Hospitalists and long-term care

Nurs­ing home docs pat­terned af­ter hospitalists

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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 criti- cally 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 full­time 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.

Unique skill set needed

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 longterm-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.”


Dr. Za­far Sharar, left, is the SNF spe­cial­ist at Life Care’s fa­cil­ity in Palm Bay, Fla.

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