You’re steering your skilled nursing facility through ever-changing waters. Every year, the Centers for Medicare & Medicaid Services (CMS) introduces new expectations for value-based care (VBC). Tighter rules and higher standards put an ever-present pressure on your center to deliver top-tier care.
Thankfully, you don’t have to navigate value-based care alone. Focusing on interdisciplinary care can simplify the complexities of the VBC model, empowering your team to handle new challenges and deliver everyday wins.
Interdisciplinary Care: The Cornerstone of Value-Based Care in SNFs
The entire healthcare landscape is moving toward value-based care. The foundational ideas originate from leaders like Dr. Elizabeth Teisberg, Scott Wallace and Sarah O’Hara, whose work at the Value Institute for Health and Care at Dell Medical School, part of the University of Texas at Austin, has influenced how the industry defines and measures success in healthcare.
For skilled nursing facilities, CMS measures and counts every care decision, making concrete outcomes the backbone of your value-based operations. When care occurs in silos, with different providers or departments operating in isolation, the patient's journey is not viewed as a holistic experience. Information gets missed, handoffs break down and results can be frustratingly inconsistent.
An interdisciplinary team (IDT) approach coordinates everyone — nurses, therapists and medical specialists —around unified goals that align perfectly with key CMS priorities and Quality Reporting Program (QRP) metrics.
Improving Functional Outcomes
Functional improvement is all about how much residents progress in daily life skills, such as dressing, eating or moving around. CMS tracks this using GG scores on the Minimum Data Set (MDS), tying real results to quality ratings and reimbursement.
With interdisciplinary care leading the charge, your team does more than check boxes. They work together to spot strengths and tackle patient barriers in real time. Nurses, therapists and physicians pool their insights and adjust care plans, setting residents up for measurable gains in mobility, independence and safety.
Preventing Hospital Readmissions
Hospital readmissions aren’t just statistics. They’re red flags for CMS and headaches for your team. Each unplanned return can impact your ratings, revenue and resident trust.
Team-based care in skilled nursing means your team works shoulder-to-shoulder to identify and address problems early. Everyone, from aides to physicians, is empowered to raise concerns fast, ensuring rapid assessment and targeted interventions.
Averting Adverse Events
Falls, infections and pressure injuries don’t just happen. CMS scrutinizes these adverse events closely, knowing your safety record says as much as your outcome scores.
Interdisciplinary care in SNFs helps close the gap on unintended harm. When everyone understands the part they play on your team, individuals can work together to prevent issues before they ever have a chance to develop.
Boosting Overall Resident Satisfaction
Numbers alone can't tell the whole story. Resident satisfaction and family feedback play an important role in shaping your star ratings and public reputation.
When staff across every department collaborate, residents and families feel heard, understood and supported. Whether it’s pain management, social needs or discharge planning, your unified team is ready to resolve issues quickly, leaving a lasting positive patient impression.
The Role of Physiatry in SNF Care Coordination for Value-Based Care
Residents of skilled-nursing facilities often have multiple medical conditions or complex rehabilitation needs that require the skills of numerous medical professionals working in tandem. Physiatry in skilled nursing is the engine that drives interdisciplinary coordination and value-based care.
In a medical landscape that values real progress while penalizing setbacks, having a physiatrist on your team helps direct and motivate post-acute care coordination. Whether your center is striving to deliver higher-quality, value-based care or develop an IDT model for a more unified approach to rehab and recovery, here's how a Medrina physiatrist can help you reach your unique goals.
Physiatrists Are Leaders in Functional Recovery
With functional recovery as a cornerstone metric, you need the right expertise at the wheel. Physiatrists undergo unique training in a wide variety of medical disciplines, including mobility, cognition and complex medical conditions, such as:
- Spasticity management
- Chronic pain
- Neuro rehab
- Stroke recovery
- CHF and COPD functional optimization
Their ability to see the whole picture brings sharper focus to each patient's therapeutic plans, so every treatment is tied to measurable progress and meaningful goals.
Physiatrists Bridge Therapy and Medical Care
In skilled-nursing facilities, exceptional care occurs at the intersection of medical expertise and skilled therapy. Physiatrists have the unique ability to translate therapy data into medical insights, adjusting plans when medical barriers arise so that complications do not sideline patients.
As the clinical care conductor, the physiatrist plays a key role in bringing patient services into sync. They keep everyone in tune, including the physical and occupational therapists, speech and language pathologists, the nursing team and primary care providers. Medical alignment allows true value-based care to happen.
Physiatrists Help Reduce Hospital Readmissions
If readmission rates outshine your patient care successes, physiatry is key to early intervention. As experts in physical medicine and rehabilitation, physiatrists are trained to detect subtle declines in function, pain, cognitive status or conditioning — before they become ER visits. By fine-tuning medications and collaborating with nurses to identify early signs of infection or exacerbation, physiatrists help prevent adverse events that can lead to hospital readmissions.
Healthcare centers with embedded physiatry report an 8% reduction in hospital readmissions, delivering a measurable win for CMS quality metrics.
Physiatrists Enhance the Patient and Family Experience
Healthcare is more than operational or clinical excellence. It's about providing the best experience for every resident under your care. How families feel and how well your staff can support even the most complicated cases speak to your value-based approach.
A physiatry-led IDT provides patients and families a clear, actionable roadmap for their recovery. Physiatrists are highly skilled in:
- Compassionate communication.
- Expectation setting.
- Honest guidance.
- Empowering staff in complex cases.
Physiatrists Align Care Plans With PDPM
A patient-driven payment model (PDPM) links your center's revenue to clinical complexity and therapy coding — but only if your team sees and documents those needs accurately. A physiatrist's unique expertise helps keep everyone on the same page, ensuring that care plans reflect a resident's actual needs. From subtle comorbidities to functional impairments, a physiatry-led interdisciplinary team will be empowered to identify issues that directly impact PDPM scoring. This collaborative effort aligns therapies, supports outcomes and helps maximize your reimbursements.
The Benefits of Interdisciplinary Coordination in SNF Value-Based Care
Interdisciplinary care coordination transforms your center from a collection of departments into a cohesive team, providing a competitive advantage in the modern healthcare landscape.
Operational Benefits for Team Leadership
For SNF owners and administrators, interdisciplinary care is a proven formula for smoother operations and stronger results under the value-based care model. Having a physiatrist on board to provide decisive coordination can allow your center to benefit from:
- Efficient care coordination: Instead of endless emails or missed handoffs, a functional IDT with strong leadership results in fewer delays, faster decision-making and actionable answers that allow you to allocate your resources more effectively.
- Stronger reimbursement performance: Accurate coding of diagnoses and therapies, guided by a physiatrist, captures the whole patient picture, helping to secure every reimbursement earned.
- Improved documentation and compliance: When all team members document in a unified way and share updates, it’s easier to show progress and meet requirements. This approach supports more accurate CMS reporting while keeping your facility protected in the event of potential audits, surveys or legal reviews.
- Reduced burnout: Instead of making critical decisions alone, real-time consultation and cross-disciplinary support minimize decision fatigue and tension across departments. This supportive environment helps you attract and keep great clinicians.
Clinical Benefits of a Physiatry-Led SNF Interdisciplinary Team
By combining diverse expertise with coordinated treatment, your team can deliver comprehensive, holistic care that transforms the lives of your patients, leading to:
- Better functional outcomes: Therapeutic alignment with a physiatrist guiding the way can address multiple needs simultaneously, allowing patients to regain function and independence more effectively.
- Lower hospital readmissions: Unified communication means subtle clinical changes are not overlooked. From a new cough to mild confusion, proactive, coordinated care prevents conditions from escalating.
- Fewer complications: Better communication and a shared understanding, guided by a skilled physiatrist, help decrease misunderstandings and reduce the risk of adverse events and complications.
- Higher satisfaction scores: Unified teams explain care plans in plain, person-centered terms. When residents and their families feel heard and see clear progress, satisfaction rises.
Improve Patient Care in Your SNF With Medrina
Moving from siloed departments to a truly connected team takes a coordinated effort. Integrating physiatry services and getting your staff on board can make all the difference in value-based care.
If you're ready to level up your interdisciplinary care coordination, here are some suggestions to get started:
- Establish a structured IDT framework: Start by setting clear expectations for the entire team — physicians, therapists, nurses and case managers. Weekly meetings and daily huddles keep everyone in sync on urgent concerns. You must also adopt standardized communications templates, so vital information flows smoothly across roles.
- Embed physiatrists into your workflow: Schedule weekly rounds with a dedicated physiatrist, either in-person or virtually. These specialists should be included in IDT meetings and case reviews so they can help shape therapy plans and tackle complex situations. Partnering with Medrina simplifies physiatrist integration, providing you with easy access to this specialized care.
- Build shared care pathways: Develop clear protocols for common conditions commonly encountered at your SNF, such as stroke, heart failure or hip fracture. Establish a unified language across therapy and medical notes for consistency, regardless of which team member is documenting.
- Leverage the right data: Remember, for care to be value-based, it must center on meaningful milestones that matter to both residents and CMS metrics. Monitor the right metrics — GG scores, readmissions, therapy utilizations and length of stay. Track trends and proactively manage performance toward CMS targets, incorporating data into every IDT meeting to enable teams to adjust and deliver measurable results.
Contact Medrina for Interdisciplinary, Value-Based, Physiatry-Led Care
As the nation’s largest dedicated SNF physiatry group, Medrina delivers unmatched expertise in value-based care strategies and interdisciplinary coordination. Our proven approach delivers real results, including stronger functional outcomes, empowered teams and measurable improvements in care quality.
Explore how Medrina’s physiatry services and post-acute care solutions can equip your skilled nursing facility for sustainable, value-based success. Contact us today to get started, and we'll begin building your next chapter in SNF excellence together.
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