Welcome everybody. My name is Dr. Aslan Tariq. Thank you for joining us for this talk today. I hope to enlighten you more about the subacute setting, the SNF setting. We have some wonderful speakers, Dr. Kristen Morris, Dr. M. They'll be talking about topics as well. So with that said, I would like to start right away. Okay, so my disclosure, I am the Chief Clinical Officer for Integrated Rehab Consultants. So I want to start off with this article that I found very interesting. It says the Physiatrist and Subacute Rehabilitation. And I'm going to read up a few lines from this just to kind of give you a perspective. The last few lines says the article focused on the issue of physiatrists in providing subacute or rehab in a variety of settings with an emphasis on the nursing home environment and explores several important issues related to integrating subacute rehab in the current and future practice of physiatry. Interesting this article was in 1996. That's quite a long time ago. It's interesting is that subacute rehab, even though it's been for many, many years, but it still seems like an area of physiatric practice that is new or uncharted or kind of a mystery. So hopefully, today's discussion and the talks after this are going to enlighten you more about what this practice entails, what is it currently, how has COVID impacted it, and also what the future might entail. So regarding physiatry, subacute does not really have a consistent or a significant definition by Medicare or most insurance companies. It's just a phrase that we use. Really, the real definition is SNF or skilled nursing facility. And what Medicare defines that as a facility, a nursing home, basically, that provides nursing care, rehabilitation, and services like PT, OT, and speech therapy. And Medicare does not specify the intensity of therapy services provided in the SNF setting. And obviously, because we are focusing on the continuum of rehab care from the time they're in the hospital to the time they are home, this is part of that continuum of care. I have a poll question here. Let me put poll question number one out. I'll read the question out here. It says, approximately how many physiatrists are currently working in the SNF setting? 300, 2,000, 1,000, or 500? All right. So the answer is 1,000. So some of you got that right. I think it surprises a lot of, especially residents and even attendings about how many physiatrists are actually doing this. I was actually pleasantly surprised myself. And this does not include APPs around the countries that might be working in the setting. And obviously, some of us are working part-time, some are working full-time. So there's a variation. So thank you for being part of that. So we'll go to the next slide here. So physiatry in the subacute setting, likely since the 1980s. Again, we have met physiatrists who work in this setting from the mid-'80s and early-'80s as well. A lot of them were doing inpatient rehab and also rounding as medical directorship in this kind of setting. And obviously, over time, as medicine has changed and the length of stay has gone down in all sorts of settings, actually, even the subacute setting, we've noticed that the acute rehab or acute hospital stay, as it's gotten shorter, the discharges in subacute have actually increased. But some of that also has plateaued and basically balanced out now. But regarding the inpatient rehab, there's been reasonable closures, there's been consolidation. But at the same time, the number of facilities inpatient rehab stayed pretty consistent. But regarding the SNF setting, you have about 15,000 SNFs in the U.S. and about 1.7 million patients are taken care of in this setting. So there's about five to six times more patients getting rehab in the SNF setting versus the inpatient setting. At the same time, subacutes are not immune to closures. I've seen a few in my area as well. There's been about a 2% decrease over the last six, seven years or so, mostly due to financial pressures. They tend to run on very, very small margins. And any significant fines or any changes in the hospital ownership and things like that can really impact them. But I'll talk more about the other trends that I'm seeing. But overall, the numbers are staying pretty consistent. So for physiatry, the trends in the encounters that we're providing in this setting have changed significantly in the last seven or eight years now. So if you look back in 2004, less than a million encounters by physiatry in the subacute setting, SNF setting. And then now in the last 2019, that was about 2 million. It's probably even higher at this moment. Maybe they might have actually plateaued. I really cannot say for sure. They've actually gone up, especially because of COVID. But the inpatient number of encounters have steadily declined from the early 2000s to the mid-2012, 2014. And they've kind of plateaued now. And that's what we're seeing with data analysis that's kind of staying consistent. So what is fueling the movement of rehab patients? Why is this happening? Why are there patients going to the setting? Well, there's a number of reasons. One big one is the 60% rule that restricts the patients that don't qualify to stay in the acute rehab setting. There's local coverage determination, which certain diagnoses are not eligible to be in acute rehab, and they have to go to subacute rehab. Managed care plans, there's so many more providers out there for managed care plans that are actually pushing the patient in that direction. Also, subacute rehab is shown to be less costly for certain diagnosis. There's a number of reasons that the trend is going this direction. And the trend is going to keep on going towards the direction of home health eventually. But these kind of combination of events are causing more subacute rehab patients. So let's talk about comparison of the cost related to this. And again, as a resident, I really had no clue what the cost would be, as I'm sending and becoming more aware of it. But for example, a tracheotomy patient with VENT, the cost at the nursing home setting might be $10,000 for the whole care. For a stroke patient, it might be $9,000, average about $8,700. But the cost in the independent rehab facility and the long-term care are significantly higher. Now, historically, obviously, the length of stay for a skilled patient for these conditions, a hip fracture, a stroke, would be longer versus inpatient rehab. So potentially, the numbers would balance out. But now, with the skilled nursing facilities, length of stay decreasing significantly over time, that number is actually kind of very close to the reality. It's the overall number. I don't know if the next is a poll. Do we have a poll right now? I'm not getting. But we can put poll number two in there. The question is, Medicare considers a visit to evaluate a new admission to a subacute timely if done within what amount of time? 24 hours, 48 hours, 7 days, or 30 days? Well, the correct answer for that is 30 days. And a few of us got that. And again, kind of a big shocker for most people who work in an inpatient setting or if you have family members in this kind of setting to realize that really the official mandate by Medicare is 30 days. Now, obviously, if that's the mandate, that's not what the facilities might be doing. And they have different requirements for their primary care and medical director to see patients earlier. But officially, that is the 30-day timeline. So is there evidence that physiatry can actually provide value? So we can work in the setting, and then we can do what we can. But at the same time, are we actually creating valuable metrics that help us? So some of the things that we did is look into the ER visits, length of stay, 30-day readmission. And this is, again, locally in the Chicagoland area, but we're actually looking across the country to see if that is making a difference or not. And overall, there was a reduction in the ER visits, reduction in the length of stay. And as time has gone on, this has been before PDPM, and we'll talk about PDPM later, which is patient-driven payment model. A lot of the subacute facilities were not focusing on length of stay. They were okay with the high length of stay because they were making more profit in that sense. But as time has gone on and hospital systems have started creating their preferred network of facilities, and they want the higher star rating, or they want the better quality of care, this length of stay has become important. So now we're way more likely to be entertained in the subacute setting for the discussion about physiatry being involved when we talk about reduced length of stay, because they actually want to hear that. But prior to that, they really weren't interested in that. So subacute challenges prior to physiatry being involved. One of the major issues is inconsistent primary care physician visit oversight. Again, the 30-day is not, even though it's a mandate, but that's not how most facilities are working. But even then, it might be once a week, once every other week. A lot of the care is provided by the nurses. You might have PAs or nurse practitioners helping out, but it's still very inconsistent. And even if it's consistent, it doesn't mean that they have the knowledge to help the patients out. So the primary physicians, nurses, staff, they usually overall lack general rehab knowledge. And it's pretty broad. I'm talking about contracture, bowel, bladder, pain, MSK conditions, strokes. I mean, you can talk about a lot of different things, even simple things like gout or polypharmacy. So, or prescription medication is a big issue. I've had patients who are in multiple NSAIDs and there are multiple narcotics or things like that. So that doesn't make a difference. There's inappropriate or excessive testing or imaging, ordering an X-ray on every single patient who has knee pain or ordering MRIs when you don't need it. I don't think there's details in this thing, but my point is that it's not the appropriate way of managing some of these patients and lack of cohesiveness between families, patients, therapists, PCP. A lot of times there's no communication between the primary care physician and therapist about patient's progress or their outcomes or the pain issues. So a lot of the communication gaps that the facility has, we can fill in and overall delay in providing specialty care. So I'm actually just rounding a few hours ago and I saw a patient that was supposed to see his orthopedic surgeon two weeks after discharge, but that got lost. The patient was like, well, I figured they would set that up for me. That never happened. No one caught that. And the patient now is almost a month post-op and still non-weight bearing and no one realized that they should do that. So that's just one aspect of it. There's many different other specialists that we can help out with. We can fine tune if someone needs to see a neurologist or somebody needs to see a pulmonologist. Of course, the primary care is managing the patients, but we can help out with that. So overall delay in providing care can impact Atlanta's stay and impact quality of care. I think we can throw in the next poll question as well at this point. Thank you. What is the federally mandated RN to patient ratio in the SNF setting? Is it one to six, one to 20, one to 50, or there's no ratio? Is this an RN has to be present eight, because every hour is seven days a week? All right. So the answer is no ratio. An RN has to be present at least eight hours because they do it seven days a week and not even 24 hours a day. Again, definitely one of those mandates that is shocking in this setting. And again, some of these regulations were made 30 years ago and the state of subacute rehab or subacute care was very different at that point. Acuity is very different. So going through this, what else? The inappropriate discharge to the hospital, we can help out with that process. Length of stay being extended, we can help optimize that, not necessarily reduce it if it's not meant to help a patient out, reduce the pain scores, reduce readmission or affect readmission rates. Obviously, facilities would have a lower Medicare rating because of a number of different things we can help out with that process. And some facilities have a very low rating, and I feel like it's more of a challenge for me to help them out. They have numerous audits and health inspections. They have lack of specialized rehab programs, fall prevention program, neuroscience program, bowel, bladder, pain protocols, and we can assist with that process because we're used to that in our residency and training. This inconsistent and poor outcomes of peer-to-peer, a lot of the facilities basically will give up on peer-to-peers because they don't have the resources, they don't have a physician who can actually help out with that. And a lot of times, our input, our notes, our discussion with the peer can really affect the length of stay and affect the care that patients desire and need. So in 2016, June 2016, the APMR had a position statement about the role of physiatry in the setting. And I'm not going to read this whole thing off, but at the same time, the reference is available. But the last one is the physiatric management of patients in the SNF setting will lead to greater functional gains by the patient, earlier discharge, and cost saving for the healthcare system. And I feel like as time has gone on, these statements have become even more important and very basically desirable for the healthcare system. So what are different practice models? I know Dr. Morris will talk about some of this stuff as well, but just to give you a broad perspective, and this could be a mix of these things as well. There could be other models that I've not even listed here, but you can be an employee, it can be an independent contractor, you could be a consultant physician who's involved with everybody getting rehab, or maybe you're seeing specific patients. You could be a consultant or employee with the APP. You could be the primary care physicians. I have some physiatry that I work with that are primary care. You could be a medical director or the rehab medical director. So they could be a mix of these things. Again, nothing is really consistent in this, but the vast majority of the physicians, at least in IRC, are consulting physicians and they're independent practitioners, but there's definitely different models. And Dr. M will talk about her model as well, hopefully. Frequency of visit, at the end of the day, it's all based on medical necessity and medical and rehab necessity. I should be more clear about that. So typically it could be two to three times a week. There are some patients that are seen less frequently. There are some patients that are seen more frequently. It really depends on the care they need. A patient that I just saw, I have to see her again tomorrow. There's patients that I see once a week. So it really depends on that, but in a nutshell, it has to be documented. It has to be, basically the necessity has to be clarified in the documentation. Otherwise, it's not considered valid. So at least my practice model, I just want to give you an idea about that is I'm an independent contractor. The practice itself provides a lot of different assistance. And I can kind of go over some of these things to kind of give you an idea, but administrative assistance is billing software. There's centralized EMR, training protocol, templates, malpractice insurance, marketing setup. There's assistance and compliance with APP recruiting and training. There's a need for that insurance company, better collection rate, potentially internal audits or their credentialing privileging. I mean, some of these things obviously as an employee, the employee will provide as well, but as an independent practitioner, it's not like I don't have this available for me. So the facilities that I work in, I happen to be in one right now is they're very different from the historic subacute nursing homes that you would imagine. Some of these places, like the one that I'm in now happens to have a Starbucks, they have a movie theater, they have private rooms. They're staffed seven days a week, but again, staffed by nursing or therapists. They have physicians around every day. They have multiple specialists. They have discharge planning is done pretty early on. So some of the stuff is very different. They look different. They feel different. They might even smell different from the historic nursing homes. So it's a very different type of model. Some of my facilities I work in, they have a zero gravity, a treadmill, they have VR, AR. It's changing because the patient's families want that. The hospitals, when they create their preferred network of facilities, they want to send their patients to, they want the bells and whistles. They want the facilities to spend money on a better therapy gym and a specialist and protocols and programs. So that's where I come in at least in my setting. Like I mentioned, they have a hotel feel, spa, they have outings and things obviously changing with COVID, but at the same time, they have a lot of these things available. I think as they're opening up now, they're going back to the way things were. I would cover six, actually at this point, six to seven, but medium to large subacute facilities in the Chicagoland area. My overall active census could be between 280, 300, 70% Medicare managed care is there as well. That is increasing as time goes on, insurance and Medicaid. All the patients from my setting, they have a primary care physician. They have multiple providers, specialists in the facility. Some have maybe two or three, some might have four or five. I even have cardiology, nephrology, pulmonology in some facilities. Again, that is not every single facility, but some that are higher acuity might have that. Some of my facilities have vent and tray capability. They have in-house dialysis. So there's a huge variation, like every single SNF is different from every single SNF, even if they're part of the same company. But some facilities have dermatology. And now with telemedicine that has changed, they don't have to come in for that. Podiatry, psychiatry, wound care, those are all the kind of things that are being offered. They're all fee-for-service. So based on the need the patient have, the facility can have specialists coming in. And PM&R comes into that as well. On average, I'll see about 25 or 30 patients a day. Obviously, part of that is going to be not just the patient visit, but family meeting, administrative meetings, potentially. I do a decent number of bedside injections with ultrasound, without ultrasound. There's biweekly, at least for my setup, I have prosthetic or chronic rounds where we take care of all the post-op surgical amputees, or people who might need AFOs, things like that. And 90% of the issues that at least I manage in my practice, again, every practice can be different, is still MSK-related, neuro-orthopedic, or pain-related, with an overlap with internal medicine as well. I had a patient that I saw right now who had extreme edema and lower extremities. I evaluated that. I talked to the primary care physician to put her on Lasix, and they did that. So it was my job to identify something and then help the patient get in touch with the primary care and change that communication gap. But still, the vast majority of stuff I do is going to be MSK and pain-related. Okay. So any medical issues that impede rehab are immediately addressed by the primary care physician. I have an active communication with the pain physician, outpatient orthopedic, neurosurgery. And again, it's important for the surgeons, the outpatient surgeons, to have someone that they can trust and stay in communication with, because when they discharge their patients, they are hoping that the patient is in good hands, that they're being taken care of the pain is being controlled. They don't want to hear about pain not being controlled or rehab not going well. They want the best outcomes for their patients. So I act as somewhat of a liaison to help them with that process. You know, at the same time, I'm helping create clinical algorithms, pathways, critical pathways to, you know, to basically with the staffing issues, with the lack of rehab knowledge the facility has, it's best to optimize things and use all the resources we have available. Admission guidelines, marketing, community outreach, in-service and staff education is a big part of it. Peer-to-peer, as you talked about, assisting accreditation of JCO and that kind of stuff, and managing difficult patients and family is one of the most important things. So again, it's a lot of things that, you know, I mentioned here, but they're not done every day. Obviously, I am there for the facility and the patients to assist in any, you know, aspect of care they might need. And hence, I can help everybody else out. So patient mix, I get asked this pretty frequently, at least from my practice. It is very similar to the inpatient rehab where it was prior to 2004, would be 30, 40% orthopedic and 15, 20% stroke and brain injury, is cardiopulmonary, and 15, 20% is cancer and others. Obviously, you know, I have about maybe 15, 20% of post-COVID or COVID-related issues as well in my facilities, but, you know, that has kind of changed. And also the orthopedic has gone down a little bit the last year because a lot of the elective procedures are being discharged straight to home. But I still see a decent number of fractures and orthopedic-related injuries, or even hip replacements, knee replacements that are complicated, have infections, revisions, things like that. So what can we provide? We provide outcome-oriented care. We provide evidence-based care. We provide cost-effective care. We provide accountability. And overall, we provide quality care. And all of this is part of the bold for physiatrists. The physiatrists are essential medical experts in the value-based evaluation, diagnosis management of neuromuscular conditions and disabling conditions. We are indispensable leaders in directing rehab and recovery and preventing injury and disease. And we are vital in optimizing outcomes and function early and throughout the continuum of care. And for me and my colleagues, subacute is a very important part of the continuum of care. With that, I have my email on the screen here. And I want to give a shout out to Dr. Steve Nats, who won the Frank Krusen Award last year. He's one of my mentors. And I live by the statement that every rehab patient deserves a physiatrist. And on to Dr. Morris. All right. Hey, guys, how's it going? My name's Christian Morris. This is the first community session that I've ever done, so bear with me. I am a physiatrist out in Albuquerque, New Mexico. Disclosure is that I do work with integrated rehab consultants. But other than that, no other disclosure. No other disclosures. So I'm going to talk about challenges that physiatrists face in the SNF setting. And to give you a little background, I've been doing this now. I graduated from residency about a year and a few months ago and just moved down here in the midst of COVID and got started in the SNFs. So some unique challenges, some interesting things, unique to Albuquerque and unique to starting in a pandemic. So if we can go to the next slide. So oftentimes in New Mexico and especially in the SNFs here, it's what is physiatry? We are not psychiatrists. We are not podiatrists. I've had plenty of nurses ask me to start clipping toenails as soon as I walk in the door. And I have to explain that, no, we are not podiatrists. An easy way to think about it is, and this is a general statement, but we are inpatient MSK. So we do a lot of ultrasound and non-ultrasound guided joint injections, pain medication management, prosthetics and orthotics, and spasticity management. So essentially everything that you're doing in the IRF minus any internal medicine stuff is they usually have a primary care doc that's taking care of all of that. Go to the next slide. So a common question from the primary care team, because when you're getting into a facility, there will already be a primary care doctor. And oftentimes they don't know much about physiatry or they haven't had physiatry in their building. And so their big question is, are you detracting from their ability to bill patients? And that's the answer, the simple answer is no. We bill the patient's insurance directly and we can also bill on the same day as the primary care doctor. We are consultants in their primary care and you bill as such. And so I've not had any issues with being reimbursed for billing on the same day and billing with the primary care doctors. Go to the next one. How do we meld with primary care while we are in the SNF? And this is unique to every facility. And there's a lot of factors that play into this, but the way I see it is we are consultants. So we're consulted by the primary care. And so in every building that I'm in, I've had a sit-down conversation and an ongoing conversation with the primary care team as to what they want me to do. So some examples here are don't use Trazodone. There's one primary care doc and she does not want me to use Trazodone at all. And there's a reason to it. It's considered a psychogenic med and she doesn't want that because that's reported to the state. And so she has her reasons. So I can't use it for sleep or mood or anything like that. Another doc, he's no longer the primary care doc at the facility, but when we first got in there, he said, I do all the opioids. And I said, okay, that's fine. And over time he kind of learned to trust me and we had many discussions about opioids and how to wean patients off of them and morphine equivalents and how to titrate them off. Yeah. It's okay. Do you do wounds? No. If you want to do wounds, go for it, but I just say no. And so they'll ask you questions about different things that you do. The simplest answer is I just say, we do whatever it takes to get the patient to participate and progress more in therapy. And we do that under whatever restrictions you would like us to. So the nice thing about not being the primaries, we're simply consultants. There's no nights, no calls, no weekends, no problem. That's a very nice thing. That was very hard for me to accept at first because throughout my whole medical career, I had never had that as even a possibility. I am working weekends now, but that's because I work at an IRF and it's just opened. And so I am back working weekends. So yeah, we can go on to the next one. So another thing is collaborating with the director of therapy and the therapists. So they can be the director of therapy at every facility. And then for the bigger groups, like Genesis is a group that has a ton of skilled nursing facilities throughout the country. And they have regional directors of therapy. And so they have a hierarchy of therapists. And I've made it my mission to get on their good side, have communication with them weekly, talk them through issues that we come across. They can really be your biggest advocates in these subacute rehabs. And there's a few of them, one in particular who we've become very friendly and we talk weekly and he's gotten me into more subacute rehabs. He's really pushed. I don't know if I'd say he's gotten me into them, but he's really pushed to get us into more and more facilities because he sees that we're a huge advocate for him. A simple example would be someone who is a right hip replacement and has been favoring their left leg and has excruciating left knee pain. And so they will refuse to participate in therapy. And the trickle down effect of that is that the therapists, they don't look as good. The therapy team, their numbers aren't as good. And that reflects poorly on the facility. So we come in and knee injection. Next thing you know, they're up, they're participating in therapy, they're getting better, maybe changing the dispo. So maybe they go home instead of going long-term care. Maybe they, that's kind of more of a drastic change, but it does happen where little things that we do make a huge difference. And the other thing to this is that they have, like in the IRFs, how you have a weekly meeting and you talk through every patient, they have the same type of meeting in the SNFs. And you can attend those. And I attended those at first, and then I kind of felt like I was wasting a lot of time because I would listen to a lot of insurance things. And so I distilled it down for them. And now the directors of therapy at every facility come to us after these meetings and actually even throughout the week and just give us a list and say, hey, these are the issues with these patients. And 99% of the time, we already know about that issue because we've been seeing those patients. And so working hand in hand, I mean, some of them, I know all of the therapists on a first name basis and become very friendly with them. And they're just happy as a clam because we truly do make them look a lot better and their numbers look a lot better. So that would be a huge thing to do if you do decide to get into the SNFs is to collaborate with them. You can go on to the next slide. So proving our worth in these facilities. Something I've learned in 16 months is that administrators of SNFs speak a different language than the physiatrists, than the primary care docs. The administrators really, they speak a different language and you kind of have to learn to speak their language just like doctors have their own language as well. The patient experiences in SNFs vary greatly. Coming into the building, they'll have varying degrees of expectations. Some of them will expect 24 seven care to be pampered and get all the therapy they want. Some of them want to come in and just sleep. And so their experiences can vary greatly. The food is generally, I mean, I hate to say it but the food stinks generally unless you're at a really nice facility. The nurses tend to have way too many patients. So PRN meds are very difficult. If you prescribe tramadol 50 milligrams Q6 PRN, they will be lucky. In some facilities, they'll get it once or twice. Some they'll get it three times. Rarely in any facility I'm in would I expect them to get it four times in a day, even if the patient needed it. And that's just because the nurses are so overburdened that it's very difficult. And then the facilities themselves, how clean they are, how nice they look, that can vary greatly. And so to Dr. Tariq's point that the mandatory minimum is to be seen by a doctor within 30 days of being admitted to a SNP. And that happens. Patients will go with all the same diagnoses that you see at a NERF. So stroke, TBI, hip fracture, anything like that, you'll see those same patients at the SNFs. And some of them will be seen once, twice, maybe three times by a primary care doc. And so the simple fact of us seeing them two to three times a week, there's a lot of patients where materially we don't do anything for them. We don't change meds. We don't do anything. But just being seen by a provider, by a physician, by a mid-level is game-changing for a lot of these patients. Sometimes I'll see a patient after they've been there for two weeks and they say, I haven't seen a doc yet. You're the first doctor I've seen. And so it's kind of humbling sometimes when you get in there and you're like, oh my gosh, a lot of these patients just haven't been seen by a provider. And there's a lot of reasons for that. So that being said, proving our worth in these skilled nursing facilities, in some places it's easier than others. In some places you're a physician, a warm body seeing patients. They don't even, they don't really care as much what you do. They're just happy that patients are being seen. And you cut down on the ACT rate and you do a lot of things just by seeing the patients. And then on top of that, the luxury of helping them progress more in therapy is a great way to prove your worth. And there are ways to speak to the administrators, speak to the therapists and the directors of therapy about how we prove our worth. And then the last thing I wrote in here is being held accountable in the weekly utilization meetings for patient progress. So in these meetings, they talk about patient progress, talk about where they're going, how long they have to stay. And so initially when I was in these meetings, I would chime in and just say, hey, with these patients in therapy that are struggling, please come to us. And we don't see them while they're in therapy. We get five minutes with them in their room. So come to us with their issues. And they like that we are so hands-on and willing to take feedback. And I think one advantage we have is that as physiatrists, we're used to being team players. You kind of have to be a team player in physiatry and you get that training in residency. And I think that carries over quite a bit because you end up doing a lot of administrative type stuff in some facilities that are really lacking and really need that help. And then in some facilities, you're strictly doing PM&R injections, pain medications, spasticity meds, orthotics and prosthetics, and that's it. You really don't touch on anything else. And so it's about being a team player, being adaptable, but the vast majority of the time, in fact, every facility I've been in so far, they just love the fact that I communicate regularly. They know that I'm accountable to them and their patients and making sure that their patients progress in therapy. I use, or I work with PAs in these facilities. And so I meet with my PAs weekly and I make sure that all of the facilities know that, that we talk about patients, we go over patients. And so I'm constantly training them in physiatry and the methods of physiatry. So yeah, we could go on to the next one. So how to get into SNFs. There's a few ways to get into SNFs. One is physiatry owned and operated companies. So Integrated Rehab Consultants is who I work with. There's a few other companies out there that do it. You know, I think we're used to as physicians and being in training, we are used to working for somebody. And so the independent contractor model can be a little bit daunting for some, but you can also just get into SNFs on your own. You can, you know, call the facility administrator and say, I'm a, you know, I'm a physiatrist. This is what I do. I will build the patients directly. You know, so you can do it on your own as well. It's a little bit more difficult. It's a lot of work up front. You're running a business and that can be a bit daunting. But so far, you know, I've enjoyed it. I'm an independent contractor and I've enjoyed it. You'll learn a lot. I've learned a ton about the business side of medicine and you learn a lot of things that you like and dislike, but you learn the system that you deal in. And so getting into these SNFs, it's becoming more and more popular and more and more well-known. I feel like in Albuquerque and in New Mexico, where I am, there is an enormous need for physicians in general and for physiatrists. And so it's a little bit easier to get into SNFs. There are some places, markets, where it's more competitive, but it's definitely feasible and worth looking into. So we can go on to the next one. All right, that's it. Thank you. Thank you, Dr. Morris. Next we'll have Dr. M talk about some interesting case studies and her background. Good evening, everybody. So my name is Natasha Milkovich, or better known as Dr. M, which nickname was given first by my PM&R residents and then widely accepted by all my other residents, including my SNF residents. So I come from Pittsburgh. I come from academia. I come from Department of Physical Medicine Rehabilitation affiliated with University of Pittsburgh. So my type of practice is a little bit different, but overall similar to the previous presenters who I'm really grateful that they accepted me to this, incorporated me in this team. Next slide, please. So Pittsburgh area overall, first, is like a really good place if you want to practice what I call geriatric rehab because Allegheny County, which is one of the biggest counties, has one of the highest percentage of octogenarians and older people in this area. So there are really multiple opportunities to practice a geriatric rehab and be a physiatrist in a skilled nursing facility. Before COVID, I basically, together with my colleague, Dr. Jennifer Shen, also from my department, the two of us covered eight skilled nursing facilities. But when we say skilled nursing facility, it's like a continuum of care. So majority of these facilities have all levels of care, including assisted living and memory units and then short and long-term care, which differs, of course, within skilled nursing facility. With COVID, when COVID hit, that was almost, believe it or not, now two years ago, I kind of became more focused to six of those facilities. And what happened is what Dr. Tariq said, due to financial issues, one skilled nursing facility I was covering basically went into bankruptcy and closed, but they did keep the assisted living facility and the memory unit open because they're private space. It makes sense. And again, I agree with Dr. Tariq. The problem is the low margin that all the skilled nursing facilities are working on. And then the two other skilled nursing facilities that I used to generate decent number of consults, just the number of consults decreased. I want to say it's COVID-related, most likely. And then pretty much the five skilled nursing facilities are within the system where my department is, which is the University of Pittsburgh Medical Center with about 249 beds. And I also cover what I say out of our system. It's a big system, Brisbane Senior Care, which is 193 beds. Next slide, please. So when I started doing this, and this was five years ago, when I came back from Nashville, I was working two years as an attending at Vanderbilt, mostly covering inpatient. And my dream was always to cover basically a post-acute care. And that's why I came mostly back to Pittsburgh. I kind of, I didn't know what to envision, but I thought that I would have like typical, you know, PM&R consults in strokes, brain injuries, spinal cord injury. And then I started just getting consults, which were basically pain management related. And when I looked at my data preparing for this lecture, I saw that basically 65% of my consults are pain management. Next slide. So I looked a little bit into this, and although this is a little bit outdated, these data from 2004, if you look at the CDC site and what they kind of documented on pain management at SNFs, is that 44% of patients in skilled nursing facilities do not get an appropriate pain management. And appropriate pain management defined by CDC would be standing orders or scheduled pain medication and or special services, including pain management program. If I forward this into 2021, I would say maybe this percentage is a little less. It's definitely much less in facilities which do have PM&R available. So I think that this percentage overall is probably still applicable. Next slide. So also, again, when I look at the consults and referrals for pain management, 37% of these cases I was treating conservatively, pharmacological pain management, modalities, topicals, etc. Of course, PT, PTOT, but that's kind of by default. And most common pain sources I got the consults are knee, shoulder, leg, back, but kind of this kind of doesn't surprise me, because once that my residents and the people at the SNFs that I work heard that I was an orthosurgeon prior to coming to this country, I have a lot of ortho experience, they started then pretty much giving me patients who they wanted me to inject, and that was almost it wasn't written as a referral for consult, but pretty much that was the reason. Next slide, please. But before I go to injections, which is my specialty, my specialty dish, I know that a lot of people who tune in to listen to this lecture, which I'm grateful for that, and who may be watching this recording, may be just starting this practice, I would like to share a couple of tips on my personal take on conservative pain management at SNFs. Have in mind that these patients that we treat there mostly are very old, if they're not old, they're deconditioned, and if they're not deconditioned, they're certainly frail, so they're in one of those three characteristics, so whenever you want to start a medication, which we usually do for pain management, whether it's like a GABA, Lyrica, or not to mention opiates, start low and go very slow, because these people are extremely sensitive to these type of medication and can respond dramatically to very low dose of medication, so these are the people that I will start Tramadol instead of 25, I'll start 12.5 in a 90-year-old and then just watch and titrate up, et cetera. Now be sure when you start something, regardless whether you're swamped by consults, always follow up on that patient and document the effects. Now when I say follow up, you don't have to maybe follow up in person, you can do telemedicine or even just call the unit and say, hey, how is this patient doing on this medication that I just started, so don't just put a suggestion and just forget about it. This number three, avoid psychotropic medication, I mean every geriatrician I worked with and most of my PCPs in my SNFs are geriatrician, they just cringe when you mention any psychotropic medication, Baclofen is a big, big no, oh my god, full risk, don't do that, and stuff like that, like Dr. Morris said about Trazodone. So just kind of be cognizant if you want to do it, make sure you discuss it with the primary care team because remember, we are just a consulting service, we suggest, we recommend, we don't just do it just because we think it's the right thing to do. And what I learned by doing this is to learn myself, so I'm not a pain management specialist by training, so I didn't do a fellowship, but these last five years of doing pain management within skill nursing facilities really did kind of sharpen my skills in pain management and constantly by my desk or by my computer, I have the Benson pain management book, which is my Bible, I just go check stuff and just be open to learning and adjusting your practices as you're asked for, because you're asked a question, just give an answer what you're asked. Next slide. So in brief, you know, this is something to kind of, just again for people who are just starting this, when you want to treat a pain issue, talk about pain, and many of the patients that I see are demented, cognitively impaired, unable to give you any kind of meaningful information. So for them, just observe, observe them, observation will help you immensely. Next thing also, if they cannot tell you what's going on, ask the staff, the staffs know them, the staff are there 24 seven, whether it's like an aide, whether it's like a nurse, whoever you can reach, because families are not there, especially not during COVID. So staff will be your best friend to ask about, you know, condition. Now this tip number two in gray, don't forget PT, how can we forget that's our bread and butter and modalities and topicals, but many of the primary care docs or even geriatrician will forget about it. So we're there just to remind them, hey, did you try, you know, moist heat? Hey, did you try ultrasound? Did you try this or that? And again, always be polite, you know, again, we're just a consulting service, we don't want to step on anybody's feet, just we want to give a suggestion. Start with non-opiates, we know that of course, but what I really want to stress out is don't be afraid to use NSAIDs, you know, when you mention an NSAID to a geriatrician, again, they cringe, they're like, no, no, no, no, no, there'll be a GI bleed or, you know, creatinine will, you know, rise, et cetera. Be mindful and of course check the creatinine that it's not something crazy before you suggest a short-term course, let's say of Mobic or something like that. And when using opiates, of course, be mindful, but not be mindful like being opiates, no, no, nothing like that, but be mindful that these people are very sensitive, use clean opiates, you know, for some reason I noticed people love tramadol, use it a lot. Elderly can really have serious side effects with tramadol and gabapentin, just to remember, so sometimes just a clean oxy will be just fine. Next slide. So again, you know, my signature dish, injections, and I don't do an ultrasound, not because I believe very, you know, strongly that ultrasound guided injections are better, but I don't have an ultrasound mobile machine, at least not as of yet. So I do just anatomic guide points or bony landmarks, and I do a lot of injections and of course, knee, shoulder, shoulder are my kind of, my specialties. And in the last, I would say maybe two years during pandemic, just when I didn't, couldn't send patients out to pain practices, I started performing much more trigger point injection more than ever, and I really found them extremely helpful, let's say for fibromyalgia patients or, I mean, with, of course, any type of myofascial problems. Next slide. Now I do have tips on doing injections in the SNF because I did burn myself by doing a lot of injections. One of the biggest things that I, especially if you're just starting, you should do is always when you're planning an injection, check the most recent white blood cell count. Having said this, I did inject a patient that I did not check a white blood cell count and in turn that it was in like a thirties. And although she did have like a hematologic disease, she ended up in a hospital. She ended up developing a septic shoulder arthritis. I did inject her shoulder. I don't know if it's connected or not. She ended up dying not of the infection, but just the whole thing, if I knew that her white blood cell count was in 20 or 30, I would have never done, but it was just like, you know, the primary said, oh, can you do it? It's just an injection. You know, if she has pain, I was like, oh, sure, sure. So never do that. Just be thorough. Next thing is, yeah, check the medication list, blood thinners, antibiotics. In my book, if somebody's on Coumadin or no need to stop unless, of course, if their INR is very super therapeutic, I would cancel the injections. But if they're within their goal, absolutely, you can do it. If they're on Eloquus and Eninoac, you most likely won't have any problems. The only issue I ever had with the blood thinners is if patients are on Lovinox, I did notice sometimes they do tend to bleed a little bit more after the injection, which still I wouldn't not do an injection, but just have that in mind. And if patients are on antibiotics, let's say for cellulitis, especially IV antibiotics, I do not do steroid injections. That's my personal kind of rule of thumb, because it doesn't make sense for me to put steroids in somebody who is already having a systemic infection, even though if it's like four weeks, but if they're still on IV antibiotics. Now, one thing I learned is always make sure injection supplies are available. The first time I went to a nursing home, I wanted to do an injection. I asked for like a, you know, like a special gauge needle and they looked at me as if crazy and said, and the lady from the central supply said the following, if you ask me for any diaper in the world, I'll have it, but that needles I do not have. So now I learned I carry everything with myself. And then keep the injection area as clean as possible. Remember, you're not doing injections in your office. This is, all those should be clean. You're doing it bedside. So make sure you clean the area really well. And don't forget timeout procedure. I have another little story about the timeout procedure. So once I injected the wrong person, I did that because I injected the demented person who I, of course, bear in mind that those patients don't have like identification bracelets or something like that. So I asked this particular patient, I said, are you, you know, Jane Doe? She said, yes, I am. Is your knee hurting? Yes, it is. Is it the right knee? Yes. So I injected and it turned out that she was, she wasn't the patient, the patient, I should have injected the neighbor. So I had to do the risk master. I had to call the medical director, the primary care physician. And the funniest thing he told me, he said, oh, I think you did a good thing. If she has knee pain, she'll, she'll benefit. So it didn't turn out to be a big deal, but it is. I learned my lesson. Now I bring the nurse, I identify the patient, I ask the nurse, is this patient, this particular patient I need to inject, et cetera. Next slide. So pretty much my referrals for PM&R consults is, as you can see, stroke 5%, neurologic condition, whether it's different type of weakness or bracing issue, about 10%, amputation 4%, debility 4%. And in the last year and a half, COVID-related debility became one of the predominant debilities and reason why they consult me. Brain injuries, only 3% trauma, 3%, spasticity 2%, although pain management often is due to spasticity, but I just kind of clumped it in because it's kind of pain. And then you, you figure out it's due to spasticity and then spinal cord injury, I don't see very often, and other 3%, next. So a couple of cases I kind of pick, this is probably one of my, you know, it's bad word, bad wording to use favorite case, but this is something you really want to see as a PM&R physician. So this is a 70-year-old female who had a remote TBI at the age of 20, and she has been in the SNF for now 11 years, but prior to that, seven years in assisted living. And her story is really remarkable because she was born somewhere. She was about, when this happened, she was 20 when that was that crazy 60s period. And she was really living an unconventional life, but then unfortunately had a car accident, was in a coma for a couple of months and recovered to a point. So I was consulted for residual left spastic hemiparesis, for cognitive speech impairments. She was wheelchair bound, history of major depression, recurrent UTI skin problems, but, and she was doing pretty well until a couple of weeks until I saw her, and then she had decreased PO intake, just didn't want to take food. She developed right-sided pain, which was her good side and new weakness. And my service was consulted for pain management. So we can maybe talk about this, what would you do? In a nutshell, what I thought was really kind of a profound case of depression that was kind of leading to all these problems, especially decreased PO intakes. I suggested basically putting her on Remeron, which she was when I kind of reviewed her charts a couple of years earlier. And I did suggest this, but again, being a consulting service, the primary care didn't really think that that's necessary. They consulted psych. So I said, no, she's just fine as is. So sometimes you just have to, you know, kind of take it with dignity and say, hey, thank you very much for this consult and move on. So that's how this case ended. I still follow her, but she was not put on an antidepressant as suggested. Next slide. Now in the last six months or more, I've been seeing more and more patients who had COVID and especially with sequela of COVID, this lady was one of the first, she was only, she is only 39 years old, status post complicated COVID, like spend 105 days in ICU, hospital assignments into some critical illness, myopathy, neuropathy, extremely weak bilateral arm weakness, severe bilateral elbow pain contracture. And so OT came to me and said, I don't, we don't know what to do. She doesn't even let us touch her elbows. Can you help? And so this was really a case where, where we can kind of hands on help exactly as Dr. Morris and Dr. Briggs said. So what I did was super, super like a simple solution for a PMNR doctor, order a x-ray, x-ray showed that she had cataractopic ossification of bilateral elbows. I did a corticosteroid injection twice of both elbows, it helped. And later on, of course, I mean, that wasn't the end solution to her problems, but a couple of months later, she finally recovered and went home. Now what would you do? Next slide. And this was also one of the, the, the, you know, like one of the things I learned in nursing homes, you can see a variety of cases. You can never be bored there, the, the, the, the, you know, variety is incredible. So this was a 41 year old female who had underlying spina bifida, spent three months in the hospital, do complicated left sacral wound leading to a proximal femoral osteomyelitis, necrotizing soft tissue infection, and then she had the left hip disarticulation and complex wound closure. Now this was really difficult patient because I was helping with the rehab plan and this was in the midst of COVID and she needed inpatient rehab at one point, once the plastic surgery was okay with her kind of starting the sitting protocol, but no, no out of the system inpatient rehab wanted to, to accept her because due to COVID they just accepted inside the system. So it was extremely complicated due to, again, due to circumstances and her being have some cognitive issues and didn't really, wasn't easy to, to, to treat. I tried a lot of things. I helped with the bracing of the, of the existing leg of new AFO. I worked closely with PT and eventually after, let's say six to seven months in the nursing comp, she ended up home. I lost track because she's about three hours from Pittsburgh. So I'm hoping she's doing well. Next slide. All right. Thank you so much, Dr. M. That was great to hear from your experiences. I mean, we've all had very similar patients, and a lot of times, like, we're consulted way after they should have been consulted. But at the same time, anything we do can help these patients out. And I feel like we're really good troubleshooters and team players, and we think outside the box and think about the whole system. So I appreciate that. We are going to take a quick break, and we'll kind of split up the attendees into small groups and basically reconvene in about 10 minutes. Welcome back, everybody. Please make sure everybody's muted. All right, Dr. M., whenever you're ready, please take it away. All right. Thank you so much, Dr. Tariq. So to be continuous, they say a season two, season two for me, at least, or season four for this lecture. So I was really, you know, kind of excited, although nobody's excited because of COVID, but I was really excited to think, to start thinking and analyzing how did COVID affect SNF? And not only how did it affect SNF, because we know that was all over the TV and news and media and whatnot, but how did this affect us as physiatrists who work at SNF? Next slide. So when I looked at the data, I was really astonished but not surprised to find that of all the deaths that occurred in this country from COVID-19, since the beginning of pandemic, 40 to 50 percent were among the long-term care residents. That's not just the SNF, it's also assisted living, personal care homes, etc. One in 10 SNF residents died from COVID-19, which is really like an astonishing, astonishing information on its own. And then today, when everybody's talking about health disparity, what's better to kind of illustrate health disparity within the skilled nursing facility than the fact that in skilled nursing facility that have more than 40 percent of non-white residents, there were three times more deaths compared to the one which have primarily white residents. I really found this, again, I would use this word astonished, but I was like, oh my god, this is what health disparity means. Next slide. So why was mortality from COVID-19 so high? Well, there are a couple of things, and those things, and I kind of just pinpointed five things, really generated a perfect storm for people to die of COVID in nursing homes. First, I'm sure anybody who ever set a foot in the nursing home, you know that it's a communal living setting, everybody's in group. Not only that, that just in some super nursing homes, as Dr. Tariq showed, and I call them four season of nursing homes, you have a private room or a private suite, but there are a lot of our residents, they live with a roommate, which they're not, I mean, they're not in any kind of relationship, they're just assigned to them. So just that fact is really communal living setting and puts you at the risk of contracting COVID. Then all the residents, especially long-term care, are very vulnerable because they have multiple underlying medical condition. But most of all, and that's why I bolded this, COVID-19 was a shock, was a shock to everybody, but was a shock to U.S. health system, which it shouldn't have been. We should have been rather prepared for something like that, especially after there was SARS in the past. And people knew that this was possible, but anyway, there was inadequate resources and availability of PPE, rapid, accurate testing. So if we think that there was inadequate resources at the hospital, we can just imagine how nursing homes, they were really, they didn't have anything even to begin with. And there is still lack of effective treatment of COVID-19, and number five, which is a huge, huge issue, it's now kind of almost like a contagion going into the hospitals, there was in the nursing homes, there is a significant staffing issues, shortages. Just to illustrate this, in four nursing homes that I covered, there are four floors completely closed, beds are closed because they don't have nursing staff. So there was a huge, huge issue. And number five, which is a huge, huge issue, beds are closed because they don't have nursing staff. So these five things really kind of generated this perfect storm of COVID, which was fatal for our residents. Next slide. So this really, CDC kind of have great slides, and like this, this on the left-hand side, this is your nursing home. Okay, so no mask worn. So people, when you go into the nursing home, none of the patients, especially dementia unit, mask doesn't exist. I mean, it's on their table or bed or on the floor. Indoor space, they are indoor almost all of the time. Sometimes they are wheeled out of the building when the weather is nice, but mostly indoor. Crowded place, as I said, they like to be together. The biggest thing in their life is to be together for bingo or some kind of event. And that puts them in increased risk of contracting COVID. Next slide. And then everybody was talking, oh my God, wildfire. It was a wildfire. And I just put a little analogy, a fire source was of course the resident staff or visitor who had COVID. Flying embers would be COVID particles, high winds, like closed spaces, communal living, inadequate PPE, poor infection control, extremely poor infection control. Two years ago, now it's of course better because federal government invested $15 billion to kind of manage this pandemic. Smoke was really the inadequate lack of testing, not required to report testing results, which I was amazed to read that for the longest time, I think in the first year, the nursing home were not required to report. They didn't have to report the testing results. High rates of false negative and lack of treatment. Next. So basically the other thing that's something to think about, if we know that 40 to 50% of deaths of COVID in this country is among long-term care residents. Also, we have to know that this is likely underestimated. So it could be much higher because again, what I said, SNFs were not required to report COVID-19 testing until recently. Lack of viral testing, again, until a couple of months ago, they started doing this mandatory testing, depending on the percentage of cases in the community, up to twice a week, depends. Then the rapid tests are great, but they have high rates of false positive results. Difficult to swap demented residents. A lot of patients with dementia, they just won't let you swap them. Simple as that. And there were a lot of typical COVID-19 presentation among these frail and vulnerable residents, which were not counted as COVID. And I would add number six, that a lot of patients that I know who died of COVID in SNFs, they did not die of COVID, but after COVID, they were so deconditioned that anything that they contracted after was fatal for them. Next slide. So how did this really affect us? Actually, I can really just share with you my personal experience. It really affected me very hard. My numbers kind of really decreased. So initially, most long-term care facilities that I covered just closed doors to anybody who is non-essential, which was from which was from March. So the close-up was, the close-down was in March to June. So it's full three months, including PM&R consult service. Few PM&R in-person consults that I was called for were mostly related to really hands-on, either baclofen pump management, which I don't do, and I wish I knew how to do it because this was the time to do it, or I was trained, but I've never got privileges, and pain management, which was like injections. And the majority of consults initially that I did was using telemedicine. And for me, that was a huge learning experience. I mean, Dr. Tariq will talk more about it, but I can tell you just my take. If you wanted to telemedicine nursing home, be quick, be very quick because somebody of understaffed, so you have an understaffed unit, and then you take somebody from that understaffed team to hold your device, whether it's usually an iPad. And if you do it really slowly, then they won't do it next time for you. So you have to learn to be really up to the point when you do telemedicine, at least my take. Next slide. And then once that initial shock kind of faded and wore out, we slowly got, as a PM&R consult service, we were allowed to go back, but with the following requirements. Of course, COVID-19 screening was happening everywhere. I had to test weekly or biweekly in some facilities. I would have to test PCR testing. So I would go in on a Tuesday so that I would get my PCR test and then go back on a Thursday so I can see patients. Or then later on, they started rapid testing. Every, for instance, Friday, I went to a facility. I would do my rapid test. I learned to swab myself, wait 15 minutes, do my notes, and then see patients. And of course, adherence to the full PPE, which, as you can imagine, can be tough, especially in the middle of the summer. So that was from June to February. Next slide. And then the vaccine was approved, and then the residents got the vaccines, which was fantastic. And the doors opened fully, opened to us, to the visitors. But for some reason, at least I'm talking about my personal practice, the numbers remained low because for many factors, which I'll kind of address a little bit later, and I started seeing more and more patients who had post-COVID-19 complications. Next. So why is that? At least, again, I give it a lot of thought, not just for this lecture, but for my sake, because this is my livelihood. And I talked about this, about some people who are higher ups in a lot of facilities. I cover their administrators and even higher than that. So one of the reasons definitely is Delta surge. Delta surge kind of just told us, oh, okay. I mean, COVID is not going anywhere. It's here to stay for a while. So we better get accustomed and figure out how to do our business with COVID around. Then low census is due to staffing shortages. As I started, a lot of the nursing homes that I cover have like four floors. You have one floor closed, which is about 20 beds. And even those floors that are existing, their census is still low because they don't have nursing staff or they don't have nursing gates. It's just an unfortunate situation. Then a lot of my consults were within the short-term stay in the nursing homes. Now, they're much less short-stay Medicare-related admissions. Unfortunately, some of my long-term residents that I used to inject every three months, they just died of COVID or of COVID complication. And as I said at the beginning of this lecture, one of the facilities that I covered, and it was a good, for me, it was generating decent number of consults just closed because they were not financially viable anymore. And then six is really maybe something else, something that I did not take into equation, but I would love to hear the opinion of my colleagues and everybody who is on this lecture. Next. So what can we do? I kind of really brainstormed, what can I do? So this is what I came up with, with, of course, advice for some really wise people. They told me, refresh your service, remind your partners at the SNF who you are, what services you provide, how can you help, be proactive, but also be patient and persistent. It's fine. It's fine. You have to kind of sail through the bad weather to get to the sunny skies. Next slide. Be flexible. That's what I teach my residents. I have residents with me fourth year once a week. And when we go in the SNF, I said, you have to be flexible. Just kind of go with the flow. Don't say, oh, I want to do it this way or this is not the right way. No, no, no, no. Just be flexible. Do your thing, but be flexible. Show data to back up your clinical value. So because of these low number of consults, I finally, after five years of doing this, decided to look into the data, to start collecting some data. I'm at the beginning of that process, kind of it did push me to do something positive. And what we can do as a part of AAP MNR, support, advocate for improving health policies, affecting SNFs, improved infection control, better trained and paid staff, telemedicine reimbursement. Remember, somebody's hearing that because as I said, there is $15 billion that current administration is giving to the post-acute care to manage the pandemics. Thank you. Dr. M, thank you so much for that. Well, you did mention briefly role of telemedicine. I'll briefly touch up on the COVID stuff as well, how that impacted our practice, but let's get into this. So first case of US COVID-19 was announced in January 20th. We all kind of know that it was obviously circulating in the US a little before that, but the middle of February, we had quite a lot of frantic emails and phone calls with our C-suite and other clinicians to figure out like what is going to happen next. And just like everybody else, we were not really prepared, no one was prepared on the setting to, into the pandemic and to get telemedicine rolling within, you know, right away. And we already saw because we have clinicians all across the country and we saw how they were affecting in the New York area, how they're affecting the Seattle area. So we started friendly talking and discussing how do we implement this? How do we, because our facilities are going to have to change. We know how rapidly COVID can spread, but there's a lot of challenges with implementation. You got to find the right technology. You have to educate the providers. You have to know, you have to have templates. How do you do a physiatry examination to telemedicine? Is it audio? Is it video? Who's going to help you? What kind of billing do you have? Are you going to get paid for the services? So there's a lot of challenges. And initially, everybody was blindsided by it and no one really knew what to do, not honestly, but we've kind of, because we're, I guess, in a way, somewhat nimble and, you know, being independent in prior practice. I mean, obviously as a corporation, we were able to kind of find resources rather quickly. At the same time, it was tough. But between the time of like mid-February to March, there's a lot of confusion again, because there really was no clear guidance on how do you define telemedicine? How do you define telehealth? And eventually it was clarified, but the waiver was passed in March 6th. And around that time, a little before that, at least from my own practice, because I'm still independent, but I have a corporation helping me out, but I was able to start talking to my facilities even before they were even concerned about COVID. You know, one was like, start buying PPEs. And that was one of the things that, you know, I'm very fortunate of doing is, you know, the facilities were really listening to my feedback and all because I was just reading articles, going to AMDA, American Medical Director Association, and finding out what they're talking and going through all the different information available to find the most relevant and most up-to-date information about how COVID potentially will spread. One of the first things we started doing was symptoms. What are the symptoms of COVID? And Dr. M mentioned that in the frail population, it could be anything. There were things that were so subtle that I would not even imagine of COVID. You know, we started basically looking at symptoms and from educating the nursing staff, educating even the CNAs and therapists, like if someone has a change in taste or smell, even a subtle mental status change or change in function or diarrhea or change in pulse, you need respiration. I mean, we just pretty much said any change, just let us know beforehand. And if someone's changing, let's quarantine them. So some of the facilities that were better prepared, you know, they were okay, but then they were okay until Delta came up and then all of a sudden they had to do it all over again. But at that point, it was really, really tough because there was no PPE. We had to source PPE from like outside the country to get masks. It was pretty chaotic. And personally, in my own practice, because I have a pretty large practice, my last estimate was about 150 patients that I lost. Many of them that I knew really well, and they were at AL, and I would see them all the time. Dr. M. also mentioned that as well. And a lot of them were at the edge, but COVID kind of pushed them over. But anyway, further clarification was provided by CMS over the next few months about what to do. So we were able to, before I go to that, but we were able to, you know, obviously, initially, with CMS, they said you can use any non-public facing, you know, you cannot use TikTok, you know, Snapchat, but you can use FaceTime, you can use WhatsApp, you can do different ways of, you know, getting telemedicine going. A lot of us ended up doing anything that was doable, so some of us was FaceTime, a lot of us used other providers, other vendors, but, you know, we were just finding anything that worked. But it was not, the difficult part was not finding technology, and most of our providers are used to using technology. The difficult part was, like, how do you, on the other end, in the nursing home setting, like, how do you have the staff use it, because they're already running, you know, a lot of the staff was working at that point, they wanted to leave because they had kids at home or elderly people at home, or they didn't want to be exposed to COVID, so we had a significant staffing issue, even at that point, which only got worse. And then we, to educate them, to find a point person, it could be a therapist, a social worker, it could be a CNA, anybody who can kind of take the device with them and walk around and have a C patient. That worked for some people, some of our, some of my higher functioning patients who had cell phones, I could call them directly, we just had to find a way, and something worked, something didn't work. But at least the flexibility was there, which definitely helped us out, and at that point, you know, because therapy was provided only in the rooms, I mean, it's really hard to get functional outcomes when your space is 10 by 10 or 12 by 12, no equipment, and therapists were, it was very difficult for patients and a lot of different challenges we talked about. So as far as utilization is concerned, you know, you can kind of see it's pretty clear that the millions of visits went from less than a million, I think it was like in the 100,000s, to up to 15 or 16 million, and then it started slowing going down, obviously, as vaccination started happening, and you know, the COVID spread reduced, but it was a significant jump. And the same exact trend happened with us, I think last year, approximately we had 40,000 telemedicine visits, and then this year, it's probably one tenth or even less than that. So why telemedicine? As I mentioned, COVID outbreak, a majority of our physicians and providers, you know, we cover multiple facilities, some of us, you know, have large enough facilities, we can go to the same one every day, but majority of them are going to different facilities. So it was obviously not a really smart idea to spread COVID in that case, a lot of facilities started saying that, you know, we prefer you only go to our place, or, so some of us had to kind of start looking at that from that angle. You know, I was very fortunate that none of my facilities had the discussion about non-essential providers coming to the facility, but... Please mute your audio. Thank you. So some facilities, you know, unfortunately around the country did mark consultants as non-essential, majority of them changed that over time, but that impacted people as well. Lack of proper PPE and testing, like Dr. M mentioned, there was barely any testing done initially. Even if you had a test and you get the results back in a week, what are you going to do for a week? And if you get positive, let's just say, I had unfortunately this false positive, and then like to get tested again and get the negative again, second negative. It was very chaotic. And on top of that, Dr. M mentioned the frail and high risk population in a congested area, very difficult. But we had a continued need to assist patients, you know, these are the same patients we're seeing before. And I had primary care doctors who were like, you know, they're maybe at the age of about to retire or they had underlying medical issues, they're like, I'm not going in at all, I'm just basically not going to show up, I'm just going to do everything telemedicine or talk to the nurse about it. And the facilities were desperate for anybody to come in. And one of the things I didn't point here that some of the nurses that I worked with while preparing for the talk told me about it, they felt that, you know, they were in the trenches, they were working in the front line. And you know, they felt like the medical team was always there and kind of doing things kind of just left them there. And with, you know, I pretty much only stopped going to, I was 100% telemedicine for maybe a month or so. After that, I changed over to the hybrid or going in. But they really appreciate the fact that I was in there with them, helping the patients out, identifying sick people, helping with pain, helping with rehab, troubleshooting. A big part of that was family members, because they couldn't visit. And once they cannot visit, then they really don't know what's happening. So I would give them updates. I would kind of discuss like what therapy saying how they're doing, the anxiety level was really high from everywhere from admin, therapist, patient, family, in every single level. So I was able to kind of be there, help them out, we did fundraising, you know, you know, getting them pizza, I mean, anything you could to increase the morale because the morale was really low. Especially when you hear in the news, there's no good stories coming out at that point. So the need for continued assistance, the patient is also important, but also providing support to the staff and the admin. So challenges, you know, main challenges, I'm going to go over a few of them, but learning curve for some providers, you know, some providers just don't like the idea of they cannot imagine physiatry practice in telemedicine where I cannot put my hand on the patient, I don't know what their tone is, I don't know what their atrophy is. But you know, we were able to kind of find ways around that and you know, help the therapist help us out or the aid help us out. Poor connectivity, just because you know, these places have a resort like feel or a four season look doesn't mean they have great Wi Fi everywhere. You know, barely any signals, so it's tough to do. The infrastructure wasn't really prepared for that telemedicine. Also, on top of that, the patients were using their phones. So it was tricky. But there was ways that we fixed to figure that out. Lack of support. That was the least of their concern that or I have to see some facilities that you know, I have to see a patient telemedicine though. You know, they're like, literally like there's fires everywhere. Everybody has COVID or you know, someone's staff has COVID and test everybody. So it was really, really chaotic. And the last thing on their mind was like, oh, we're going to set up telemedicine for you and get you a dedicated staff that's going to do this and we're going to pay for the staff. Like none of them were like jumping up and down for that. But obviously, with the right partnership and the right education and dealing with this early on helped out in certain setting. In certain settings, our providers, they said no, you're not you're not going to come back in until like COVID goes away. You know, that obviously hasn't gone away. But you know, they eventually changed some of those regulations and the internal regulations. But regardless, it was very uncertain. There was uncertainty about consent. You know, how do you get consent? How do you document consent? Audio versus audiovisual. Can you do an audio call when the audiovisual is not working? Like you can call a person when you tried the telemedicine video and the video signal is horrible and you can't listen or can't hear or talk. Billing, you know, are we going to get paid for this? Is Medicare going to pay for this? Are other insurance companies going to pay for this? If you do all this, are we going to have a significant number of audits and we'll get all this money taken back? HIPAA, of course. Payor rules, like I mentioned before, the rules kept on changing constantly to keep up with it. Pay parity. Is it the same to see a patient through telemedicine versus not telemedicine? How does it work? And that all those things were obviously over time clarified. Some of these are still not clarified. Documentation requirements. You know, what constitutes a full exam? Can you do an initial eval without the telemedicine exam? So we were able to create templates, doorway exam templates, telemedicine templates, audio templates to the best of our knowledge. Honestly, it was kind of tricky, but we were able to do some of it. And then you have patients as well that have dementia who might have a CBA. They're not able to communicate. They have aphasia, vision impairment. Someone's got to be there to help them. Some of them have difficulty following commands or consistent commands or answering or, you know, there's many different challenges, obviously. And there's this patient population. You obviously have a higher percentage of patients with dementia. So that just becomes more important. And like I mentioned before, you have to modify the exam to fulfill the requirements for documentation. And, you know, it's hard to do a thorough PM&R exam to telemedicine. It's very difficult. But at the same time, how do you check reflexes? How do you get a therapist to go check your reflexes? You can check range of motion. You can check strength against gravity. But how do you check tone? How do you check correctness? There's so many different things that, you know, you really are not able to document, but you did at the best of your ability. Whatever you could, and you tried your best of the patient to tell you what the pain was or have them do range of motion. So thankfully, AAPM&R also helped a lot with this because they had a lot of guidance regarding this. What are the benefits? I kind of mentioned a few things already, but reducing anxiety and social isolation. Social isolation was probably my biggest and this probably uncounted number of patients who have declined in function just because of depression and socialization, and they never actually got COVID. So they never recovered from that. I'm sure there's data out there. I'm going to look that up. But that was a huge part of, unfortunately, the problem with COVID because all of a sudden, you're not only are you in a nursing home, but you're not, you not have any family. No one can see you. Everybody has a mask on. You have, you already have some dementia memory issues. It is just imagine being in prison. And, you know, obviously like, you know, the death all around you, your neighbors dying, everybody's talking about COVID. So, and you have the TV on all day. So it was very, very difficult. A lot of us really hard for us to put ourself in that position, but it was very difficult. And then, you know, like I said, we were able to screen patients for COVID symptoms, you know, when there was not enough testing available, at least just get an idea of someone has any kind of symptoms of that, you know, isolate them, put them in a different unit versus spreading them. And there's a lot of controversy about that with, you know, do you move them from that location to a different location? And the vast majority of the spread at least from what I've read in AMDA and from my experience was from staff to patient and then, you know, staff to other patient, that kind of stuff versus patient to patient. But, you know, that there was also patient to patient spread as well, but not as much burden, reduce the burden to the hospitals, obviously. So if you can keep a patient in the, in this SNF without having to send them back to the hospital for things that you manage with the IV fluids or with the diuretics or with the medication management or antibiotics, or even COVID treatment, potentially mild COVID treatment, you know, the hospitals were completely burdened by this. So anything we could do, and we did. And then we were in constant communication with the hospitals about like, you know, overflow, a lot of the patients that could have been in the hospital setting had to come here. Some said, we're not going to send anybody to the nursing home. Some hospitals said, we're not taking any patients to the nursing home unless they get tested, which is the right thing to do. But it was really chaotic. Troubleshoot problems with limited resources. So, you know, you have limited therapy in the room. How do you have someone walk 500 feet or do stairs in a room that they cannot leave? Very, very tricky. But, you know, you find ways, the therapists were great. Unfortunately, just like anything else, I think it was 10,000 medical, it might be higher, medical professionals in the world. I am blanking on the number, but a lot of medical professionals died. I personally know physicians and therapists and nurses who died from COVID over the last two years. So, you know, limited resources, limited amount of staff, you have to figure out what you can do, reduce the need for scar, you know, basically limited resources. That's a good thing as well about telemedicine is that I didn't have to put on a new PPE every single time I went to a patient's room if I could call the patient directly. And that, you know, hopefully saved a lot as well. And PPE is extremely expensive in the beginning when the funding wasn't available. When the funding slowly started coming in, it became less expensive. Engaging nursing and therapy staff, talking to them, encouraging them, motivating them, engaging the physicians who weren't coming in or were coming in who wanted to help because they were really creative. A lot of the geriatricians or internal medicine docs were also covering the hospital and also covering the SNF. So basically it was a lot of work. But like I said, we still ended up performing a decent number of visits to assist with this process. And again, it was staggered mostly in the beginning and then kind of slowly tapered off. But, you know, let's talk about long-term though. Is this a new normal? What is it going to be telemedicine in the future as well? But, you know, obviously, as we've seen, the trends have kind of gone down. A lot of my patients that I happen to telemedicine in now, I've just become more open to the idea of it. And that's what most residents will say. That a simple follow-up for a procedure or a medication change or a therapy update, it doesn't really need to be in person. I can save a lot of time and save the patient time and prevent that waiting room stuff in the clinic or, you know, visiting room to room in the facility. But, you know, that, you know, you obviously have a lot more patients and providers who are used to it. A lot of the patients in setting are used to FaceTiming or things like that with their grandkids. So that helps them get more used to the process. But, you know, I think what this really opens us up to as a corporation and as hopefully as a specialty is other avenues of helping patients out remotely. And for us, we're developing and have developed many different things, including remote patient monitoring, remote therapeutic monitoring that's happening hopefully by January 1st, SNF and hospital at home. And that's a big project we're working on as well. Increased access to remote locations. So, you know, closing the gap to coverage. Basically, if I'm not able to, you know, for example, I do a clinic in which I have prosthetic patients in, you know, there could be 300, 400 miles apart and I can do the business back to back. So you can definitely help assist in different patient populations, not just SNF, just because we're more used to it now. And, you know, the clarifications that there are now, the billing is more clarified, the notes are more clarified. So it's going to get more and more clear hopefully soon. But, you know, CMS hasn't come up with a clear, you know, basically that guideline of what happens next. State by state, they have different rules, which is very tricky for a group like us, because we're all over. But at the same time, there are some guidance coming up. And will virtual care become care? Is that the new future? You know, that's how care could be provided. And you call it the same thing. Telemedicine or medicine? It's medicine. So that's my hope as people are getting more used to it as, you know, the patients right now in the 60s, 50s, 60s, 70s are getting older. They're already used to it. So hopefully that is what happens. But I think, you know, for our practice and physiatry in general, I think this really opened up an opportunity to explore more things and also continue doing telemedicine and providing our expertise to areas where they don't have physiatry. That note, we have Dr. Morris next. All right. Thank you, Dr. Tariq. I am now going to talk about CMS regulations and billing in the SNF setting. Go to the next slide. So a couple of trends, old people are aging and living longer. I don't mean to be an ageist, but that's what's happening. SNF versus IRF. It seems like insurance companies are the great dictators. SNFs are cheaper. Dr. Tariq went over that. An interesting thing that I've found here, these SNF operators have some epidemiologists who I've met with. And they're studying outcomes and showing similar outcomes at the SNF and the IRF. And I think that one of the reasons, one of the biggest reasons is that there's very poor triage of patients going to IRF versus going to SNF. And I mentioned this previously that I'm seeing, and my bias is that I'm speaking from Albuquerque, New Mexico, and this may not be what's going on everywhere. But the triage here is very poor, meaning you're getting the exact same diagnoses at the IRF and the SNF. And, you know, these, for example, hip fracture, TBI, stroke, spinal cord injury, I see all of these, and there's no real delineation. You know, at the skilled nursing facilities, I've seen, you know, C6 Asia A, C6 Asia B that are fresh off a surgery, or, you know, maybe they haven't had surgery, but they still come to the SNF. And so I think that's one of the biggest problems that IRFs are having in terms of showing benefit. And then I think we touched on, there's just a lot more SNF visits per year. I don't have to read through all of that, the 60% rule we talked about. So those are a couple trends. I wrote down something else. Oh, another interesting observation that I thought about was that, you know, we're seeing these same diagnoses, and in the IRF, I can bill for a right hip fracture seven days a week, and I can bill at a higher level. But in the SNF, I can see the same hip fracture and not bill at the same level, and I don't bill seven days a week. So I find that very interesting. And that's just another thing to think about, where as a provider in the IRF, you can see these patients and bill for them and bill at a higher level more often. So another trend kind of thing that I noticed. We can go on to the next. So credentialing with insurance companies. Some are easy, others are hard. When I first got here, there's a group, Presbyterian, and I'm still not credentialed with them. We've been working, I've been giving them every piece of information about my life that they've ever asked for, and they just are really slow, and they have really poor reimbursement. But luckily, I have a good team helping me. So I would just say, find someone to do it for you. So that would be my suggestion there, find somebody. And I can direct you in a few ways as well to find somebody if you're fresh out of residency and need that. We can go on to the next. So the Medicare Claims Processing Manual. I'm not going to read the whole thing, but basically what's in the quotations is that the overarching criterion for payment in it is medical necessity, so appropriate billing. And something that I find funny is that, you know, that they want you to bill at the appropriate level, but they're much more concerned if you bill at a higher level. So I've never seen it where that you bill at a lower level and they come back and say, well, are you sure? You probably should have billed at a much higher level. So it's always, they're always trying to make sure you're coming down to the correct level. And so there's, you know, my advice there would be to, you know, document appropriately. The fact that we are seeing these patients as they're going through therapy necessitates or gives that medical necessity to see the patients, two, three, there've been a very few cases, but I have seen some patients four times in a week with very, very active issues. So, but usually it's about two to three times a week in the SNF setting. We can go on. So this is, Medicare consists of four parts, A, B, C, and D, and this is something good to know as you're learning to speak SNF language, administrator language. Part A covers the inpatient hospital, skilled nursing, hospice, and home healthcare services. Part B is what pays us. They pay the labs, outpatient preventative care, and other services. Medicare Part C or Medicare Advantage is a combination. And then Medicare Part D is for drugs and prescription medications. So that's something good to know because you'll hear that come up. Now, I'm not going to read through this. These are the SNF regulations, what it takes to meet Medicare guidelines to be admitted to a SNF. The nice thing for us is that I don't have to worry about this at all. So the facilities are so worried about every patient that they get meeting all of these criteria that I've never really had a patient who doesn't meet these criteria. They're just simply not admitted. And so, I truly don't worry about these criteria at all because every patient admitted has gone through, there's six or seven administrators that go through all the paperwork and make sure that they meet the requirements, make sure that they have the correct insurance, that they're going to be reimbursed, et cetera, et cetera. So it's not really something that we have to worry about once we're there and seeing the patients. Go on to the next. So what does it look like on a day-to-day basis? So, like I mentioned, you see every skilled patient two to three times a week. And for people that have not been in skilled nursing facilities at all, it's good to know, I didn't even know this when I first started, is that there's a skilled section and a long-term care section. Skilled section is usually about 25 to 30% of the overall population. So if there's 120 beds, it's usually about 25 to 30 are skilled. Those are the patients that are fresh out of the hospital for whatever condition, have much more active issues, getting much more intense rehab, nowhere near as much as in the IRF, and still quite variable from facility to facility. I have some facilities where they actually end up getting two to three hours a day and sometimes even a little more. And then some facilities where they're lucky to get two or three hours a week, even if they're on the skilled side. So, and there's a number of reasons for that. And then there's the long-term care side. So I put this in parentheses, but there's a number of long-term care patients that I see every three to four months for a joint injection. So as you can imagine, a lot of these long-term care patients, five, six, seven, eight, nine, 10 years that they've been there, some even longer than that. And so it's a very welcome visit for a lot of reasons. Especially during COVID, I felt like I was as much a person to talk to. There were a couple of times where some patients I felt like I may have injected a knee or a shoulder and they really just wanted somebody to talk to. But that kind of is what it is. And depending on how many facilities you go to, the type of facility. So if they take a lot of ortho procedures, post-op ortho patients, you'll probably do a few more injections. Depends on the population and long-term care. But I average about 10 to 15 joint injections a week. And I have, like I mentioned, I work with some PAs and I've trained them to do knee injections. And I'm working with them to do shoulders and hips. I think Dr. M mentioned that the most common thing, most common pain management thing that she's been doing are knees and shoulders and then trigger points. And I've recently, I didn't do a whole ton of it in residency, but throughout this past year, I've done a ton of trigger point injections. And patients love them, especially in the long-term care setting. And a lot of it is just because they're just sitting in their rooms all day. And I think their muscles get really tight. And so it's been a great relief. At one facility I'm at, I did trigger point injections and I consistently see the same lady and her family is just absolutely over the moon with me. And so that looks great. The facility administrator really likes that because the family is just constantly, they have my phone number now and they text me. They send me goodie bags and things like that just because I'm making their, it's their mom, I'm making her quality of life that much better just by doing these trigger point injections. And then, you know, one of the, I mean, it's the bane of every provider's existence, but in the SNFs, most of them use one of two EMRs, point-click care is kind of the big one. It's the only one I use and it's fine. It's not great. It's not great for coding and billing. It's a little bit bulky and kind of difficult to find some things. So, you know, you end up spending about 40 to 60 minutes a day dedicated to coding and billing, which isn't, you know, isn't the best thing, but there's some EMRs out there that are working on linking up with point-click care and kind of making note writing and coding and billing much easier. So that's good. The last thing, the length of visit and billing are not well correlated. You know, like I mentioned, a lot of people in this setting need somebody to talk to. And so, you know, you can spend a lot of time with a lot of different types of people and you can end up being a bit of a psychiatrist even though you're a physiatrist just because they need somebody to talk to. And so on a day-to-day basis, you know, for me, it's kind of evolved since I've been here. I do a lot of training with my PAs now and I don't see as many patients and I'm also in an IRF. And I think that's mostly due to the lack of PM&R in Albuquerque. So, but anywho, I think the, and I mentioned this in a previous slide, when I first heard about physiatry in the SNF, it was through a recruiter at IRC and he contacted me and he told me, oh, there's no nights, no call, and no weekends. And I thought, all right, this guy's, you know, this guy's full of it. There's no way that that could be. But until I joined with the IRF, it was truly that. It was no nights, no calls, no weekends. And, you know, we're a great, in some cases, we're a great luxury for the patient and some cases we're, you know, invaluable to the patient. And so I've really enjoyed working in the SNF. It's been very redeeming, although very difficult during COVID. There have been times where it gets a little more difficult and some of the facilities are not as nice as others, so, but overall, I've really enjoyed it. And yeah, I think that's, oh no, I have one last slide. This is what a census looks like. I've taken the names off of it. The numbers that you're seeing up there, the dates, that's the last time that either PTO to your speech has seen them. Then there's their insurance, Medicare Part A, Part B, and then the total number on PT and OT, and then the ones, yeah, Medicare Part A and Part B. So Part A, those ones are getting much more intense rehab. Part B, getting a little bit less. Usually long-term care that are getting some therapy is Part B, and Part A are the skilled patients that are fresh out the hospital. So I just kind of wanted to show that that's a snapshot. Conclusion, medical necessity is there. You're very much needed. It's variable by SNF, and the future of inpatient is skilled nursing, in my humble opinion. So that's why I'm doing it. Thank you for your time. Of course, thank you so much for that feedback, and great presentation, I appreciate it. So we'll open it up. We'll have all the presenters available for panel discussion. If anyone has any questions, please feel free to ask in the chat box, or you can raise your hand as well. I'm gonna actually put my name and email address. I'm gonna do that. I'll put my phone number, actually, and email address if anybody has any questions. I'll put that in the box. While we do that, I'll mention a few things that I discussed before. One is, you mentioned the percentage of patients that are short-term versus long-term in the facility varies all over the place. There are places that I've worked in that have 100 beds and only have five skilled. There are places that have 100 beds and only five are Medicaid or long-term. So you can have a switch. The one I'm in right now, literally, is 90% short-term, and they focus on, they're called medical resort. There's not many buildings out there, but obviously that's changing as time goes on, become more and more specialized. So that is something that Dr. M also probably sees. Some are more, some are less, and obviously with the floors being shut down and things changing, that is all over the place. So it could change. Yes, I agree. Yeah, absolutely. One more thing I think is important that I didn't mention before was the three-day stay in the hospital. The overnight stay, you need to qualify for a subacute stay, but that was waived with the pandemic. And I mean, there's a pretty high chance that's gonna stay, that waiver. Obviously, they've seen the benefit of not keeping patients in the hospital longer than they need to be, and they can get discharged, but that could change things. I mean, obviously, if the waiver is taken away, the subacute will suffer quite a lot because I see a decent number of waiver patients now. So they'll even have more issues with admissions and keeping the beds full. Something to think about. So- We've actually seen that in the IRF as well, where that waiver's in place just to get patients out the hospital. And I've definitely seen, I mean, not every time, but fairly often that, yeah, okay, yeah, you didn't need to be in the hospital anymore. You're good to go. Right. One of the things that I've done, and maybe you've had a chance to do that, is there's patients that come straight to the SNF from the hospital setting, but they're really appropriate for acute rehab. And I have to have that discussion with the primary care, primary care team not as important in that case versus the admin, because they're looking at numbers, money. And then I try to convince them that, you know, this person, their level of care, that requires acute rehab. And we'll talk to the acute rehab hospital. We'll talk to the physicians there, and, you know, we'll let them know we're sending a patient over. We've done that a few times, and the acute rehab is IFRS or anybody in that setting. They're shocked that they got a patient from the subacute side. And once that happens, we realize how good of a partner this is, partnership this could be, and that creates that bond. So that actually helps them if they do that. One interesting route that I've done because I work at both the IRF and the SNF is that I've had long-term care patients at the SNFs that have come to IRF. They've deconditioned at the SNF, come to the IRF, got a lot better, stronger. Then they go back to that same facility, but their SNF, again, they're skilled for four weeks, and then go back to long-term care. So it's kind of a win-win-win where they, because the skilled nursing facilities get paid more for skilled patients versus long-term care patients. And so they're able to skill them again for four weeks, and then they go back to long-term care. It's so important for us to find the appropriate level of care for these patients and not just focus on like, well, their hair now is fine. But I've had patients who were not really progressing well in beginning and they started perking up or getting more energy. And like, you know what? This is the perfect person right now for acute rehab, they can handle it. And you can send them back and they come back. So we have a really good question. Actually, I'm gonna have you guys answer this. This is, what do you wish you were taught about SNF work or subacute work in residency? Dr. M, you wanna say something about it? I can start, I can start. So I had no idea what I was going into. So I did residency at my UPNC program where I'm now. And at that time, really, this was not, this was in the making as an idea. So once I went in, I knew nothing. So it was a learning curve. So I don't know, I wish I knew a lot more and I'm really happy that there is a lot of, you know, like information right now. And I wish I knew some people who could have kind of guided me better. So I think this is really helpful if you're thinking of starting this practice. Dr. Morris, you're the most recent out of residency. You can probably talk about this. Yeah, I mean, I was, I latched onto this right as I heard about it. And, you know, so looking, you know, hindsight's 20-20. So yeah, I wish day one from residency, I would have learned about it. But a lot of this is self-taught and, you know, working with you and, you know, talking to some other people that have done it. In our breakout session, I talked to Dr. Mayer, who's on here, and he is at John Hopkins and he is getting the residents there some sniff exposure, which I think is great. So I think, you know, to answer the question, I wish, you know, I would have been exposed to it because I did not work in sniffs once during residency. I learned about it during residency and kind of did my own research on it, but I wish I would have had exposure to it during residency. So I, you know, I think it's such a dominant, I mean, it's the main player of post-acute care. It's where the vast majority of our patients go post-acute. And so, you know, and physiatry is just so blatantly necessary that, yeah, I think residency is where we need to be exposed to it. I can add a few things about that. So 2012 is when I finished my residency. And for years since before that, even after that, fellowship is like the thing to do. You know, you want to apply for pain fellowship or sports or spine. And I mean, that trend is probably not going to go away anytime soon, unless something significant changes with the reimbursement or the, it's just very, you know, some people just want that, I get it, you know, for sure. But, you know, I think the future there will be, and I've already had medical students and early on residents reach out to me about sub-acute. That would have never happened four or five years ago. It was always like people already finished their training and they want to change a lifestyle or they don't want to do acute rehab and things like that. But, you know, you're an example of that. It was in three, I think it was year three, I think. But I've had people in medical school thinking about that as well. And I think we have a couple of residents here as well. The point is that I think in the future students who are applying for residency will look for programs that actually provide that, you know, exposure. I think a lot of students, especially in this generation, want to know more about the business of medicine. They want to know more about other practice styles, telemedicine, and just get exposed to different things and not just be like focused on inpatient only or regenerative medicine only or sports only. That's the key, I think, is getting, you know, providing mentorship to the residents early on, not being overly concerned. and I know it's hard for, you know, someone like in my city to say that, but not be concerned about that. Someone's going to take the resident away from the academic setting. Uh, but providing that education and the platform so they can, they can have success in the future. I was very spoiled in our, our residency because we had a subacute unit. We had subacute rotation. We had attendings doing subacute. So I came out of residency knowing everything I possibly could about it. Uh, which is why a lot of us ended up doing it, but, uh, there has to be early exposure. Gosh, you have a lot of great questions. I got to answer. Uh, look at this. Uh, so I love Carrie's question. Carrie, uh, yeah, fabulous question. Let me read that out because people can't see that. So it says, do any of you reach into acute hospitals to help influence discharge disposition, uh, to the right post-acute setting, uh, for example, or versus sniffers, a whole milk, or generally at the mercy of the hospital case manager. Uh, so, uh, Kristen, you're part of kind of part of both of it. I can give you my perspective as well, but yeah, uh, my perspective is, uh, that here's what I think should happen. Um, and then here's what happens. So here's what I think should happen is that there is a physiatrist who's, um, or someone else that's trained, uh, well enough to do it, but somebody who is triaging these patients to the correct level, given the resources that they have, uh, at their disposal. So in Albuquerque, we really have three IRFs and then we have like 25 sniffs, um, and, and a lot of home health. Well, um, you know, and like I mentioned, it's a, it's a grab for beds. So that's what dictates where they go is sniff says I have a bed available. Now case managers does great. It's yours. Um, we have liaisons at, at the IRF that I'm at, or developing relationships and getting, um, you know, trying to get more of the appropriate patients, but in the same breath, if they're taking a deconditioned patient who, you know, probably should go to a sniff, um, but they need the beds. And so it's extremely frustrating because, you know, um, you know, that these patients are out there that need to come to an IRF, like I mentioned, I mean, C6 Asia, ABC, you, I mean, do they need to go to a sniff or an IRF? I mean, that's a no brainer, you know? And so to see them at the sniff is, is a little bit heartbreaking. Um, but it's in Albuquerque and which is what I can speak to is, is, you know, sniffs are trying to fill beds, IRFs are trying to fill beds. Um, you know, and that's what it is. And there are some sniffs that have longstanding relationships, longstanding relationships with sniffs, uh, and hospitals, acute care hospitals. So, um, you know, I'm kind of, uh, pretty blunt with it, but you know, there's, uh, a sniff group. Uh, they own a bunch of sniffs and they employ some cardiologists from university of New Mexico. And where do you think the cardiac patients from the university of New Mexico go? Well, they go to these sniffs. I mean, it's not like a, you know, uh, I know there's probably some, you know, stark law, something like that, whatever, but, um, you know, there's always ways around it. And so it's frustrating as a physiatrist to see that. Um, and so to be honest with you, no, I'm kind of powerless, uh, to do anything. Um, but I, I poke and I prod and I suggest, and I, um, you know, I get patients that, you know, like a C6 Asia B that goes to sniff, then goes long-term care at the sniff. Um, you know, I talk them into letting them, you know, go to the earth because I'm showing them that they can bring them back and sniff them. And then, you know, and so it's a win, win, win all around. So there's ways that I kinda, I try to help the patients maneuver the system, but in the end it's, um, case managers, it's longstanding relationships and it's the health insurance companies, uh, that are the great dictators to, to, to that. Yeah, I would agree with all that. I think it's very difficult to make those changes unless you're on the, at the, at the table and in that discussion. And at least for, for us locally and somewhat other places, we've become part of post-acute networks for hospital systems, and that's when you can have some leverage, you can create some protocols, but if you're not part of a network and you're just like the individual person, it's really, really difficult to do it. Um, let me just interject, Carrie accidentally direct messaged me. So I just want everyone, uh, to see full disclosure. She says I still practice part-time, but also work within insurance industry, not as the payer and try to influence policies on this and focus upstream pre-acute hospital, DC, et cetera. So I think she, she then said, sorry to D that it DMD. Uh, I don't know, Carrie, I'm not very good with zoom either. So I, you know, no worries. Yeah, we did get that here as well. Okay. So, uh, next question is a good as a MedPAC often references concerns or prescription of therapy in the SNF leading to excessive, uh, excess cost to Medicare. How do you see this changing with PDPM and how do you see this, uh, affecting physiatry's role in the SNF setting? Um, I would love to talk about PDPM. Anybody else have anything to add in? Cause I can definitely go off on that. So PDPM, so for most who don't know, I really didn't touch that. There's so many different things on top. We did not talk about cause it's so much to discuss. We really didn't get into the level of codes and the complexity. And the PDPM is a big thing you got to talk about in general about payment. So before PDPM, uh, Medicare payment for the facility, for the patient was based on the number of therapy minutes they had to received. Uh, and obviously some facilities running on a very short, a small margin, they were maximizing therapy and the rug scores were super high. So Medicare changed that regulation in end of 2019 to PDPM, which stands for patient driven payment model. I recommend every single physiatrist, uh, look, working in the post-treatment setting, it doesn't matter if you do something good or not to be aware of what PDPM is, cause that has significant impact. All of a sudden the payment for a patient, for the, for the facility change from therapy focus to nursing focus is a significant shift. Um, and, uh, the, the, uh, about 40% of therapists were let go in the, in the, in the sub acute setting at that point. Some of them were brought back because they were concerned about the reduction. Overall PDPM was supposed to be budget neutral, but it was not budget neutral, it was over budget. And obviously in the future, I can imagine that just like Medicare would, the whack-a-mole will, you know, find ways to reduce that. But long story short, you know, it's a very complex talk by itself an hour. And hopefully in the future, we'll talk about that as well. But with PDPM, uh, the physician and provider, I'm going to add them together. PA and P's, uh, are one of the most important part of the process now before they weren't as important. And the reason is that, uh, the patient's diagnosis, um, is what gets the facility reimbursed. And the only providers who can diagnose as physicians and PA's and NP's, therapists cannot, nurse cannot, they cannot make up a diagnosis, a billing person in the facility or admin. What that does is puts a lot of, uh, you know, work on us and clinicians to document correctly what happened in the hospital. If someone went to the hospital in acute rehab for sepsis, uh, the sub-acute cannot take that sub-sepsis diagnosis and plug it into a SNF diagnosis because the sepsis has dissolved. But you can have, you know, critical illness myopathy, you can have other conditions that come along with sepsis, dysthasia, cognitive changes, metabolic dyslipidopathy. And there are certain diagnoses that pain more under PDPM, including speech issues, uh, respiratory issues, things like that. The point is that the focus is more on diagnosis and documentation, which actually helps us a lot, if anything. And, you know, we have a few other people from, uh, uh, you know, my colleagues that get mentioned, but if anything, our role has solidified even more than before, uh, in the facilities that I work in that I work with the MDS coordinator, basically means the, uh, biller, billing person in the facility, they, and the fact that I'm able to capture some of these diagnoses that are already existing, and I'm just documenting dysphagia, obesity, malnutrition, things like that. It gets them to be able to provide the appropriate level of care since they get reimbursed for that work. So long, long answer, but the point is that it is, if anything, this is a positive for psychiatry and physicians in general, because before they weren't really, you know, didn't care as much about documentation. I hope that answers that. Do you guys have any questions about that individually, Dr. M, Dr. Morris? Well, one thing I can say, because, uh, for me, when I first heard this from one of the geriatrician, I was like, what the heck is PDMPM, but then there was a podcast and that has a really good podcast. You can listen to a lecture. I did listen in the gym and I was like, Oh my God, this is really good. And it's really about like the value of us and capturing everything, just like an inpatient rehab, pretty much. It's, it's, it's like, uh, it's, it's the similar thing and how you can, by capturing everything as Dr. Tariq said, really help the, the, the facility financially, which is at the end of the day, it's all about the dollars. Yeah. I mean, I'm all about helping the facility, but you know, it has consequences. Like you said, a facility that is not able to financially be viable, it shuts down. So indirectly you're actually affecting patient care with the staffing issues right now, I like, you know, I'm literally working today and I talked to a CNA that I know well, and they're getting $25 plus an hour. Because, and majority of the nurses, because there's not enough nurses that you get, uh, agency nurses or PRN nurses, and they're not going to charge normal prices. They charge 50, 60. I mean, the prices are crazy. So what ends up happening is that your, uh, expenses keep going up. The, the quality of care keeps going down and who suffers in the end, the patients do. So there's anything I can do to kind of help balance that, uh, imbalance by, by mentoring CNAs, by educating, uh, nurses, by, uh, you know, helping out patients or helping the facility to get paid appropriately, we're not doing anything to make them get paid inappropriately. We're just documenting what exists, but they cannot get paid by someone has dysphagia. I had a patient today. I just saw, they're like, you know, I, I'm having difficulty swallowing and I'm like, okay, I'm going to make sure I document that because that's the truth. Gets you on to CC space therapy, which then ends up getting the facility higher reimbursement because they have to provide different care for them. Someone had, he's getting a med line. Uh, someone's getting IV fluid. It's a different payment for that. So you're helping the patient out in the end, I think, in my opinion. Yeah. The thing I tell people that are, you know, when you become like an independent contractor and you really have to get into the business side of medicine and you can kind of feel, you can feel a way when you're, you know, um, you're billing patients cause you're, you know, it's kind of like, man, this is, it's just a different way of looking at it compared to you're just always used to getting a salary and residency. Um, and so when you're an independent contractor, you really have to understand the business side of medicine. And what I tell people is, you know, there's two arguments to be made. And one is we can argue the system, the system that we're in, um, whether it's good, bad or indifferent, but. You are in that system. So you have to learn the system and you have to learn to maneuver within the system and like any system you can learn to, uh, once you thoroughly understand it, which I'm still learning it, you can help patients maneuver through that system better, um, and you can in the end help patients more by understanding the business side and by understanding that, that the system, and I'll come back to the bringing these long-term care patients, uh, to the IRF and then back to the SNF, uh, IRFs get paid, SNFs get paid, but in the end, the patient. Really ends up doing a lot, lot better. Uh, they get a lot better care. And so you can kind of feel away. You're like, well, I'm just, am I just enriching IRFs and SNF owners? Am I just, you know, that's, that's kind of a separate thing. And, um, you know, a lot of us, most of us get into this because we like helping people. And so to attach a dollar amount to everything we do is difficult. Sometimes it makes you feel kind of a certain way, but, but it is the system. And once you learn that system, you can learn to help patients maneuver within that system and take advantage of certain things so that they have better outcomes. Now set a better, great, perfect. Um, at the same time, peer to peers, right? So no one wants to volunteer and say, how am I going to do a peer to peer? But I'm that person. I'm happy to do it. If I feel strong enough about a patient and you know, the peer to peers are changing, uh, you inpatient rehab docs are used to that anyway, and outpatient as well. But in the subacute setting, the managed care, other plans, there's a lot more peer to peers and there's never a real true peer. Uh, they're not never physiatrists that I'm talking to, uh, on top of that. Um, you know, some of the insurance companies are denying, uh, peer to peers to say, you're not even allowed to do it. I don't know how legally they're allowed to do that, but you have to send a medicare is a lot. Medicare is doing that a lot. I think I've noticed, I don't know. Yeah, it's really interesting. I'm not sure, but you know, basically like they're not even allowing peer to peer, they kind of deny the family has to keep on appealing. Well, my point is that peer to peers are basically my fight for the patient because you're fighting for the right for rehab. Uh, we do it different ways, but for me that that's what it takes. And, you know, I'm, I'm not very pleasant in my peer to peers. I'm actually like, I know way angry. I'm like, how can you not see this, that this patient is not able to do stairs, have stairs at home. They cannot go, you know, go back to the hospital. So, you know, that's at least my perspective. And, you know, knowing the system is exact same thing. You kind of have to know it so you can find the ways to help the patients out. Oh, okay. A couple of other things. I mean, we probably will do five more minutes of it. I think we're all exhausted and tired. Uh, but how, um, we talked about creating a residency. Um, but yeah, how do you deal with primary care doctors that happens so frequently primary care doctors who just don't understand PMNR, you know, goal or what we're trying to offer. And Morris, I know kind of what you would say, cause you talked about it, but Dr. Uh, Emma, I want to hear more of your perspective of primary care doctors who might not be open to the idea of PMNR. How do you tackle that? How do you fix that issue? Well, you, you fix it, you show them what you can do. That's the point. You just have to be given a chance. Once you give a chance, don't waste it. That's, that's my, you know, kind of like, so grab it. Like one thing I'm teaching my residents, there is not, they like to use this wording, inappropriate consult. That does not exist. So forget that word. If you want to be accepted, nothing is inappropriate. Accept the answer or the challenge, you know, uh, kind of tackle it, heads on, do the best you can and you, they will eventually see our value. So if you say, you know, and, and again, like, I just cringe when I hear that word, there is nothing inappropriate. You can always help either as, as a Christian set, just talk to them, just by showing up and, you know, like bursting that social isolation, you helped, you helped somebody like somebody smiled because you said the joke and that's enough for me. So like, and that does not answer your question about the primary care physician, but actually I kind of try to, you know, just be there every time they ask me something and eventually they'll ask me the right question, the right patients. Once I show them what I can do, that's it. You know, they're, they're, as they say, they're sold. So that's a simple advice I can do, but don't use and don't use strong wording. Always be very polite. Remember we are secondary. We are consulting service. There is no like, Oh, what did they, no, no, no, no, no, no. Just very verb. Wording is extremely important. Almost like you're a lawyer. Whenever you write a note, just very gentle, gentle, just come, it has to come across, but gentle and don't be, don't step on anybody's feet because we are on somebody else's turf, just so you remember. Great advice. Great advice. Yeah. Physiatrists being a physiatrist is being akin to a diplomat. Exactly. 100%. One of the, was something I heard somewhere I read, I love this, like the way to describe the role of physiatry in any setting, but you know, in this setting, definitely a lot more so is, is physiatry can be divided by three parts. One third is medical management. One third is rehab management. One third is cheerleading. So a lot of what I ended up doing, honestly, is like, you can do this. I mean, this today I saw a patient, I was like, so happy that I just said that you'll be able to go home after this. Oh, I thought after my hip fracture, I'll stay here forever. It's like, no, you'll be fine. You're, this is where you're at. I'm going to help you with your pain. And that made her day. Like that subtle thing of being a cheerleader or a therapist who kind of like this runs into this barrier and you kind of help them figure out, no, we can go more, the stroke is not done recovering. So that's, that's what we do. We're great at motivating people. We're great at motivating our patients. And I feel like this is an, this is a amazing opportunity to work in this setting and I hope it keeps on growing. I think it is growing. I, if there's no other questions, I would love to end the call at this point. Please join the community. You know, we are not very active, but we plan to be more active. I'll have some slides up here. Proclaiming CME and also I think this concludes the discussion. Thank you so much for your time, Dr. Morris and Dr. M. I really appreciate you taking time out and being part of the discussion. Thanks for having me. Thank you. Have a good night, everybody. Take care. Thank you. Bye.

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