Thank you all for joining tonight's member community session. Before we get started, we just wanted to go through a few housekeeping notes. Here we go. As a reminder, this session will be recorded and you will be available to will be made available on the academy's online learning portal after the session. For the best attendee experience during this activity, we ask that you please mute your microphone when you're not speaking and you are also invited to keep your camera on and to select hide non-video participants. This will ensure that the speakers are prominent on the screen. Also, if you would like to ask a question, please use the raise your hand feature and unmute if you're called on or otherwise you can use the chat feature to type your question. Just a quick note about the Zoom platform, the microphone and the video controls are located on the bottom left of your task bar and are controlled by the caret to the right of the icon. 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So, you know, if you want to review it later on or want to spread it to other colleagues, please do so. So, you know, I'll start off with basically, I mean, the topic of physiatry in the SNF setting. Last year, we did a three-hour talk and I want to basically summarize it this year because we'll have a few talks this year in person in Baltimore, which I highly encourage, you know, the people attending this virtual clinic to also come to. So let's start off. I am Dr. Aslan Tariq. I am the Chief Clinical Officer for Integrated Rehab Consultants. This is my disclosure. So today, hopefully my part of the talk, I'm going to talk about the current status of SNF physiatry and then talk about some of the past and some of the trends that are happening and then we'll keep on continuing discussion after that. This is an interesting article that, you know, I came across a year ago. So it was from the Clinical Rehabilitation and Physiatry Practice Journal. It talks about, you know, what the role of physiatry is at that point. It was talking about how it's a new level of care, how there's a trend of patients that are not staying in acute rehab, they're transitioning to outpatient or subacute care and how, you know, having physiatrists being able to focus on the different settings will help the growth of physiatry and the future practice of physiatry. But what was really interesting about this article was that this was in 1996. So the physiatry in the subacute setting is not new. It's obviously getting a lot more, you know, a lot more common now than it was maybe even a decade ago, but it's nothing new. I've had mentors who've done subacute physiatry from the 80s, but, you know, obviously there's a whole lot more people doing it now. And for a lot of reasons we'll discuss in the next few slides. So there's a few missed opportunities. You know, one is that subacute does not have a consistent definition and it's not really defined by Medicare. So, you know, typically in the Medicare language, they'll mention nursing home, which is NF, which we use acronym, or you can have SNF for school nursing facility. But, you know, Medicare does not specify, you know, to certain criteria, what the intensity of therapy services are, should be provided in the SNF setting. And there's obviously a lot of opportunity for physiatrists to be involved in this continuum of care. So, as I mentioned before, physiatry in this setting has been around for a long time. You know, the number of reasons that most residents in residency and afterwards as new attendings don't know about subacute is because a lot of subacute physiatry is not being practiced in the academic setting. There's a lot, you know, more trend towards that. And some prime examples are in Hopkins, for example, or even Russia, Chicago, and other places where subacute exposure is happening now in an earlier stage. But, you know, I was lucky enough to be in a program that we had a dedicated subacute rotation. We had attendings doing subacute for decades before us. We had in-house, we had a taxed subacute unit in our hospital, but it's probably one of the most unique programs out there. There's a couple of programs in Florida that have that, but the trend is towards, you know, the residents are asking for early exposure, which is a good thing in my opinion, because it is part of the continuum of care, but, you know, the exposure is still lacking. And it's partially due to the GME requirements and things like that, which are not in a lot of control for the hospitals too. But, you know, obviously there's a lot of trends in length of stay. Length of stay has gone down significantly for all sorts of settings and also for certain conditions. You know, I was reading an article yesterday about how 95% of, in a specific major practice in the Midwest, their knee replacements are going home the same day, where even before COVID, you know, more than half of them were actually going to nursing homes or something acute rehab. So there's trends across the board of reduced length of stay, less hospital, either SNF or home. So as far as the amount of patients in these settings, you know, approximate number 375,000, 400,000 are staying in the acute inpatient or inpatient rehab facilities. And there's 15,000 skilled nursing facilities with 1.7 million patients. So a lot more patients, almost five times more patients are getting rehab in the skilled setting versus in the acute setting. So there is a time and place for each one, but the trends are more towards the direction of, let's go home sooner. And this is the trend in the calendars. You know, we have some data from 2004. We have some new data from just now, from 2022, where it's pretty clear that the trends of acute rehab visits, and this is what the graph is showing, that the green is the inpatient rehab facility visits by PM&R and calendars, and the green, the dark green is the SNF and calendars. And you can clearly see that the numbers doubled from 2013, 2019 to 2020. From 2013, 2019, the number of subacute visits were being done by physiatry versus there's a plateau of the acute rehab visits. And I, in my, and I think I can predict this, that it's probably gonna plateau and maybe bump up a little bit, but I think overall the trend is towards home, where subacute kind of comes in the middle of that. One of the things that are filling the movement is gonna be the 60% rule that restricts certain non-compliant patients or patients that don't qualify for going to acute rehab. Then you have a lot of local LCDs that basically specify that the subacute has to go in a certain diagnosis, have to go to subacute versus acute. You have much more Medicare Advantage plans now. I think it's a 30% or so approximate of patients are on Medicare Advantage. That's a huge trend toward that direction. And the more managed care plans they have to reduce that, the stay comes along with that, less SNF, people are even getting denied to get SNF care from the acute rehab setting, let alone acute rehab. And the subacute rehab has been shown to be more cost-effective, so for certain conditions. Now, there's a lot of different variables in that. It depends on the, sure, the cost could be lower potentially, but it's also the quality of care that's important too, or length of stay is important too. So those are the things to keep in mind. And that's what this next slide, which MedPAC published this table, and I know Dr. Quarg is gonna talk more about this as well, is looking at the cost. And what does it cost for a trach patient event in a skilled nursing versus independent inpatient rehab or long-term facility? So a stroke patient, for example, I'd look at one example here is 8,900 or so for skilled nursing, 3,400 for the inpatient rehab, or 3,000, I'm sorry, and 31,000. Now, again, and I think MedPAC was looking at a lot of data and they were trying to compare stuff, and there's probably some nuances there that they're now looking at that. But overall, it's overall pretty clear that stroke patients are cheaper to manage in a skilled nursing facility. And sure, they might have a higher readmission rate, but overall, in general, they're cheaper, or less expensive, I should say, for the system. But still, that does not equate to better care. And that's why physiatry, I think, fits in, because if the trend is going that direction anyway, I'd rather be in that setting and helping the patients out to improve outcomes as our system overall goes into the value-based care system. So this more evidence of like, does physiatry actually provide value? There's a lot of, I shouldn't say a lot, but there's a decent number of studies out there that talk about the value of rehabilitation. There's minimal number of studies out there talking about evidence-based, that physiatry is cost-effective or value-based. There's obviously great studies for spine care, brain injury, ventric patients. There's almost no studies for subacute patients. And also, there's very, very minimal information about how physiatry can affect length of stay. And I'm working on something right now to basically hopefully make it into some kind of a post-presentation that will review all the data out there. But for us, as physiatry, we looked into this data to see how do we affect ER visits, length of stay, utilization, readmission, those kinds of things. And again, if you have an involved physiatrist in the facility doing the way that we train our docs and we at least try to educate them how to practice, that tends to show better outcomes. And outcomes will pretty much lead the next generation of payments and models. So it's good to be ahead of the curve in that sense. So what are some of the challenges prior to subacute? Subacutes have before physiatry, many of them, and Dr. Smith will talk more about those as well but inconsistent primary care visits. I mean, just today I was on a call with the primary care physician who only shows up once a month, and that's pretty standard for a lot of nursing homes. A lot of times the nurse practitioners might be covering the facility. You have many, many providers in the setting, including primary care and nurses and other staff that have basic lack of knowledge of brain injury or stroke or orthopedic issues or any kind of conditions that are rehab related. There's obviously a lot of polypharmacy going on as well, which we try our best to avoid, which would be over medication of NSAIDs and narcotics and other medications like that. So a lot of inappropriate or excessive, I should say, testing being done, lack of cohesiveness between families and therapists. So obviously it's a very stressful environment for family members too, especially after COVID where you have the guilt of leaving your mom and dad in a nursing home or a SNF or a subacute. And if there's not enough communication that's happening between what's happening, what the progress is, how long they have to stay, what the next steps are, that creates a lot of issues. So we end up being that person helping out with the flow of patients. There's also a lot of delay in providing specialty care. So a lot of times like, you know, the primary care too, they're, you know, sometimes they have to because the resources they have, but you know, they just cannot offer certain things. A majority of places that I work in myself would talk about my practice. You know, there's a bunch of basic specialists and consultants in the facility. Not just me, there's nephrology and ID and cardiology and not every single facility can handle that or do that because again, there's not enough physicians and the resources are very limited, but at the same time, the trend is going that direction. There's inappropriate discharges. That's the big, big penalty for a lot of nursing homes. There's a recent study that came out that said out of this 1800 nursing homes in Illinois, only five of them did not get a penalty. So that means everybody had a penalty for discharge to the hospital. So it's very challenging for them to not have high readmission to the hospital without having adequate support with the staffing issues, not having specialists in house, having to admit sicker and sicker patients. So all complicated things in which they have to leverage a service like a specialist or consultant to help them out or someone who's a medical director, who is a physiatrist who can help them out, kind of be the team player and look at the quality across the board. So high length of stay, pain scores, high readmission rates, you know, Medicare star ratings are extremely important for facilities because that's how they end up going into, you know, plans of tiers that hospitals will only send patients to a certain Medicare star rating. That's a topic by itself of how those ratings are done. And now the ratings are actually evaluated by staffing level as well, which is completely unfair in my opinion, because staffing is an issue in every industry. And, you know, it's hard enough to like, you know, basically hire CNAs and nurses and to go to work in a nursing home setting, especially after COVID. So, you know, it's a really tricky place to be in and the facilities are always in a tough spot to provide the care without actually, you know, going broke. And I've actually unfortunately had to witness a few facilities actually going under and then having to basically transfer patients out. So those are real challenges. And again, as we go in as people who love working in teams and can help out these patients, it's a benefit for them. But there's a nuance to that and how we do that. And again, I'm sure my other speakers will talk about that. So discharge to home is also important versus back to a nursing home or audits and health inspections. Those are also challenging. There's a lot of challenges that we can help out with. A lack of specialized care. A lot of, most of the nursing homes that I work in did not have a fall program or a bowel bladder program or pain program, or if they had it, no one was implementing that. So those are important. And there's a lot of inconsistent and poor outcomes from peer-to-peer reviews. So that's a big part of our practice. Actually, this is a big part of practice, but it's part of my practice now. Thankfully, it's not a big, massive part, but, you know, once or twice a week, I have to do peer-to-peers and, you know, those peer-to-peer reviews are getting more and more tricky because they're just asking for more and more information, which is not assessable on time, and they deny care all the time. But I tell myself, I tell our physicians that we are advocates for patients. We do what we can to protect them. So if that means I have to get on a phone call, talk to someone, I'll do it. So this is the APMNR position statement that was released in 2016. There's a new one that's gonna be released soon as well, but this is pretty much in a nutshell what, you know, what the APMNR says. I'm gonna read some of this verbatim, but some, obviously, the link is down here, which you can look at or just look up on the website for APMNR. But physiatrists, by virtue of their training, experience, and knowledge of rehabilitation, impairment, and function have the unique qualification to be expert and leaders of the SNCC rehabilitation team. In the ideal situation, a physiatrist setting will serve as a consulting or co-treating physician and visit the patient two to three times a week. And it's a common question I get asked all the time is how often do you see a patient? And again, there's no perfect answer for that. It's all based on medical necessity, but at least you have some of this from the APMNR upstatement that says two to three times a week probably seems right, again, depending on medical necessity. And when I started working 10 years ago in this setting, obviously, there was patients that would stay for 80, 90, 100 days. It sounds crazy at this point because my average length of stay is about 20, 25 days now, so it's gone down significantly. So, you know, two to three times a week seems very appropriate now, especially if the primary is also seeing the patient a couple of times a week. You need enough of those touches to actually make a meaningful impact. Otherwise things, you know, happen and no one knows about it. And next thing you know, the patient declines towards the hospital. So our data has shown that the two to three times a week seems to be the appropriate amount to make a meaningful change. And again, the last statement, the physiatric management of patients in the SNF setting will lead to greater functional gains by the patient, early discharge and cost saving. And again, this has been proven in studies too. So what are the different models? You know, there's many different types of ways of doing it. Very rarely there's an employee model. Employed by the facility is extremely rare, employed by the ownership, most likely employed by a physiatry practice or a hospital. There's independent practitioner model, which we can just, you know, potentially do this as a side gig, if you want to call it that. There's a contracted independent model, which, you know, some groups obviously do, including our group. And then you can be a medical director, you can be a rehab medical director. In our practice, at least we have a handful of doctors who are medical directors in the facility as doing both primary and doing physiatry. And, you know, some of them have a strong background in internal medicine or they were acute rehab, and that's also possible. You know, usually when you're a medical director or a rehab director, you have some leadership, you have some things you have to do, meetings, things like that, but typically you are also getting a stipend. It can be a consultant physician, which basically is like independent contractor. We only, you know, basically evaluate patients getting therapy, and also you can be a physician who has APPs. Now, APPs, you know, it's a very controversial topic for some people and not so much for us, because, you know, we feel like that's one way of leveraging our physicians to actually provide more care without actually diluting it too much, because we're very involved with our APPs or NPs and PAs in the building. We're just co-managing with them and they're helping us out. But that is another model that there's not enough physiatrists to manage all the facilities. There's too many, there's 15,000. So it's extremely unlikely for every physiatrist tomorrow to become a sub-agreed physiatrist. So kind of have to help do that, but we try not to do it as a first thing. Like I said, two, three times a week is the frequency visit determined by medical and rehab needs. I'm not gonna go through all this whole process here, but the idea is that, you know, as an independent contractor, you know, there's a lot of things that, you know, are done in the backend that, again, not saying that, you know, people cannot do this themselves, which is, you know, people have done this before independently, but typically working in a bigger practice or something that already has structure and has already figured out the nuances and mistakes that they can make, you know, having that assistance, the software, the training protocols, the malpractice, the marketing, the compliance. I mean, there's a whole lot of stuff, audits, credentialing, privileging, insurance, negotiation, all things that, you know, companies end up doing for you. And that's one way of kind of reducing that overhead or work or the over work that you do. But again, some people can do this independently as well. I work in an interesting area in the Midwest, in Chicago, specifically, and, you know, my nursing homes, I have a handful of nursing homes, but some of the high ends like literally look like they're, you know, a NASA therapy gym. They have like zero gravity, a treadmill and a swimming pool and all sorts of things that the facilities have to spend money on this to attract the patients and to attract the hospitals. But the vast majority don't look like this. You know, some I have working that are affiliated with the hospital. Some have full-time NPs and physicians, but I just seem to have some that are opposite of that. So the trend is going towards like super sniff or the medical resort model where patients just come for short-term rehab, improve almost like acute rehab, short stay and go home. And a lot of these places are actually contracting with managed care plans to basically grab the patients before they go to acute rehab. So there's some competition there too. You know, private rooms, five-star hotel feel, outing, chef-created meals. I mean, a lot of this stuff had to slow down because of COVID, but, you know, now they're back and, you know, families are Googling and putting on Yelp and things like that to find out the facility to tour that and make sure their mom and dad are happy. And a lot of times, unfortunately, the facilities might look really nice, but the care is pretty poor, but, you know, these first impressions are important. So they're really spending a lot of money on that. So I work in, like I said, multiple medium to large subacute facilities across Chicago, and my insurance breakdown is about 70% Medicare, 20% managed care, and that number's up pretty 25, 30% now, and so only going up. And all the patients have a primary care physician. The patients that I manage, you know, it's an open medical staff model. It basically means fee-for-service. We have to be credentialed at the facility. The patient has to get consent to our treatment. You know, there's cardiology, nephrology, derm, podiatry, again, depends on the resources. The hospital, a lot of times, can actually force certain things, like saying, no, we want, you know, our dermatologist to see the patients there, our neurologist to see the patients there, but most facilities don't have multi-specialty. They're mostly just one specialty, primary care, or not specialty, just internal medicine or geriatrics. They have psych usually, might have wound care, you know, a few things, podiatry maybe, but majority of the time, you might be the only specialist there. I typically see every 25, 30 patients a day, and, you know, some of us see less, some of us see more, depends on your efficiency and the work, you know, flow that you have. You know, there's meetings that come along with that. I do bedside injections, so very, very MSK-related type of practice to prosthetic orthotics. So, you know, one of the things that people are very fearful of, especially the docs coming from outpatient maybe, or they want to do subacute is that, hey, I have not done a huge rehab for many years, but important to know that 90% of what I do, at least my practice specifically, and what most of us do is MSK, neuro-orthopedic-related, pain-related. There's obviously things that are, you know, above and beyond that, and usually the primary care is made aware of those conditions, they help out with that. So any medical issues that are out there, we address, we communicate with primary care team, the specialist outpatient, you know, we create pathways, algorithms that we work on, work on guidelines, marketing, in-services, peer-to-peers. I mean, I'm really truly involved. I'm not saying that acute rehab, we don't do the same thing. In our practice, we have acute rehab as well, but, you know, in this setting, we need that leadership. And the hospital settings have a lot of resources, the SNFs have no resources at all, so us doing just this is really good for them. As far as the patient population, about 30, 40% orthopedic, at least my practice, very similar to acute rehab was back in 2004, and then 20% or so max of stroke and brain injury, 20, 30% of cardiopulmonary was post-COVID as well, and the rest are cancer and other deconditioning, weakness, dementia. And again, it does depend on the facility, it does depend on the area, the neighborhood, the city, the state. I mean, there's so many variables, but at least overall, my practice and most of us, we have that kind of setup. So what can we provide? Outcome-oriented care, evidence-based care, cost-effective care, accountability, quality care, all the good things. So again, as part of the AAP MNR's bold new vision, we are essential medical experts in value-based evaluations, diagnosis, management, and of disabling conditions. We are indispensable leaders in directing recovery and preventing injury, and we're vital in optimizing outcomes and function, early and throughout the continuing care. So for me, my main purpose is to promote subacute physiatry. Get involved, get educated, get exposed, learn where the patients are going, learn what your role is hopefully from these talks and future talks, and then see if that fits your practice. Maybe it does, and maybe it does, but at the same time, most acute rehab docs that I have talked to over the years, they don't really understand subacute as well. So I think overall, just having a knowledge base of what happens in the setting is extremely important. On that note, I'll leave my QR code up here, so you can always scan this in. It goes into all my links and my email down here. Happy to connect with anybody after. Thank you so much. Start off with Dr. Smith. I think Britannia is going to set up one of the poll questions, Dr. Tariq. Oh, that is great. I apologize. I forgot about that. Let me do that right now. So I'm going to launch a poll question here. If you guys can answer that, I'll give a bunch. Okay, I'll end the poll here. Yeah, almost everybody is in attending. Great. Great. I'm hoping for more medical students and residents so they can get exposed early but I'll take that for now. Okay. That's great. I love it. Well thank you very much, Aslan for that excellent overview. That was so good. I learned something every time listening to you and it's extremely encouraging to me to meet other physiatrists that are interested in this, because I think there's such a huge need, and I think every year we're learning more and more how to do this better and getting more and more people interested. My disclosure I'm Charlotte Smith, I am living currently in northern Idaho, that's my background there, my backyard, and my disclosure is that I work with an IT company that just happens to be providing PM&R services in post acute facilities, and that is actually huge advocates of PM&R and believes that PM&R is the best specialty as do I. And so that's what I'm doing and that's my disclosure. Let's see here. So, I guess the big question right off the bat is, should PM&R physicians be in SNFs? And the answer I think is yes, I think there's no question, you know, exactly like Dr. Shrake said, you know, we're following the patients. They were in IRFs, they've shifted to SNFs, somebody needs to take care of them, you know, either we're there or not, and they don't get services, you know, we've led IRFs, we have the skill sets, we know how to take care of these kind of patients. And the other big issue is that the current CMS standards, like was previously mentioned, are not really very good in terms of getting best outcomes for skilled nursing rehab patients. So, you know, when you're seeing a patient one time every 30 days, and the first visit may be day 29, you know, that's probably not going to lead to the best outcomes. And I think also the other thing, and this is really near and dear to my heart right now, is skilled nursing facilities are under attack. Between everything that's happened with COVID and just the changes in regulations and how they're paid and everything like that, you know, a lot are dropping dead. And if they fall apart, it's going to be very difficult for people to have access to skilled nursing services, which impacts every level of health care. Because if you don't have skilled nursing bed capacity, then the key care hospitals back up, and there's no throughput. And that is a very frightening thing because we really need to have throughput and we need to have places for people to go and home is not always feasible. So why don't we have physiatry in every SNF? Well, there's a lot of reasons, and I'm going to go through some of the big ones. You know, there are factors within the industry. Bottom line is that most skilled nursing facilities, administrators, and their medical directors still don't really understand the benefit we can provide. And even further, some skilled nursing medical directors who are typically internal medicine, family medicine, geriatrics, generally, they could be other things, they may be very threatened by the whole idea. Like if you mentioned co-managers, they're like, heck no. You know, I'm the leader of this facility. I'm paid to do this. I don't need your help. Then some SNF administrators are scared to death that a physiatrist is going to come in there and start ordering tests and ordering things that they can't deliver and drive up costs, especially under PDPM. Before PDPM, when it was rugs, we were a huge asset because the more therapy that was ordered, the more the skilled nursing facility got paid. But that all changed with PDPM. And so now therapy has gone from being basically a revenue generator to a cost center. So there's fear that it's going to be over-ordered and it's going to put them into bankruptcy and they have very tight margins often. But the other big thing is the reimbursement models are a barrier. It is a very different type of medicine that we practice in skilled nursing. And if you don't really know how to bill or document or do it efficiently, it really can be a challenge to do this and be profitable and hit benchmark salaries. So why are we not in there also? Well, part of it is not just the facilities, it's us. And, you know, most of us don't have any exposure training. And I say this to you humbly as someone who had to figure this out the hard way, because I started seeing patients in skilled nursing in the 90s. And at that time, they were hospital based. It was just one more unit of our inpatient rehab facility. And of course, they all transitioned out into the community. And what I've learned is the rules of the game keep changing. And about the time that you figure it out, you have to do something different and have a different strategy. And of course, it doesn't help that you're not given any of this in residency or fellowship or training. You know, so you have to go out there and just figure it out and see if you can do it a little bit better than you did the year before or the day before. The other thing is a lot of physiatrists just don't see SNF as sexy. You know, it's just like not nearly as attractive as sports and spine or interventionals maybe. Or, you know, the perception of being a nursing home and nursing home patients is sometimes something that puts people off. And it's kind of interesting because the perception and the reality are quite often very different. A lot of physiatrists are just too busy. You know, I don't know a whole lot of physiatrists right now that are, you know, wanting more things on their plate. You know, they're all pretty busy doing their gig and what they're doing. And then, you know, the other big issue is just so many are burned out or on the verge of burnout. And so, you know, the trick would be, gosh, you know, would this be something that helps or hurts burnout? We'll talk more later. I actually think the skilled nursing level of care can decrease burnout if done the right way with the right partners. But the other key thing is, you know, there are not enough of us to go to every skilled nursing facility in America and cover what we already need to cover. So there's a shortage of us. And so, you know, these are things that we struggle with as a specialty. So another big thing is sometimes what we do inside the facility. And, you know, I will say to you that, you know, this is no one's fault. I don't mean to in any way put blame or shame on anyone, but I've had quite a lot of phone calls where they'll say, you know, Dr. Smith, I need you to come to my facility and fix this physiatrist or get them out of here. And I'll find out it's not someone I know or someone I'm working with, but they assume we're all in the same group because how many physiatrists can there be? And it's usually someone that's very well intentioned and outstanding physician, but they just don't know the rules of the game. And if you go into a skilled nursing facility and do the same things you do in an inpatient rehab facility, it's not going to end well. It just won't because it's a very different ballgame. Sometimes also people come in and they just don't know what to do. You know, it's like, well, they already have a medical director. I mean, what's my job? I don't know what to do. I've had several that have said, I don't like this because I don't know what to do. I'm not sure what my role is. Nobody else there can tell me this is not fun. And it's sad because I think that, again, is just an education issue. But they end up not being effective because they don't know what our core mission is, which there's a big one. And then despite good intentions, you know, if you write orders that can't be implemented because it's not feasible or you're ordering things that are very expensive or you're really worried about a patient and you just, pull the trigger and send it back to acute care and call 911. You know, things like that can be really problematic if you're not playing well with the team and it creates big problems. And then last but not least is the reimbursement is less, you know, so you have to have a model that works. It can be, I think, very lucrative if done properly. But it is a very different resource base, if you will, than inpatient rehab and other types of things. So, you know, if we're not sure what we're doing in SNFs, and the facilities aren't sure what we're doing in SNFs, you know, what could possibly go wrong? Especially if the facility medical directors are used to being the boss and doing their own show, and they've never worked with a physiatrist before. You know, and the truth is, there's a lot that can go wrong. Because if you don't know what you're doing, they don't know what you're supposed to do, and they're not sure they want you there, you can imagine sometimes it does not end well. So what goes wrong? Well, one of the things that's a big deal is just expecting a SNF to operate like an IRF. It's just not going to happen. There's different resources, the nursing ratios are different, they have fewer licensed people. So rather than RNs, you may have more CNAs. Therapists now may be outsourced. Some facilities own their own and employ their own therapists, and they're consistent, and they're always there. But especially since PDPM, a lot of outsourcing, you have agencies providing therapists. And it may be like the speech therapist only comes if requested, or they merely only come once every two weeks. You know, so there's facilities like that. There's ones where the staffing is phenomenal, too, where it's good or better than any inpatient rehab facility I've been to. So, you know, one of the key things to remember is that skilled nursing facilities have the highest variability, probably, of any segment of the healthcare industry in terms of how they operate, in terms of their outcomes, in terms of their quality. And so, you know, staffing can be variable in different places. The other thing is they may not even have an EHR. Like, most of them are using point-clip care. That's kind of become like the epic of the post-acute world. But there are other kind of weird, quirky ones you'll deal with. And then there's some facilities that still have not made the conversion to electronic, which is kind of crazy, really. But that can be challenging. And then the other key thing you heard earlier, you don't only have to see a doctor once every 30 days. There's no requirement for specialists. And then there's also sometimes very limited lab, radiology, and other ancillary services. So they are a lot of times outsourced and not right there in-house and not readily available, which can make care a little bit trickier. So what are the solutions? You guys want to hear the solutions. That's why you signed up for this panel, not to hear more depressing things or to discourage you. And I will say to you, you know, this is one of the most gratifying aspects of care I've done in my entire career. I love it very much and do it because I choose it. But the thing you have to do is you have to learn to adjust your expectations and work within the constraints of the facility. And you have to realize that, you know, there are some things that are realistic and some things are not. And what I have finally learned is you err on the side of communication. It's better to ask than to do something wrong and figure it out because you really messed something up. And, you know, communication is really everything. It's so important. But you also learn not to write orders that are going to already take an overburdened staff. They're also spread thin, especially since COVID. And, you know, if you're writing orders that are realistically never going to be implemented because it's just not feasible, then you're part of the problem and not the solution. And you also can cause that facility to have audits and fines and patient and family complaints. So we don't want to be doing stuff like that. And that's where getting to know your facility and getting to know what its resources are and what it's capable of doing is very important. You also don't want to create expectations for the patient and family. You know, if you say, oh, well, we're going to have you out of bed three times a day for meals, then we're going to do this, this, this, and this, and it doesn't happen. Oh, that's bad. Because if they complain, it triggers the state complaint nurse. And what Dr. Tarik was talking about with the star ratings, a lot of it's based on complaints. And there are not scarier words in the English language than the state Medicaid nurse complaint nurses in the building. And that really is terrifying for a family. So you don't want to create expectations that can't possibly be met because it really becomes a big problem for the facility. The other big thing is just not understanding their complexities and the challenges. So, you know, in my opinion, my humble opinion, I think skilled nursing is the most challenged aspect of health care today because of the complexity coming in. You know, the patients that you see there now, it's not an unusual thing to see somebody post-op day three after a 360 fusion. Fastest going demographics for spinal cord and brain injury are over the age of 65. You see an awful lot of central cords. You see a lot of brain injuries. They are very complex. The level of comorbidities that you see in these patients can be very high. The challenge also, too, is the reimbursement has not gone up with the complexity. And there's more and more regulatory standards. I get very upset sometimes at the things that CMS mandates and the things that they rate these facilities on because they don't have control over all the variables sometimes. The length of stay has gotten shorter. You know, woe be it to get a patient who's told in the acute care setting, oh, you get 100 days of SNF. Well, that's not anymore. You know, basically, the lengths of stay have been squeezed down to about 25, 30 days on average, I would say. But what's really interesting, in some markets, one that I just came from, the major payer there that was a managed care payer, you know, basically wanted all strokes out in 10 to 12 days. Okay. Now, average length of stay for a stroke and inpatient rehab at that time was like 14 to 17. And that's with three hours of therapy a day and daily doctor visits and full infrastructure. You know, and these are theoretically sicker and more debilitated patients. You know, so I'm like, hmm, how realistic is that? And that took some negotiation to work through. Staffing challenges are crazy. It's just so hard right now to find staffing in any level of care in, you know, healthcare right now. But SNF tends to be the least attractive. It's, again, not as sexy as delivering babies or working in a clinic or in the ER or the ICU. And the patient family expectations are very high, very high, because they recognize this may be the last shot that their loved one gets to ever go home again and be functional. And then let's just say COVID. COVID has caused so many problems financially, just the perception of skilled nursing, fear that people have of going to skilled nursing, staffing. It's been pretty difficult all the way around. So another solution, if you can get to know your SNF's unique challenges and work with them. The thing about PMR that I love is we're scrappy. We're used to figuring out a solution when nobody else knows what to do. And so, you know, if you get to know the administrative medical director and you're their ally and you ask them what their biggest challenges are, they're going to probably tell you all the things that are on this list. Staffing is probably number one in the country right now, if I were to guess. They are all worried about admissions and readmissions and functional outcomes. Census, even though there was a lot of people busting the seams during COVID, there are a lot of facilities that are still struggling with staying full. And within margins, not being full creates a lot of deficit situations. And there's a huge number of skilled nursing facilities still closing down every single month. It's mostly the smaller ones that are locally owned, a lot of the not for profits. And it's really challenging to keep the doors open if you don't have a full census. And then, of course, you know, costs, complaints and CMS ratings are always things they're worried about. So, you know, I try every time to think about a facility to walk the doors, what are their biggest challenges? And, you know, my number one goal when I show up is just to not make things worse. And if I can show up and just help them a little bit, if I can just help one patient that day do a little bit better, I feel like that's been a good day. And what you'll find if you go in with that attitude is you'll have more good days than bad and you get better and better. And just finding solutions that help them are, I think, what they're looking for. So how do we help them? There are so many ways, you know, and I won't go into all of it. It's way beyond the scope of this talk, but here's the bottom line. Our specialty teaches us some really useful things. I mean, in addition to being scrappy, we also are pretty smart about programs. And being able to put together programs that work inside facilities so that the nurses and the therapists aren't as freaked out by things makes them more efficient and decreases their stress. You know, as we decrease the stress of the nurses and the therapists, they're less likely to quit and turn over. And a happy staff that stays together has a better shot of providing excellent care. And so a lot of what we're doing is really supporting those teams and being there. You know, I know if I get called in the middle of the night over something I haven't done for like 30 years, like managing an acute EKG abnormality, it freaks me out. But if someone wakes me up over dysreflexia or anything, spinal cord or anything, brain injury, I don't even, I'm not worried. It's not a big deal. But think about how these people are in these skilled nursing facilities every day may be that really, oh my God, I've never seen this before. What do I do? And I don't have many resources to work with. That's very terrifying to them. So anything we can do to provide expertise and support and education, you know, and just programmatic structure is very helpful to them. Patients and families, their biggest fear sometimes is I'm going to be dumped in a nursing home and I'm going to go there, I'm going to die and nobody's ever going to get me out of bed. This is the end of my life. And the minute you walk to their bedside and you say, you know what, I'm a physiatrist and I'm here. I want to see you get to the highest level of function you possibly can. You know, they just, their stress level just goes way down. They know they have a specialist. It's like a really big deal. And of course, what that leads to is more confidence, acute care facilities that know there's a physiatry team in a skilled nursing facility automatically will tend to refer to them as a preferred provider because they know that their patient is going to get good care and they're going to get rehab and they probably won't bounce back. And then last but not least, there's all these administrative, what I call high hassle factor tasks, the face-to-faces for durable medical equipment, home health, all the peer-to-peer calls, you know, all the rehab plans of care. You know, we actually read those things and look at them. And sometimes in the facilities, they'll ask the physiatrist to take over signing off on those, which is really great because then you really get to see every single one and you really get to know your team very well, but it helps them. It's taking things off of their back and gives them more time to really do patient care. The other big thing is, you know, it's really impressive to me how many people that work in SNF stick with it. You know, some of these are people who are not being paid as much as they could be in other environments. It's really amazing. A lot of them have increased job demands of less resources. They're almost always short staff. They may get called into work doubles all the time and weekends and holidays. Many times the staff that are in facilities are multicultural and they may have limited English proficiency. And it's challenging because then you have patients that have a different language proficiency and it creates all sorts of cultural challenges. You know, there are oftentimes educational knowledge gaps, which again, contribute to high stress. And they're also, they get a lot of abuse. Sometimes patients and families are just frustrated. They're not home and they're stressed out. And these are the people who end up getting the brunt of their abuse a lot of times. So all of this could lead to staff turnover. But what I've learned is one single nurse assistant can make the difference between success and failure and treatment care plan. And I'll give you an example. Sometimes pain, you know, the easy thing to do is just give them a narcotic, but sometimes really, you know, what needs to happen is you need to position them differently or try some non-pharmacologic things. You know, if you can work with a staff and teach them how to do that so that they have some tools in their toolkit, that can make that pain management program successful. And it's like that with so many aspects of skilled nursing care that, you know, a single person makes all the difference. And sometimes your superstars are not always your most highly trained people. They're the people, the bedside that I really consider just heroes. So other things that can go wrong, medical director dyssynergia, and this is where you're not syncing with the medical director. And it's so imperative that we get together with them and talk with them and see, you know, what patients do you want us to see? You know, how do you want us to get referrals? How do you want us to communicate? You know, I've had medical directors are like, you know, please don't write any orders, just make recommendations. And I'd like you to put it in this section of PCC or one team was like, can you just email me everybody you saw that day and anything really critical? You know, some say, call me if there's a problem. Some say, just do whatever you want and you don't need to bother me. I'll read your notes. It's all good. So you really have to think about, you know, each facility and what they want, even things like how do we deal with urgent or emergent issues? You know, one of the things that I've tried to do in my facilities and I think has been helpful is just like, look, you know, I've got your back. And if I have that 360 fusion that just rolls over today and you're not going to be here till tomorrow and they need pain control, you know, I'll help you, you know, I'll text you and let you know what's going on, but I'm happy to step in because I'm there, I'm in the building. And I think, you know, helping each other, we have a better shot of doing good care. And then proactive communication. I, we have protocols for everything like PM&R consult protocol, who are the likely people that need consults? Cause if you have to wait for an order or someone to put it in the chart, you're going to basically lose a day or two or three. And the problem with that is as a day or two or three, the patient's not getting the best rehab program or you're missing PDPM comorbidities and things like that. You want to try and be aggressive. You also want to let them know when you're going to be there. One of the challenges is someone's like, we never know when the podiatrist is there. You know, we didn't even know we had a podiatrist. That's not good. You know, they need to know when we're there and we need to be actively involved with like in the team conferences and around the nursing station and the therapy gym. And then, you know, also very simple things like where do you document? Like if you just scan your notes and you upload them into the miscellaneous document section of PCC, which is always the last tab, they may never read it. But if you cut and paste just your recommendations into the progress notes of PCC, you can actually flag that. So it goes to the doctors and nurses and they see it, which is great, you know, and you don't want them to have to read the whole thing. And even, you know, how you put your notes in, whether you go with soap versus putting the assessment and plan at the top, things like that make a big difference when everybody's in a hurry. And then, you know, it's helpful if there's a process, sometimes it's you like putting it in there and cutting and pasting or putting it in the paper chart. But, you know, if you can find any administrative support or you have that infrastructure with your group, that's super helpful. And then letting them know how to reach out to you and contact you. Very important. You know, our name's not on the chart. We're not the ones that are going to get called. And so oftentimes the person who is going to get called may have questions of us. And we want to make sure that they know how to reach us and that we're helping with any problems that come up, especially if we created them. The other big thing can go wrong is being an impersonation, impersonating the internist, where we pretend that we're like doing internal medicine duties, rather than really the areas where we add value. And the key thing to recognize is every skilled nursing facility has to have a medical director or they're out of business. Bottom line, the administrator will always side with their medical director, because if they don't medical director, they're like doomed. And most of us aren't willing or able to take on a 365, 24 seven responsibility with all the acute emergencies. So we need to respect them. And we need to recognize that they're the ones whose name is on the chart. Some of these guys do it by themselves. They don't have a group. Others have a group and they have a very orchestrated way that they communicate what's happening at checkout procedure. So it's really important. And if we like blur the lines where we start managing things that, you know, are chest pain or diabetes, it confuses the staff. You know, if you have too many people writing orders in the same area, you can get medical errors. You can end up annoying the medical director. And he's like, you're out of here. You know, if we, you know, sick and guess I've seen that actually before I've seen a physiatrist that turned in the medical director, because they didn't think they were doing very good care. And they turned them into the state board, which was really bad. And that was just not the way to go. And it's, you know, they didn't know better. They were brand new and thought they were doing something highly ethical and moral, you know, by doing that, but it didn't help anyone, honestly. And that person obviously was asked to leave. And the other key thing is if we're focused on the internal medicine, who's going to do the rehab, you know, somebody needs to keep their eye on that ball. And that would be us. So key thing, I'm going to go just very quickly to the co-management model. And I want to say one thing, if any of you guys take this piece of paper or take the co-management model, which has been, I actually started it in the nineties, the early nineties and inpatient rehab. It's a long story. It was controversial at the time. I think it's actually saved PM&R because I think at that time, nobody wanted to do inpatient rehab because the patients were so sick. And by bringing in internal medicine doctors to help with the comorbidities, we had a resurgence of people willing to go back into inpatient rehab because it became fun again. But that being said, it is a model, not a guideline. Okay. It is not a Bible is not, you know, the definitive thing because ultimately our names on the chart, we don't get to make the rules of the game, the internal medicine doctors. Now, what we can do though, is use this as a tool for communication, education. Again, they don't know what we do. They don't know what we can do, but by providing some options and how models have worked in other levels of care and in other facilities, it's a starting point of discussion. And I think you have to go in it humbly with that type of approach. So partnering with the medical directors and the attendings is critical. You know, when we're on their side, they really love us because they need all the help they can get. And they know we can really be helpful, really problematic, depending on how we communicate and how we agree on the rules. And the thing I'll tell you is it's always better to establish boundaries up front and do it right than to fix it when it all goes wrong. And that's where the co-management model comes into place. And even the name co-management model may be off putting to some of the internal medicine directors. They're like, what do you mean co-management? I'm the boss here and the medical director. So I've actually started calling it the rehab co-management model, but you could even call it a different name. So it's not threatening to them. So co-management, we work together. It's used, it's been in IRFs for a long time. It's now more and more common in SNFs. One's attending, one's a consultant. Typically it's used because of the complexity, trying to provide continuity of care, patient safety, liability issues. You know, once you're a certain number of years out of training and you're not actively managing diabetics with all the things that are coming out and you do something wrong, that potentially is medical liability. I don't ever want to practice outside of my area of expertise and my skillset. And I think we realize that the further out you get in your training, the harder it is to do internal medicine types of things. But the other big thing is two of the highest burnout specialties that there are, are internal medicine hospitalists and physiatrists. And I think that by each of us working together and staying in our lane and our area of expertise, I actually believe that there is a higher probability that we can work and not get burned out by sharing the burden, which is huge. And in ACO environments, it also helps because so many of the things that go wrong, if we don't have, you know, proper internal medicine support or a good rehab plan of care, you know, you get penalized because you're not going to have the outcomes that you want. So it's, it's really economically wise, as well as good medicine. There's two models. The model we're talking about is model two, where usually internal medicine, geriatrics is admitting, and we're consulting. In IRFs, you basically see the opposite. And as Dr. Tariq mentioned, there are some facilities, SNF facilities, where the PM&R is the medical director, but they still tend to have a lot of internal medicine presence and consultation. And typically they're going to manage, the internal medicine doctor is going to manage all the acute, urgent things. They're ultimately the one that pulls the trigger and return to the acute care facility, not us. And they typically are in coordinate like the nephrologist, the cardiologist, and the medical subspecialists. Whereas we're really focused on rehab issues. We're working in PTOT speech. We're working with nursing. We're looking at bowel and bladder care. We're really developing functional team goals, perhaps overseeing pain management that's negotiated facility by facility. But I will tell you that that's a huge need often, especially given the guidelines that went into place in July of 2019. CMS put a bunch of really strong regulations for skilled nursing facilities managing pain, and they are very challenging. I don't know how any facility could pull it off without having physiatry or dedicated pain service. We participate in the team conferences, patient family conferences, and discharge planning. That all sounds very familiar. That's what we do in IRF. And basically the whole idea here is we're focused on the rehab diagnoses, PDPM comorbidities, the functional status, length of stay. We may help with the admission orders for the original rehab plan of care, or just maybe evaluate and treat and we modify them as we go through. We also can determine level of rehab need after discharge. So everybody has some level of rehab after discharge. It may be a formal IRF program because they're doing staged rehab. Maybe they were a low level stroke and now they meet the criteria for going to inpatient rehab. Or maybe they're so good they just need a home health program or just a home exercise program without home health. So determining what they need next and figuring out the next best level to maintain or continue to move forward. We help a lot with referrals for these things, prescribed DME. And then I think one of the roles that we should do that's important is having the continuity of care with the doctor who was primarily involved. If the person has stroke, you probably want to make sure that you send some sort of note to the neurologist. If somebody had a spinal cord injury and they had an ortho spine, put them back together again. That person probably liked to know how they didn't sniff because the records don't communicate back and forth. Sometimes people say that patients go into the skilled nursing environment and it's like this black hole of information. You just never know what happens against the abyss. And so that's where I think we can be helpful communicating with those people. And again, the whole idea is that we're stronger together when we divide the labor and the tasks by delineating the duties, we're more efficient and we have improved communications to all the other players. And this can be a real status symbol by having co-management. First of all, it's a status symbol to have a PNR doctor. If you are a skilled nursing facility, you have a physiatrist that right off the bat takes you to the top in terms of quality. But if you are actually working synergistically with your internal medicine team and have co-management, that is even better because the two reasons that people go back, you know, a lot of times are pain problems and also because of medical emergencies. So things you've got to think about is, you know, you've got to educate the patients and the staff. If the patient thinks that you're going to fix their diabetes and you're not the one doing it, it's internal medicine that can create some friction. You've got to teach the staff who to call for what, you know, how to stat tests. You know, if somebody gets a stat lab, you know, if they give it to you instead of the right doctor, that's a problem and vice versa. So it's important, you know, to really come up with communication tools and really protocols and policies and have ongoing dialogue because you can always change it. If it's not working, you know, we can evolve. And so that's really important. And here's the other thing. The number one thing I see as a problem if we go into a facility is if we fail to accomplish our mission. And, you know, if you have a facility that doesn't know if they have a physiatrist or not, they're probably not accomplishing their mission. You know, and the bottom line is we need to focus on the essential tasks that get people home and get them to the highest level of function. So we should be the leaders in overcoming barriers every day that they're not able to speak in PT and OT, either because of pain or incontinence. That's a day loss. That's like gold being thrown, you know, just out the window into the trash, looking at risks, fall risks, cognitive risks, skin risks, looking at the re-implanted care and making sure we're really focusing on the right thing. And the goals are appropriate. You know, just increasing gait distance may not be the right thing. If you've got someone that has a problem where you're working on, you know, patterning of gait or where they have musculoskeletal issues, they get worse with longer gait distance. So looking at that, it's not just going PT, OT, evaluate and treat, continue. Having a safe and realistic discharge needs to happen from the beginning. That person is home by themselves and you know that their high fall risk is going to put them at risk for more falls and they've already come in twice. You know, we need to, from the very beginning, be looking at that and then patient and family education, the appropriate DME, and then really the next level rehab. Those are our essential missions that we need to do when people come in there. And you know, really when you go into the skilled nursing environment, we may be the only ones that see the big picture. Everybody else sees our little piece, but we're the ones that really can pull this together and look at the big picture. All right. Well, with that, I'm, this is my email address. If anybody has questions, I am not as high tech as Aslan is with his, his little bar scan thing and all of his social media, but I'm happy to dialogue. I'm passionate about this area. I care so deeply about these patients, about these facilities and just any of you that are interested in this, I just encourage you to talk to all of us because we really would love to see this be a dominant force in the industry where physiatry is in every skilled nursing facility. So thank you. And I'm going to turn it over. Thank you, Dr. Smith. Love hearing you talk. I can hear you talk for hours. What you brought up with the whole rehabilitation co-management, it's interesting that you and I have been in the industry for a while. We came up with the same idea about the same time, because I've been telling our physicians that align yourself with the rehab team, more so than the medical team, because most patients have a pretty positive out, you know, overlooking over the side, over towards rehab and versus the medical team kind of feels like we're stepping on their balance. So say we're part of the rehab team. So that's a very important point. Totally. Yeah. All right, Dr. Quargue, you can go ahead. I think we have one more poll question and then I'll jump right in. Yeah, we can ask them later on. It's fine. Oh, okay. Then I'll get started. Let me just share my screen here. Oh, wait, I got to do poll first. I will stop the share. Go ahead and do the poll. There we go. Wait a few more minutes, or not minutes, seconds and we'll get going. Price and that mistake of time but out of the seven answers we have the question is do you currently practice instead of setting or planning to for say yes to no and one is unsure but interested. Okay. Great. Yeah. Good breakdown. Different experiences. So my name is Juwan Clark, I work with every rehab consultants as a consulting physiatrist I have an interest in this field I get to talk about next. Which is a future trends for physiatry and skilled nursing facilities I'll sniff from here on out. The big thing here is I kind of wanted to look at a broader picture of where US healthcare is going in general. I think we all kind of have a sense of doom that things are not going well in US healthcare but we don't really understand what the terms are and I want to kind of empower you to know what these terms are when you hear them. So you could be empowered to kind of set aside how you want to navigate changing waters, as they change and we're going to probably change soon and dramatically, I think. And by the way, thank you to Dr. Tariq and Dr. Smith for their wonderful comments. Very, very helpful. So, here's my disclosure. I already discussed this. And so current state of US healthcare as you can see from the image, it's a little bit pessimistic, but we'll kind of go into more data driven information. This is a curve that was set up by the Peter G Pearson Foundation that basically looked at per capita spending per patient or per patient annually. And then life expectancy, and you will see that most developed countries have this linear regression curve that they mostly fit into, the more money you spend you would expect that you will have a higher life expectancy. America, though we spend the most money by far, we are quite the outlier, our quality measures are not quite good, and we don't live as long. And a lot of this has been blamed on a lot of different factors, but one of them being that we focus a lot on acute care but not really anything else. So there's talk a lot about, you know, they say that's almost as dangerous to have a baby in America, as it is in, you know, a third world country. Well, the data does show that we are certainly falling behind quite a bit from what even is the average safety during childbirth, it's even more sad to see primary care, something like asthma treatment or diabetes treatment. I mean, these are things that if we treated well we could avoid a lot of acute care that is extremely expensive and complex, but instead we neglect that in order to take care of the patient who shows up with the heart attack. And this is the one measure where we're even not the best at that despite the money we put in, but we do have the newest and greatest technologies and procedures to take care of people who get heart attacks, but not really so much of a focus on for example treating risk factors such as diabetes, such as hypertension, smoking cessation, etc. And this is all led to people terming what we're at right now as Humpty Dumpty care. We don't really care about Humpty Dumpty while he's on the wall but then when he falls down, that's when we send all the king's horses and all the king's men to somehow put him back together again. But I'd argue that's probably too late. We have high complexity, high acuity. He probably will have chronic health issues at this point that are beyond the scale of being treated in a preventative manner. And we have been incentivized to do this by a paper procedure model. We may be familiar with this in terms of our previous experiences of ordering imaging, we get paid for the procedure that we ordered. If we order therapy, we get payments from the amount of therapy that the patient gets, but there's really no focus on what the outcomes are. It's just, I did this, and I should be paid for it. Famously, up to the 90s, a surgeon could amputate the incorrect leg, bill for it, and then amputate the correct leg and bill for it again. And this was valid in the 90s because a surgeon did two procedures. And so there is a real break here. And as we know, there's black and white, but there's also a lot of gray in what we do. There's also a lot of demand in terms of concerns about liability, in terms of patient requests. And I think that when you are in a paper procedure model, and it's a 50-50 gray zone decision, you can't blame a physician for going with the one that you can say, I did more for the patient, and I got a little bit more reimbursement on the side to take care of him. But that has led to very, very high costs and also low access. This is a very common thing you'll see when we talk about healthcare systems, especially when we compare systems from country to country, and there is a huge amount of variability. Essentially, it argues that the iron part of the triangle, meaning that you only can choose two of the three things. There is no messing around with this. You have to make a choice about what you are going to prioritize. And the three qualities are high quality, so that can be two things. One could be you have the latest and greatest drugs, the latest and greatest imaging. It could also mean all those primary care measures of, you know, your population isn't smoking as much, the population isn't obese, all kind of go hand-in-hand with the idea of quality. Access, you prefer them, all your citizens can have access to healthcare. America is not doing such a great job. I think about 20% is still uninsured with no access to healthcare. Preferably, you'd be more like a country that does give everyone at least something basic. And lastly, cost. We would like this to be a low-cost system. If you are any kind of system, we want it to be low-cost because then that means you can do more with the rest of the money that you have. And so the argument is, once again, when you compare systems, for example, the UK, right after World War II, they were decimated, they were firebombed by the Nazis. When they were rebuilding, they didn't have money, so what did they do? They reduced costs, they increased access. But you hear all the complaints about the quality of British healthcare and the wait times for that. Vice versa, somewhere like Switzerland that kept their hands clean during World War II, after the Cold War, well, they were doing great. So they actually have a mandatory private insurance. So their quality is excellent. You get everything you want in Switzerland. Access is excellent because everyone's required to have health insurance that's bought from the time that you're an infant. But the cost is high. And so we all have to make decisions. America, what are we? We try to have it all because we threw a lot of money into it and really don't do great at any of them. I would argue maybe we are good at quality, but only on the technological side. Once again, when it comes to preventative medicine or population health, we are not looking great. So how urgent is this problem? We keep talking about money, money, and it kind of sounds like a dirty term. But the fact of the matter is a hospital that can't pay the light bills, can't take care of patients. And we got nowhere. We're going to get the money to take care of our patients. And this is urgent. In 2026, Medicare Trust Fund has already stated that they will no longer be able to pay for all costs in the current model. That is in four years. That is going to affect the majority of us. It's not going to be like a 2026 or going to stop paying all bills. But they have already said in 2026, they will only be able to pay 91 percent of costs. So that's going to affect us. It's going to keep going down in the percentage that we're going to be able to cover until Congress can come together and actually come up with a solution to get more funding for Medicare. Social Security, the other safety net, is also predicted to run out of money a little bit later, but frankly, in our lifetimes. And so this whole pay-per-procedure model has led to a system based around high quality, high cost, and low access, just like I said. It's actually 25 percent uninsured out of 2020. So once again, we're not swimming in great water right now. Something has to change because the way we're going right now, we have about four years before this will roll back to our bottom line. And so there have been other attempts at the side. You've heard of HMOs, you've heard about capitation models, lots of different things. The U.S. is, in particular, kind of unique because after World War II, we had not that much damage to repair in our own country, but we had a lot of money because we sent out a lot of weapons to fund the war. And so we found ourselves with a lot of money. And while the young men were gone, the employers had to find a way to incentivize people to take their jobs. And so first there was a wage war, then there was a wage freeze because it got out of control. So then they started adding in bonuses, health care being one of the first ones. And so we're pretty much the only health care system that's employer based. And that has led to more complexity here. But really, everything is kind of following CMS's guidelines right now. And so I'm going to focus on what CMS is doing. The private payers and everyone else is going to probably follow step by step. And Validus Care describes a health care delivery model where compensation is based on patient health. So as opposed to what did I do? It's like, we don't really care what you did. We care about what the patient looks like after you do it. So it is a kind of drastic remodel of how we view outcomes and how we view how people should be compensated for what they do. There's going to be a focus on increasing access and lowering costs. Why Validus Care is so popular? Because it directly addresses the most ugly pieces of our health care system right now. There are multiple different models that we'll discuss starting from the next slide. And I'll just keep moving on just for time's sake. I'm a bit of a health history major. I apologize if I used your name with a deep dive. So let's talk about just some of the more common models. And this is the most common. This is the one that probably a lot of you have already encountered if you work in the larger health care system. It's called pay per performance. So separate from pay per procedure, pay per performance means that you still get your regular salary. Sometimes it is lowered, which does not lead to happy practitioners, but it happens. And then you incentivize a doctor to be more valid based care by providing benchmarks. And if you meet the benchmark, whether that be blood pressure control, smoking cessation, how much weight you lost, et cetera, you get a bonus. And if you don't meet the bonus, then you don't get the bonus. You just stick with your salary. The additional thing here, though, is there is no payment for never events. Now, I don't care what you did for the patient. If something bad happened that was within your control that you could have helped with, Medicare will say we don't believe that you deserve this money and we'll take it back. Never events are going to usually involve things like health care related complications. They could also involve things like rehospitalization. And that's a tricky subject, especially at SNFs. We have a real big challenge with that, especially with increasing complicated patient populations. So the next model that has been proposed is called bundled payments. And really, this is just a term that describes any model that gives one single payment based on the health event with a modifier in the patient's complexity. So essentially, a patient presents to your ED. They have chest pain. That triggers a bundled payment kind of argument between the payer and the hospital. And you decide on a single payment based on the severity of the medical event. If you're worried about heart attack, that can be somewhat severe. But also the patient's previous comorbidities. If the patient has a history of multiple strokes in the past, he is a current smoker, he abuses drugs, well, then you should get more money for taking care of the patient, even if he has the same event as the next patient who is healthy and this is the first event that has happened to him. By giving a lump sum at the very beginning, you are encouraging efficient care. Because at that point, it is your responsibility to play with that pot. Get that patient as healthy as possible with using the least amount of resources or at least the most appropriate amount of resources possible. And then send them home in a safe manner. If they are rehospitalized, then you risk getting that money taken back. So you really have to skate that line of appropriateness now as opposed to just doing whatever you can. Important to note with bundled payments, this is usually based on health event. Whereas the next term you may have heard of is the accountable care organization. The ACO takes responsibility for sensitive patients and their health-based needs. So now this is not based on event, this is based on the population. And essentially you take care of that population for a full year. You will probably, as a healthcare system, if you decide to adopt this model, you will take the patients that already see you. You will have to get their permission, of course, because patients don't love being forced into a healthcare system that they didn't agree to. And you're on the bill for them. So everyone from the guy who just gets a regular checkup to the person who is extremely complex and goes to ICU every 12 days or 12 months out of the year because he is non-compliant. That whole population is yours. Of course, the less complex patients give you less complex care, but they also give you probably... And you get less payment for them, but you get to keep more of that payment as long as that patient stays healthy. The complex patients, you've got to offset that risk with those healthy patients by doing a better job of requiring their care. So like I said, there is an annual fee calculated and agreed upon, and that's based on the patient population as well as the complexity. This is going to generally require a larger health organization because when an ACO basically agrees to take on these patients, they are saying that they are now on the hook for anything, any cost of that patient's care required in a year. That includes primary care, that includes any hospital stays, including ICU care, specialist care, nursing homes, as well as other practitioners. So if your patient goes on travel and gets sick in Las Vegas or Georgia or wherever, you're responsible for that bill. And so you are going to be trying to get that patient to come back sooner. You're going to be communicating with those other healthcare systems sooner to get their records because ultimately you're on the bill for that. You want to be keeping relatively within your system as much as possible to control risk, to control cost. And once again, this is going to push us to be more holistic and preventative because those are the patients that are going to really give you the easy money to offset the risk of taking on the more high-complexity patients. And certainly there's been some arguments that the system leads to some systems trying to not take those high-complexity patients. But I think that there will be stopgaps placed because those patients obviously will need to have healthcare. And we will have to figure out how to get them there. The next model is accountable health community. This is probably the most radical. I'm not sure if this is going to work, but it is just part of this continuum. It's an ACO, but essentially the healthcare system says we're going to take care of the population based on geography. So not just the patients who you're already seeing. You're literally taking on a range of zip codes or voting districts or what have you. And you're saying we are the big hospital system in this city. We are going to take on all these patients. And in return, you'll get a huge single payment based on the population and complexity. But in return, now you have this full population. And that will be very high risk. This will also probably end up with patients not having as much autonomy in choosing what healthcare system they go to. There will be districts where if you really feel strongly that you want to live in our healthcare system, then you move to that zip code. And so for a lot of reasons, I think this may not be the model we go with. But a lot of people have been proposing it. So far, the data has been good that this value-based model is leading to savings as well as increases in quality. Bundled payments plus ACO has found that there is, in general, a change in episode spending of $500. That's significant, especially to a nursing home. Moreover, they found that readmission rates dropped by about 4%. So you show those numbers to a guy who is playing with just one pot of money that he received through January 1st. They're going to look for any way that they can cut costs while improving quality. Because that is the whole point of this new model of healthcare that we're going into. A summary slide, but really kind of also echoing what Dr. Smith and Dr. Tariq have already talked about. We really want to be looking more into a holistic view of the patient. And what I haven't added in this slide is physiatrists were prepared for this. We are taught to look at the patient as a full human being because anything from their mental health all the way down to what's going on with their feet can affect their ability to be independent. We're also taught to be team players. And not just team players with other doctors, but team players with the physical therapists, occupational therapists, social workers. We just have to expand that even further in SNFs to talk about our partners as chief medical officers, administrators, chief of nursing officers. You really want to create that team because they spend the most time with the patient too. And they can be your eyes and ears to really help you do the best job you can to help these patients meet the landmarks that you want to. So talking about skilled nursing facilities in general, I'll just rush through the kind of introductory stuff since Dr. Smith and Tariq did such a good job with it. Really, the essential thing is we are facing more complicated patients. We are facing more regulations, which are leading to it being harder to stay in business. And one of the biggest things right now is re-hospitalization rates. As of 2022, it has been found that about 25% of skilled nursing facility patients are re-admitted to the hospital within 30 days. This, of course, is associated with a higher mortality rate. This, of course, will lead to a lot of take-backs from the government in a value-based care system because they don't care what you did. The patient is back in the hospital and in the ICU. You guys should have done more when you did it, when you accepted this patient and you accepted the payment. And so this is kind of what our skilled nursing facilities are facing right now. And most of them only have a primary care physician who is checking in once a week, once a month minimum. So once a month, it's usually what you'll see. And you'll see a lot of stressed-out nurses in mid-levels, too, who are stressed out because the primary is busy with their clinic or work in the hospital to answer their calls. And now you have a physician, a physiatrist who's in the building who can address these concerns. And the doctor primary care is more likely to pick up the phone for, at least in my experiences, because I know how to kind of triage these issues and hear the things that I take care of and the things that I think he should take care of. I just make him aware. So this is really going to be important for us to move in players to communicate openly because the SNFs know that they're in trouble. They just don't exactly know how to get out of it yet. When they hear about the psychiatry, they're open to it. They're like, wow, this is a solution to our problems. But a lot of people come in with their own histories and past and preconceptions. And that's what we're trying to change here. We did talk about patient-driven payment models. Dr. Smith did, called PDPM. This is recent, and this is the first foray of CMS changing nursing home payments into more value-based models. It was first proposed in July of 2018, and after some fighting, was implemented in October of 2019, right before the COVID pandemic hit us. The biggest change was that therapy was no longer paid for procedure. So it was no longer about maximizing physical therapy. It was no longer about having nursing homes begging the physiatrist to put in more costs with PPOT because we get paid no matter how well the patient is already doing. And instead, it became more of a daily reimbursement for therapy, based on their complexity. And what this means is, now the payment models care about patients getting an appropriate level of therapy customized to their unique situation. They don't want us overdoing therapies because that leads to increased costs, which will cut into the initial payment or reimbursement that we received at the beginning. We also cannot under-provide therapies because, one, it's wrong, two, it will lead to poor outcomes, and three, it will lead then to Medicare audits and take-backs and et cetera. So, it's more about the appropriate level, not about giving them the most or giving them a little. It's about the right amount. And, for example, when we talked about trends and length of stay shortening, this is very much reflected in that. I always organize my talk to people about what I do in three parts. I talk about orientation, then the day-to-day, and then the discharge. Dr. Smith and Dr. Tariq, once again, went over this kind of in detail, so I'm not going to go over that stuff. I'll go over what I think can change as we move into a value-based model. I think number one with PDPM, reflecting complexity becomes extremely important. It was important in the past. It's even more important now because you basically have a period of three to five days to report to the payer, hey, this is the patient's issue, and this is how complex they are. And that will determine how much money you get for that patient as that one lump sum. There are some ways that you modify for some complications along the way, but for the most part, that is what you accepted to repair that patient, and that is what you're going to work with. So you have to provide accurate diagnoses and an accurate picture clinically of this patient and functionally of this patient to get appropriate reimbursement, and that way you can provide adequate repair. If you don't get appropriate reimbursement, you're going to lose money, and you're not going to stay in business much longer. There was some concern about how it's going to affect payments to the skilled nursing facilities. There was some reassurance that this will not lead to lower payments. Actually during the pandemic itself, the first months of PDPM, people actually saw increased reimbursements. That probably was because of the weird stuff that we experienced during COVID. I would agree that we will probably get less reimbursements as things continue. Just a demonstration of how much reflecting complexity actually matters, NTA or non-therapy adjuvants is one of the terms they use to reflect complexity of the patient. So say that you were kind of the usual lazy guy who puts in the primary diagnosis, puts in two others, and calls it a day because you don't want too long of a list. You will be compensated about $109, so you have your three to five diagnoses. You said that they had a heart attack, and then they had a history of hypertension, diabetes, and high cholesterol. Sure, almost everyone has that. If you really want to reflect the patient's complexity, you got to look at the whole thing. Does he have left hemiparesis because of a previous stroke? Yes, that is a diagnosis. Do they have extreme spasticity or contractures? That is a diagnosis. Do they have obesity? Something as simple as that. That's a diagnosis. Malnutrition? That's a diagnosis. There are all these functional diagnoses that we could be providing our partners, but the primary carers are usually too busy to put them all in. Hospitalists only focus on that event on hand. Even if the patient's amputated, I'll often find out when I see the patient that they had the amputation, it's nor in the hospital notes. I think it's extremely important for us to be able to provide this insight into the patient's actual ability because then we have the money to be able to give them the care they need. I think that that's something that the nursing homes have really appreciated from us. Our early data says that we have been helping our partners get more appropriate reimbursement based on our diagnoses that we provide. Next is the day-to-day. This is what me and my team calls watching plants grow. We check on our patients two to three times a day, or two to three times a week, depending on the appropriateness. Really a lot of these patients, especially if you took in the time early to establish those connections with the rehab team, with the nursing team, things should run smoothly, just like a good IRF. Things are going to go smoothly. Patients are going to progress slowly over time. Our job is to, one, catch the root rot or whatever that would signify that something may slow down their progress, either by looking at the progress and saying, hey, Mr. Smith has still been mod A for about two, three weeks now. What's going on? What can we be doing differently? But also by seeing the patients themselves and seeing what their concerns are. Do they feel their pain is uncontrolled? Do they have a mental health issue that's not being addressed? Do they have some other kind of concern? Is the family not being helpful? These are all kind of things that we have to keep in mind. Frankly, we get a lot of patients in nursing homes right now who don't even know what their prognosis is. A lot of them can come in with a stage four cancer. Some of them could come in with an amputation. And literally no one has told them what to expect. And so even just sitting down with them and talking it over with them at the beginning of their visit or somewhere early on, that saves a lot of problems at the end because otherwise you have an upset patient at, you know, one half months trying to get out of bed on his own with a AKA balls, dehisses, et cetera, and he's like, well, you guys don't walk me. So, you know, I had to do it myself. So these are all kinds of things that we can provide that frankly, the primary care physician may not have the time to provide. The mid level may not feel comfortable educating on, or you know, any other staff may not be able to do. And ultimately the other thing is we are doctors that matters to the patients that matters to the facility that matters to the families. And if someone with a white coat comes in, sits down and talks to them, they feel more confident that they're leaving their mom and dad heads. And that is something that is essential. I mean, even in those Yelp reviews that is something that you will see pop up all the time. My mom and dad was at the nursing home. They never saw a doctor. So us even going in there once a week, that is much better than the PCP who come in once a month. We do provide value there. Lastly, discharge planning, this is not as much, well, I guess the big thing is we are trained to know how to do a safe discharge and we know what's appropriate for the patient. And we know what kind of equipment they will need. So anywhere that we could help so that the patient doesn't fall on their own in their home and comes back to the hospital, that is a win for the nursing home and the hospital system as well. And so our training with discharge planning is going to be helpful to our colleagues because it's going to help reduce the re-hospitalization rates. I add a bonus thing in PMR's role in SNFs in the future, and that's innovation. The tides are changing, whether we like it or not, it's just a matter of how we want to navigate it. And I think the people who see that the tides are changing early are the ones who are going to be able to make a big impact and really be positioned to succeed. I don't think that change is necessarily bad. I think that actually the best thing is to realize when the writing is on the wall and you adjust appropriately. We talked about how post-acute care has been under or misutilized for the majority of its time. How often do we hear from the hospital that the hospitalist or the case manager just has to empty the bed right now. And so they don't really pay attention to the level of care. They don't even pay attention to the facility that they're sending their patient to. It's just, I got to empty the bed. But now with value-based care where you're on the hook for that patient, even after they go to nursing, sub-acute care where there's an acute rehab unit, or it's an ALF, or it's a SNF, you want to care about the metrics and the outcomes of those patients now. Because that's going to affect your bottom line. And so I think that as we transition to these payment structures, there's going to be a lot more interest in seeing what we do in post-acute care and how that helps in value, in quality, and savings. Like Dr. Smith said, all SNFs are not created equal. So once again, anyone who's had to send a loved one to a post-acute care center knows that they are very different. Some are wonderful and state-of-the-art. Some of them, you would not want to wish your worst enemy to go to. And so we have to find ways to make this really easily understandable to the acute care team. Because when they are trying to get this patient out of an acute bed, we also want to make sure they still pay attention to where they're sending them. I think branding is going to be important. So all those things in terms of modifications, do you have a spa, do you have a Starbucks in there? Those things matter to the patient. But you also want the case manager or the PCP to be saying, well, but this facility, it doesn't look as nice, but there's a physiatrist there. There's a doctor who's going to see you two times a week. And I find that all my patients go there, do so much better, and go home, whereas other facilities may look nicer, but they don't have that care. This is something that really, frankly, should be discussed whenever a patient is being discharged. And so I think that people are going to start looking into that more seriously. I think our SNF partners will look more into branding. And I think that's where they're more consolidating right now to go under an envelope organization of a big name so that acute hospital systems can say, OK, I recognize that name. I feel like I trust that facility more than others. I also think that in marketing, the physiatry presence is very important. And I think that it's important for us to demonstrate by data that we are useful. Our company, IRC, I think Dr. Tariq already shared this data early on, but we did publish this as a white paper about our experiences in Chicago. That's where our company is based. And Northwestern Medicine. And essentially, what we did is what many of our colleagues do not do. We collected the data and we analyzed it. And we found that patients who are at an IRC staff facility have less ED visits, less re-hospitalization, less length of stay. And that top right corner is about complexity. We reflect complexity better, and our partners are getting more compensation to take care of their patients because of it. For that reason, when we show this data, health care partners, including Northwestern, have been interested in creating partnerships with us and preferentially now send their patients to facilities with the IRC partnership. And I think this is going to become increasingly a model that people will look into in the future. I certainly know there's health care systems here in Los Angeles where I'm based that have been curious and asking. Other kind of technological advancements, telemedicine approved in March 2020. Long story short, this was because of pandemic, but now the cat's out of the bag. It's here to stay. And telemedicine is going to be very important because we are having staffing shortages, and especially in rural areas. This was an area from even before the COVID times. And we don't have enough physiatrists, even if we all convert to SNF care, to provide this useful resource to health care. And so I think that with telemedicine, we can utilize mid-level providers and colleagues to go there, and we could then provide staffing for that. That's still better care than the patient not seeing anyone from a physiatrist standpoint, at least in my view. I also think that it will be a resource that will be helpful to the staff there because they're going to feel increasingly isolated. Remote monitoring is another idea in terms of providing technology to monitor vitals, functional activities, et cetera, especially if you're looking into the accountable care organizations or the health communities. You want to distribute these to all your patients because what if that patient who is in their 50s and really doesn't show up to the hospital now is running blood pressures in the 190s over 100s? You know to call them and bring them in right away before something catastrophic happens and costs the health care system a lot more money. Also, just for the patient's sake, this is a much better thing to do. We don't do that right now. I think that now when we put health care systems on the hook for the patient's outcomes, it's something that people are going to be very concerned about. And lastly, there have been models that have been put forth for SNF at home, hospitals at home, mainly kind of empowered by telemedicine and remote monitoring. I imagine they'd still want to have a nurse and a physician going in, for example, with a hospital at home model. But the idea is basically how can we distribute access of care further to fit different patients' unique situations? So that's something to think about. We're already kind of running out of time, and I want to make sure we have time for questions. I'll just kind of speed through the last part here. Dr. Gams, who was a former president of AAPMNR, a gentleman I really respect, he has his own ideas. He has published papers and posters in the past. I encourage you to look at them. Basically proposing a single building where all post-acute care levels are housed. So ARU1 level all the way down to outpatient care at the bottom, allows for easier communication, more smoother transitions from level of care. You have an ARU patient who is not able to tolerate three hours of therapy. Well, then move him down to the SNF level first. And then maybe when he is more cognitively intact or his pain is better under control, you can move him back up to the ARU without having to spend those ARU days and really make the most out of those days. So I think this is something that hospitals would be interested in, because then you also don't have to worry about where are we sending them. Just automatically send them to that building, and then the psychiatrist from there will triage them and put them at the level of care. That's appropriate. And it will be a fluid process where they'll continue that until the patient goes home safely. And lastly, focus on well care. Like I said, I think that the more you're on the hook for a person and their outcomes as opposed to just doing what you do, you care more about the person themselves. And I think that even this investment that seems silly to us right now would actually make quite a bit of sense in the future. I envision big healthcare systems buying up gyms for the cost of $10 a person a month. That's probably how much it costs in a gym, honestly, system-based. You could just provide gym memberships for free. That is an advertising tool for your healthcare system. Your patients will stay well. They'll not have the sedentary lifestyles that may lead them to problems. And you could even place like a trainer or a PTOT or a nutritionist there to have a desk, and then you could provide those resources to patients as well. All relatively low cost, all can prevent an acute issue or complication that can cost a significant more money to the system. Even incentivizing good behaviors, like if you lose this amount of weight, or if you quit smoking, or if your blood sugars remain in this range, you are entered automatically into a raffle where you could get a cruise or a trip to Disneyland or Amazon gift card. People have done a lot more for a lot less. And I think that being innovative and thinking outside the box is going to really benefit healthcare systems in the future in this value-based model. This is my last slide. This is something that I feel very strongly about. And it's just, we have to think big picture. I think I've already demonstrated, we've demonstrated that physiatry is very useful and is as a place in skilled nursing facilities. I think that we are the best position to do well and to provide the most value to healthcare in that position compared to our colleagues and our specialists. And I think that we have to step up more in general as a medical profession to be involved in decision making. Right now, only 5% of hospital administrative leadership are physicians. Not to disrespect the people who are in hospital administration, but I think a lot more doctors should be in there. And especially in a time of change, like when we're converting to value-based care, we need doctors in there to help navigate and to advocate for our patients, advocate for our colleagues who are working hard, because ultimately what happens up there in the C-suite is going to affect us whether we like it or not. So let's have our voice listened to. And frankly, if a doctor is interested and is educated, or at least shows some kind of initiative, it's really hard for a leadership group to say, well, we don't really want to listen to our doctors. So I would encourage you to kind of learn about this stuff, get educated about this stuff, get involved with leadership early. Don't think that you have to be in clinical practice for 20 years before you can start. Start just allowing yourself to be involved with projects. And I think that you will find that we can demonstrate our value very quickly as long as we respect the environment, respect the process, and demonstrate our value. There was one study that found that there's a high correlation between hospital ranking systems as problematic as it may be, and physician leadership. I have pictures here of Mayo Clinic, because that's where we all go for our awards, at least until recently. That is physician-run. Same with Cleveland Clinic. All the big names that we hear and respect, they tend to have an MD or DO in the CEO position. Most of the health care systems we work at do not. So let's get up there. Let's help guide this change. So thank you very much. I threw a little Maryland meme for those of you who are going to be attending. Eat some good crab cakes over there. We have the AAPR information once again, as well as my personal information if you have any questions or would love to reach out. I love talking about this stuff. But over time, I will stop here. Thank you. Awesome. Great talk. That's a bit wonderful. Yeah. Thank you so much for coming to the poll right now. Great talk. And I feel like the first part of it should be required for all residents, but just learning and knowing what ACOs are and bundle plan, I mean, most of us coming out of training had no clue. So thanks for doing that. Let me do the last poll. Then we'll have an open question and answer. And here we go. The question is, did you have exposure to subacute SNF work practice during training? I mean, residency and fellowship. And while people answer that, it's interesting that our residency program is pretty unique because we had subacute, acute, outpatient, day-to-day rehab all in the same building. So it was phenomenal to actually see the whole continuum of care for the patient. But that's extremely unique. That doesn't happen often. So looks like most people at least who have answered have said no, they did not get exposure. That's how across the board we usually see that. So on that note, we'll end the talk. I know we ran a few minutes over, so I appreciate people who stuck around. And I actually received a bunch of questions on the side, not to everybody. But I think one thing I can always address would be a question was asked about physician assistants or nurse practitioners and if they're allowed to bill for initial evals. And the answer for that is yes. And the next is, does a physiatrist have to co-assign notes? The answer, it depends on state. You have to check the state laws. Then next was kind of the same is that if you're a primary care doctor, you're required to do initial eval, but you're not required to do that as a consultant. And as far as supervising the APPs, it depends, again, on the state. The APPs usually, if they bill, they collect 85% of what a physician would collect. There's no split, shared, or instant to billing in this setting. So either you are the one rounding and you bill or the PA rounds and they bill. So there's some nuances there, but those are a little bit complex questions about billing. I know we initially thought about doing a breakout session, but because we're kind of out of time, you only have a few people left here. I'll open up anybody that wants to unmute and ask any questions, they can feel free to do that. Obviously, our emails or contact information is on the slides. You can also send the slides over. This will be recorded, so you can approach us afterwards, anytime. I think, Dr. Smith, I don't know if you were going to be the AAPM or not, but I'll be there in person. Yes. And we have a few more talks coming up as well, and I'm not entirely sure I should confirm that, but we're going to have a get-together as well, a networking event, in which we can all get together and kind of just run through some ideas, challenges, problems, success stories. All righty, so on that note, I'm going to end the session. Thank you, everybody, for your time this evening, and I hope to see you guys soon.

physiatrists

skilled nursing facilities

challenges

exposure

training

perception

facility administrators

medical directors

communication strategies

collaboration

co-management model

value-based care

payment models

patient outcomes