Skilled Nursing: Staffing Doctors is New Necessity

Investing in partnerships with physicians pays off for skilled nursing providers who can reap the benefits of fewer unnecessary hospital readmissions and a higher likelihood of continued hospital referrals. 

Nursing homes will have to learn to adapt to new systems and requirements, said Dr. Theodore Homa, medical director at Arlington Heights, Ill.-based Lutheran Homes, during a panel on the evolving role of physicians in nursing homes at an Life Services Network session in May.

“[Incoming residents] have to be obsessively and compulsively handled from the moment your patient leaves the hospital and enters your facility,” he said.  

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About 45% of hospitalizations among skilled nursing facility residents who are Medicare beneficiaries are potentially avoidable and result in billions of dollars of costs, according to research from the Centers for Medicare & Medicaid Services (CMS).

Five conditions—pneumonia, congestive heart failure, urinary tract infections, dehydration, and chronic obstructive pulmonary disease—are responsible for nearly eight in 10 of the potentially avoidable readmissions, but lower-level staff generally aren’t trained or equipped to identify early warning signs. 

Skilled nursing providers have been upping their staffing level with medical directors, physician partnerships, and nurse practitioners to better their ability to provide quality care at a reduced cost to a more complex census with high acuity needs, the panel said. 

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But partnerships don’t necessarily mean more salaries for skilled nursing providers to pay, according to Jill Krueger, CEO of Symbria (formerly known as Health Resources Alliance), an Illinois-based senior care and services provider. When SNFists—full-time physicians in skilled nursing facilities—work in post-acute care settings, they can bill Medicare for their services, she says.

It’s a win-win not just for the skilled nursing facility, but also for Medicare: when doctors stay in nursing homes, their productivity usually increases and they see patients more frequently, according to Krueger.

The typical physician may have an office-based practice and will also make visits to patients in the hospital or in a nursing home, spending time on the road in between visits. A SNFist who stays at the nursing home has no drive time and can see more patients more frequently—especially compared to old Medicare standards that called for once-a-month visits. 

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With more doctor’s visits come fewer readmissions, according to Krueger, who has seen readmission rates drop anywhere from 6-8%. While an average physician visit could cost Medicare around $80, one day in a hospital could cost $1,000. 

“There’s a tradeoff: Doctors are seeing patients more frequently, and my sense is, I’d rather pay the doctor two extra visits a month and drastically reduce the readmission rates,” Krueger says.

It’s a lose-lose if the patient goes to the hospital, she says.

Hospital readmissions are almost entirely preventable in patients whose deteriorating conditions are caught 72 hours ahead of time, according to Dr. Homa, the medical director of Lutheran Homes. But once it gets within a 24-hour window, there’s almost nothing that can be done to prevent a hospitalization. 

If a resident of a nursing home without a physician partner spikes a temperature on the weekend, a facility nurse may call a doctor, who could be out at dinner or playing a round of golf. The doctor has no obligation to drop what he’s doing and come to the nursing home, and to be safe, he tells the nurse to send the patient to the hospital. 

“If the skilled nursing facility has a doctor on call seven days a week, they bill Medicare Part B for their visits, and they’re there [at the facility]—they don’t send a patient to the emergency room unless it’s necessary,” says Krueger.

As post-acute providers seek to reduce readmissions, for-profit long-term care providers including Brookdale Senior Living (NYSE:BKD) and Kindred Healthcare (NYSE:KND) have hired their own medical director staffs, while not-for-profit senior care organizations such as Symbria are doing the same. 

Based on the CMS definition, the role of a medical director “could mean a thousand different things” regarding the implementation of resident care policies or the coordination of medical care in the facility, said Dr. Rajeev Kumar, president of the Illinois American Medical Directors Association, during the LSN panel. 

“It’s what you make of it,” he says, adding that his role means two different things at the two facilities where he is a medical director.

The recently-announced partnership with a physiatrist at Oak Trace, a Lifespace continuing care retirement community (CCRC) in Downers Grove, Ill., functions as a medical directorship. 

“It’s becoming more and more common [for skilled nursing facilities to have doctors on staff], especially with what healthcare is becoming by partnering closer with hospitals,” says Chris Andersen, the executive director of Oak Trace. 

In the past few months, the CCRC has increased its rehabilitation focus, including the partnership with Dr. Subhash Shah, who will oversee all rehabilitation services at the community. 

“Because of provisions under the ACA, in certain cases hospital payments will get docked for readmissions within 30 days,” Andersen says. “They’re forced to partner with more skilled nursing facilities to help ensure outcomes are stronger.” 

In the near term, increased partnerships between senior care communities and physicians with clinical specialities will be the norm, according to Andersen.

“I see a future where the continuum of care is more predominant in outcomes than before, and hospitals and skilled nursing facilities are forced to work more closely together,” he says.

“Alignment with physicians is going to be key [in the healthcare reform era]. It’s going to be about efficiencies and quality,” Krueger agrees.  “…Hospitals have to pick their [ACO] partners. You have to be strategic, or else you’ll be left in the dust.” 

Written by Alyssa Gerace

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