetera. Initial patient presentation was bed down, not even tracking. Max, probably actually more total assist, severe left-sided neglect. These are the type of cases, not necessarily this particular case, but in the past, a 62-year-old female would end up in an IRF more times than not. This is just kind of the way the entire industry has moved as Dr. Nats and Dr. Tariq have already hit on. So maybe not this stroke patients, but many stroke patients obviously ended up in an IRF setting in the past, but this is not atypical at all to end up with this patient in your skilled building these days. Not doing much, cut already on week two. Obviously, if it's a CBA patient, they were already denied from an IRF initially. Only 62-years-old, really painful for the family and everybody involved, honestly, including our team and our therapists to have to cut somebody after seven to 10 days of rehab after a stroke patient that young. So anyways, after the week two cut. One second. Switch here. Sorry. We asked for a peer-to-peer after the cut. This is also different in a skilled nursing building. In an IRF, you're in the setting, everything revolves around a physiatrist and an IRF. When you get into a skilled nursing building, I like stealing Dr. Natsos' favorite saying, when you've seen one skilled nursing facility, you've seen one skilled nursing facility. When you walk in, I know for a fact, Aslan's facilities may be a little bit more advanced than some of my own. I started my buildings downtown Chicago where there weren't as many resources, whereas Dr. Tariq works in some more suburban facilities, Northwest Indiana, where they had more resources, et cetera. But anyways, what I'm getting at is you sometimes have to insert yourself into the conversation as far as something like a peer-to-peer. They may not even know that a physiatrist would help with a peer-to-peer. The model that we run, which we encourage most physiatrists to use as we are the consultant. Aslan talked about some doctors going back to the 1980s doing this in terms of some of our pioneers, the very first physiatrist who did this. A lot of those acted as the primary and as the physiatrist, just like they do in an IRF setting. I will say that makes it a little bit more difficult on a couple of fronts. One, when you're having to manage the other consultants, the medications, the labs, it becomes a lot more difficult to distill it down to just the physiatry piece and get into function, why someone's not getting better, et cetera. The model of being the consultant really helps you be a physiatrist first and foremost. And then another thing that happens if you choose to act as the primary is you're gonna be stepping on other toes in terms of the primary care doctors, whether that's other physicians in the building, physicians at the hospital who are referring patients to that skilled nursing building, the medical director, et cetera. So that's the model we run as a model we encourage. We work very closely with AMDA, American Medical Directors Association today. They're rebranded as the Society for Post-Acute and Long-Term Care, and they encourage a co-managed model as well and have been gracious enough to kind of take us under their wing as physiatrists in a subset of their membership. So getting back to this case, after the peer-to-peer, after the cut, and before the actual peer-to-peer, remember, you're rounding in these buildings two times a week, maybe three times a week. This isn't an IRF where you're there five, six, seven times a week. After the cut, we asked for the peer-to-peer, but before the peer-to-peer occurred and after the cut, the patient actually progressed quite a bit. So I rounded this particular facility on a Thursday. My peer-to-peer was on Monday afternoon. I actually got an update before the peer-to-peer from the director of rehab. And in that time period, patient was able to start tracking in the room a little bit, probably was coming off some of the sedating medications that they'd been on at the hospital, which may have been still affecting them. But either way, they were able to actually get to the gym. And even though they were max assist, they did some things that were important in being able to keep the patient there at the building, which is past the video swallow in the gym, tracking max assist versus total assist. Peer-to-peer with the insurance physician was able to extend. This happens often. I know as physiatrists, we're like, okay, great. We're gonna have them for six, seven, eight more weeks. We're gonna be able to do A, B, C, and D. This is gonna happen. The insurance doctor was like, okay, we'll pass the video swallow. You're working on a few things. Can we give you a directive to DC plan? And that bought us about another seven to 10 days. Again, these physicians do work for the insurance company. That doesn't mean they're not gonna be fair, but they know where their bread is buttered. And so again, we got to the point where we had an extra seven to 10 days. Moving on here. Second. Performed a stand pivot transfer. This is in the time period after we passed the pivot, passed the peer-to-peer. Mod Max assist extended two more weeks. At this time, we didn't need a peer-to-peer evaluation. Again, you're not always gonna need to do a peer-to-peer. If they're cut, it typically comes down to their cut. You ask for more time from the building, and they say no. At that point, you can ask for a peer-to-peer. And again, feel free to interject yourself in these conversations at the building. Get to know your social worker, because unlike an IRF, this isn't gonna be second nature for the building to understand how to properly utilize a physiatrist. And again, you are a tool that they should be able to utilize. On day one, when a physiatrist comes in, you're asking all these questions. How's so-and-so doing? Can I help with this? Can I help with that? Honestly, they're gonna look at you funny a lot of times, because a lot of them are used to the internists who wanna get in, get out. They don't wanna be asked questions. They're just looking to do the bare minimum, get out of the building. I'm not saying they're all like that, but that type of physician tends to be more common than someone who wants to be involved in care in the skilled nursing building. So anyways, patient tolerating more rehab, referred to Mary and Joy, which is where we did our training. We worked very closely with Northwestern, which is obviously RIC. We actually, I'll talk about, when we talk about bundles, we actually wrote the orthopedic bundle with Dr. Nats' help for their ortho bundle, and now we run Northwestern's post-acute network to the point where any building in their network, it's a requirement to have an IRC physiatrist. So that's definitely a feather in our cap. Something that we should hit on, the initial denial was from RIC, so you need to be creative with these. If you send patients and they're denied once, it's gonna be harder the second time. So don't be overzealous and immediately referring to an IRF or referring to IRFs over and over. Once you get one denial from them, it's gonna be difficult. The initial RIC denial was from the hospital. Again, not a bad decision. At that point in time, the patient wasn't even tracking. They would not have been able to tolerate three hours of rehab, but Mary and Joy had not denied them before, accepted the patient, a lot that we were able to do. At the IRF, improved quite a bit. Returned to the SNF after four weeks. That point, they got a whole nother month in the SNF without having to do any of their peer-to-peers. And that patient, again, this isn't typical, but that patient discharged home at a contact card supervision level. They're not totally independent, but remember, at day 10, when we got the cut, they were laying in bed max slash total. How much could they have gotten done with home health, which was approved, three times a week, a 45-minute to one-hour session three times a week with probably no speech therapy, probably not been able to do a whole lot. Moving on. Next case is Dr. Drake's case. The case I did have was on bundles. I myself have 10 minutes, so I'm not gonna get too much into the bundles, but it's something that we should hit on briefly. A lot of us are seeing bundled care patients in the SNF setting, whether it's a stroke bundle, orthopedic bundle, cardiac bundle, as both Dr. Drake and Dr. Nasset on the orthopedic bundles, a lot of those patients are going straight home now. It's something where there's not as much of a need. These patients are doing well. We understand that. I think when we wrote the bundle for Northwestern's orthopedic patients, at the very top, we put 75% of the patients that we discharged straight home. Again, do we wanna see patients? Of course we do. But if you're not gonna be honest about the real needs in today's type of work that we're doing, you're not gonna have credibility with the hospitals. If you don't have credibility with the hospitals, you're not gonna have a seat at the table. So I think be careful in who you choose to work with. If you choose to work on your own in skilled nursing buildings, that's fine as well. It's not the old way in which you could just get yourself credentialed, go in, see some patients, bill, go home, stress-free. Today, there's a lot more in terms of having to have relationships. Are you allowed to see bundled patients? Is this hospital okay with using their patients? Because overall, physiatry is a fairly cheap cost. Our average collection is about $72 per visit. That's blended across all visits, including whatever injections we may do, initial HNPs and follow-ups. And whenever you're considering how low that cost is, you may not consider it to be a big deal, but hospital systems, even if it's only $72, if it's $72 a couple of times a week, a lot of these orthopedic surgeons, they realize every dollar you take out of a bundle is $1 that they're not getting. So even though you may think that's not much of an expense, you need to show value. I stress with Kavitha and the AAPMNR, we always wanna have a seat at the table. So these conversations are out there, they're happening. We all know we do a great job as physiatrists. Unfortunately, not everybody knows that. So I encourage everyone to get involved and make sure you're at the table when the hospital is having these bundled conversations. Getting into the second case, that's with Dr. Tariq's patient. This was just a fun case, showing how big a difference a physiatrist can make. And they could end up at a skilled nursing building with literally this type of presentation. And without the physiatrist there, if it's a fairly uninvolved internist, which is not uncommon, who knows where this could have gone. But 72-year-old male, status post cervical spine fusion, pertinent history prior to lumbar surgery. Prior to that, carpal tunnel. Presentation was went to ortho. Initial complaint of numbness in legs, hands, ortho treated, imaging. Symptoms, never had a full neuro exam. I'm not saying this always happens with orthos, but a full neuro exam is probably more a physiatry thing versus a lot of orthopedic surgeons. Dr. Tariq saw them here. Sorry. Patient presented with a hypophonia, mixed upper, lower motor neuron. Signs, weakness, spasticity, speech swallowing issues, fasciculations, the whole gamut. Prelim diagnosed with ALS. We sent to Rush. Again, that's the beauty of working in Chicago. We're always referring back and forth from Rush, Northwestern, UIC, you name it. We get to work with a lot of tertiary care centers. Depending on what your community is, even if you're not actively in the hospital, try to establish a good relationship. It makes a huge difference in what you're able to provide for patient care, even though you're not in the hospital. Again, officially diagnosed with ALS, returned to SNF. for rehab prior to going home. Moral of the story, in the subacute setting, you know, you are the ortho, neurosurgeon, you're all pain, room, PMR. You're a little bit of everything. That's one of the other reasons we encourage you to just be the physiatrist and not try to be the internist as well, as far as don't be the primary and the physiatrist. That's, those are two cases. This is, again, this is a really amazing case. You end up with ALS, ended up all the way through, who knows how many people saw him at the hospital, they ended up with Dr. Tariq in the SNF and were able to diagnose these. So the value that we provide is, it's incredible. I encourage everybody, even if you don't decide to do physiatry full-time in a skilled nursing building, educate yourself. It's becoming a huge part of what we do as physiatrists and really exciting in terms of the momentum we've had. We're on, going into our 11th year. We couldn't have done it without our team, Dr. Nats, Dr. Tariq, Matt, Sue, everybody that we have working for us, but a lot of momentum now. This is where things are moving to. We love IRF. I tell everybody, if you can get your patients care in an IRF setting, please do. But the reality is a lot of patients don't qualify. So rather than bury your head in the sand, we can really go into these types of settings and make a big difference. And I am pretty much right at 15 minutes. So I would like to introduce Charlotte and she can continue with the next part of the presentation. Thank you, Charlotte. So anybody asking questions, please feel free to keep on doing that. We will address them all in the end all together. We'll just make sure everybody gets a chance to talk about it. But very good questions coming in so far. All right. I have a little bit of a challenge getting my screen to share. Let's see here. Okay, there we go. So hello, everybody. It's actually afternoon now in Seattle again. We've been having early mornings in some of these meetings. I'm going to talk a little bit about some success strategies in subacute rehab and what it is that you can do to, when you get into one of these settings, be someone who really makes a big difference and be well received. And my disclosures, I have a financial relationship or position of influence. I'm chief clinical officer with U.S. Physiatry. I'm an associate professor for the University of Washington Rehab Medicine. And then I'm also finishing up serving as an average member at the AAP Menard Board of Governors. And so the key thing I want to really stress to you guys is that you can be an absolutely fabulous physiatrist, an ER for outpatient medicine or an acute care hospital. And that doesn't necessarily mean you're going to be successful in a skilled nursing or subacute rehab environment. And the reason is there's just so many things that can go wrong. We are not taught the rules of SARP, if you will, in residency, fellowship, or anywhere else, unless you're in a really unique situation. And they're different. They're absolutely different. The teams are completely different. Our roles and what we do is very different than traditional inpatient rehab or consultant in an acute care hospital. And as you've heard many times, every facility is different. And even as you go in and you learn one facility, it evolves and the rules of the game change. Like, for example, when PDPM came in, the rules for all my facilities changed and how things were managed became very different. So it's a constantly moving target. So why do things go wrong? And it's really the big R's. It's rules, not understanding them, lack of understanding about roles in our responsibilities, relationships, reasonableness, and then the reality of the situation. So how in the world can we ensure success? And we have basically a toolkit for success that everybody that I know is listening or going to watch this in the future has access to, and it's education, empathy, communication, and then using your entire full set of PM&R skills correctly. So one of the first success strategies is going to be education. And you really want to learn the rules of the game for sniff and snark. And what you find is that it's a different game. You've got to understand what is the criteria for being accepted, who's a good candidate, who is not a good candidate, and people that you don't want to bring in, and what can you do and not do inside of a skilled nursing facility, and then understanding also that your role is completely different. And, you know, the bottom line is you don't ever want to start playing the game before you know the rules. So given that this is not taught in residency, you guys are going, okay, where do I learn the rules? Well, here's the good news. I did a search on the AAPM&R website, and there were over 266 items between the online learning portal, the PM&R Knowledge Now part of the website, and then courses like this. So there's more and more information coming. So AAPM&R is one place. Also, AMDA, which is the Society for Post-Acute Long-Term Care Medicine, has great resources. But the other thing, and I would never, ever undermine or underplay how important this is, you can learn from the staff at your skilled nursing facility. I have learned so much from the therapists, the nurses, the CNAs, the administrators, you know, and the whole team there. And when you get to know your staff well and you work together well, what you're going to find is that they will teach you as well. So it's a two-way street on education for sure. So you have to know your role. And, you know, the first decision is whether or not you're going to be a consultant there or the medical director. The vast majority of the physicians that use physiatry are consultants, but we do have some that are absolute medical directors of SNF. And what that basically means is you are essentially responsible 24-7, 365 for the overall care of the facility, and you have a very defined role. Now, in contrast, if you're a consultant, that role may not be so clear. And you may have to actually develop the role because they may not know what a physiatrist is, what you do, how your skills can help the facility, and how to best work with you. So ultimately it's up to you to teach them, which you can imagine it's challenging because when you're still trying to understand and learn the facility and the culture of the facility, that can be a little bit challenging. So one of the things you want to do is you really want to figure out if you're the consultant, what do they want you to focus on? You know, where do they need the most help? Who does what? You know, if you have a medical director there and you start doing some of their work, it's sort of like a too many cooks in the kitchen situation. So you want to figure out who does what and what are specific duties and tasks that you can own. So like, for example, a lot of the doctors that work in skilled nursing are absolutely overwhelmed with tasks. You know, they may not come in there very often and there's piles of paper. So one of the things that I've done in one facility, just to make it easier for them, is I took the rehab plans of care and I was the one that signed off on all those and reviewed them. And it was actually a really good thing because I actually understood what all the information was and it gave me great data when I was doing consults. And then also I used that as an opportunity to really grow my rehab team and my therapist and really help them develop their skill sets because I could learn a lot from these notes as to what they were doing and strategies and where their strengths and weaknesses were. And that helped with program development. Also questions like, do they want you to write orders, make suggestions in the notes or talk to them? The last facility I spent five years at, we were all in one room. So I had an on-site geriatrician and nurse practitioners and the rehab team. And we were like one big happy family in a workroom. And we just talked to each other and it was so easy to pick each other's brains. I just started a new facility last week where everybody's spread out. You don't see them, but they're very, very email dependent. And so they really don't want us writing orders, but we do notes and suggestions and then kind of give them the highlights each day when we come in of what we'd like to see happen with different patients. So every single facility is going to have a way that it works best. And you've got to figure out what that is. The other key thing is what kind of patients do they want you to see and how do you get referrals? That's not easy. You may go to a place that has 300 people there and you're like, okay, where do I start? And generally, you can talk with the rehab team or with the medical director and really identify which types of patients you want to focus on. Maybe it's certain diagnoses, maybe it's certain patients that are receiving therapy services. There are all sorts of reasons why you might get involved, pain, spasticity. And I recommend that you put that in writing or at least figure out a scheme for when it's appropriate for you to see patients so that you're not waiting to be asked because that slows things down. If you can get agreement up front, it's so much smoother. And then the other one is, what can you do in the facility? There are some things that if you do them in the facility, it might bankrupt them. If you do a lot of Botox and it's not a carve out, that can cost more, one injection and they're paid for the whole hospitalization. So you want to be very careful and thoughtful about what you can do. And you also really want to understand who's in charge of the various aspects and respect those lines of authority, working with them rather than against them. It's very important. It's critical to get to know your team. So one of the other success strategies is knowing and communicating well. What's really challenging for all these medical directors is they may have another full-time job and do this as a part-time gig. I had one facility where the medical director was a very nice internal medicine doctor who worked full-time at the VA and they were only available at night and on weekends. And it was challenging because you'd get acute post-op patients that came into the facility and I'd be rounding and there would not be orders for pain medicines and things like that. And so learning how to work with a person like that versus having a full-time residential care team where you've got two geriatricians and three nurse practitioners that are there every day is a very different situation. You also really want to know if your consultants come to the facility versus if you send them to their offices because both things can happen. You don't really ever want to do politically inappropriate things like refer to a different orthopedic surgeon when you have one that comes to the facility or plastics. It's just not good because they're taking the time to come there. Advanced practice providers are very commonly working in skilled nursing facilities. So getting to know them and working well with them is really important. And then understanding too the nursing structure, you know, what are their credentials? Because you may work with a lot of people who are not RNs and learning how they work and how you can best support them important and what their fund of knowledge is. You know, they may not have ever done a bowel or bladder program before. And then the same thing with the rehab team. It may be that not every facility is going to have PTOT and speech there all the time. A lot of times these therapists are contracted with different companies and it may be they only have speech therapy come through every two weeks. And it may be that they rotate through and you don't have a consistent team. So that's important to know. And then the admissions team is also something that's very important because who comes in the door to some extent depends a lot on what the outcomes are going to be and how the facility is able to manage that person. And some admissions teams may have people that are very good clinicians and are very well seasoned and understanding clinical issues. But then you may also get marketing people that have no clinical expertise and hopefully they'd be willing to involve you. And then last but not least is the administration. It's notorious in this industry to have a lot of turnover administrators. And you may have people who've been there for decades who are fabulous and on top of their game. And I've learned so much from them. Or you may have the administrator of the month or week and with a lot of turnover. So learning all of that is so important. And the other thing to know is that it is really hard to recruit excellent staff to subacute. You know, it's not traditionally been the sexiest and most attractive area of medicine. And so it's really important that you value the team members you have and develop the relationships because how you and your team work together impacts dramatically the ability to provide great care. And we may not realize it, but sometimes just showing up and having a positive attitude, we can set the tone and we can set the tone for building like relationships and having a strong sphere of influence. And I think that's really, really important because these facilities need people to show up and just support them and be positive. So how we do this, you know, attending team meetings, most of these facilities have a Medicare meeting similar to our team conferences. I go to those just because I get great information and it's an opportunity to dialogue. And then just making a point of connecting and listening to people is very important. So another success strategy is accepting reality. You know, you've got to have reasonable expectations of what the facility and its providers can do. You know, it's not reimbursed the same way. It's a different type of patients. The staffing is different. There's different resources. Length of stay is different. You know, so there's a lot of different pressures in a subacute facility compared to say an inpatient rehab facility. But here's the point. It doesn't mean things are always worse. You know, I have come to understand that if I have a really severely impaired stroke patient who's like densely hemiplegic and very debilitated, being able to be at a skilled nursing facility with a strong neuro program where they get a longer length of stay, maybe one or two weeks to allow for more time, they're going to do better than if they get a 14 to 17 day stay in an inpatient rehab facility. So it doesn't always mean that it's bad. But the other thing you have to understand is that the gaps you see are really your opportunities to be useful to them. And that's really why they need us. And so, you know, it's not about them being perfect. It's about all of us working together to do the best we can with what's available and provide the highest level of care to a patient. So the other key thing that I see that's really important is, you know, this is not an environment where you go and go, oh, I only do neuro or, you know, I only do ortho and pain. You really have to be adaptable and use all of your PMR tools. And that means you have to be willing to see many types of patients. You know, you have to also be willing to understand that a facility, you know, may be struggling, like they may be struggling in length of stay. You know, their patients are all told to be acute care hospital. You get 100 days of sniff and which is not actually true. And their length of stay may be higher than benchmark. What puts them at a very big disadvantage in bundles and, or their costs may be overrun, or they may have terrible patient satisfaction issues. And so, you know, really one of the things we should be doing is helping them with those metrics and trying to make things better. You know, the other thing that we can't do is insist on things, you know, when they're not feasible, like, you know, asking for certain medications or interventions to be done when either they're not available or the team doesn't have the expertise. And then last but not least is the regulatory changes. You know, this is a area of medicine that's been highly scrutinized. Audits come in all the time, state agencies come in, the feds come in. I mean, everybody's scrutinizing. And so you want to be sure that you understand the regulatory rules and you're on top of it because how we document and what we do helps them in scenarios where there are audits and helping them to stay on the right side of things. This next slide is kind of busy, but I just want to just show you the range of what you're going to see. And I don't mean for any of these things to be like lined up, like orthopedic pain medication. That's not each thing horizontally in a row is not definitely aligned. But the key thing to understand here is you're going to see everything from orthopedics to geriatrics, to amputees, to neuro, to chronic care. You're going to see, you know, all sorts of problems that we're so used to. These are things that are every single day in our team, in our toolkit, you know, we manage pain, we manage spasticity, we understand incontinence, we understand cognitive deficits, you know, so those are things we're used to. And then the interventions are things, again, every single physiatrist that has worked in inpatient rehab or done acute care consults, understand how to do and can do with their hands tied behind their back. So one of the key things, being adaptable, using all of your pain realm, our skill sets, you know, key things that I see that sometimes people do wrong, and it kind of makes me worry a little bit because it makes them not really reflect well on human are, it's just signing off and rehab plans of care, you're not really looking at it and seeing if the goals and the strategies are optimal, you know, not stepping in when patients fail to progress, keep in mind, this may be this patient's last shot at rehab, they may not get another chance. And so if they're not making good progress, if they're not able to participate, you know, trying to figure out, you know, is there a medication side effect that's making them groggy, you know, are they in pain, you know, are there other factors that is a barrier to their making progress, that is really where we need to step in and give them that last chance, you know, helping out with difficult patients and families, skilled nursing gets them as well. And they get chronic pain patients, they get patients with behavioral issues, you know, some of the families are very unrealistic, they didn't want their patient together anywhere, anyway, because they were, you know, fearful that, you know, they're putting my mother in a nursing home. And, you know, it's, you have to really work with them and build relationships. And you have to explain to them, you know, just what you're able to do and work with them and get the best outcome you can by building a dialogue with them in a relationship. You've got to help difficult discharges, just like inpatient rehab has people that it's hard to get home or elsewhere, same story with skilled nursing and subacute. And so you get very good at complex discharge planning and knowing what's in your environment and knowing your options for discharge and strategies. And then program development, what Dr. Natz was saying is absolutely right, the more that we can teach skill sets and standardize things, the more likely it is that we're going to provide a consistent quality of care, and that needs will get met appropriately. And then the key thing is just, you know, our notes, the documentation is so important, you know, just saying, you know, rehab goal, continue PTOT or pain management, continue nursing and pain medicines and discharge planning as per social work. Those are not good recommendations, you know, because the team, the patient are looking to you for guidance, and we need to be their expert, not just repeating what they're already doing. And that's critical for proving our value. So bottom line, communicate well, always be a resource, be willing to educate, be situationally aware and sensitive to needs, you know, see deficits and problems as opportunities, be useful. And I think this is one of the things I try to do, sometimes situations are so tough, you know, and I show each day go, okay, what can I do today just to not make things worse. And most of the time, that may be my only goal for the day, because there's just, you know, so many challenging situations that you're dealing with. But you know, that's an important thing to recognize that when you have strained resources, you know, we don't want to add to the problems. You also just want to be nice and imperturbable. You know, Sir William Osler said that was one of the highest attributes of a fine physician slash surgeon, and staying calm. And you know, just being positive, even if you have to fake it, is really a good strategy in today's healthcare environment. And then being adaptable, and always challenging yourself to keep learning and improving. And I think that is the most important thing. You know, I can tell you every facility I work at, I learn things, you know, I'm humbled a lot of times, because, you know, I feel like I've got this, I know it. And then you go into a situation and you may have a team with a completely different dynamic and different expectations. You know, so we're always learning, it's never the same old, same old. And so with that, I'm going to close and thank you. I want to thank every single person that is watching this currently live and also in the future for your attention and attending this. You know, we need all the help we can get in this very, very critical area of healthcare, our patients need us. And we really need everybody that does it to do it with excellence, because we want every subacute facility to desire a physiatrist and need one. You know, and by doing that, you're being bold, and you're helping to make PM&R essential in every part of the healthcare continuum. So with that, I think we're gonna turn it back over to Dr. Tariq for questions. And there's my email address. If anybody has questions later in the future, you know, we're all happy to help each other out in this area. Thank you. Thank you, Dr. Smith. That was awesome. Great. Thank you so much. You're always a phenomenal speaker. We do have some questions. And Dr. Nats, do you have the poll questions? Do you want to put them up on the screen? Or should I just answer these first? I'll leave it up to you. I think actually Sean has them. Okay, Sean, sir. Let's see. There are some. It looks like there's a couple of questions on the screen. I'll read them out because I have them listed here. Oh, there we go. Actually, we have the poll question first. Let's do that first. All right, good. Looks like you got a pretty good sampling. 83% full-time. There are actually, there are a number of people that like SNF work because it can be part-time. I don't know how many, what you guys think about that, but you don't necessarily have to do it full-time, whereas working in an IRF, if you're pretty much an IRF attending position, at least, you're probably gonna be full-time. Yeah, with the flexibility that this work provides, you can make it anything you want. You can work twice a week, three times a week, five times a week. Aslan, I know you're, there's a question on the chat board about COVID patients. I know you've had some experience with that. Maybe we should address that. Sure, I mean, at this moment, I have a couple of, actually, at least 10 COVID patients. I've unfortunately had a lot of COVID patients, more so in Chicago than Northwest Indiana, but it's been challenging for a lot of different ways. Obviously, I've challenged for my own health and my family and taking care of these patients in this tough environment. At the same time, it's brought a lot of opportunities to be a leader in the team. So the therapists were struggling to find things to do because the therapy gyms were closed and you had to do all therapy in the room. Finding goals and obviously all the post-COVID symptoms of neuropathy and contractures and strokes and falls and those things that go along with that. So the toughest part was, at least for my practice, was when the initial feedback came out that are we considered essential or not? And I was very thankful that my facilities had a relationship with me and I've been a part of them for many, many years. They considered me essential and they never actually told me I couldn't come in. We had to do some telemedicine, but at the same time, I've been able to work there. But that's at least for COVID. And Aslan, I see the one question on challenges with the quarantine for 14 days. So that's the dreaded PUI, patient under investigation. It's something we have to deal with. Obviously, it becomes extremely frustrating the few total knees and hips we do get. I still get a few of those. Obviously, if you're a total knee replacement and you have stairs to get inside the house and you end up in a skilled nursing building and you can't do any rehab outside of your room, 14 days pretty much covers what you're gonna get for a knee or a hip bundle patient. So it's difficult. We do the best we can. I know one facility actually has four wooden stairs that we're actually able to take to the patient's room. You gotta be creative, but there's no easy answers to that. But yes, we are facing a lot of challenges with even the non-COVID patients, because again, they are on that patient under investigation PUI for 14 days. Great. There's another question about, I'll take this one because I think I brought it up. Advise building protocols. Yes, I do advise building protocols, but I also think you have to not be hurt if your facility doesn't accept the protocols, right guys? I mean, we build a lot of things and I present them to the facility and they may go, oh, that's a great protocol, but we're happy doing things the way that we are. So I think sometimes as a physiatrist working in a skilled nursing facility, it's helpful for you to have those protocols in your head, but they don't necessarily have to be formally adopted by the facility in order for them to work, right? I've found the most success with protocol development when there's a problem. So one of the first things I do when I go into a facility is I kind of ask and just get to know people and listen. I try to not change one thing for at least several weeks and just learn from them. And if I find that they're having an extremely difficult time with like, say, for example, they're getting a lot of central cords and they don't know how to do the bowel and bladder management because the nurses have not been trained, or if they're having issues with pain, like their quality surveys are such that they're not doing well pain management, then I offer to help them and find out who owns that problem and partner with them. And I found that's your easiest way because then what happens is you develop credibility, especially when you see their scores and their metrics change. That is such a good feeling. And then you get asked to do more and more things. But I think that's easier than, you know, trying to impose something artificially on them that they may or may not be interested in when they're, you know, feeling like they're pushing a boulder up a hill, you know? And I think just that whole idea of making problems going away and adding something to make it easier for them is the way to go. Well, the easiest way that I've found to be involved is to focus on falls, because obviously every facility is fearful of falls, fractures, vines. And, you know, what I do is basically tell me on a daily basis or weekly basis who has fallen, I'll go evaluate them, see if they need therapies, anything I can do. Is it polypharmacy? Is it, what are the needs exactly? And then once they see your value there, then they open up everything. They say, oh, you know, you can do falls. How about, can you help us with a stroke? Can you help with this? So it can snowball from there, but they have a trust to you because a lot of times it's a trust issue. So our question number one actually says, we have 74% attending, and I'm glad to see some residents here and some APPs. So I'm glad that there are some people early in the career. Um, I'll be able to answer that. I'll go to a question that was asked earlier. It was about in the SNF setting where I practice getting imaging studies, like MRIs is a big challenge and SNFs have to absorb the global cost. How do you manage this type of problem? And I know Dr. Patel and Dr. Nance, you guys answered this. Anything from you, Charlotte? I'm sorry about the attending. About imaging, I'm sorry. So, you know, how do you manage that? You know, obviously we don't have advanced imaging available in the facility and you can't just order MRIs and everybody has low back pain. So how do you balance that out? So it depends on the facility. And it also depends a lot of times on just, you know, what, how critical it is to know that information. But in general, the facilities I've worked at, they had absolutely no problem with us ordering imaging. You know, it was a lot of portable stuff for like urgent things, but then getting someone to a CT or an MRI or a doctor's visit, not a problem at all. They provided transportation and it doesn't come out of the reimbursement, you know, for a lot of these cases, unless it is a bundle of some sort, in which case you're going to be talking to the people who referred it. But that has not been a problem. It's easier than inpatient rehab in many ways because it doesn't come out of a whole global payment for that patient's care. But there are some things- Maybe talking long-term patients, because there are now a lot of long-term patients that are managed by Longevity and some of these ISNIP plans. ISNIP plans are basically where a skilled nursing building will get X amount of dollars for a long-term care patient's care. So every little dollar that is spent does come out of that. But I, again, once the building knows who we are and what we do, I haven't had pushback and I probably cover at least 15 skilled nursing buildings. I have three APPs. I go to them all once a week, but I also have APPs who go to my buildings. And it's been a long time since I've had someone talk to me about ordering those type of tests. But I do remember when I started many years ago, it's been seven, eight, nine, 10 years probably since I've had that issue, but it does exist. Once they know the value you provide overall, for example, I may be charging them or the building may get charged more. Obviously we're not charging them because we send a patient out for an MRI, but at the same time, how many patients are we able to keep in the building to manage their pain appropriately to do trigger points, shoulders, knee injections, et cetera. So overall, I think we're doing a good job saving the facility money while providing better outcomes. So once they know what you do, we haven't had this problem, but again, it can happen and it's difficult when it does. Yeah, I think if you know about that something is gonna come out of the global payment to the facility, it behooves you to go to the administrator and say, look, I really need to get this and just explain why, because it's kind of, I think it's always better to get it out up front rather than to have them discover that you ordered something very expensive that's gonna come out of their daily rate. So knowing what the payment system is, knowing what things are included and not included, I think will keep you out of trouble. Sure. And if I strongly believe that imaging might change my management of other patient, then I'm not gonna keep them there. If it's a catechoin or obviously something like that, if I think that could change surgical management, then at that point, the facility rather discharge the patient into the ER and get them admitted. So I'm really careful about advancing imaging. So we're getting some answers here. So does your SNF have specific rehab programs or pathways? Is this half and half? So what we expect. And while people are answering this, if you have pathways, did you help develop the pathways? A good question here is from Jeff here says, is anyone involved with the restorative care side of things? In my facilities, Aslan, I think you're the same. We do see the Medicare B patients restorative. I don't actively manage the restorative side, but I know the restorative aids in almost all of my buildings. And they know, especially if somebody has had a fall, if someone's had a decline, those are the people who know best. If someone had very little difficulty getting out of bed a couple of months ago and they've declined since they were taken off skilled therapy and they're a long-term care resident, we do pick them up for Part B care. So they do get therapy. Some people call it maintenance therapy under the GEMO case, which the GEMO case, if some of you aren't familiar, is where Parkinson's patient's family sued Medicare saying that they should get restorative care as part of their benefits. And they do. So you can do restorative and refer them even to therapy under Part B if it's for a restorative type of need, but definitely if they've had a decline. So I would say the answer is yes, we work with restorative, but we don't actively manage the restorative side. There's more communication in which when they've declined, they get picked back up for therapy. But I'll tell you the one place that I actually did there, just a restorative care, as Amish just mentioned, is a nursing function that basically takes over some of the daily activities for patients that have gone beyond physical therapy, right? So they've progressed out of physical therapy. They're usually now being taken care of by a nurse or a nurse's aide, usually a tech, for restorative, which basically can be more maintenance. But I think it is helpful that, a lot of times those aides and techs, they don't really know anything about rehab. So one thing that I found to be very helpful is, we have some materials, some programs that we've put into place, teaching aides and techs, some basic rehab skills. And I think that can be very helpful in a restorative program. If you recognize that your restorative personnel are not skilled therapists, they're actually somebody who's more like an aide or a tech who may or may not have any rehab experience at all. I mean, maybe all they're doing is walking with the patient, but even if they're doing that, they need to be aware of certain things like, is a person gonna be a fall risk? Do you not leave them, do you not use their neglected side or something like that to assume that they're gonna be able to see you, right? So I think that there's simple stuff like that that we can work with the restorative programs. We actually had a process improvement team that was thoroughly just designed to improve the restorative process, because we had a lot of patients that had complex issues and something as simple as being able to put their splints on and doing range of motion properly was really kind of baffling to some of the restorative aids and it improved our functional outcomes and patient satisfaction tremendously. So that's an example of how we can get involved, you know, with providing education and systematically, I think, creating protocols and templates and, you know, just pathways that make it easier for the restorative aids. It was a PT involvement as well as nursing and physiatry that did the process improvement. Right. Okay. We have a question here. So it says, what is the benefit versus cost of signing with a company like yours, IRC, physiatry, NHR, as opposed to going it alone? So I do want to start off with just a few things about that. So, you know, obviously our panel, everybody seems to, you know, as IRC or just physiatry, but my real intention is to promote physiatry in the subacute setting. I certainly hope that the next time this talk happens is people who are not part of this company, but at the same time, my intention and our intention is to promote this, not specifically our companies. You know, the many different benefits and, you know, obviously historically before these companies came about, physiatrists were doing this independently. It's a very different environment now than it used to be. You could pretty much go to a facility and knock on the door and, you know, they might or might not say, yeah, you can come in and start working. But there's a lot more regulations now. Facilities are a lot more aware of what they need. And a lot of times they don't even talk in the individual level. They want to talk in the CEO and CMO level, Dr. Patel can talk a lot about that. And at the same time, you know, it's, but it's possible, doable though. A lot of physiatrists are doing this independently. It doesn't mean that it's not possible. It's a little more difficult to do, let's just say that. And a lot of times companies like IRC and other companies like that, or use physiatry, the protocols are created and the templates are done and you have a lot of support. It's much easier to start. Anything else you want to add? It's super helpful, I think, to be part of a team because if you're doing this all by yourself, you know, sometimes you're, you're guessing what is the right thing to do because there's not an definitive textbook or, you know, place to go to that's authoritative. And I found like the most helpful thing is just to have colleagues that you can bounce ideas off or call and go, what do I do? And, you know, just also, I think when you look at the practice of medicine right now, and you look at the costs for billing and collections and credentialing and, you know, obtaining benefits and things like that, I think one super helpful thing is if you're part of a group, it's essentially gives you the option to be part of a large group practice. And, you know, if you look at the big picture, we need that, you know, we need in medicine for there to be opportunities for doctors to still have group practices and private practices. You know, if all the physicians are employed by hospitals or insurance companies, or, you know, even academic programs that limits our job options, you know, so I think, you know, these groups are a really important part of our workforce. And I think the future of PNR and us being able to do our practice the way we desire to. Yeah. And I'll chip in there too, because I, you know, I think I'm a, I believe that there's strength in numbers. You know, I think if you start thinking about all the things that you'd have to think about as an independent physician, physiatrist, going into practice for yourself, you know, whether it's an inpatient or outpatient practice, you think about not only the billing and collecting, but all the legal issues, compliance, MIPS, you start adding all that up. And I mean, literally, in addition to seeing your patients, you'd be spending, you know, another five to eight hours a day managing your, your practice. And there are physicians that like that. I understand. I mean, my uncle was a solo practitioner for his entire life, and he loved it, you know, and he was like, I would never join an organization, no matter what. So I think some of it is personality. My own personal preference, I like to be part of a group because they do a lot of things for me. I can go to their lawyer. I can go to their, you know, to somebody and get, you know, get what I need without having to, you know, figure out how to get that all organized. So I think some of it is personal preference. If you really like, you know, dealing with the business side of medicine, and you'd rather spend time doing that than seeing your patients, yeah, go out there and do it on your own. I mean, you know, but I think that it just does. One of the things that always made a difference in my career that I felt was important was for me to be able to take care of patients and not have to worry so much about the business side of things. So that kind of tipped the scales for me. And I said, well, that makes it easier to be with a group. Yeah, Ben, listen, all, there's nothing wrong with doing it on your own, to be perfectly honest. We've got probably well over 150 providers. If this type of group existed, I probably would have just signed on, to be really honest with you. I still probably am one of the three or four busiest providers. I love seeing patients. I don't really even see that as work. It's just something I enjoy doing. But if you join a group, do ask what resources they have. I know U.S. Physiatry dedicates real money and resources to what they provide for their physicians. I know our group, Dr. Nats, for example, is full-time as a CMO. He's not seeing patients himself. So, you know, what are the resources? What's the technology? If it's a group that's taking, you know, a significant percentage and, you know, they don't have a real chief medical officer for you, they don't really have any technology to help you with, just think twice about it. We tell everyone it's probably a red flag if somebody's pressuring you to sign with a group without ever being introduced to a facility. We've had unfortunate situations the past few years where there's certain groups that are moving people all around the country. Then somebody lands in an area, you're an independent contractor, and they say, oh, sorry, you know, the building renamed on their promise, or there's just no, there's no beds for you there. You don't really have much resources as an independent contractor, and you're moving your whole family 2,000 miles, and you don't have any beds. It can be quite stressful. So those are the only things, you know, ask pointed questions. Don't feel bad about asking questions. It's you committing to them, and that's quite a commitment you're making to any company or yourself when you're working with all the work that everyone has put in to get through a physiatry residency. So ask what they're giving you resource-wise. Don't sign a contract unless you've actually been introduced to buildings, etc. So, you know, some of that's common sense. This one, because somebody asked a question about what do you mean by technology offered? Well, you know, just to give you an example, in two years from now, and some of this may be delayed a little bit because of the pandemic, but according to the CARES Act and the Cures Act, you know, every physician, whether you're an independent practitioner or working with a group, you're supposed to have an interoperability, there's a mandate for interoperability between your electronic health records. So if you go with a company, whether it's U.S. Physiatry, IRC, they're probably going to have some kind of technological capability for you to have for your billing. If you're scribbling things down on a little piece of paper and handing it to your billing person, that's not going to fly in a year or two. You're going to basically have to have some kind of electronic health system that's a health care record that's going to be HIPAA compliant, and it's going to allow for interoperability with these other systems. So try to do that on your own. I mean, I'm sure there'll be companies that pop up, you know, that will try to take care of that for you for a fee. But again, that's a part of your overhead. So, you know, as it gets more complicated for you to be in the business of medicine, and there's more regulations and things that you have to deal with, that's the other thing I think that tips the scales towards a group that has the resources to be able to provide that technology to you. We only have about a couple of minutes left, and I do want to make sure we go through all the questions. The one question was, how do you approach a SNF to attempt to consult there? And I did talk about this at the end of my other talk, but just to give you a quick summary of this, you can go different ways. You could be the IRF physiatrist and find out where the patients are going and follow the patient like Dr. Nat said. You can communicate with the facility. A lot of times these SNFs are pretty much looking for referrals, and that's how they keep their doors open and the lights on. So, that might be the potential idea. You can also approach them by cold calling and setting up meetings with the therapist or the medical directors. Majority time I think it's best to go with the medical director route and see if they have a need and, you know, tell them about your services and what you do. They have a number of different things that they're afraid of. They might be concerned about billing, that they might not get paid for their service, or over-utilization of services, or you taking over their patients. I mean, there's different things that, you know, you have to deal with. Another way would be to obviously use a company, or you could just knock at the door. I mean, obviously COVID time is tough to do, but if you are part of that community, and I have a clinic here, I work in the hospital, it's much easier to go into a facility. A lot of these decisions are at this point made by the upper management, like chief medical CEO, and some of these are big, big companies, and they want to see numbers before you just show up. You can't just promise things. They want to see the data behind what you can do. Just a couple ideas. Last question, I guess. Actually, we are, time is up. It's 3.30, but I guess we can answer this quickly. How do you deal with APNs being used by SNFs to replace physiatrists? We haven't seen that. We work in several buildings where there's a full-time nurse practitioner to help the building and care overall. Usually, that care is dealing with the internal medicine side of things. We use APPs. I love APPs. I think, Chris, my APP is on right now. Hi, Chris, and thank you for everything. We really use APPs as an adjunct or as an addition to something that we do. I, myself, still do the business side of it with IRC. I still run as a CEO, but I love seeing patients. All my buildings have a PA or an NP that goes in with me and not physically with me, but in the building every week. We alternate visits. We really haven't run into a situation. We're not a company that would ever try to send only an APP into buildings unless it's a rural-type situation where we can't get a physiatrist. I'm sorry, I really can't answer that. I think maybe the question, if I have a minute, the question was maybe there's a facility out there that puts an APP, like a primary care APP in place, and they sign the certificates for the rehab and things like that. I've been in that situation where the APP was told, this is what you do. You just sign these certificates. When I got there, it was when I walked into the building, and the APP basically fell down and said, oh, my God, I'm so glad you're here because I had no idea what I was doing. I think that there probably are places where that's happened because people don't understand that rehab is specialized, but when it does happen, then unfortunately, if they don't have a physiatrist, the patients there get substandard care. If they have a physiatrist, I almost guarantee that the APP will become your best friend in that facility. He explained the question more, he said, about talking about a PM and our doctor using APPs and not going themselves ever. That's just not good practice. Good practice. We wouldn't recommend that. We definitely don't recommend that. It's a co-management model. We use APPs in a different way, so they're maybe following up on patients. I do the initial evals. I do injections. I mean, it's a co-management model with the APP if that is ever the case, but you definitely don't want that kind of scenario. It's not good for the APP or the facility or our specialty. You don't want to be considered just an APP type of specialty. It might not even be legal. Basically, you have to have supervision of your APP as a physician. Unless you're supervising them, it's probably not really even kosher. Well, I think this last answer is great. It says, do you feel that stiff rehab is enjoyable? We have 100% on that. I do agree with that. If anyone has any questions, I did leave my email. Obviously, these lectures slides will be available. All the panel members, if you don't mind putting your email addresses in the chat box just in case, so they don't have to go through the whole slides. Feel free to ask any questions. Please join the member community and feel free to ask any questions there. I think we definitely need to be a lot more involved in this. Thank you for everybody's presence. Thank you, guys. Thanks, everyone. Appreciate it. Thank you. All right. Take care. Bye. Bye.

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