Published in the July 2019 issue of Today’s Hospitalist
TALK ABOUT THE GROWING PRESSURE on skilled nursing facilities (SNFs) to keep patients from bouncing back to the hospital, and hospitalist Stephen Wilber, DO, will point to the success his group had in driving down SNF readmissions. But his experience illustrates the challenges that health care will face in reforming the quality of care that SNFs deliver.
Dr. Wilber is part of a private hospitalist group that practices at Baxter Regional Medical Center in Mountain Home, Ark., which used to have hospitalists and advanced practice providers (APPs) follow patients into a local SNF. The hospitalist who discharged the patient from the hospital would see him or her in a day or two at the SNF to do a history and physical, then the patient would be followed in the SNF by one of the group’s NPs.
The results were impressive. “We cut readmissions from that facility by 50%, which reduced the hospital’s overall readmission rate substantially,” says Dr. Wilber. “Having someone at the SNF paying attention and answering questions in real time was very helpful.”
“We have enough trouble staffing the hospital, so it was a stretch staffing the SNF coverage as well.”
~ Stephen Wilber, DO
Baxter Regional Medical Center
But despite that success, the group scrapped the service after two years. “We couldn’t make it work financially and staffing-wise,” Dr. Wilber says. The big problem was that the SNF service strained the group’s workforce.
“We have enough trouble staffing the hospital,” says Dr. Wilber, “so it was a stretch staffing the SNF coverage as well.” When the group asked the SNF to subsidize the service, it was turned down and the service was shuttered.
But now that Medicare has begun to penalize SNFs for excessive readmissions, Dr. Wilber isn’t convinced the service is really dead and gone. “We are kind of expecting a call from that SNF,” he says, “reconsidering its decision.”
Across the country, there are signs that he might be right. Hospitalist groups that already provide SNF coverage say the demand is now coming at them faster than they can handle. And groups that have covered SNFs for years say the tone of discussions taking place between SNFs and hospitals are dramatically different than even a year or two ago.
That’s because SNFs are finally being forced to join the world of value-based performance and quality that hospitals have lived in for years. Skilled facilities can no longer shrug off bouncebacks to hospitals or just run out the clock on Medicare bed days.
Payment changes “are driving a culture change in that facilities now will be held accountable,” says Cathy Rowe, RN, performance network manager for TeamHealth. Ms. Rowe supports clients and operational teams to develop and implement the performance networks that TeamHealth’s hospital clients want the company to help them set up. “SNF administrators are realizing that for the first time, they need a reliable clinical presence in their facilities and clinicians focused on the same goals they are.”
“SNF administrators are realizing that for the first time, they need a reliable clinical presence in their facilities.”
~ Cathy Rowe, RN
But which clinicians should take on that role? While just about everyone agrees that SNFs have to up their game in terms of the care they can provide, not everyone is certain that hospitalists should be the clinicians providing that care.
Some hospitalist groups became interested in covering SNFs when Medicare rolled out its bundled payments initiative. Participating groups quickly realized that they could cut costs by managing the post-acute spend across episodes of care. Then last fall, Medicare made more changes to SNF reimbursement. As of Oct. 1 SNFs began facing the same 2% readmission penalty for excessive readmissions that hospitals have learned to live with.
Even bigger changes are coming this Oct. 1, when the CMS rolls out its Patient Driven Payment Model (PDPM), a new case-mix classification system for skilled facilities. Under the new model, SNFs will for the first time start using ICD-10 codes. That’s important because it will help usher in an even bigger change in SNF payment: Instead of all SNF beds being reimbursed at the same rate, regardless of how sick patients are, Medicare will now pay SNFs more (or less) based on patient acuity and comorbidities. Sound familiar?
“If you’re dealing with a patient who has a stage 4 decubitus ulcer and is on a wound vac and IV antibiotics, Medicare will now pay more for that SNF patient than the person with a broken hip who’s taking only blood pressure medications,” says Waseem Ghannam, MD, MBA, MHSA, CEO and cofounder of TeleHealth Solution, a telehealth company that provides virtual coverage, mostly nights and weekends, in more than 180 SNFs nationwide. (See ““After-hours SNF coverage.”) With SNF administrators trying to figure out how to succeed under their new payment model, “the market is just bursting,” Dr. Ghannam says. “We keep getting calls asking, ‘How soon can you onboard 10 new buildings?’ ”
That surge in national demand is also being felt in local markets, explains Mahdi Ajjan, MD, MBA, CEO and cofounder of Optimed Hospitalists PLLC in Davidson, N.C. His 30-provider private group covers two hospitals, a wound care center and about a dozen SNFs.
“We haven’t done any marketing to skilled facilities,” says Dr. Ajjan. “They all came to us—and they continue to come through word of mouth.”
“The telehealth transitional care service is separate and distinct from our hospitalist program.”
~ Brian Bossard, MD
All of that demand is raising questions about who is best-suited to treat SNF patients. SNFs that call TeleHealth after-hours, for example, reach a physician only if SNF staff believe a patient is having a change of condition that could warrant an ED visit or an inpatient admission. Routine requests (for Benadryl or Dulcolax, for example) are fielded instead by TeleHealth’s NPs and PAs.
Because his physicians are being consulted on what may be emergent or acute changes, Dr. Ghannam likes to hire hospitalists, ideally with geriatric training or interest, and ED doctors.
“If you want me to reduce returns to the hospital, hospitalists have the skill set you need,” he says. “I have nothing against an urgent care doctor manning a SNF telehealth service, but when was the last time that physician worked in an ICU?”
In Lincoln, Neb., Bryan Telemedicine has likewise launched a telehealth service to help cover SNFs. This one, however, provides 24/7 coverage.
Brian Bossard, MD—who’s CEO of both Inpatient Physician Associates, the hospitalist program that serves the Bryan Health System, and Bryan Telemedicine, the telemedicine program—says the telehealth service was launched this year “to support the hospital system as it participates in the bundled payments program.”
During the day, a dedicated hospitalist APRN provides tele-coverage to several SNFs—with this twist: Frequently, the APRN connects face-to-face with patients clinically many times before those patients are discharged from the hospital.
“More and more doctors in our hospitalist group want to be involved in post-acute care.”
~ Darren Clark, MD
Envision Physician Services
But when the SNF tele-coverage needs to be kicked up to doctors, the APRNs don’t consult with hospitalists working at the hospital, but a separate group of physicians dedicated to staffing the telemedicine program. In addition to the SNFs, that program also provides care for patients discharged to swing beds in several critical access hospitals in the region.
“This is a dedicated pool of physicians who have a passion for rural health and an expertise in managing SNF patients,” says Dr. Bossard. “These physicians possess a unique skill set and interest, and the telehealth transitional care service is separate and distinct from our hospitalist program.”
Steering clear of a hybrid practice
Robert Reynolds, MD, national medical director, post-acute innovation for TeamHealth, brings an interesting perspective to the debate over who should provide SNF coverage. More than 20 years ago, he tried to maintain a “hybrid” practice, employing hospitalists who also covered SNFs.
“I learned that post-acute medicine is a separate specialty,” Dr. Reynolds says. Not only do post-acute facilities operate under completely different state and federal regulations that hospitalists aren’t used to, but “a post-acute setting has a very different clinical workflow and fewer available resources.” Under TeamHealth’s typical model, each SNF physician supervises around three advanced practice clinicians (APCs) who are assigned to either one or two facilities, while doctors cover up to four or five.
TeamHealth’s post-acute service line has 1,400 clinicians, 65% of whom are APCs, who provide coverage in 2,300 SNFs. While some of that SNF coverage for years was provided by hospitalists, TeamHealth is actively eliminating use of that hybrid model.
“We can be much more aggressive in our treatment of SNF patients with IV fluids and antibiotics.”
~ Mahdi Ajjan MD, MBA
Optimed Hospitalists PLLC
“TeamHealth has now adopted the philosophy that our post-acute clinicians are post-acute specialists,” says Dr. Reynolds. He believes the ideal candidates to work in SNFs are generally ex-primary care physicians, although some former hospitalists now work that service line. And “NPs are generally excellent post-acute candidates because their nursing background translates well to this specialty.”
James Levy, PAC, managing partner of Michigan’s iNDIGO Health Partners, which covers about a dozen SNFs, agrees. While the group’s hospitalists cover 10 hospitals throughout the state, iNDIGO’s post-acute care is provided by a completely separate division within the company.
In iNDIGO’s case, however, that separation doesn’t stem from a practice philosophy, but from the fact that none of the group’s hospitalists want to become a SNFist or work a hybrid practice.
“I approached several hospitalists but, at that time, the pay differential was too much,” Mr. Levy says. That problem, he adds, has since been addressed and the post-acute division has eight APPs and three physicians. One of those physicians is a former primary care doctor and the two others (including the division’s lead physician) are ex-hospitalists.
“The lead physician makes essentially what a hospitalist makes,” says Mr. Levy, “but he does that through several SNF medical directorships, administrative fees that we pay and being very heavily involved in clinical practice.” Other productive clinicians, he points out, “do fine financially with the right structure.”
Making the case
But not all hospitalists are opposed to the idea of working a hybrid practice. While those who work in both acute and post-acute care say it can be tough to pull off, they like covering both settings.
Darren Clark, MD, is one of 90 hospitalists with Envision Physician Services who serve 12 hospitals in Dallas-Fort Worth. Dr. Clark, who has had a hybrid practice since 2011, says that SNF coverage has become such “a big part of my practice” that he is now regional medical director of post-acute care for Envision Physician Services.
Why do advocates of a hybrid practice like Dr. Clark say it helps to have hospitalists follow patients into SNFs during the day? Dr. Clark finds that patients benefit from being seen by someone familiar, and that SNF care is always better when you can access patients’ hospital records.
It also helps that his group members who work some SNF coverage into their hospitalist practice—about one-third of the group—earn basically the same compensation as their colleagues who work only in the hospital.
“Those of us doing post-acute work switched to RVU compensation and away from collections two years ago, and the group seems to be pretty pleased,” he points out. Good evidence that their compensation is appropriate, Dr. Clark adds, “is that more and more doctors in our hospitalist group want to be involved in post-acute care.”
Dr. Clark usually visits the two SNFs he covers twice a week, while the NP he works closely with visits on alternate days. Helping him maintain a hybrid practice is the fact that one of the SNFs is “literally 500 yards from the hospital,” while the other is only a mile away.
At Optimed, Dr. Ajjan says that his group members can choose to do only hospital medicine, only post-acute care or work a hybrid practice. Dr. Ajjan, who maintains a hybrid practice himself, says the slower pace and greater schedule flexibility in SNF practice is a good break from hospital medicine. A typical hybrid practice might be seven days on in the hospital followed by three weeks of Monday-Friday SNF coverage, eight hours a day.
Dr. Ajjan defends hospitalists providing SNF day-time coverage, saying that the fact that increasingly sicker patients will be treated there calls for the type of skills hospitalists bring.
“We can be much more aggressive in our treatment of SNF patients with IV fluids and antibiotics,” Dr. Ajjan points out. “We’re applying a lot of what we do in the hospital to skilled facilities.”
Key changes needed
While there’s a lot of debate over who are the best physicians to cover SNFs, other factors going forward will also make or break SNFs’ ability to succeed under their new reimbursement. For doctors to provide more aggressive treatment—and antibiotics started within four hours—”SNF nurses need to be retrained,” Dr. Ajjan points out. “That’s not something they were used to in their previous care model.”
Dr. Ghannam agrees, noting that his company provides onsite training for SNF nurses when it takes on a new tele-client. “We also make sure they have the hallmark medications we use,” he says. According to Dr. Ghannam, 80% of all hospital bouncebacks from SNFs are due to one of five conditions: heart failure, COPD, pneumonia, diabetic complications and UTI.
“Does the SNF stock solumedrol, Lasix, Rocephin, Novolog?” Dr. Ghannam asks. “If we have those, we’re already at the 80% mark together.”
In Dallas-Fort Worth, “Physicians are going to require SNFs to be able to provide more services to prevent patients from needing to come back to the hospital,” Dr. Clark says. He would like to see SNFs have more RNs, available respiratory therapy, a quick turnaround on labs and, in some facilities, telemetry. ”These are the kind of discussions we’re now having,” he points out. “These are the types of care that SNFs will need to be able to provide.”
Technology also comes into play, even within service lines that don’t use telemedicine for SNF coverage. In Michigan, for example, iNDIGO’s post-acute division maintains its own EHR using GEHRIMED software, which allows the group’s SNF APPs—who rotate one week of after-hours call—to answer questions about patients with whom they’re unfamiliar.
TeamHealth likewise maintains its own post-acute EHR. Another innovation that TeamHealth is now piloting: a texting platform that all its clinicians, including post-acute, will use to communicate with each other.
“Hospitalists will be able to text a warm handoff to post-acute providers, and vice versa,” says Dr. Reynolds, who adds that the texting platform can accommodate documents. The company’s ED doctors will use the same app to communicate back and forth with post-acute clinicians, should SNF patients end up back in the ED.
The move to preferred networks
For TeamHealth, that enhanced connectivity will achieve a larger goal: The hospitals that TeamHealth contracts with want to work toward having what Dr. Reynolds refers to as “post-acute performance networks,” also known as preferred networks.
“Very few hospitals have that kind of effective network,” he says, “so this is uncharted territory. But our goal in putting these networks together is to create better communication, a smoother transition, and better quality outcomes at a lower total cost.”
In Dallas-Fort Worth, Dr. Clark says his group has historically not tried to steer their hospital patients toward any particular SNF. Now, however, “We are working collaboratively with the hospitals and SNFs to form a preferred narrow network,” he says. “We want to align with facilities we all think provide high-quality care.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
After-hours SNF coverage
WHEN WASEEM GHANNAM, MD, MBA, MHSA, first began offering to provide after-hours tele-coverage to SNFs in 2016, many facilities reacted the same as hospital administrators presented back in the day with the concept of paying for hospitalist coverage.
“We would go to the facility owners and they’d say, ‘Why should we pay for this? We have a medical director who shows up during the day.’ ”
Three years later, SNF administrators no longer need to be convinced. Dr. Ghannam says that the company he and his partner founded, TeleHealth Solution, is the first national telehealth company providing (predominantly) night and weekend SNF coverage. It now has nearly 200 SNF clients in more than 20 states.
“I have to be very cognizant of territory in medicine.”
~ Waseem Ghannam, MD, MBA, MHSA
The company charges SNFs a flat fee based on their number of beds, and it relies on a clinical staff of close to 70 physicians and advanced practice clinicians, many of whom are moonlighting virtually. The company’s custom-designed app routes SNF queries to either NPs/PAs (for routine questions) or to physicians if patients have a change of condition. The same app also manages the company’s metrics, including its number of callbacks and DRGs.
While SNFs are technically TeleHealth Solution’s clients, Dr. Ghannam says the SNFs that use his service are now marketing themselves to hospitals, touting the service in a bid to be part of hospitals’ preferred SNF networks.
And while 80% of the company’s business involves covering nights and weekends, “We’ve built a rapport in some markets with the SNF medical directors so they may be OK if SNF staff uses our services during the day when they’re not in the building.”
According to Dr. Ghannam, “I have to be very cognizant of territory in medicine. We are never going to replace bedside medicine, but we’re a great augmentation tool when a provider isn’t available.”