SNF Essentials Understanding differences between IRFs, LTACHs, SNFs, LTC, AL/IL and other facilities, part 2 Charlotte H. Smith MD, Chief Clinical Officer

Topics of Discussion How are SNFs different than IRFs? What are the differences between these levels of care? How does the PMR role differ? What are SNF success strategies?

Differences between IRFs and SNFs There are differences in how physiatrists function in these environments including: Different goals Different lengths of stay Different rules related to how rehabilitation services can be provided Different rules related to billing & reimbursement Different rules related to documentation Different resources available within the various levels of care

SNF = Skilled Nursing Facilities SNF costs = approximately half of post acute care costs Highest volume of post acute facility destinations Licensed differently than acute care and IRFs Highest variation in quality in the post acute continuum Highest variation in cost of the post acute continuum

In general, the goals of SNF are SNF Goals: In general, the goals of SNF are to improve the patient’s medical stability to improve the patient’s functional status enough to be discharged to a community setting such as: patient’s own home, assisted living, independent living or an adult family home

SNF qualifications: Medicare requirements Must have a qualifying stay of 3 days in an acute care hospital Can be readmitted to SNF within 30 days without a 3 day acute care stay 100 days /benefit period Benefit period = begins on the day patient starts getting inpatient hospital or SNF care. Once patient uses 100 days, current benefit period must end before patient can renew your SNF benefits. If a break in skilled care lasts for at least 60 days in a row, this ends current benefit period and renews SNF benefits. NOTE: NOT guaranteed 100 days (must meet specific criteria) Patients must meet criteria for either 1) nursing care; or 2) rehabilitation services.

SNF Length of stay (LOS): Longer than IRFs Helpful in context of neurological recovery Being squeezed similarly to IRFs Varies tremendously: 14 day joint programs Avg 30 days Long LOS: Not perceived as providing highest quality May be getting a different mix of patients (neuro, medically complex, difficult to place) May not be selected as post acute partners for ACOs

RUGs: Payment to the facility varies by the patient’s RUG level: determines the daily rate of reimbursement at the SNF. Rehabilitation RUG levels are generally set by the rehabilitation therapists in conjunction with the physiatrist. RUG levels determines the number of PT/OT/SLP minutes that will be provided per day. All patients have initial, comprehensive assessments by nursing and by any discipline of rehabilitation that they are referred to.

Rehabilitation Plan of Care done in conjunction with the initial assessment that is done by each involved rehabilitation discipline (PT/OT/SLP) must be approved/signed by a physician (Attending internist or physiatrist) Rehabilitation reevaluation: required at regular intervals during the SNF stay must also be approved/signed by a physician. Physiatrist Role: To ensure that the services provided are reasonable and appropriate To ensure that appropriate interventions are being done for clinical condition

SNF Meetings: Medicare meeting: Required for all SNF facilities weekly interdisciplinary meeting attended by nursing, social services and a rehabilitation therapist. Patient Care Conferences: SNF facilities are required to have patient/family conferences after admission and as appropriate throughout the SNF stay. Administrative meetings: Standup/Daily census meeting Quality Council Other

Physician Services at SNFs Medicare requires patients be seen by a physician every 30 days Availability of physicians is highly variable: Residential Care Team (RCT): consisting of physicians (generally internal medicine hospitalists or geriatricians) and/or midlevel providers, such advance nurse practitioners (APNs) or physician assistants (PAs) that are on site. Physician consultants: come at certain intervals or upon request Most common consultant specialists are physiatry, psychiatry, podiatry, wound care and dentist. Outpatient physician visits: covered by Part B of Medicare not subtracted from the daily SNF reimbursement, it is common (and generally encouraged) for SNF patients to go to private physician offices for specialty services while they are in the facility.

Medical Directors at SNFs All SNFs have a Medical Director- oversees administrative issues provides care call coverage. Internist, geriatrician or physiatrist (usually) Co-Management Model (see Co-Management materials for more information) Many SNFs are using this model to provide care to the residents. Shared responsibilities between Internal Medicine and Physiatry Allows optimal balance between coverage of medical issues and rehabilitation specialty care

Diagnostic Services in SNFs Less pressure to avoid ordering diagnostic services in SNFs: not subtracted from the daily SNF reimbursement less conflict with missing PT/OT/SLP therapies (no ‘3 hr rule’) Diagnostic services (such as radiology, lab, etc.) are generally provided by either: mobile services that come to the facility; or patient is taken to a facility outside of the SNF Some SNFs have limited diagnostic services available on site.

Strategic Differences in the PMR work : In addition to how you do your duties, there will be other strategic differences in: How you obtain referrals How you work with other physician specialists How you help your facility achieve success How often you see your patients The focus of your visits Your role and how you support the team

How do PMR doctors get referrals in SNFs? Direct referral requests from attending physician/internist/consultants Requests from staff (nursing, rehab team, SW) Referrals from Medicare meeting Patient/family request Triggered referrals via protocol: All patients getting > two disciplines of PT, OT, SLP) Patients within diagnostic groups (CVA, SCI, neurology, ortho, etc.) Patients with specific issues: Pain Bowel/bladder Spasticity Patients needing DME or rehabilitation services after discharge

What is the physiatrist role and focus? Depends on the facility: Internist/other physician preferences Needs of the patient Needs of the patient/facility If co-management, focus is on rehab rather than medical issues Supporting the rehab team with program specific interventions (CVA, SCI, TBI, complex ortho, amputee, pain, etc.) Rehab oriented issues (bowel/bladder, rehab goals, discharge recommendations, DME, etc.) Always ASK what is needed/desired! Writing orders Timing/urgency for consults PAIN management approach should always be discussed.

Typical Physiatry Duties in SNF   Performing consultations on predetermined patients within the facility (see PMR Referral Protocol) Managing medical issues commonly managed by physiatry such as pain, spasticity, bowel/bladder, skin issues, etc. in conjunction with other physicians Determining which rehabilitation disciplines are appropriate and writing orders related to PT/OT/SLP Attending the weekly interdisciplinary Medicare meeting Reviewing and signing off on Rehabilitation Plans of Care and reevaluations Documenting functional status and progress in consultation notes Assisting with determining appropriate rehabilitation goals and level of rehabilitation services Problem solving when patients fail to participate in rehabilitation Assisting with managing length of stay and discharge planning Assisting with patient, family and team education Justifying and prescribing durable medical equipment Justifying and prescribing home health care and outpatient rehabilitation Communicating and coordinating care with referring physicians (especially orthopedists, neurosurgeons, plastic surgeons, etc.)

How often should physiatrists see SNF patients? USP promises 2 times/week availability Depends on patient need and medical necessity: Critical/ongoing medical issues (spasticity, AD, etc.) Pain management Bowel/bladder issues Cognitive/behavioral issues (agitation, safety issues) Psychological/psychosocial issues Review of functional progress & discharge planning Bottom line: based upon medical necessity as documented in the medical records (range daily-monthly in SNF)

Billing and Documentation in SNFs Different billing codes: IV 1 Detailed (25 min) 99304 IV 2 Comprehensive (35 min) 99305 IV 3 Complex (45 min) 99306 F/U 1 Problem focused (10 min) 99307 F/U 2 Extended problem (15 min) 99308 F/U 3 Detailed (25 min) 99309 F/U 4 Comprehensive (35 min) 99310 Based upon: History PE Medical decision making Problem severity Coordination of care/counseling

Documentation in SNFs Documentation should support: Level of service being billed Necessity for being in SNF Rehabilitation plan of care: progress towards toward goals Recommended changes in rehabilitation plan of care Medical issues/co-morbidities being addressed Time spent on counseling or coordination of care Resources: AAPMR Billing & Coding Companion MD Coder US Physiatry audit team

How do physiatrists add value in SNFs? Ensure operational integrity Improve outcomes Improve patient satisfaction Support employee retention Support medical directors/ RCT Improve the reputation of facilities Attract patients (right ones in the right way…)

How are SNFs rated? SNFs are compared and rated on multiple factors: Length of stay Cost of care Iatrogenic complications (such as skin breakdown or infections) Readmission rate to acute care hospitals Patient satisfactions Functional change efficiency Discharge to home/community (vs. to long term care facilities/nursing homes) Star ratings They are looking to US (physiatrists) to help them score well on metrics. To attract patients To be chosen as PAC partners by ACOs

‘Not a candidate for SNF’ SNFs try to limit or avoid cases that: Longer LOS anticipated than covered days cost more than their reimbursement (such as patients requiring expensive medications) High risk of readmission to acute care ‘Difficult’ patients Note: This varies depending upon: the facility type (for profit vs not for profit), facility census, payer mix; and the facility’s integration/alliance with referring hospital networks.

SNF Challenges Current regulatory environment with the maze of Medicare regulations and rules- RAC audits State surveys Limited resources: Staffing expertise

WHY should Physiatrists be available in SNFs? Becoming an expert in these arenas will allow you to provide the highest level of care possible to your patients. In addition, you will have expertise that is critically needed in our current health care environment. There is currently no arena of healthcare with a higher variation in both cost and quality than the post-acute continuum. Physiatrists are in a unique position to impact outcomes as they become leaders in managing patients throughout the healthcare continuum, including post-acute care environments

US Physiatry’s Strategy: US Physiatry’s strategy is to provide physiatry services in all aspects of the healthcare continuum. It is our belief that patients benefit from having physiatrists involved in all levels of care: Acute care hospitals Inpatient rehabilitation Skilled nursing facilities Assisted living/independent living Long term care facilities Home health care Outpatient care Wellness/prevention

The Focus of Rehabilitation in SNFs The focus of rehabilitation varies depending upon the setting but includes: Improving function related to disabling conditions Prevention of secondary complications Managing disabling conditions across the patient’s lifespan Disease/disability prevention

Opportunities within SNFs: Increasingly, rehabilitation services are being shifted to less intensive and lower cost settings (‘ALF is the new SNF”???) Due to the tremendous shift from inpatient acute care rehabilitation facilities to skilled nursing facilities, SNFs now provide the majority of facility based rehabilitation. There has been tremendous growth in the volume of home health services and it is anticipated that there will be additional scrutiny and regulation related to home health care.

Providing VALUE vs QUALITY: Hospital networks are increasingly attempting to choose post- acute care partners that perform well by providing high value services: High quality care (good programs, comprehensive services, high patient/family satisfaction) Short length of stay Low cost of services Low readmission rates to the acute care facility Good outcomes (to community rather than long term care) Remember the definition of value: VALUE = HIGH QUALITY --------------------- COST

How do physiatrists provide VALUE in SNFS? Managing all types of patients Preventing complications Optimizing function Decreasing length of stay Navigating patients to the correct level of care after discharge from SNF Preventing readmissions Optimizing patient/family satisfaction

RISKS for Physiatrists in ACO environments: Being at the ‘end of the food chain’ Not being invited to the party