Okay, I'm sure we'll get some stragglers, but in the interest of starting and stopping on time, I'm gonna go ahead and get started here. For any of you that don't know me, I'm Dr. Steve Natz. I'm Chief Medical Officer for Integrated Rehab Consultants and have been involved in skilled nursing facility rehab for a while. As you may know, significantly more inpatient rehabilitation occurs in a SNF setting today than it does in an acute inpatient rehab setting in America. And while we as physiatrists have no mandate to be involved in skilled nursing facility-based care, I think that we should. As I was saying, I followed my patients into the SNF from an acute inpatient rehab setting because I found that more and more that's where they were going. And that if I wanted to see my patients, then I'd have to go to the SNF to see them. And so that's how I started my practice in this area. But I think as time has gone on, it has become clear that it's a very important and emerging area in physiatric practice. So in the next hour and a half or so, we're gonna try to give you what I think is a basic course in why physiatrists should practice in the SNF and taking the, I think we titled the course, Taking the Mystery Out of SNF Practice. Not that there's any big mystery to it. It's pretty much like practice in any other level of care with a few caveats that we'll get to during the course of this session. So ideally, one of the things that you'll find about your patients when they go to the SNF compared to an inpatient rehab facility is that they tend to be more medically stable. Patients who are going to an IRF today generally tend to be, I mean, sometimes they're characterized as being right out of the ICU, but they have a lot of medical issues as you probably know. But also patients in the SNF setting will challenge you. They'll rely on your guidance. They'll be better because you're there. And the rehab team in the SNF really does need you. If you compare the rehab team in a SNF to a rehab team in an IRF, one of the very first things that you find out is that the level of expertise, particularly when you come to some specialty types of expertise, is not there. The rehab team in a SNF often has very good general skills about rehabilitation. I'm talking about your therapist in particular. But maybe not the specialized area of expertise. And some of that, you might have to work with them, you might have to teach them. The US healthcare system as a whole will do better in terms of lower costs and better outcomes if you practice in a SNF. And I think we're gonna talk more about that in our course that we have on Saturday if you're interested in more of how things work at a system level or more advanced topics, then check your calendar for Saturday morning at 10 a.m. We'll be here with a different group of experts talking about how the value is added from what we do as physiatrists in different post-acute levels of care. As I said before, IRFs are all very similar. They're similar in terms of intensity. Some of that is dictated by regulations. They have to have three hours of therapy. They have to be able to participate in it, things like that. And if you've seen one SNF, you've seen one SNF. They're all very different, as I'm sure our other speakers will attest to. And the SNF rehab teams differ in their skills. One of the biggest things that you'll notice when first you start practicing in a SNF is the level of nursing education. Oftentimes the nurses that you're dealing with in a skilled nursing facility environment are good nurses, but they really don't know a lot of the rehabilitation-specific things that you might expect that they would know. And so there's a big need to standardize protocols, pathways, outcome measurements, and things like length of stay by diagnosis in a skilled nursing facility. Some of that has been kind of the Wild West, if you will. But I think as facilities move in to the new payment system that came into place in 2019 called the PDPM, Patient-Directed Payments Method, that they'll start to see that things are more standardized. The PDPM is really a movement towards some sort of a prospective payment system for skilled nursing facilities, and I think it's gonna help standardize things. So working in a SNF will maximize the quality of their rehab programs, minimize, or right-size, I should say, the length of stay, maximize the discharges home, and avoid unnecessary hospital readmissions, support our patients, guide our healthcare systems, and help you enjoy your practice and avoid burnout. If you want a little bit more in-depth of things that I'm just talking about right now, you can look at some of the online CME courses that the Academy offers. There was a position statement in 2016 that talks about the physiatrist role in skilled nursing facilities, and there's also a brand new, it's only been out on the website for about a month, a Enduring Materials and Online Learning Portal on the physiatrist role in skilled nursing facilities that Charlotte Smith and I did. So with that, I'm gonna thank you, and I'm gonna turn the podium over to my esteemed colleague, Dr. Aslan Tariq. There you go, I think we just do this. You're gonna have to get your slides up there. I'll do it. I've got a band in us. Yeah. Need some tech support. There's a guy in the back. All right, thank you everybody for coming in on Thursday afternoon. And I have a, first of all, I'm a really fast speaker. On top of that, I have laryngitis, so please hopefully keep up with that. And if you have any questions, obviously we'll have a Q&A in the end as well. I'm extremely passionate about SubAQ and I've done it for almost 10 years now. I love talking about it. I pretty much give a talk every year, but I'm hoping that the stuff we talk about today, hopefully make it into a half day or a three hour course in the future. So people can have more information about this. And just because you don't get a lot of exposure in residency, some people do, most people don't. I think it's important to have that knowledge base and it's really hard to get everything covered in this like short 20 minute talk that I have in the rest of the time after that. So we'll kind of get the nuts and bolts of this though, but I'm the Chief Clinical Officer for IRC. We're gonna talk about hopefully past, present, exposure to SubAQ, consultant role versus primary role, logistics and resources that you might have available. What's the patient population that you manage? What are the regulations, the coding and audits, liability, so a lot of stuff. So hopefully we'll get through some of this stuff today. So this is a really interesting journal article that came at the Clinical Rehab and Physiatry Practice Journal. And what's interesting about this, I'm not gonna read this verbatim and this could be in the slides, is that this came out in 1996. Just today in the morning, I'm the chair of the SNF community and we had one of our attendees who mentioned that she's been doing SubAQ for 20 years. I've known people doing SubAQ for 30 years. But it's kind of this mysterious thing people do on the side and nobody knows how it works and how do you not do acute rehab? How do you follow the patients? How do you get paid? There's a lot of mystery behind it, so hopefully the idea behind this to make it more palatable and less of a mystery. But physiatry in this setting has been going on for years, but it's definitely a lot more prevalent now. From our estimates, there's close to 1,500 physiatrists in the country right now doing this. There's, and we'll talk about more data points after that as well. So since the 80s most likely, the trends of length of stay has been significantly changing over the last couple of decades. The amount of time people stayed in a stroke unit. I remember in my own residency that a stroke patient would stay for 40, 50 days sometimes and that was changing while in residency to 15, 20 days. So the same thing is happening in the SNF setting too. So where do the patients go? They have to go somewhere if they can't go home. IRFs, basically the number of beds have pretty much stayed stable, maybe gone up a tiny bit, but the number of subacute facilities and the number of beds have pretty much stayed the same. It may be a slight decrease during COVID because of consolidation and some of the old school facilities had to shut down and basically were bought off. But there's a lot of consolidation happening. The trends are towards facilities that are these super SNFs. Basically they have in-house dialysis, in-house ventric. They are affiliated with a hospital. They have to kind of basically evolve that way, otherwise they get left behind. The number of encounters from the SNF setting and the acute rehab setting, you can clearly see a trend there that acute rehab encounters are kind of stabilizing versus SNF encounters are going up. So either the inpatient physiatrists are transitioning and doing subacute or more people are doing subacute. So either one of those things are happening, or probably both. So what is fluid in this movement? This movement started off years ago, but it's basically accelerating now. A 60% rule which restricts the number of patients or the number of medical diagnoses that are appropriate for acute rehab. In the morning today I was hanging out with a physician who works as a utilization review director for an insurance company. And he was telling me about this stuff that they deny stuff a lot based on algorithms and clinical acumen, whatever they use. But that's gonna accelerate as more managed care plans obviously come in the picture. Then you have LCDs basically. You have advantage plans we talked about. Subacute is basically less costly. Now again you might argue that this less cost means better quality. For the perspective of the MedPack, really they are looking at both those things. They know it is cheaper and actually it's as good for certain conditions, not every. This is from the MedPack. Basically it's showing the cost of care for a trach with a vent or a respiratory with a vent or a joint or a hip fracture and stroke. And there's some significant difference in the prices here in the cost. And as Medicare basically goes bankrupt and they have to figure out a way to basically make the system not crash, they have to find payment models and cheaper cost of healthcare and better utilization. We had this amazing attendee today in the morning and he was talking about how he's basically as a physiatrist trying to help out with the flow of discharge. Where should a patient be at discharge planning for the hospital? Should they go to LTAC or SNF or acute? And that kind of stuff is gonna become more and more prevalent where the facilities at SNFs will have to be part of a tier system or some kind of a dashboard where they get the patient because they provide better care. And the facilities, now they're realizing that they can only provide better care if they have better physicians, better engagement and that kind of stuff. So that's where we kind of plug in. So this is evidence that physiatry helps. This is basically evidence that was presented at the JAMA, which is the Journal of American Medical Director Association. And this shows that we help with reduction of ER visits, length of stay, overall quality ratings, all those kind of things are helpful. Now we're, basically as a corporation, we're trying our best to basically have more data to show this because the next level where the bundle plans and the ACOs, they want this data. They're not gonna partner with a practice or a group or a hospital if they don't show this data. So this is the statement that Steve was talking about and it's gonna be a new one I think coming out soon as well. Just a little bit of a change, a few things, but nothing major changing. The main thing is that AAPMNR as an organization has a position statement which you can use to basically get more knowledge about it. Obviously attending these lectures and the lecture that Steve just gave off for the website is to understand the lingo. What does it mean to when someone says PDPM or what does SNF and ALF and IRF and what does Med A mean or Med B? Those are the kind of things that you have to be ready for when you're in the setting regardless of doing independently or not. So from a PMNR perspective, AAPNR perspective, it could be as a consulting model or a co-treating model and visiting the patient two, three times a week. These patients are not sick enough to be seen seven days a week like acute rehab patients would be. At the same time, they're not well enough to be only seen once a month. So current regulations for subacute are that the federally mandated visit for a primary care doctor is once a month. So a patient gets admitted on let's say January 1st. They have until January 30th to see the patient. That's not how the patient population is nowadays. They're actually leaving. They're going home in 15, 20 days. So the acuity is changing but the regulations are kind of far behind. But from our perspective, usually the twice a week and the AAPNRs, that seems to be the happy medium. Now what do we do in the setting? We address pain. That's one of the biggest things we do obviously based on function. We maximize functional status. We understand function better than anybody else. We understand prognosis, diagnosis. We can help with the team. We reduce overall cost of the healthcare system by reducing readmissions, falls, polypharmacy. These are all the kind of the talking points that you have in the facility. We right-size the length of stay. We don't necessarily, might not reduce it all the time but we right-size it. I still stand up for my patients for peer-to-peers. I call the insurance companies and fight for the length of stay to be increased when it's the right time. At the same time, if I see someone who needs to be in acute rehab, I'll fight for that. I'll call my local physiatrist and say, hey, this person had a recent amputee. Now they can tolerate therapy. Now is a good time to get them in acute rehab. So you can actually create the whole continuum of care. Address patient questions about their conditions. Many come to see me or I see them and they have no idea about their prognosis or diagnosis. Improve satisfaction. Assist in reducing barriers to discharge home. Advocate and appeals. A lot of times you have inconsistent primary care coverage. I mean, some facilities that I work in, we have a primary care in-house three times a week. Some are once a month. Some have a nurse practitioner in-house. Some have someone that comes in once a week. It's extremely all over the place. Even within the same organization, same type of practice. Majority of the primary care physicians, they think they know rehab, but they don't or they might lack overall general detail knowledge of it. They might over-prescribe medications that should not be done. I've had many cases of people on multiple muscle relaxers or multiple medications should not be on. Inappropriate imaging. Imaging for every single thing. Not knowing what type of imaging to do. Basically, the patients, the families, the therapists, the primary care, all these different dots that you have in the healthcare system and not talking to each other, we come in the middle and kind of quarterback that. We educate all the team members about the appropriate level of care and discharge planning. And again, delay in providing specialty care. We are specialists. We can do pain, injections. We can still do a little bit of neuro, a little bit of rheumatology, that kind of stuff, but a little bit of orthopedics and non-surgical. But really, we are that person in the building, the eyes and ears of the outpatient surgeons, the outpatient neurologists, the outpatient PM&R, that we can help the workflow. We can help the coordination of care. Again, other stuff is the lowest star rating, the lower rate to discharge to home. A lot of patients in certain facilities might go to the nursing home. They might stay there and never actually get to go home. So these are kind of things that, as we get more involved, we can improve those outcomes. A lot of audits. Nursing homes, as a system in place, is the third most regulated in the U.S. after nuclear and NASA. So it's really, really regulated. There's a lot of challenges. Throw on top of that staffing, then COVID, then payment models. I mean, it's a challenging place to be in. We have to go in there and act as that extra level of support and saying, you know, we understand it's tough. We're gonna help you out as best as we can. And we can't do it for every single patient, but overall, generally, we can. Lack of rehab focus. They might say we're a rehab center, we're focusing on rehab, but are they really? I mean, there's a lot of modalities that I see in the nursing home. Therapy gym, never used. Diet therapy, ice, that kind of stuff. Tens, or the therapist kind of just like, lack that next level. Okay, let's try something different. Or the person has pain, let's put them on Norco or something else like that, or hydrocodone. Let's not do an injection. So those are the kind of things we come in and help out with. When does someone need a prosthesis? When does someone need a certain medication? When does someone need an EMG or not? When does someone need Botox? What is a contracture versus spasticity? Those are kind of constant challenges every day, and that's why I love my job, because I have something to do every day, and the patient population is so mixed that I can do something for everybody, pretty much. And one of my mentors mentioned that the physiatrist role is pretty much threefold. One is we are rehab management. We do rehab management really well. Second is we do med management or medical management, which could include pain as well. And third is we're good cheerleaders. You know, for me, a lot of times I have to go in the facilities and the patient's room and say, come on, you gotta do it. Let's get up, let's do therapy. And that could be enough for that day, but majority of the time you have to do more than that. So inconsistent, poor outcomes with peer-to-peer denials. Now the denials are getting more complex because they don't even offer peer-to-peer. They say, well, just send us your notes and see what happens. But they're finding ways to make it more complex, but we fight the fight. So basically, missed opportunity, and I think some programs out there are actually including this, and it's a whole issue with the GME and how they basically reimburse for the months of the training, the rotations, but I think the exposure to subacute is important because it's a continuum of care. You should get exposure, even if it's not a whole month of rotation, but there's gotta be someone. One of your attendings, we have one of our colleagues talking about this after this at UPMC, or maybe a local physiatrist you can round on, or just at least get exposure to it to see what that level of care looks like because if you don't know what it is, the unknown seems very, very daunting. And then five times as many patients are in the subacute setting versus acute. I mean, there's 15,000 subacutes. At the most, I think physiatrists are covering maybe 1,500, 2,000 at the most. There's so many more out there. Obviously, a lot of them might be rural, small, there's not enough manpower in the area, but there's a lot of opportunity to help these patients out because if they don't have us, they don't have physiatry, so we have to be involved with that. I don't know what happened. I'm playing a TV. Oh, there you go, sorry. Yep, you're good. All right, so how do you set the practice? You can do certain things like cold calling. You can just show up at the facility, knock the door, and see what they say. We've done that before. It doesn't work too well because they don't know what physiatry is. You gotta have that pitch ready in 15, 20 seconds to get their attention. It can't just be like, oh, I'm gonna help you with pain. It's gotta be above and beyond that, but that could work. Maybe it's connections. Maybe it's the local hospital system. Maybe you're covering acute rehab. Maybe you're outpatient and you see a need. There's no physiatrist in this facility and you can go in and talk to them, but you gotta get that pitch ready. You gotta know who to talk to, what to say, how to say it, and what kind of involvement you wanna have and how often you're gonna be there, what kind of staff you're gonna dedicate to that because you can't just show up, I'm gonna be the physiatrist. They're not gonna know who you are. You can work with national groups or you can work with local groups. Some of these groups, like IRC, for example, we've done it for 10, 12 years now, so we kinda know how to do it right, but it doesn't mean that that's the only way. It does help, though. Now, definition of the subacute versus acute setting is different for a consultant or primary. At least in the subacute setting, from the way I have it set up, is that I'm a consultant for the patient, but that doesn't mean I see them one time and then I sign off. It's usually because I see them the length of stay. So my value is to get access to the patient and see them early on, to the continuum of their stay, to manage stuff before it becomes unmanageable or needs hospitalization. So for me, it's that twice a week touch point, the 20, 30 days they're there. Now, sometimes in the acute rehab setting, the consultant could be like, well, this consulting is for discharge planning. Typically in the nursing home setting, the consult is more for co-management. This is a person getting rehab. They want us to help them with their pain, function, disability, discharge planning, everything. So it's a little different model. Now, there is a clear delineation of the role. The primary care is primary care. They manage internal medicine issues, they get a stipend, they cover admissions, discharges, call, all that stuff, and they're happy to do it. I mean, once they hear that we're, the way we have it set up, they get jealous, but regardless of that point, the primary care has a specific role they're used to it. A majority of these are family practice or internal medicine, some geriatric. A lot of them might have a mixed practice, too. They cover acute rehab, but they also cover subacute. There's not many SNFists who only do SNF work. That is a significant challenge, I would say, for our practice. Across the country, most physiatrists is, how do you convince the primary care to let you in, to let them co-manage? Because they have a fear, because they think, oh, PM&R, you guys cover inpatient rehab, you guys are medical directors, you want my job. So it's a very important discussion to say, no, I wanna be a consultant like your wound care doc or psychologist or palliative. I wanna be an extra level of care. So that relationship is very important. You know, there's obviously always concerns about liability and billing. The primary care might come back and say, well, I'm gonna bill the patient, then I can't get paid for that day or the work that I put in. That's obviously not true, because in the hospital setting, many multiple specialists see the patient the same day. So there's no issues with that. It has to do with your NPI and your specialty. And relationship with admins, nursing, and rehab. And you might create an amazing relationship with the admin and the nursing, and like a week later, they're all gone, because you have to switch over. The DONs, the director of nursing and admin, high turnover rate. So the relationships have to be deeper than just one person. But that can be complex. And also, they have to know what your role is, what you're trying to do, that your hours are nine to five, not overnight, not weekends. So those are the kind of things, as a consultant, is different. If you're a medical director, though, because you could be medical director, that obviously changes things. Then you become that medical director. So employee, independent practitioner, contractor, independent practitioner. You can do many different models in this kind of setting. You can be medical director or rehab medical director in certain cases. Some physicians get away with getting a stipend. Most facilities are not open to that. They're running low on money anyway. They're mostly negative. But they don't want to give money to a consulting physician unless you're primary care. But that could be local, though. So actively involve the patients, seeing Med-B patients, which are patients who are in the facility, live there, and they get picked up by therapy because they had a fall, they had an injury. So those patients I see infrequently. And again, you can have a consulting, you can be a consulting physician with APPs, or nurse practitioners and PAs. And that could be a model for you to expand your practice beyond just one person. And a lot of successful people would do that. So logistics, a lot of stuff here. I'm not gonna go through everything. But again, based on the type of practice you have, you have to do credentialing. You might be right out of residency, you have to credential with the insurance companies. When I came out of residency for my outpatient practice, I applied for Blue Cross Blue Shield. They said, we're not taking any more physiatrists. I'm like, what does that really mean? And then they said, another one said, oh, you have to wait nine months to get credentialed. So it's challenging as an independent practitioner. You can always hire people to help you out with that. But that's not as easy as saying, I take insurance, and here you go. So creating rounding lists. Who do you see? Who's gonna send you the name of the patients you have to see? Do you see everybody? How do you do the EMR? Do you use your own EMR? Do you use the facility's EMR? Do you do third party? That's all challenging things to think about. Pharmacy, just because I order a medication, I say stat on it, doesn't mean stat in a nursing home setting. Stat basically means two days, three sometimes. X-ray stat, two days. So you have to understand the limitations of the facility. They're not a hospital. They don't have an in-house pharmacy. Pharmacies are usually outside. Someone comes in a van twice a day, you know, they drop off the medications. You can't order the fancy medications, you know. You gotta be very careful about generics. You have to be careful about not ordering a lot of imaging. Those are the kind of things that you have to understand and because you don't get exposure in residency, it gets challenging right off the bat. So that's important. Meetings, high staff turnover, crazy high turnover. But staffing is another big issue. So that's something you have to navigate. Do you basically fight the fight every day? I need to train every single nurse to become the best nurse possible. That's tough, you know, because you're gonna not see any patients then. Then you have meetings. Which meetings do you have to attend? How long do you have to attend the meetings? Are you required to attend the meetings? Communication, how do you communicate? Do you communicate via text? Do you do calls? Do you do meetings? Relationships, you know, again, relationships could be at the facility level or it could be broader. It's important to have broader relationships because that's how you sustain your practice long-term. The staff is not gonna assist you at the facility level. I mean, the fact that you're coming in, they're happy for that, but they're not gonna say, oh my God, finally a doctor, red carpet, here's your physician lounge with coffee in there. No, you'd be lucky if you found a spot to just sit and put your laptop on. But, you know, it is what it is. I'm gonna go see my patients and work from home if I have to. But these are things that you gotta think about. You're not prepared for that usually. But the staff there, at the best, you can have a director of rehab help you. And they're gonna give you a list of patients. Here you go, doc. That's it. So very different with outpatient setting where you have an MA that puts the patient in the room and you walk around. So those are challenges. There's obviously a lot of benefits too, but there is, we talked about medications, the DME rule, it's 48 hour rules, which is a really archaic rule that if someone has an amputation, they cannot get their prosthesis until 48 hours before discharge. So they can be in the nursing home for two months and not get that prosthesis, do the prosthesis testing. But that's a rule. You gotta play with it. Injections, if you do injections, can you do Botox or chemotherapy intervention? You can't because it's not covered. Who's gonna cover the Botox? Ultrasound, sure you can do ultrasound, but who's gonna carry the ultrasound probe with you? Again, I'm throwing questions at you guys. I know all the answers to these, but the point is that you gotta think about these things. A complexity of patients, they're getting more and more complex. I mean, I had facilities that had made the brand new orthopedic unit for post-op care and private rooms and ice machines everywhere and COVID happened and now we don't see any more orthopedic patients. We see hip fractures, no more knees and hips. They all go home right after surgery in the surgical center. So there's a lot of chronic conditions, chronic pain issues. There's dementia. That's a major challenge because you have a bunch of patients that have dementia. How do you navigate that? Their POA, what kind of medication they need to be on. So challenges, but still there are solutions. So IRF, obviously population was very similar to the subacute now. I think it's probably less orthopedic now, but I still see a lot of fractures and spine issues and some complicated post-op, hips and knees, decent amount of stroke, a lot of post-COVID now, cancer. Those are kind of the mix of my practice and some practices might be nothing but pain. That's all they do is consultant role and some might have a mix, but I have a mix. Now, regulations, we talked about some of the timing and frequency of visits. How often do you see a patient? How soon do you see a patient after getting admitted? Typically, a couple of days is ideal and how frequently talked about already. There's things like MIPS and PDPM that Steve talked about. These are things you have to kind of think about. And then you have other models. Sometimes ACOs are like, nope, we are not gonna have a physiatrist see our patients. And I'm in a facility now that is a major sniff in the Midwest, not sniff, I'm sorry. ACO, they're like, nope, we have our own physiatrist. And they don't have their own physiatrist, but they still don't want me to see the patients. But they do when they're in real trouble. At that point, the patient's been admitted for two, three weeks and they're a wreck. And I'm like, if I was involved early, but that's another story. So the point is that you have to kind of talk to these payer and say, hey, I am beneficial where the data comes in. Managed care, peer-to-peers, a lot of stuff. Audits, so frequency of visits, how often you see a patient and how many patients see a day are both potential audits. Also depends on the area of the country you're practicing because you're compared to peers, you're compared to different, all of a sudden you have a mid-jump in the number of visits. Things to think about. So liability, lawsuits are pretty high in the nursing home setting. Thankfully not for physicians and definitely low for physiatry. Primary care get much more of this stuff because they get blanket lawsuits where wounds and ulcers and medication errors and deaths and those kind of things are pretty high liability. Thankfully when you are the consultant, that helps with that. But the facilities get sued all the time. So malpractice coverage and PREEMS, think about not a lot of malpractice companies cover SNF care. And if they cover SNF care, they might not even cover physiatry. If they cover physiatry, they might say, well, you're a one-off, we're gonna charge you the highest price. Those are the kind of things to think about. You gotta talk to your malpractice and say, hey, do you cover SNF consoles? So typical day, 25, 30 patients, 80% are follow-ups, round in therapy gym, focus on rehab, use a DOR I can mention. You can use a facility EMR, which I highly discourage, or you can use a third-party EMR that has templates and dot phrases, those kind of things. You know, we use a company for that too. And overall, it's still very rewarding. I did talk about a lot of negatives, but just to kind of give you a quick 20-minute thing which I'm a little over now. Very flexible work, that's a major benefit. I have two kids and I, you know, the fact that I can go to doctor appointments and not have to cancel patients. Work-life balance, you can take vacation as independent contractor. There's no need for coverage really. Like in acute rehab, you have to have coverage for you. You can have the primary care manage stuff while you're away. And you know, thank you again for being bold and making PMNR essential in the continuum of care. And I have a fancy QR code here in the slide. You can always look up later on for contact. Thank you so much. All right. Thank you, Dr. Tariq. You know, listening to Dr. Tariq talk is always like getting information out of a fire hose, right? I mean, you know, it's kind of like, you just get blasted with it. But, hopefully, a lot of that sunk in and you got it. What we wanted to do was present in this forum some different ways that physiatry can deal with patients in a subacute or skilled nursing facility environment. So, our next speaker, Dr. Natasha Milkovich, is gonna talk to us about the academic side of things. So, thank you so much for being here. First, it's a pleasure to present with my co... I went both ways. My colleagues who kind of shared the same interest and I'm glad to see people live after, what, three years. So, yeah, and because of that, I forgot to even bring my presentation on the thumbstick. So, I hope the slides will work. If not, imagine this is a TED Talk. My name is Natasha Milkovich. I come from Pittsburgh, PA, mostly known as Dr. M because nobody can pronounce my last name, which is fine with me and my patients in the SNF also either call me Dr. Natasha or Dr. M. I have no disclosures. I'm an academic physiatrist. I'm affiliated with University of Pittsburgh Medical Center, which we are kind of, we have a big residency program, nine residents, and I'm very fortunate to work with residents in a skilled nursing facility as well as geriatrics fellows. I also teach about work at SNF as a physiatrist, as a part of didactics for both PM&R residency and also geriatric fellowships. Now, I won't go what Aslan talked about, why should we shift our focus to SNF. We should shift our focus to SNF because of the numbers that he showed, because of the number of nursing home and number of patients in those nursing homes that can benefit from consults if they're provided by us. So that's the big thing. The other thing is also the money. Post-acute care pretty much eats about $74 billion and this number can just be higher because of COVID and all the federal funds that went to the SNF due to COVID. And so I will talk about how I kind of practice at the SNF as an academic physiatrist. So first, how do we get referrals? How do we get consults? So we do not have automatic orders. So when a patient at the SNF, if he or she has been seen by our consult service at the acute care side, they have an option to put in a depart orders in our power chart that the patient should be seen by a physiatrist once at the skilled nursing facility. For doing this for, oh, okay. Thank you so much. So let me just see. Next slide, please. Okay, so anyway, so how to get a consult? So one is if we can put it in a depart orders and the other one is I have been working with staff at the skills that I've been covering for about seven years now. So any physician, physician assistant, nurse practitioner, nurse, physical therapist, or any therapist can put a consult if they deemed needed. So that's one thing how we get a consult. Now, how, when we get, yeah, you can go scroll down. Scroll down. You can scroll down, scroll down. A little bit about myself. You can scroll down. Next slide. Next slide. We can go down. Next slide. Okay, we can stop here. So usually, who do we get consults for? So when we started this service, we kind of were brainstorming what would be the patient that would benefit the most from the consult. And this was seven years ago when I was thinking about it. I would say, oh, yeah, the usual rehab diagnosis, stroke, brain injury, spinal cord injuries, amputees. But now, seven years later, I will put pain management, number one, because that's 75% of my referrals are pain management. And then I would definitely put stroke, brain injury, spinal cord, amputees, spasticity management, evaluation for a brace, orthotic assistive device, and road back to rehab, meaning some patients who need to come back to inpatient rehab to, we really, we do peer-to-peer for them and evaluate them. Next slide, please. I talked about this. So, I mean, bottom line, in academia, we do not have an automatic order for a PMNR consult and SNF. Next slide, please. Now, this is really something that I teach my residents and fellows. Number one, when you do a consult, recommend a realistic, reasonable treatment plan. Always think, as Aslan said, you're not in a hospital setting. You have to think what's available. And so you know that if you order an MRI, this will take months to get an MRI. So order something that can be done within the nursing home, which would be like a plain x-ray, plain labs, Dopplers, that can be done in a nursing home. If it's anything more than that, really think, is that really necessary? Is this going to change the treatment or not? And then, when you formulate this reasonable, realistic plan, share this plan with the primary team, talk to the therapist about it. And I know this is painful, but if you're asked to call the family, call the family. It will carry you a long way. Everybody will be happy. I usually do it from the car when I'm on my way home, so I don't wanna say it's not a nice word, waste my time, but when I'm at the SNF, I just wanna see patients. Document the encounter, and most importantly, follow up with the plan. Don't just start somebody on gabapentin and then don't show up three weeks, and that's it, next slide. Make sure you have privileges to the electronic medical records. Make sure not to arrive too early, too late. Patients older like to sleep. Don't come in before nine o'clock. They'll be grumpy, you'll get nothing, okay? Don't come at five, they're getting their dinner, they're not interested in seeing you, they're getting back to bed. Never, never, never come when it's bingo. You cannot get them out of bingo. Or if you are, have somebody play their numbers. They won't do it, they just don't, they're living for their bingo, I kid you not. And make sure you're seeing the right patient for the right reason. In nursing home, there are no identification bracelets. They're mostly cognitively impaired. If you say, are you Mr. Jones? Yes, I am, although they can be Mr. Brown, doesn't matter. Please make sure. Bring a nurse in and say, nurse, is this the patient? Especially if you're doing injection. And always be friendly and positive. These places are depressive. And just bring good spirits. They will appreciate that more than anything. Just be, have a smile, even if you're not having a good day. Now, how to build a concert service. If you don't have the buy-in from the main administrator, don't even bother going there. So you have to have a buy-in from the main administration. They have to understand what you're bringing to the table. Meet with everybody you can, medical team, therapist team, social worker, and just be friendly. From the moment you enter in, say hi, learn the name of the hocks of the front door person. Just be friendly. Next. Be consistent. If you're showing up on a Tuesday afternoon, no matter what, show up on a Tuesday afternoon. If you have no referrals, they'll find referrals. They'll just be used to seeing you on a Tuesday afternoon. And then once you see the patient, again, document in a timely fashion. Timely fashion is not like inpatient rehab. You can document within 24 hours. I say to my residents, send me a note 48 hours. Now, what is working with residents and fellow means? Means that very few programs, residents in US, have access to SNFs. I want to dare to say it's about 17% have access, and the rest do not have access for residents. And on the contrary, the interest of residents in getting SNF kind of skills to do consulted skills is on the rise. Next slide. Can you scroll down? Thank you. So I kind of formulated this, what does working with fellow residents means to me. First, there are barriers. You have to get approval from the SNF to bring residents and fellows, more people. During COVID, that was very, very hard. Now it's getting easier. Then you have to get them access to EMR, although you can kind of surpass it. And then you have to see with your residency program director, how can you incorporate this into existing outpatient rotation electives, et cetera. You have to be compliant with ACGME rules. And COVID-19, of course, barrier for everything including that. Now, what are the pros? I love. I love teaching residents. I love working with them. I like the learning experience. I learn a lot from them. And I would venture to say that they enjoy it. At least they're indifferent. Nobody told me they don't like it. But they mostly enjoy it. But most of all, the patients at the SNFs, they love seeing young faces. They love communicating with the residents and fellows. And it's really, they really enjoy it. So what is the con? It slows me down, OK? Yeah, you have to teach. You have to spend time. You can see less patients. And that affects your productivity. So these are some comments. I kind of started sending a survey to residents. And you can just read it. One, this is from my chief resident. She said, I have been discharged many patients to post-acute care without ever really seeing behind the curtain. I like that term. Which was really helpful to understand the setting options limitations. But they also enjoy this continuing following. As Aslan said, we don't see them just once. We see them constantly. So multi-week rotation, able to follow the same patient at the SNF. And because of my background, I was an orthosurgeon. I do a lot of procedures. My residents really enjoy doing the procedure at the SNFs without all the hassle of documentation or stuff. Everything is basically done. And also, they like doing the gym rounds. Next slide, please. So although this is all great and groovy, I do have my concerns. I'm asking myself, as many are, like, what is the future of skilled nursing facility? So overall, there is decline in skilled nursing facility profitability. If you look at the literature, more than half of US SNFs are reported to be operating at a loss. There are increasing number of SNF closures. And there is increased push in favor of home and community based services. So more federal dollars will go to home care instead of nursing homes. So, you know, there is a question, can we adjust finances? Can we kind of see more Medicare than Medicaid patient kind of affect that reimbursement? That's a whole different story. Next slide. During COVID, people lost trust in nursing home. I found this in one of the, I kind of shivered when I read that, and said, death trap. That's exactly how that was defined. One of 10 residents in SNF, especially long-term residents, died of COVID. I have a lot of my long-term residents who died, I follow them for knee injections. So how do we rebuild the trust that we are not sending them to die? So potential solution, there are a lot. I think for us as physiatrists, we cannot solve problems of that magnitude. What we can do, we can really focus definitely on short-term residents who are there really kind of almost like, because they are a sort of an inpatient rehab just at a subacute setting. Next slide. So what is the take-home message? Regardless what I said, nothing is gloom and boom. SNFs are here to stay. There will always be patients at SNF. They will always benefit from our services. And PM&R residents, especially new graduates, are shifting their focus towards SNF, and they're asking for better education about SNF. And we should be able to provide during residency better education. And that's it. Thank you. Next, we have Dr. Ed Burnetta. Dr. Ed Burnetta. I'm a physiatrist from Philadelphia. My practice is I'm an inpatient medical director of an acute rehab unit at Nazareth Hospital, a community-based hospital in Philadelphia, which is a 20-bed unit. And I have a majority of my practice is in the subacute nursing home setting in the Philadelphia and Fort County suburban area of the city. You know, I just have a quick question for the audience, by show of hands, I'm just curious, how many of you go to a skilled nursing facility or a nursing home? So, pretty good number. This side's stronger than that side. I don't know what you guys are, lagging a little bit there. But I also thought it was funny with the bingo, the academic is nice to the patients. I basically bribe them. They usually have a quarter per game. I pull out a dollar bill and say, this is for the next game. Take my patient away to take care of their knee injection or whatever. So it's kind of a different approach for different folks in this setting. So I basically, the reason I think they asked me to come here was I'm an independent practitioner. How many independent practitioners in the audience? Man, tough audience. So that's what has been my practice. And the way, I know Steve has spoken in the past how he got interested in skilled nursing facilities and, I don't know if that goes, there we go, there we go. So Steve has spoken in the past about how he got interested in following his patients from the acute side to the subacute side. I actually got interested as I, kind of early in my career, colleagues of mine who were residents with me, I was in the graduate hospital Penn program in Philly, asked me to cover a nursing home for them. So that was really my first time ever in a nursing home was really not that long ago. And I noticed in Anna's notes there that she mentioned that one of the residents commented on the fact that they really enjoyed the fact of interacting with a patient, doing a treatment, and not having a massive amount of complexity or documentation required to do that. And then maybe come back and see them and see the results of what you've done. And that's the part of it that I've always really enjoyed. And since I started, that's really been one of the key factors of my practice. My practice has grown over the years. Actually, I'll go back a second. Facility benefits, I think Aslan touched on quite succinctly. The practice benefits, I think both speakers mentioned about the flexibility. There's a tremendous amount of flexibility in a nursing home practice. I think it's important to mention with nursing homes, I think a lot of times we talk about subacute and SNF, which are key components of a building. Really the building often consists of the long-term care patients and the skilled component of the building. And take, for instance, any kind of building, maybe 150 senses in the building, perhaps 30 of those beds are skilled, 120 are long-term care. It's always been my approach to buildings that if there's 150 patients there and there's opportunity to see some of those folks that are among the 120, I'm going to see them. My practice, when it started, was primarily pain management. That's what our main focus was on. A lot of my patient mix now is still pain management, but we have in some buildings gotten into the rehab model in terms of helping with the subacute and helping progression in there. One thing I've noticed that has changed in nursing homes fairly recently is the fact that they are looking for us. There's always talk about alignment. One of the things I think that we lacked as physiatrists perhaps 5, 10 years ago was being able to align our skill set of running an interdisciplinary team, helping with therapy, helping with maybe pain interventions that would allow a patient to progress on. In the interest of the nursing home, we don't really need a succinct short-stay admission. We really could live with this patient staying a little bit longer. But now, as the insurance situation is changing, I think more and more they're seeing the value of us being in their building. I think it's very positive for all of you that are considering going into it or early to it that this is a very promising era for skilled nursing for physiatry. Another thing to mention too about physiatry in this setting is that we are the fastest growing specialty by number of encounters. So of course you have the geriatricians and the primary care docs that go to these buildings, but among the specialists that go to these facilities, we are the fastest growing. So obviously, if we're the fastest growing, we want to kind of prove why we are there and what benefit we're bringing to the building. So that becomes an important factor as well. I should switch, right? Pressing the right button. So why I started, I kind of explained that. I really feel like we have a very positive impact on the patients that we encounter. I feel like why I started was really, as I described to you, why I maintained it and have continued to do it is I find it very enjoyable. I find it a career that I get tremendous satisfaction from. And I think as you get on and as your practice grows, I actually have a slide, but basically as your practice grows, you realize that you're, you kind of become, when you start practice, you're very fully involved in the clinical aspects. As residents, you're really pretty much involved in clinical aspects of care. You're not really involved in the management or administrative piece, which can be... Come on. There we go. That's a good slide. So as you progress along, as your practice grows, your administrative responsibilities increase. And I think a lot of people that go into skilled nursing will ask, you know, is this something I should do employed or is this something I should do independently? And I think it really comes down to your individual preferences. I think you can do either or. And I would say to you that as I've increased the number of buildings and number of patients that are involved with my practice, the administrative piece has become more important, part of my daily routine. And the clinical side, not as frequent. So it's one of those things where you have to develop a balance there where you're happy with the clinical amount of work you're doing and also the administrative piece that you're involved with. This week, in fact, on Wednesday, the day yesterday, I had a day that was kind of a classic combination of both. I went to a nursing home in the morning, suburban woods, saw some patients that needed to be seen from a pain perspective, did a few injections, headed over to Roosevelt Center where I met a couple of regional managers from a large nursing home chain who introduced me to the administrator and introduced me to the director of rehab. Basically, we've been in that building on the long-term care side. Now they want us to participate in the sub-acute side, which is rare. Prior to recently, I haven't really seen nursing homes reaching out from that perspective. It's been us going after them. Following that, I got in my car, where I do a lot of my work because there's a lot of travel from building to building, phone call to a director of nursing at another facility, Belvedere, outside of Chester City. Talked to the DO in there. She had been introduced to my name via an internal medicine person who I overlap with in another building. I'm going to be going there Tuesday, and that will be my practice's 46th building in southeastern Pennsylvania. So continue to grow. Finally, I printed out a contract and signed it for I'm going to be a medical director of an I-SNP in Pennsylvania. That's a whole other topic. I think we're going to talk about that on Saturday. An interesting part of our practice model is these payment models like ACOs and I-SNPs that are becoming increasingly important in this setting. The question always comes up, employed or independent. That is not my car. The analogy is if you're going in an Uber, it's great. Clinically, you get in the back seat. You let them drive. You let them get the insurance coverage. You let them handle the gas filling, all those things. But you do give up the independence of being able to choose your exit ramp, your highway you're going on, which way you want to go from A to B. So I don't think there's any wrong choice there. I think certainly there's different models available. There's a wonderful group of physiatrists. It's a physiatry-led company that is, I think, amazing. Then there's also the independent side. The other thing I want to say is I have a busy, big practice, but certainly you can get involved with skilled facilities at a much lesser level, even going to one or two buildings and familiarizing yourself with that environment. If you like it, you can always expand. You can always go get busier and busier. That's just my... I don't know. I figured I'd give you a chart of my practice. Basically, as you grow, you need to have your... I have a practice manager with two assistants now and full-time, part-time staff as well as students and new. I'll talk a little bit more about that with the nurse practitioner section. Basically, I have 11 nurse practitioners that work with me, four are full-time, seven are part-time. It's grown over the years. The way I got to a point in my job... I got to a point where I realized more and more buildings were coming into play and individually I wasn't able to cover those buildings. I felt like I really needed to seek out somebody else or another person to come in. I did look at physiatrists. I did talk to some physiatrists. It's tough from a physiatry standpoint in that you commit a lot to your education, your residency program. What I needed at the time was really part-time individuals, like two days a week. What I found is in the nurse practitioner world, there are those individuals that have family obligations, they've gone through their training, they're CRNPs, they're good at what they do but they're not really looking for that full five-day plethora of care or treatment. That's how it started. Betsy Mostovic was my first nurse practitioner 12 years ago and she's still with me. She is the one who started all this. She worked at Nazareth Hospital. She worked for the nephrology group. I knew she was a great worker. I got references on her. She came on board and basically came around with me. That's the way we started this process. We would go to buildings together and see patients together and over time she got more and more adept. What I've been doing really of late over the last 5-6 years is bringing in student nurse practitioners to our practice. They come in, they rotate with us for about 2 months and it's fantastic because they get to see whether they like the practice as we do it and we get to see how good a worker they are. That's really how exclusively I've done my recruiting onto the practice is from the students that rotate with us. Some of my nurse practitioners do injections. They primarily stay with the knees and shoulders for the most part. Some of them have gotten a little more advanced. Some don't do them at all. I always play it that whatever confidence level they have I'll respect that. We always maintain a relationship where I tell them I never want them doing anything that they're uncomfortable doing. They become really good at evaluating muscle skeletal pain, neuropathic pain, muscle spasticity, they know to modify asthma or scale scores. All those things, they're excellent representatives of the practice. As the practice grew just to give you I looked at this recently, 2016 we had just under 10,000 encounters with my group at the end of the year. 2022 we're going to surpass 18,000. It's an 80% increase over that period of time, 6 years. If you break that down artificially to a daily rate it was about 38 visits per day in 2016 and this year it's averaging close to 90 encounters a day. It's been great. I enjoy it. It seems like a big enterprise but I never really thought of it that way. I think this career is really fulfilling. I know we talk a lot about physician burnout and physiatrists are fairly high in that category but I feel like this area of medicine this skill care for physiatrists is a fantastic area to get involved in. Tremendous flexibility. I've never missed my kids' sports games. Make all them. You can go in. I realize your respect. Again, university based. Don't go at dinner. Don't go at bingo or breakfast. But we tend to basically go when we can. I have nurse practitioners that work with me that actually go sometimes exclusively on Saturdays so that flexibility really works extremely well in this environment. Accountable care organizations and ISNPs these are terms you're going to be hearing. Accountable care organizations are here. So are ISNPs. They're both legislated federally. They're permanent legislation so these aren't going away from that standpoint. Medicare Advantage has continued to grow. I believe next year it's anticipated that Medicare Advantage will surpass original Medicare fee for service in terms of percentage of patients that are in that system. So the world is going towards a Medicare Advantage world. Underneath Medicare Advantage is the ISNPs. They're actually a subcategory, the special needs patient insurance products. ISNPs are insurance products for people that are quote unquote institutionalized, primarily people that are in nursing homes for greater than 60 days. So if you're working in a nursing home environment, you're gonna see ISNPs in those buildings. They make a lot of sense for these patients. It does change the paradigm for physiatrists because prior, in a fee-for-service environment, you can go to a nursing home, you can say I can see your patients, I can improve the quality in this building, I'm not gonna really cost you anything. In an ISNP setting, if you're seeing an ISNP patient, that patient, oftentimes the building is a co-owner in that insurance product. So they are paying your check for seeing that patient. So they have to see value in why you are in there seeing a patient. If they see value in you seeing that patient, that's a good thing. If they feel like, hey, this is costing us too much, they get a per month probation payment, and that's eating into it, that could be problematic. So it's a very fascinating area of post-acute care that I think if you can make Saturday, it'd be great because I'm talking about the ISNP model on that day. So I'd like to see all of you there. But I think that's it for me for this. Okay, thanks. Thank you. Okay, I think we have a microphone. And we have a few minutes for questions. If anybody has any, we have about 10 minutes left. I'll start passing the microphone around. And please speak into the microphone. For those of you that just heard Dr. Burnetta, as I said, he is an expert in the ISNPs. And on Saturday, we are gonna be talking about, in general, how you prove your value to some of these new payment models that are coming in as a physiatrist. So that's something that, looking towards the future. First, you gotta figure out how to practice in a skilled nursing facility. That's what we're here for today. But looking forward, you gotta figure out how you prove your value in the skilled nursing facility world, too. So I thought I saw a hand go up over here. Yes, sir. Yes, sir. Hi, you had made a comment where you said more than half of the skilled nursing facilities in the country are operating at a loss. So the question I had was, for how long has that been the case? Is that only a recent phenomenon, the last five years? Has it always been the case for the last 20 or 30 years? And you're not that worried about it? And then if you're operating at a loss, are you seeing a phenomenon where a nursing facility might exist for five years, go out of business, another one pops up to take its place, and that goes out of business, and so on and so forth? What does that look like? I'll take that. I'll take that one. It depends on who you ask whether nursing homes are going out of business or not. If you ask MedPAC, which advises Congress on it, they feel that the skilled nursing facility industry is fairly well-funded, and it makes good profits. But if you ask the skilled nursing facilities themselves, they have a different way of accounting things. There's different ways that you can account for things. And so I don't know where the real answer lies, but I think it's somewhere in between. You don't see a lot of skilled nursing facilities going out of business because they ran out of funding. I can tell you one thing, is that if a nursing home is running at operational loss, it doesn't mean the operator is running at a loss, if that makes sense. So whoever owns it has ways of basically not losing money, or the state covers the rest, or they find ways to make it work. There's still nursing homes that shut down, obviously, but not a whole lot. So that phenomenon has been existing for a long time. Oh, yeah, for sure. A lot of consolidation. An important consideration, though, is you should always make sure your skilled nursing facility knows that you're not costing them any money, right? I mean, they have consolidated billing for a number of things that they have to provide in their facility, but one of them is not physician services. Physician services is off the books for them. So your value to them doesn't really, they have to make it on their own in terms of being able to have more revenue than they have expenses, but you as a physiatrist, you're not a part of that equation. So I think that's another important aspect of this. Yeah, I would just add on that, is that that's coming back to that reasonable plan. Don't order expensive tests unless, because the things that are going to go from per diem, nursing homes are paid per diem. So you have to make sure that what you're asking of them is reasonable. Of course, we're just consultants sometimes. If something unreasonable, they will not order it. Number two, I think with how everything is shifting, we are seeing more sicker patients at the SNF, which are eating more money simply to put, which are on expensive medication. So I think this medical complexity, which is being increased at the SNF, is also costing a lot, so. One last thing is that PDPM was supposed to be budget neutral, but actually it wasn't. It's a 3% increase in the expenses, right? So the next thing is gonna be, they're gonna cut the reimbursement for PDPM, but the sharper, smarter operators out there are taking more complex patients, which basically means higher reimbursement. So you wanna align yourself with those kind of operators. You know, there's a nursing home in my area that just got shut down because they're just not able to manage the new model. They just don't have the know-how. So the best way from the outside is to see how they're succeeding. Are they growing? Do they have multiple practices, multiple locations? Things like that. Pass the microphone back to the gentleman back behind you, if you don't mind. Hi, thanks for this great session. Please correct me if my impressions of things over the years are wrong. It used to be that a lot of the SNFs promoted themselves as being able to provide the same number of hours of therapy as acute rehab, and that was their big selling point in the past. They could do the three hours as well as acute rehab could. With the changes in reimbursement, the PDPM, I think a lot of therapy hours are now cut. I know in our area a lot of facilities have let go of a lot of therapists, and the hours are reduced. Do you see that at all affecting the type of patients being admitted for skilled rehab? Is it more the so-called medical subacute as opposed to the rehab subacute? And I was pleased to see your point about referring back to acute from subacute. So I'm curious about your opinions about how this may shift the actual intensity of rehab for people who really need that more intense rehab. Go ahead. Does one take it? I think that's one reason nursing homes are very interested in physiatry getting more involved in the subacute setting, because I think we're better able to direct the therapist. I think that amount of intervention is important, because as you said, without the rugs any longer, there's no real hourly or time-related care with the therapist. So it comes down to more focused therapy for the patients. And to get focused therapy, I think we're great at doing that, at trying to accentuate areas that they should work on specifically for these patients. So for us, I think it's a good situation to have the PDPM model in there. And I think, as Linda has mentioned before, when we go to see patients, M25.519, right, bilateral shoulder pain, that goes on the chart, that's part of the PDPM, they can count that towards the complexity of the patient. And without thinking about it, we can generate a lot of ICD-10 codes by what we're seeing that they're not really looking for. I'm gonna add one thing about PDPM. So PDPM was a big change for the therapy companies, because all of a sudden there was a significant change in therapy-led payment to now nursing-led payment. But the data shows that the quality of therapy did not suffer from this. So the length of stay, so basically therapy companies had to streamline the process, do better education, do group therapy, right-size therapy. Before it was like everybody got the maximum amount of therapy. Now it's like you're a stroke patient versus an orthopedic patient, let's figure the modalities, that kind of stuff. So I think it's a good thing. I think physiatry is amazing. So now we have a lot more value in like, okay, let's right-size therapy. All right, Pratt. I'm an outpatient pain provider. So I'm just trying to transition to a more flexible situation. So is there any pushback from your payers about injecting for acute relief when you have chronic pain? Is there any pushback? And then where do you, and then in terms of consumables, are you providing the consumable or is the SNF providing consumables? I can't speak for them, but I provide my own consumables. And they're okay with that in terms of? Totally okay with that. Initially, when I was a young guy out there at the nursing homes, I would write orders for my Triamcinolone, et cetera. I'd go back and no one would know where it was. And I'm thinking, the time I'm waiting here, I could probably spend better just bringing in the equipment. My entire practice walks around with it looks like a lunch bag. And we have our syringes, our Triamcinolone, our Lidocaine 2%, and basically we were able to do, if we see someone who has, we've been asked to see for a painful joint, we think that it's legitimate to get it injected, we inject it. The thing I'll quickly say is that with this value-based care model that's really kind of impending, that's one of the best things we do at the nursing home because we're saving transportation costs of about 250, 300 for an ambulance, $60 for the service person to go off the floor with the patient. The patient care, they have to go on a bumpy ambulance ride to an office where they waited four weeks to get there. We see them two, three days after we got the consult, they're doing it, we're dealing with bedside, they're not moving anywhere. They're, you know, maybe they pay us whatever they pay us, but it's much less than what the cost is to the building. So that is one of the best things I think we do in the buildings in terms of what the value-based care models would be looking for from us. I would agree. So no issues with the pairs, except trigger point injections, they can get tricky. I've done ultrasound guided injections for a decade now and no major issues there as well. You can do other more advanced stuff, obviously. As far as the injections, you know, I do a mix. I have the backup, which is my own because I have an outpatient clinic, but usually write the orders down and the pharmacy knows when we order it. So they're good about sending it over and the facility knows where to find it, but it can be challenging. But, you know, typically I have to leverage both my own and the facilities. But it's, you know, $7, $6, $7 per injection, the catalog. So if I do a lot of them, then it's best to come for the pharmacy. This gentleman right next to, and then you next. Great talk, first of all. Great, you know, spectrum of perspective on the subacute and the SNF model. So one of the things I kind of always like to understand in the world of value-based care, I know we throw that term around quite a bit, is understanding how we validate the metric and how each of you are partnering from the academic model to the private practice model of understanding how we're showing the quality reporting. You know, we're reintegrating the IMPACT Act again and seeing that model being thrown out by CMS. So how are their efforts to kind of align on the quality reporting side to show the validation of what physiatry brings to the subacute arena and the SNF arena? Oh, you're leading us right into Saturday morning. So, but I'll let you guys take it. I'm stealing your thunder there. Yeah. And I do think there is, I think, from my perspective, us as physiatrists have to prove our worth. I don't think anyone's kind of looking to say, oh, let's look at physiatry and see where we can get savings from them. I think we have to show up with the numbers. And that's one area where I know AAP Menor is well aware of this. And I think they're very open and involved to that. And that's something I forgot to mention in my talk was volunteerism. Just very briefly, volunteerism. I'm involved with the continued care committee. I'm involved, I was involved with RPRC. We did the SNF think tank together. And I just wanted to mention that to you because consider that for yourself because I'm in independent practice. So if I'm not working, I'm not getting paid, all that sort of thing. I get tremendous value out of participating in the AAP Menor program. I get to meet individuals like this that really know a lot about the area that you practice in. And really, anything that I've put into it, I've gotten far more out of it. So just a pitch there for consider, even if you're in a private practice, whatever, you learn so much by participating in the meetings here. Gentlemen, I think we might be out of time after him, but we'll see. Thank you so much for this nice presentation. So I'm from the Metro Health System in Cleveland. We're the safety net hospital for the city of Cleveland. We are a level one trauma center. We are a spinal cord injury model system center. So we have a classic academic practice with focus on complex cases, TBI, SCI, and stroke in our acute rehab. Many of these go to skilled nursing afterwards. We are starting a partnership with a skilled nursing outfit. They are gonna create 100 beds on our facility. And so my question to you is this. The issue of TBI and SCI specific or specialized SNF care, does that exist? Does it make sense financially? Because in our system, many of our patients who go to SNF disappear. They come back with lots of complications. And so could, if they're gonna be in our facility, we would like to create a SCI, TBI specific SNF care so that we'll prevent these complications. And it could be a new place, if you will, also for PM&R in general, also for academic practice. If you can comment on that, that would be really appreciated. Sure, thanks. You wanna take it? Yeah, sure, sure. Our academician will take it. Yes, an academic physiatrist, yeah. So yes, I think that's a great idea. We made a proposal to UPMC, okay, specialized stroke care. They did not act upon it, to be honest. Why did not act? Not because it's not a great idea. The idea is great, not because I'm one of it, but the inventors. It's because it costs more money. And as we started this, having specialized care for these patients would cost more money. And again, you cannot get it from insurance. Now, having said this, there are programs and you can kind of connect with them. And I know it's Baylor and Rutgers. They do neuro-restoratives, but they are subsidized by state grants. So there are grants out there which would help these units exist because they do exist and you have TBI specialists rounding on these patients weekly, especially I know in Baylor. And that's a great idea, but you have to find funding because this will cost much more, you need a neuropsychologist rounding. So there is a lot into it. So the hospital system where I'm based for was not in it because I don't think that would bring money back. That's it, it's not profitable. So SNF is a very well-defined level of care, but within that level of care, there's a lot of flexibility, right? And like I said before, if you've been in one SNF and seen one SNF, you've seen one SNF. So you can drive that model in a particular direction. And a lot of post-acute networks actually have. They've added very specialized facilities for TBI, SCI, things like that. But you can also think about it from a system standpoint. Do we really need the person in a facility at all, right? Can we do this in the home? Can we do it in some other type of setting that maybe we can get everything set up there? Particularly for the TBI patient that can't really participate in a lot of therapy anyway at certain points in their course, you might put them at home or put them in another type of institution but really for the purpose of having them have some time to just get better before you start rehabbing them. So I think that you have to think about it from the standpoint of how you can use these different levels of care, what's in them and what can be in them, and then you can devise it. But most post-acute networks are kind of thinking about the same issues that you're thinking about. My one goal and plea to all of you is that involve a physiatrist in the makeup of that setting so that you have someone that's actually watching over the patient's care. I go to a building, Aristocare Meadowsprings in Plymouth Meeting, Pennsylvania, that has about 140 patients that are post gunshot wound, spinal cord, intubated, et cetera, recently extubated. And that's just sort of their, that's their population. And in that situation, physiatry, I really enjoy spasticity and trying to manage spasticity, Botox injections, et cetera, and that's a great opportunity for physiatry in that type of setting. Well, I think we're out of time, but our speakers, I think, will stick around for a few minutes. I think you have maybe a break coming up. So thank you very much for your attention. Thank you.

physiatry

skilled nursing facilities

rehab programs

specialized skills

models of practicing

staff turnover

communication

collaboration

COVID-19

physiatry residents

value-based care