Hello, I'm Dr. Steve Natz, and welcome to this presentation on the podiatrist's role in skilled nursing facility. The skilled nursing facility represents a unique part of the continuum of post-acute care. You're probably all familiar that when patients have a disabling condition, they often start in an acute care hospital. And from the acute care hospital, once they're initially stabilized, they'll then subsequently go into some type of post-acute environment. Probably 25 to 40% of patients who leave an acute hospital don't go directly home. They go to some type of post-acute setting, whether it's an institutionalized setting like inpatient rehab facility, IRF, or a skilled nursing facility, which we're going to be talking about mostly today. But you should also be aware that there are long-term acute care facilities and home health or community-based options as well, such as home health or outpatient therapies. Now, how did I get involved in physiatry in the SNF? I actually followed my patients there, probably starting in about the mid-2000s, 2010, 2012. And I started to notice that as an inpatient rehab medical director, a lot of my patients were going to skilled nursing facility to have their rehabilitation there. So if you look at this slide, you can see that between 2004 and 2019, that the number of encounters for a physiatrist by site of service, this is nationwide, diminished quite a bit for IRF and has been rising steadily for skilled nursing facility. We'll talk about some of the reasons for that in the next few slides, but just to be aware that the IRF level of care has now stabilized at a reasonable number of encounters per year, but the skilled nursing facility encounters continue to rise. And while most rehab patients in IRF will see a physiatrist, still today, most rehab patients in a skilled nursing facility won't see a physiatrist. So what is fueling the movement of rehab patients to a skilled nursing facility environment? Well, the 60% rule, some of you may be aware of, is a CMS regulation that limits the number of patients that can go to skilled nursing, to inpatient rehab facilities, I'm sorry, based on their diagnosis. And so because of that regulation, a lot of non-compliant patients with the 60% rule have been getting to rehab in skilled nursing facilities since that regulation was reintroduced. Also, there are other factors like local coverage determinations by fiscal intermediaries may specify skilled nursing facility rehab for certain diagnoses, Medicare Advantage and managed care and other private payer insurance may direct post-acute care to some of these areas. Also, we're finding more and more today that even the risk-bearing entities like post-acute networks within ACOs, hospital systems, may be directing their rehab patients to skilled nursing facility rather than to IRF. And again, this may be based on cost analysis and other factors. And SNF has been shown to be less costly for some diagnoses, we'll get into a little bit of that in a second. Also, subacute providers have been starting to recognize the need for physiatry-directed short-stay rehab programs in the skilled nursing facility environment. So let's talk about the costs. This is an old slide, it's from MedPAC. MedPAC is an organization that advises CMS and Medicare on costs and advises Congress on CMS. And it shows that a comparison of different types of cases ranging from tracheotomy to stroke were generally less costly in a skilled nursing environment than in other environments such as an IRF or in a long-term acute care hospital environment, LTAC. So I think, though, when you look at this slide, this was shown to senators and congressmen who were evaluating the cost for Medicare. You have to recognize that we're really comparing apples to oranges here, that you can't imagine that someone who's got a tracheotomy on a vent is going to do better in a skilled nursing facility than in an LTAC, despite the fact that the cost is 10 times as much or more. You could argue that for a hip fracture patient, maybe it does make sense that a skilled nursing facility is not comparing apples to oranges, that in fact the cost may be lower in a skilled nursing facility than in an acute rehab environment or another environment. But I think that this does kind of point out a danger in comparing costs when you don't know the actual characteristics of the patient. So where does physiatry fit in? Well, as you know, being a physiatrist, physiatrists have a unique role to play in the coordination of rehabilitative care in any level of rehab care. However, in the SNF, it's not mandated. You probably recognize that there's a requirement by Medicare that an inpatient rehab facility needs to have a rehabilitation physician. No requirement exists in the skilled nursing facility. So in nearly all the cases, the skilled nursing facility patient undergoing rehab will already have a primary care physician assigned to them. Also that doctor may or may not be designated as the SNF medical director for the facility. If not, then there will also be a medical director mandated by Medicare regulations who may or may not be indirectly involved in the patient's care. As a physiatrist, you'll usually be considered a consultant physician in the SNF. We'll talk about a couple different models in a minute. But consultants in general don't admit patients, we don't discharge patients, we consult, and we make recommendations to the primary team. We don't generally take call or get called in emergently, which is the good side. The bad side is that the consultant is in a position where the attending physician doesn't really need to take your recommendations. They can treat the patient as they see fit, including admission and discharge decisions. So that's kind of where most of us who are doing skilled nursing facility physiatry work live. We're a consultant. Ideally, as a consultant and as a physiatrist, you should be following all the patients within the skilled nursing facility that are participating in active rehabilitation therapy. That's my opinion, but I think that that's also something that most people would agree with. There are some exceptions, of course, that if the patient or their power of attorney refuses or objects to your consultation, then you should respect their wishes. If the primary care physician or medical director requests that you do not consult on a specific patient, once again, it would be prudent for you to withdraw. This is their patient, you're the consultant. If the patient comes under a managed care plan, which does not contract with you or your company for physiatry services, you may not be able to see that patient just because you're not in that work. But the physiatrist's role in the skilled nursing facility rehabilitation case is very much like the physiatrist's role in any case in a patient rehab facility. You're addressing pain issues, limiting function. You're trying to maximize the patient's functional status and understand what function is possible in their case. You're reducing the overall cost of the healthcare system. You're right-sizing the length of their rehab stay and maximizing the improvement per day. You're reducing re-hospitalizations. You're addressing patient questions about their disabling condition and helping to prognosticate for them. You're improving patient and family satisfaction through answering their questions and providing support. You're assisting in reducing barriers to discharge home and to the community. And you're advocating, unfortunately, this is happening more and more today, you're advocating for the patient in the case of a denial or an appeal to a payer that the rehabilitation is medically necessary. So physiatrists, by nature of our training, experience, and knowledge, have unique qualifications and expertise to contribute to the SNF rehabilitation team. In the majority of cases, as we've said before, you're a consultant, but I want to also point out that in many of these cases, you'll not only be a consultant, but you'll be co-managing patients within the skilled nursing facility. So your role might be in collaboration or cooperation with the primary care team, providing input and participating in interdisciplinary team meetings, assessing and implementing therapy plans, shared responsibility, authority, and accountability for the care of the patient with other treating physicians and other treating providers in the skilled nursing facility. So you're acting as a team, which is nothing new for you as a physiatrist working in a skilled nursing facility as opposed to an IRF or any other setting. Now you can also serve in other roles in the skilled nursing facility sometimes, and I'm familiar with physiatrists who are acting as primary attending, or even the skilled nursing facility overall medical director, or both sometimes. Or another category, which is kind of becoming more common, a rehabilitation medical director for the facility. Those may or may not be available in your facility, I just want to point them out. So what do you do in the SNF? Well, essentially your role is very similar to what you do in an IRF. And again, these will all sound like some very familiar activities for you. Assessing history and physical examination pertinent to the physical medicine rehab aspects of the case. Assessing physical cognitive impairments, activity limitations, participation restrictions. Reviewing, ordering, and interpreting laboratory and imaging studies data for the patient. Coordinating special services if there are needed. Coordinating all rehabilitation care, musculoskeletal, orthopedic, neurologic, cardiopulmonary rehabilitation. Prescription of appropriate medications. These could be, but not limited to, pain medications, vasticity, bowel and bladder, others. Prescription or oversight of evaluation and treatment by physical therapists, occupational therapists, speech language pathologists, psychologists, and others. So you'll have similar team members in the skilled nursing facility that you would have in an IRF. Prescriptions for durable medical equipment, orthotics, prosthetics, wheelchairs, things like that. Implementation and strategies for preventive care, including fall prevention, wound prevention and wound care. Prescription of next level of care, rehabilitation services, such as a more intensive level of rehabilitation like might be found in an IRF. Or outpatient, moving out of the inpatient setting to an outpatient setting, day rehab or home therapy. You might be recommending where the patient goes next to continue their rehabilitation journey. Outpatient physiatry follow-up, if needed and available. This may or may not be a part of your practice, but it may be something that you want the patient to follow up with a physiatrist on an outpatient basis. And then education and training of the facility staff and rehabilitation principles. Now there are some significant ways in which SNFs and IRFs differ. Having been in this business for about 10 years, I can tell you that all IRFs are very similar in their rehabilitation therapy intensity, the equipment that they have, and the competence of their therapy and their rehab nursing staff. One of the biggest things that you'll notice at first glance in any skilled nursing facility environment that you enter is that the nursing staff does not have the rehab nursing skills that they would have in an IRF. So one of the things that you may want to be aware of that and prepare for that in terms of being able to educate your rehabilitation nursing staff to the extent that you can, or just recognize that they may not have the rehab nursing expertise and experience that you might be expecting coming from an IRF. And as it's been said, if you've seen one SNF, you've seen one SNF. They're all different, whereas IRFs are very, very similar all across the country. IRFs may be very different. They may not specialize in acute inpatient, acute rehab therapies. They may be specializing more in long-term care. And rehab, at least short-term rehab, it's kind of a sidelight for them. They may or may not actually, while they may want to do it, they may not be very well prepared for it. So just be aware of that as you go into skilled nursing facilities, that they're all very different. The other thing to be aware of, of course, is that there is no mandate for a physiatrist in a SNF. You're there because somebody felt that you would provide some additional value. But I can also tell you that physiatry services may be misunderstood, foreign, or even threatening to some of the existing SNF personnel and medical staff who are unfamiliar with our ideal model of having a physiatrist follow and take care of a rehab patient. That being said, there's strong evidence that physiatrists practicing in a SNF provide better patient outcomes, lower overall costs, higher reimbursement for facilities under the relatively new, since 2019, patient-directed payment method that now skilled nursing facilities are paid under, lowering complications and lowering returns to acute care, and of course, most importantly, more effective and cost-effective rehab in general. I'm going to show you a little bit of studies that have come from our company, but I have no reason to believe that this is not generalizable to general physical medicine rehabilitation. This is a little bit of an older study from 2019 that looked at a regression analysis of all Medicare data across the country and showed that physiatry had the effect of lowering 30-day emergency department visits, lowering risk-adjusted length of stay, at that point before PDPM, we had the effect of increasing the overall acuity of the patient through a rug mix, and lowering 30-day hospital readmissions. Once again, these are cost measures that your facilities, and particularly if they're in a post-acute network, are going to be very interested in enhancing these things because they get dinged if they have higher-than-average numbers in these areas. You might say, well, that was a study that your company did that was maybe tainted, but this was a second study that came to us from a post-acute network here in Chicago area, the Northwestern system, came to us and said, we think we'd like to compare you to controls. If you compared us to controls, we also had average length of stay that was lower and reduced hospital readmission rates. Once again, I think you can compare this generally to a well-organized physiatry program in a skilled nursing facility. You will be a benefit to your post-acute network if you provide these services. Another aspect that we can talk about is that as a physiatrist in a skilled nursing facility under the PDPM model, at the risk of being a little bit technical, the way that the PDPM pays for patient care in a skilled nursing facility is a daily rate that is based on patient characteristics, in particular, ICD-10 codes. The starting point for those ICD-10 codes is the patient discharge diagnoses from acute care hospital. On the left-hand side of the screen, you see the discharge diagnosis for a particular case. This is a real case, but, of course, the names have been removed to be in HIPAA compliance. But for a hip fracture with routine healing, if that was the only diagnosis that the patient qualified for skilled nursing care for, their daily rate would be in the range of $554. A lot of this depends on where in the country it is, things like that. But just suffice it to say that, if the physiatrist starts to add some functionally related diagnosis codes to the patient case, things like poor balance, dementia, some non-therapy ancillary costs, such as wound care, then all of a sudden the daily rate that the skilled nursing facility obtains for that patient is much more appropriate to the needs of the patient. And so you go from a 554 a day reimbursement to a $630 a day reimbursement based on the real needs of what that patient is gonna cost to take care of in the skilled nursing facility environment. So the PDPM payment for the facility is increased. Now, physiatrists are not the only providers who may be putting ICD-10 code data in. Your therapist may be putting it in, your nurses may be putting it in. But we like to argue that, in fact, the physiatrist is very well-versed in what these different functional aspects and cognitive aspects of the patient's case are. And so we like to feel that physiatrists are the best suited to describing the patient accurately in terms of their ICD-10 codes, and therefore will result in the facility having a much more appropriate reimbursement for that case. Switch gears a little bit. Again, going back to kind of operationally, what do you do in the SNF? Well, of course, you're responsible for the ongoing direction and monitoring of quality of rehab care, and you should endeavor to ensure cost-effective utilization of rehab services. Now, because of the unique nature of SNF, a lot of times these rehab teams have been working on their own for quite some time, and the facility may be quite dependent on what the therapists have been recommending. So the recommendations of the therapy and nursing teams should be highly regarded by you as a physiatrist, unless there's a significant reason to diverge. So there may be times, though, when you need to direct the rehabilitation care counter to the recommendations of a single therapy discipline when it's in the best interest of the patient. I just bring that up because this probably happens in a skilled nursing facility much more than it does in an IRF. You just need to be aware of it. Also, you should be available to ensure appropriate counseling of the patient, and when appropriate, significant others such as family members. You should serve as an advocate and make all efforts possible to obtain the services needed for the patient. And you should utilize available protocols, pathways, and benchmarks to set reasonable goals for the patient outcomes, observe for variances, and establish best practices in the SNF patient population. But I also wanna let you know that, of course, no patient is average, and therefore, you're gonna have to customize the rehabilitation program for most patients, including intensity of therapy and length of stay. Oftentimes, you'll be sitting in a interdisciplinary team meeting, and there may be a case manager from an insurance company who will come in and say, this patient has seven days, which is their average rehab course. And I would usually say, well, seven days might be right. It might be five days. It might be nine days. We're just gonna see what this patient is capable of. So my advice here is to consider that no patient is average, and you'll just have to kind of individualize your length of stay based on the patient's needs. So deviations from the benchmark length of stay are gonna be expected. Now let's talk about how frequently you're gonna visit your patients. Most sources, this comes from the 2016 physician paper of our academy, consider the two to three times a week to be normal, frequency for a physiatrist visit, and the SNF for a patient undergoing active rehab. I know these guidelines, this position statement is under revision, and this may vary somewhat in the future, but I think that the point here is that the frequency of a physiatrist visit should be dictated by the needs of the patient as determined by their medical complexity and their progress in therapy. There really is no Medicare guideline for the exact or expected frequency of a physiatrist consultant visit in a SNF other than this statement that comes right out of the regulations, which is that visits should be as often as medically necessary for the diagnosis of an injury or illness. And so that's good and bad. I mean, it means that we get to decide what we think the medical necessity and frequency of our visits should be, but it also means that you could be second guessed by a third party, an auditor or someone who says, I don't think this is really medically necessary. And then it's incumbent on you to prove that it is medically necessary. So compared the SNF practice to the IRF practice, this is one of the other aspects that I think you should be aware of, is that medical necessity is not a foregone conclusion for a physiatrist seeing a patient in a SNF. It's dependent on you documenting that the patient really needs the level of care that they're in and that they need the services that you're providing them. Well, you need a referral to see patients in a still nursing facility. There's no Medicare rule or regulation that specifies that a physician of order has to be placed for a physiatrist to see rehab patients in a SNF. Even as a consultant, back in the day when there were consultant codes or fees, it was required that a referral was generated for a consultation. Well, today, because of that change in the regulations, you're really providing just a new patient visit or an established patient visit rather than a consultation. So also the requirement for a referral went away with that abandonment of the consultation codes. But all that notwithstanding, it should never come as a surprise to either the primary physician, the medical director or anyone else, the patient or the family that you as a physiatrist is participating in the patient care. So my preference is that physiatry referrals are generated by the facility administration, but they can also be generated by therapists, by nursing staff, even patients or family members. And I know Charlotte's gonna talk about in her presentation a situation in which a family requested a physiatry consult. That's not an uncommon scenario that the family says, we recognize that physiatry is valuable in this level of care and they want to have a physiatry consult. I think that the preferred method is that the facility have a policy that even if it's a blanket physician order that all patients in active rehabilitation have a physiatry consultation. It's quite easy to establish that. You can always say that a patient's not appropriate to see if they don't really have rehab goals or they're just not someone that you need to see. But I think it's really helpful to have the facility think through the process of who needs to see the physiatrist. Sometimes they do it by diagnosis. Sometimes they'll do it by just anybody that's in active rehabilitation going to therapy. Those patients need to be seen by the physiatrist. So you as a physiatrist should have an overall responsibility for the patient's rehabilitation program, similar to what you would have in IRF, that's my opinion. And this responsibility may or may not, sometimes it should include decisions of admission, determination of their goals, needs for a continued stay, medical management and discharge planning. And decisions of admission and continued stay should be based on specific criteria. Certainly they're going to have to have a rehabilitation or rehabilitatable problem, cardiovascular, neuromuscular, skeletal, cognitive, some type of impairment or disability with a need for ongoing inpatient treatment at the SNF level of care. If the patient can go home, there's no reason for them to be in a SNF. They should have a prognosis for functional recovery or for maximizing function for long-term care placement. Not all patients are going to be expected to go home in this level of care. Some are going to be expected to go to long-term care or maintenance type of environment. But even then, maximizing their function is going to help them to have a much better quality of life in a long-term care environment. They'll need to have a need for professional therapy, treatment services, and a realistic discharge disposition and plan, even if that's to go to long-term care. So the goals of rehabilitation and discharge planning should be accomplished through the physiatrist's participation in periodic interdisciplinary conferences, which usually include physical therapy, occupational therapy, all the nursing and case managers, people that are involved in the patient's care, the team. And these will revolve around the prognosis and progress of the patient. Another important aspect that I always like to use is that strategies to eliminate barriers to discharge should be discussed as much as possible. And I think it's good practice, maybe I'm repeating myself, it's good practice for you to be following most, if not all, of the active rehab patients under Medicare A and private insurance, and particularly those that are in some sort of risk-bearing environment like an ACO. Although your Medicare B patients, the ones that are usually in long-term care that may only be receiving your services under the Medicare B side of things, can also be appropriate patients to see from time to time. Their progress will generally be slower, but physiatric reevaluation in a long-term care patient after an acute change in their functional status, such as after an acute medical illness or a fall with injury, can be important in maintaining their quality of life in the facility and reducing the likelihood of any preventable functional decline. So, in conclusion, you as a physiatrist practicing in today's conventional facility environment can help assure that patient care is delivered in a safe, professional, clinically effective, and cost-effective manner, resulting in the best outcomes for patients. So I hope that this has been a helpful overview to you. It certainly is just scratching the surface of what physiatrists do in the SNF, but it does give you a sense of what we're talking about but it does give you, I think, hopefully an overarching idea of what physiatry practice is like in the SNF. I've been doing it for quite a while and feel that it's very rewarding and enjoyable. And with that, I will leave you and turn the podium over to my esteemed colleague, Dr. Smith. Steve, thank you for that outstanding overview of our role in skilled nursing facilities. I'm super excited to be able to help with this presentation because this is such a critical area. And so many of us do not get training during residency, fellowship, or otherwise in how to provide value in this environment. And all the information that you provided was right on and certainly, I think, very, very pertinent and applicable to all of us that are trying to do skilled nursing care. What I'm gonna do is present a case because I'd like to bring this to light and make it more realistic for the kind of things that we're seeing every single day to give people a better idea of what it looks like for us to be involved. So this case study is about a 90-year-old man who undergoes a hip replacement. And he does this because he developed arthritis that was limiting his ability to play 18 holes of golf and drive across the country. He had had a previous hip replacement and sailed through it, did fantastic, and fully expected the same outcome with this one. However, he developed some post-operative cognitive changes, multiple falls, and a decline in function. He then developed severe back pain. He had an excellent diagnostic workup in the hospital and they found that he had a T6 spinal compression fracture. He had a kyphoplasty, but it didn't improve his symptoms at all. So he got sent to a five-star skilled nursing facility in his town for rehabilitation. Immediately, they found that he had a urinary tract infection that treated that very well, but he continued to have intractable back pain. And every time they would increase his pain medications to control the back pain, he would have adverse consequences cognitively and not be able to participate because of his level of arousal or becoming confused. He made very limited progress in physical therapy and occupational therapy and was essentially at a moderate assistance level for mobility, but dependent on activities of daily living. And he essentially refused to participate. After one month, he just quit. And so his family was contacted by the staff who recommended referral to hospice. And the family is understandably pretty upset about this because he had been playing golf and driving across the country and this wasn't how his first placement went. And so they asked for additional information from the attending physician and treatment team and they were told there's nothing else we can do. So the family asked for a team conference with nursing, physical therapy, occupational therapy and case management. And there were several issues identified. One was that he had severe back pain that was impacting participation. He was not eating and was probably having a poor appetite due to constipation from pain medications. He was not sleeping and he was also depressed. He was getting noted that he was thinking of giving up because he did not feel like there's any end in sight and was concerned that he would be in that facility for the rest of his life. He wanted to go home but the levels assistance was too high to safely go home to this 84 year old wife or two assisted living or independent living facilities. And the patient was refusing long-term care. So this limited their options of what they could do for him which is why the hospice referral was initiated. At this point, the family requested a physical medicine rehabilitation consult and they asked for a team and family conference to discuss the situation with the physiatrist. So the physiatrist got involved and made several recommendations for interventions. They included trying some non-pharmacologic interventions for pain. A very good hands-on exam was done and it was identified that there were different pain generators than just the vertebral compression fracture. So manual medicine, the shock absorption binder, topicals were implementing and these completely resolved the pain. He was also given magnesium to help with sleep. He started an antidepressant. Family was asked to bring favorite foods in from home and his rehabilitation plan of care was completely modified to change his goals to be more realistic towards going home versus the original goals that were set. And most importantly, this patient really needed to understand his functional prognosis. He was given a fem tracker which showed where he was before his surgery, where he was upon admission and his progress to date and where he needed to go in order to be able to go home safely. So he asked the physiatrist, what are my chances? Will I be able to get to a supervision level of care that is needed to go home? And the physiatrist indicated that he had a very high probability of going home but only if he participated. And then he asked the physical therapist and occupational therapist, what do you guys think? How long would it take for me to be able to go home if I participate fully? And they estimated that it would be two months. Well, what happened? Well, the patient went home having met or exceeded all goals within two weeks. And he has now remained at home for five years with a good quality of life. Well, how do I know this? Because this is my father-in-law. And unfortunately, not every patient in this situation has the good fortune to have a daughter that's a physiatrist that can fly across the country and do an intervention. But what this shows is just how important it is to have a physiatrist involved in these rehab cases because we can make a difference. Some of the takeaways of what went wrong here that I think are important to look at because we can learn from them were just the first thing was not getting to the root cause of the pain and this meant really doing a complete assessment and a hands-on physical exam to look at musculoskeletal issues rather than just radiologic issues. Also not resolving the medical issues like dealing with constipation, nutrition, and sleep. If you don't deal with those adequately those could be big barriers to participation and that can impact outcomes and progress. And then not providing a functional prognosis early on in a way that the patient can understand not partnering with the family center. The sooner we get the family involved the more likely we are to have their support and they a lot of times can encourage the patient and help with the participation and all the motivational factors. They also have a more realistic understanding of discharge planning and what's happening in the rehabilitation program. There's also a challenge in many facilities which is the lack of coordination between nursing and rehab. The rehabilitation team generally always wants the patient pre-medicated so they can participate in rehab because they aren't in intractable pain but oftentimes that's not coordinated well with when nursing is passing medications or the medications are given and the patient's groggy and there's an inability to titrate it and you miss therapy for the day. So that's a big challenge in many facilities. Then also the lack of understanding expertise to modify the rehabilitation plan of care. You know goals have to be modified depending on how patients respond to them and as we learn more and more factors about why they're making progress or not making progress adjusting those and adjusting your strategy and your treatment plan becomes imperative. And what happens when you don't do these things? Well the result is you have wasted days and very limited options for patients. So in this particular situation the options were to get long-term care or to go to hospice and this is so common and so sad because this is oftentimes the last opportunity a patient has to get functional improvement so they can return to the previous living environment. So why do cases like this happen? Well it's very very interesting because skilled nursing is different than any other level of care and most MDs, nurse practitioners, physician's assistants, and other providers get very little to no instruction or exposure to the skilled nursing level of care. And even worse there's been just dramatic tremendous change in skilled nursing facilities over the last decade. The patient acuity has increased tremendously. So whereas stroke patients and spinal cords and brain injuries used to all go to inpatient rehabilitation, many of them now are being shifted to skilled nursing and this causes tremendous stress to the skilled nursing facilities who are used to having more generalized ability patients and not these complex diagnoses or people so acutely ill. And so it's been a very big challenge meeting their needs. The reimbursement system has also changed. It used to be under the RUGS system that rehabilitation was incentivized because facilities received more funding if they did more rehab. Under the new PDPM model that Dr. Natz mentioned it's just the opposite. Rehabilitation ends up becoming a cost center which is a big problem because it ends up being shortchanged often. And then there's also limited resources. Every level of care in health care right now is having staffing challenges. Skilled nursing is probably the hardest. It's difficult to attract staff and it's difficult to retain them. There's also been a huge amount of cost related to PPE and supplies for rehabilitation oftentimes are getting shortchanged because the money is being spent in other ways and there's limited resources. It's also very difficult to get specialists to the skilled nursing facilities and you have these highly complex patients with many medical issues that need subspecialty care but getting a subspecialist to see them can be a very big challenge. And then last but not least one of the big problems has been the so-called hassle factor in which the administrative demands and what's needed to care for patients has increased just tremendously over the years. And I'll give you as an example the fact that you have to do a face-to-face evaluation with rationale for prescribing durable medical equipment or home health care. And all of these factors have made it very difficult to provide care that meets the needs of the patients, the families, and the health care networks. So what is the role of PM&R? I'm going to go back over some of the points that Dr. Natts outlined but get a little bit more granular again. So what role do we play? Well the key thing to remember is what we do is entirely different than internal medicine and the primary medical team. Most of these patients have an attending physician and we have completely different tasks and focus than the primary medical attending physician. So our biggest area of focus is on optimizing function. Now keep in mind that the primary medical director a lot of times has a lot on his plate. He has many patients to see. The standards for seeing these patients are not very high. CMS only requires one physician visit every 30 days. And so a lot of times the patients are not being seen on a regular basis. When they're sick or when they're having medical issues that always gets prioritized to the detriment of rehabilitation goals. So our biggest area of focus is optimizing function and making sure that everything is done that can help that patient return to their highest level of function within the resources that are available. And the other thing we do is we recognize that this may be the last chance this patient has to get their function back. So we focus on things that help get patients home. We're team oriented and very proficient with patient and family education and those skill sets are very helpful in the skilled nursing environment. And last but not least we can partner with facilities to help them achieve superior outcomes and increase patient and family satisfaction. This is incredibly important in ACO environments as we'll discuss. Now the things that you see in skilled nursing facilities are things that we are extremely familiar with. Everything from musculoskeletal care, neurologic rehab, joint replacements and post-operative care and then medical rehabilitation are things we deal with quite a lot in other levels of care. Now who should we be seeing a skilled nursing? Essentially it's any patients receiving therapy services such as PT, OT or speech. They're a candidate for PM&R. I would also say any patient that has complex rehabilitation medical issues such as spasticity, pain, bowel and bladder issues. Those are also patients where we can be useful in their plan of care and being consultant. So the other key thing to remember is right now the medical directors that work in skilled nursing facilities are really overwhelmed with many tasks and our job is to support them and make their job easier. One of the ways that we do this is through the co-management model and this is where we work with the internal medicine team to manage various aspects of rehabilitation while they're actually managing the internal medicine and other issues. So this helps support the rehab team, nursing, case management, social workers and all the other medical team members with the rehabilitation plan of care. We also participate in team and some family conferences to help with the communication and the education. We're involved in assisting with the formulation of goals and projection of rehab needs and then we help with these very difficult rehab challenges as I mentioned. One thing that I really focus on a lot in these populations is when we have patients that are failing to progress and not making a lot of progress. Those are the ones we want to zero in on to see if there are factors that could be corrected that would improve their ability to make progress. Again remembering this may be their last chance to have anything that improves their function as a rehab program. So we really want to focus on them and then also difficult things that are hard for the facility to proactively or address once they're severe such as contractures is something else that we can be involved in. There's just many things that are happening where the medical director and the other medical team needs support. Now also discharge planning and justification for why they're even there or why they need durable medical equipment is very important. So common discharge planning issues such as patient family education training and adjustments disability and functional prognostication. A lot of times these patients have come from acute care facilities and they've had something like a stroke and nobody's really talked to them about what does this look like in three months or six months and what are the odds of recovery. Many times because the length of stay is so short and because the fragmentation of care in acute care facilities it would be impossible for them to do that. But we have the benefit of seeing them more often usually for at least a couple of weeks and we have the ability to connect the dots and provide more guidance. We also can help with recommendations and justification for durable medical equipment such as wheelchairs, home health services, and outpatient therapies. And all of these things require very specific wording and documentation and something called a face-to-face encounter. This is something we can do to help the team and take the burden off of the primary medical attending. We also help with length of stay managing by determining what disciplines need to be involved, what dosage rehab, how frequent, and the duration of therapy. We also can really determine whether or not therapy services need to be continued. Are they making enough progress or if they're not making progress is it realistic that with a modification of their rehabilitation plan of care they can be successful? And then last but not least really looking at proactive discharge planning for safe discharges. These patients are at very high risk for falls again, for cognitive issues, and just determining what a safe discharge environment is and making sure that they're not going to bounce back to the emergency room is a really critical function for physiatry. The other key thing, and this is so important especially with neurologic, is determining what the next appropriate level of rehabilitation is. So sometimes patients are so weak and so debilitated they're not great candidates for inpatient rehab, but they have complex rehab needs such as a partial spinal cord injury or a brain injury or even a stroke. And these are patients that once they get a skilled nursing can be improved with regard to the level of endurance and activity tolerance to the extent that they do become good inpatient rehab candidates. And so a lot of times we do something called staged rehab where patients go from skilled nursing to inpatient rehab and it is a very successful strategy in terms of getting people to their highest functional level. And it's especially important as we look at neuro recovery because how many patients that have had spinal cord injuries at the time of transfer have no movement but then they progress and have increasing amounts of movement or the same with brain injuries and level of arousal or strokes in their amount of neurologic improvement. So this is a huge thing where we can monitor that and work with our partners in the acute care inpatient rehab facilities to look at staged rehab. Outpatient therapy is also something that needs a very specific referral and prescription. It's difficult sometimes to get into certain types of outpatient therapy so you have to plan in advance because there's limited capacity. Home health care rehab is also something that's very critical. It's becoming harder to get people in home health as well and there are oftentimes weeks-long waiting lists before patients can be seen. So it's very important to start that early and to coordinate and to really come up with a home exercise program and other interventions in the event that home health care or outpatient can't be started quickly. Community programs can be a major part of a patient's discharge plan as can a restorative program if they happen to have to stay in long-term care. So all of these things are really critical because there always really is a next phase of rehab whether it's the home exercise program that's independent versus one of these other formal interventions. Now the other one is transitions. It is so important that when we transition between acute care and post-acute that we can assist because we can look at patients that have injuries or illnesses and determine what their rehabilitation potential is. This is really critical to the receiving facility and making sure that we get the patient to the right level of care so that they can be successful. Identifying comorbidities is critical as Dr. Natt said because this impacts reimbursement and a lot of times these are overlooked. Identifying the pre-transfer diagnostics and interventions that need to happen before the patient comes and this is incredibly important when you have something say like a PEG tube needs to be put in and somebody has a feeding tube that's nasogastric. These are things that need to be considered not just for inpatient rehab admission but also for SNF. And then really thinking about what the post-acute rehabilitation realistic goals are and determining whether this is someone who will be home eventually or whether this is someone that is probably going to need some level of support after they complete the skilled nursing facility acute care phase. Prediction of length of stay is so important right now. Facilities are having very big challenges with patients that come over that are having very long lengths of stay or don't get to go home because what happens in a situation like that is patients go from being a short-term skilled nursing patient to long-term care and that can be very detrimental for the skilled nursing facilities. If all the short-term rehab beds become inhabited by long-term care there's several issues. One, you don't have the ability to accept a new short-term rehab patients but also the reimbursement ends up spending down to Medicaid which is financially very problematic for facilities as they tend to lose money. So all of these things are critical but the key thing too is we want to help our facilities be preferred providers. They want to be chosen as the facilities to work with for ACO bundles and by major networks. So one of the goals that we need to be doing in PM&R BOLD is partnering with other physiatrists at every level of care because we can't be in all these by ourselves and it may be that physicians of the SNF level get to know the consult physicians in acute care or the inpatient rehab physicians so that we can coordinate, we can discuss cases, we can cross-refer and really find what's best. And this is something that really we need to consider you know not just at the individual level but really facilities have to be thinking about that so that we're really a bigger and better team across all levels of care so they can really impact patient outcomes. And this key thing of value is so important. This is the original hypothesis that came back from Peter Orszag who was the director of the Congressional Budget Office and this was the hypothesis for the Affordable Care Act and how ACOs came to be that the idea is that delivering value requires a focus on systems of care for populations and care coordination across the continuum. Every single thing we've talked about today has to do with efficiency and safety and if we can really have well-defined care paths, less costly sites of care, coordinated care, increased access to care so people don't fall through the cracks and predictive care paths, we have a very very good opportunity to improve value. Likewise if we all work together we can avoid all of the quality and safety issues that contribute to waste. And the idea is that by optimizing value and decreasing waste we could save as much as 700 billion dollars a year and I would bet that number has gone up since the slide was made back at the time that the ACA was passed. So in addition to the money and ACO goals you know really the reason all of us went into this is we care about patients and I think it's so important to recognize that every patient deserves a shot at functional recovery and oftentimes at the skilled nursing level of care this is their last opportunity and we want to try and get patients to the highest level of care possible. That is what physiatry does and so for this reason you know I'm very very happy that you're watching this and that you're learning about the skilled nursing level of care and you can be part of the team provides value to this population. So I hope this has been useful to you and helpful and there are many resources the American Academy of Physical Medicine Rehabilitation has for all of us that we can learn more and work together to ultimately be outstanding providers at every level of care including skilled nursing facilities and I encourage you to keep learning more. Feel free to reach out to me. Those of us that are involved in this part of care are very passionate about sharing what we know so the patients get as much value as possible and that we're really all working together as a specialty. Thank you so much.

physiatrist

skilled nursing facility

SNF

rehabilitative care

pain management

functional status

healthcare costs

rehospitalizations

patient advocacy