'SNFists' at work

As hospitals prepare to face readmission penalties in October, post-acute experts are making the case that nursing home specialists are the change agents who will improve the care of skilled-nursing facility residents—and lower rehospitalization rates.

The trend in nursing home specialists—sometimes referred to as “SNFists,” nursing home-physician specialists, or long-term-care specialists—began to emerge about three years ago, said Dr. Kenneth Scott, corporate medical director at Cleveland, Tenn.-based Life Care Centers of America, which operates 225 skilled-nursing facilities in 28 states.

It was in March 2009 when Dr. Paul Katz and his colleagues at the University of Rochester published an article in the Annals of Internal Medicine that emphasized the need for a nursing home medicine specialty that recognizes the nursing home as a “unique practice site.” Doing so, the article suggests, would do much to fix the existing problems in skilled-nursing facilities and better serve the roughly 1.6 million residents in U.S. nursing homes.

Meanwhile, in its report to Congress this month, the Medicare Payment Advisory Commission reported variation in rehospitalization rates from skilled-nursing facilities (See chart) and found that hospital-based facilities had lower rates partly because they have access to ancillary services and because “there is an increased presence of physicians and registered nurses who can diagnose and treat emerging conditions more rapidly …”

And physicians who are nursing home specialists can fill that role in nursing homes in the same ways physician hospitalists do in hospitals.

“Although physician extenders are wonderful adjuncts to help, the bottom line is the patients coming to our nursing home are the most critically ill and complex patients that medicine treats today in this country,” says Scott, who also leads Life Care Physician Services, the company's separate entity that is focused on placing these physicians as nursing home specialists.

“If we want this outcome and we want these numbers to improve, we need to have a full-time physician manage the patients,” he says.

Life Care has recruited about 40 physicians to serve as nursing home specialists at its facilities, which average about 120 beds. Patients can choose to receive care from that physician or their personal physician. Scott says it took the company a year to develop a business model, which is similar to a hospitalist model because the nursing home covers the physician's salary.

It's not the only approach, however. Some nursing homes, for instance, contract with physicians, rather than employ them, while others contract with hospitalist groups. When he served as a hospitalist, Scott says the biggest complaint he received from patients was that they didn't know who their physician was by the time the patient was discharged. That's why Life Care chose a model in which a physician is present as a nursing home specialist 40 hours a week.

According to Scott, Life Care's approach is working, as evidenced by patient and family satisfaction scores, and also in the hospital readmission rate, which he says is about 13% overall.

Katz, the author of the article that promoted the need for nursing home specialists, is working with Life Care as the company advances its model. Now the vice president of medical services at Baycrest Geriatric Health Centre in Toronto, Katz is also the immediate past president of the American Medical Directors Association, which represents more than 5,000 long-term-care physicians and nurse practitioners. Katz explains why there is such a strong need today for nursing specialists in nursing homes.

Regardless of the term used, “the rationale behind it is that physicians require a unique skill set to practice in this highly regulated environment where patient acuity is increasing dramatically and where you need to practice within a truly interdisciplinary environment,” he says. “The last decade or two, patients are going into nursing homes much sicker now than before.”

And the need will continue, Katz says, as family members find it increasingly difficult to care for their older relatives adequately.

In his Annals of Internal Medicine article, Katz proposes that a nursing home medicine specialty should “take a lead from the hospitalist movement” and be characterized by three key attributes: the degree of physicians' commitment, physicians' practice competencies, and the structure of the medical staff organization where they practice.

“What we're trying to get away from: Let's say you have 100 residents in a nursing home and 30 attending physicians, each caring for a small number,” Katz says. “That ‘open staff' model does not allow the physician to spend enough time in the nursing home to deliver high-quality care,” he says, adding that it's “not impossible, but more difficult.”

According to Katz, the AMDA has been developing core competencies for attending physicians in nursing home care. There are between 40 and 50 competencies that the organization will vet with other healthcare organizations related to geriatrics to identify a curriculum for physicians and nurse practitioners.

Dr. Jonathan Evans is a Charlottesville, Va.-based geriatrician and nursing home physician who says the time for nursing home specialists has come, in the same way earlier specialties and practices developed. For example, Evans says, the first half of the 20th century was devoted to specialization by body part (cardiology, urology), while the latter half—after the Vietnam war—shifted to specialization by site of care (ER, intensive-care unit, critical care).

Then the late part of the century focused on specialization by site of care (office-based physicians, hospital-based physicians, nursing home physicians). As the healthcare industry tried to become more efficient, the demand for physicians at any site increased, making it difficult to be, as he puts it, everywhere at one time.

“What used to be gratifying about hospital care doesn't happen in a hospital anymore,” Evans says. “For example, seeing people get well. We see the possibility of getting well, but we don't see the illness resolved,” he adds.

There's an opportunity for that to happen in nursing homes, he says, where physicians care for patients with a wide range of illnesses and also develop longer-term relationships with families. And there is also a financial incentive.

“It used to be that the majority of physicians were in solo or small-group practice, but that's becoming unaffordable for many, and young physicians don't have as much interest in it,” he says. Long-term-care medicine “makes sense economically because there is less overhead for practitioners and creates a way for doctors to spend more time with their patients.”

The findings in MedPAC's most recent report to Congress highlight the work that specialists have ahead of them, as the report outlines some factors that are within a skilled-nursing facility's control to avoid rehospitalizations. These include staffing levels, skill mix and frequency of staff turnover, drug mismanagement, transition care such as medication reconciliation, patient education about self-care, communication among providers, staff and the patient's family, and hospice use and the presence of advance directives.

As this specialty continues to develop, experts agree that success—in bettering care and lowering rehospitalization rates—will depend on the very feature that defines nursing home specialists: the physical presence of a physician in a nursing home each week.

“The thing that matters most is being there,” Evans says. “Being there for patients when they're sick; being there for families when they're in need; being there for staff to provide support and ongoing education,” he adds. “You can't be part of a team if you're not present.”