Published in the December 2014 issue of Today’s Hospitalist
THE PATIENT received a tracheotomy in the hospital for advanced laryngeal cancer and was discharged first to an LTACH, then a SNF.
One of the patient’s major goals was to not return to the hospital. Although the patient had difficulties with respiratory function, the SNF team of hospitalists and nurses was able to treat and stabilize him, eventually sending him home with hospice.
The patient’s wishes could be honored “and the readmission avoided “because his care was bookended by hospitalists: The patient transitioned from an acute care hospitalist to a SNF “extensivist,” both of whom worked for the same company.
“Approximately 20% of our physicians work in both acute and post-acute settings.”
That company “Elite Patient Care, which is based in Austin, Texas, and has many of its physicians working both in hospitals and nearly two dozen local SNFs “is part of a growing movement that aims to transform post-acute care.
Hospitals and health systems, the thinking goes, will not succeed with population health and capitation as long as skilled nursing facilities remain resource-poor and understaffed, fueling a chronic cycle of bouncebacks from SNFs to hospitals.
Hospitalists are seen as a big part of the solution, either splitting their practice between acute and post-acute settings or by developing much tighter working relationships with post-acute colleagues. Hospitalists, after all, can treat the higher acuity of patients now being discharged to SNFs. They also bring the organizational know-how that many post-acute facilities need.
That leaves health systems and physician groups experimenting with staffing and compensation models to get hospitalists interested in post-acute care. But that can be a challenge, in part because hospitalists are still not quite sure what they think of working in post-acute facilities. The setting is still so new to the specialty that hospitalists haven’t even settled on what to call themselves: SNFist, extensivist, transitionalist, post-acute hospitalist, even “hospitalist lite” are all being used.
Still, a growing number of hospitalists agree that moving out of the hospital, at least part time, can boost both patient care and their own career satisfaction.
“As a hospitalist, you don’t often have the luxury of providing care for patients throughout the continuum of care,” says Tony Gamboa, MD, the Elite Patient Care extensivist who treated the cancer patient in both the LTACH and SNF. “As extensivists, we have that opportunity.”
Problems with perceptions
For many hospitalists moving to post-acute care, the more intense pace of care at LTACHs makes for a relatively smooth transition. But hospitalists moving to a SNF may face more challenges, not the least of which can be overcoming their own perceptions.
Many physicians still view SNFs as a setting that lags behind in terms of technology, pays less than acute care, and is ruled by outpatient doctors and hospitalists who rotate in once a month on their days off.
But hospitalists who have made the jump say that view is often no longer accurate. They say they’re challenged by their SNF patients’ high acuity and regularly diagnose pneumonia and treat renal failure. And by playing a much bigger post-acute role, they’re able to more readily prevent medication errors and readmissions.
At Elite Patient Care, for example, which was founded in 2009, readmission rates from SNFs back to hospitals have fallen from 25% to between 5% and 7%. Company officials point to the presence of hospitalists when explaining that reduction.
“The only way to reduce readmissions system-wide is to use post-acute care and have patients in those facilities managed at high levels,” says Reuben Tovar, MD, chief medical officer of Hospitalists Now, a national hospitalist practice based in Austin that has physicians in both acute and post-acute settings.
For some companies, the best approach to covering both acute and post-acute bases is to deploy doctors in the same company to separate realms, keeping hospitalists working exclusively in acute care while other physicians in the same practice cover post-acute facilities. That way, hospital-based physicians transfer patients to colleagues at SNFs and LTACHs who work for the same company and know each other.
“People in the same practice sharing the same care platform can avoid the miscommunication that generally exists within care transitions,” Dr. Tovar says. Both acute and post-acute physicians who work for Hospitalists Now, for instance, share an internal EMR. Hospital-based doctors discharge patients electronically, with each post-acute hospitalist covering three facilities.
Working with their own practice partners makes acute-care hospitalists more comfortable expediting a discharge to a SNF, Dr. Tovar explains. That in turn produces better performance in terms of LOS and readmissions.
Banner Health in Colorado likewise has employees from its health system in various acute and post-acute positions. Eighteen months ago, Banner hired its own three nurse practitioners (NPs) to staff four area SNFs. One part-time Banner physician “who used to be a hospitalist “as well as one Banner primary care physician rotate through those SNFs. All tests and procedures, including labs and X-rays, go through Banner.
Keeping everything in-house and limited to certain staff avoids the pitfall of “having different providers round every week who don’t know the patients,” says Edward Norman, MD, Banner’s post-acute care program director for Northern Colorado, who also helps out in the four SNFs. It also speeds up discharges by “avoiding the struggle to get patients accepted in a care facility” and gives nurses access to patients’ hospital records.
IPC The Hospitalist Company Inc., the national hospitalist management company based in North Hollywood, Calif., has made a major push into post-acute care. According to Jerome Wilborn, MD, a fulltime post-acute hospitalist who is national medical director for IPC’s post-acute services, the company’s physicians and affiliated providers now practice in more than 400 hospitals and 1,200 post-acute care facilities.
Dr. Wilborn points out that a good percentage of IPC doctors are in “hybrid practices,” with individual doctors rounding in both acute and post-acute settings.
“Approximately 20% of our physicians do both,” he says, “but there’s an increasing trend toward having them do dedicated skilled-nursing facility work.” And all of IPC’s providers communicate through its proprietary, Web-based “virtual office.” “The virtual office connects both acute and post-acute providers in real time in markets where we have both types of practices,” says Dr. Wilborn. In addition, “we’ve developed a proprietary handoff tool that we’ve embedded in virtual office as well.”
Opting for affiliations Elite Patient Care in Austin favors a hybrid model, with eight of its 10 physicians serving both as inpatient hospitalists and as post-acute medical directors; the other two physicians “including Dr. Gamboa “work exclusively in post-acute care. The doctors who are also hospitalists typically visit post-acute facilities weekly, and each physician is matched with a facility located near his or her hospital base.
But not all hospital systems have their own physicians staffing post-acute care. Ochsner Health Systems, for example, which has 13 hospitals in Louisiana, does own one post-acute facility that it staffs with hospitalists. But it stopped sending its physicians to other SNFs several years ago, says Kevin Conrad, MD, MBA, Ochsner’s medical director of community affairs and health policy in New Orleans.
“We needed to focus on expanding acute care services at that time,” Dr. Conrad says. “We are now looking at re-entering the community SNF market.” In the meantime, Ochsner formed affiliation agreements with SNFs that handle their own staffing. Those agreements spell out transfer protocols and initiatives. Now, when a patient is discharged, hospitalists make it clear that Ochsner is affiliated with certain post-acute facilities.
“The hope is that having more patients concentrated in certain locations will lead to better communication,” says Dr. Conrad, who meets every two months with SNF representatives. To further improve transitions, Ochsner recently piloted giving affiliated SNFs access to the health system’s EMR, an initiative that helped reduce readmission rates over six months.
And many staffing strategies are still in flux. Kindred Healthcare, which is based in Louisville, Ky., operates close to 100 LTACHs and nearly 100 SNFs nationwide.
But while a growing number of hospitalists are treating patients in Kindred facilities, the company does not employ “or even pay “the physicians who staff its facilities unless doctors are also medical directors. (While directors are paid by the hour, all others bill Medicare or private insurers.)
But that could change, says Sean Muldoon, MD, MPH, Kindred’s hospital division’s senior vice president and chief medical officer.
“Everything is on the table as shared risk becomes more widespread and payments become more global,” Dr. Muldoon says. In some markets, Kindred is experimenting with formal contracts for medical groups, including hospitalists, that are either independent or part of ACOs or integrated systems.
The nurse connection
While hospitalists play an increasingly visible post-acute role, they say that working as part of a team with nurses is critical.
In Colorado, Banner physicians rely so heavily on NP support that not having one is a deal-breaker when it comes to convincing hospitalists to work in LTACHs or SNFs, says Dr. Norman, who practices as a hospitalist at McKee Medical Center in Loveland, Colo.
“Physicians won’t go into a nursing home unless there’s an NP,” he says. “Having one cuts down on the number of phone calls you get.”
Elite Patient Care currently employs 16 full-time NPs, maintaining a ratio of one NP to every 1.6 doctors. Each NP covers an average census of 90 patients, while physicians typically see between six and eight patients a day in a post-acute facility.
IPC depends on its NPs to “watch the house,” says Dr. Wilborn. “It’s a good return on investment for physicians because they always have somewhere else they need to go “another nursing home or hospital,” he explains.
IPC also adjusts its NP-physician ratio depending on patient acuity. Recently, for instance, IPC organized one 130-bed SNF into separate units with unit-based rounding. One unit is for patients with dementia and severe illness, such as pancreatic cancer plus emphysema; one unit is for knees and hips; one is for stroke; and one is for mostly custodial patients.
“There are more NPs and fewer physicians on the knees and hips unit,” Dr. Wilborn points out.
Working with subspecialists
Subspecialists are more likely to consult on the more acute patients in an LTACH, Dr. Muldoon points out. But that’s not always the case for patients in SNFs.
“The two- or three-hour turnaround for consultants in an acute care hospital is not realistic or needed in a SNF,” he says.
Proximity can sometimes help keep specialists’ attention. Ochsner’s SNF, for example, is located so close to the main campus that post-acute staff have easy access to subspecialists, with subspecialists visiting from the hospital. And at Banner, specialists are part of the medical group. Even when they’re not physically in the SNF, post-acute care staff can call them directly and get a quick response.
Elite has helped create specialized units within some facilities, which attract specialists who bill Medicare or private insurers. Those units focus on cardiac or pulmonary care.
And Hospitalists Now has found that volume can be a draw. In one SNF with 200 patients, a psychologist visits daily, while a psychiatrist and surgeon (for wound care) come once a week.
Payment strategies and tradeoffs
Dr. Muldoon points out that the physician fee schedule in LTACHs is the same as in acute care. And while income from a SNF practice is often less than that for acute care, IPC’s Dr. Wilborn says, “the differential is no more than 10%” for IPC-salaried physicians.”
According to Dr. Gamboa, Elite pays physicians based on productivity. While that payment model could change with the advent of more shared risk, he points out that it adds up, at least for now: As a SNF medical director, physicians seeing between 10 and 15 patients per week earn $80,000 to $100,000 per year. That still gives the company a margin of 20%.
At Chicago Internal Medicine Practice and Research (CIMPAR), which staffs hospitals and nursing homes in Chicago, physicians are salaried with a productivity bonus. CIMPAR contracts with facilities for services, receiving $125 an hour for physicians and $80 an hour for NPs. On average, each physician sees 20 patients per day in a limited geographical area to keep travel time to a minimum.
The company prides itself on offering SNFs a cost-effective option for physician staffing. “Even though we’re private, we have the same outcomes for much less than hiring a physician and paying benefits,” says Dheeraj Mahajan, MD, CIMPAR’s CEO and president.
And at Hospitalists Now, physicians choose to either be salaried or to work based on collections; an ideal census is considered 15 to 18 patients. Doctors earn more by serving as a medical director, which Dr. Tovar says is a common trajectory. They also earn bonuses based on meeting metrics such as patient satisfaction.
The greatest transition?
Regardless of how compensation is structured, many say the most difficult transition for hospitalists can be learning to live under post-acute regulations. Ignore those, and doctors may find themselves returning some billings.
For example, a physician is supposed to see a patient within 10 days of a SNF admission, says Dr. Gamboa. (Some hospitals mandate seeing those patients within 24 hours.) Every SNF patient must be seen every 30 days for the first 90 days, then every 60 days thereafter if they’re in same facility.
Dr. Wilborn cautions hospitalists to be particularly aware of F-Tag regulations, which outline duties for doctors practicing as SNF medical directors. These complex regs often bring tremendous scrutiny to SNFs.
“As we grow our presence in these facilities and take more ownership in outcomes,” he notes, “these regulatory issues are applying more to us and, on occasion, becoming punitive.”
Dr. Mahajan from CIMPAR recommends getting extra training, such as through a medical director association, to get up to speed. Then use that knowledge as a competitive advantage when building your SNF business, he suggests.
“It gives me the edge to go to the facility to talk the talk about nursing and regulations and so compete with other physicians from acute or outpatient settings,” Dr. Mahajan says.
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.
The right hospitalist for the job
WHO’S RIGHT for post-acute care? The work is better-suited for doctors with some primary care and acute care experience looking for a less intense opportunity, says Edward Norman, MD, the post-acute care program director for Northern Colorado for Banner Health. “I can’t imagine too many 60-year-old hospitalists working the same schedule we’re working now.”
For former hospitalist Tony Gamboa, MD, an extensivist who practices in both LTACHs and SNFs for Elite Patient Care in Austin, Texas, the road to post-acute care was inspired, in part, by not seeing himself lasting in the hospital for another 15 years. Now, he says, his hours are more flexible, there’s less stress and he works fewer holidays.
“It’s a significant improvement in quality of life,” he says. But it comes at a cost “potentially money “and a shift in perspective. “You are more invested in a setting where the patient is there for 90 days,” says Dr. Gamboa. “You become their PCP.”
All hospitalists are clinically equipped to see post-acute patients, he adds. But the “right physician needs the mentality to accept long-term responsibility. You have to recognize that this is an investment and not just showing up to work.”
Sean Muldoon, MD, MPH, is hospital division senior vice president and chief medical officer for the Louisville-based Kindred Healthcare, which operates LTACHs and SNFs nationwide. He gravitated to post-acute care in the 1990s, drawn to the idea of a more integrated care plan.
“I liked the challenge of prolonged mechanical ventilation,” says Dr. Muldoon, who’s a pulmonologist.
But it’s not for everyone. “Physicians who want to get more involved in systematizing delivery tend to like this,” he says. “Physicians who really want to be superb technicians in a narrow band of illness or intervention tend to hate it.”