Physiatrist Consultations in Skilled Nursing Facilities

This article is sponsored by Integrated Rehab Consultants. This article is based on a Skilled Nursing News discussion with Steve Gnatz, Chief Medical Officer at Integrated Rehab Consultants. The discussion took place on September 1, 2022 during the Skilled Nursing News RETHINK Conference in Chicago. The article below has been edited for length and clarity.

What is a Physiatrist's Role?

Skilled Nursing News: We’re going to talk a little bit today about physiatry. Tell me a little bit about physiatry and your role.

Steve Gnatz: Physiatry is the medical specialty of physical medicine or rehabilitation. For anybody that’s not familiar with what a physiatrist does, my mom never knew what I did as a doctor. She would say, “What kind of doctor are you?” I’d say, “Mom, I’m a rehab doctor.” She would say, “Well, what do you do?” I’d said, “Well, I take care of patients that have problems that need rehabilitation.”

One time she fractured her hip and she went into Rehab Institute of Chicago and said, “Steve, all these people here seem to know who you are.” I was like, “Yes, mom. That’s because this is the type of doctor I am. I’m a rehab doctor.” She said, “Oh, this is the type of doctor you are.” I think you have to need a rehabilitation doctor before you actually know what one is. In a skilled nursing facility environment, one of the things that I think you may recognize is that you’re getting more and more rehabilitation patients.

I think you can think about rehabilitation patients like you would think about a cardiology patient or a pulmonary patient. You would want to have a behavioral health patient, you’d want to have a specialist who’s taking care of that patient on your team. That’s where we come in in physical medicine rehabilitation because we are the medical specialists who take care of patients with disabling conditions and work with them to get them back to life.

How Can Physiatrists Provide Value?

SNN: Talk to us about the value-add that the physiatrist does in working with patients.

Gnatz: If you come from a multilevel system with rehabilitation like inpatient rehabilitation, acute inpatient rehabilitation, and skilled nursing facility, you’re probably familiar with physiatry or rehab doctor working in your acute rehab. It’s actually mandated by CMS, that you have a rehabilitation physician. In a skilled nursing facility, it’s not mandated that you have a rehabilitation physician, but I think that the need for the expertise is still there. You wouldn’t want to go into a specialized program like rehabilitation without the specialist.

SNN: When looking at choosing a physiatrist, what do you think members of the audience should really hone in on in terms of background skillset?

Gnatz: A physiatrist comes out of a training generally in an acute inpatient rehab. They may know that very well, physiatrists by nature are multidisciplinary. We work with your therapist, we work with your nurses, we work with your team. We’ll know that multidisciplinary aspect of things and that is really where some of the value comes in. The other thing that I would mention is that you need to make sure that the physiatrist that you’re working with understands the skilled nursing facility environment.

That not always do they carry those skills over from acute inpatient rehab into the skilled nursing facility environment, that there may be specialized things that they’re working with in your environment. As we say, when you’ve seen one skilled nursing facility, you’ve seen one skilled nursing facility. They all look very different. They may have different types of patients there and different programs. In our company, one of the things that we do is we use a lot of protocols and pathways that we’ve developed over the years to be able to teach our physiatrists who are working in your facilities the aspects of care that add those values.

SNN: Earlier, you talked a little bit about your mom recognizing what you do, and I think that’s fantastic. Talk to us a little bit about the role of a physiatrist when it comes to patient outcomes.

Gnatz: In the skilled nursing facility environment, you have a wide range of different rehabilitation issues. You may have people with strokes or spinal cord injuries or orthopedic problems, or they’ve had general deconditioning, debability, those types of things. Your physiatrist is going to be familiar with all the medical aspects of that. I think one of the other important things for you to recognize is that your physiatrist is going to also be a person that knows the pathway or maybe even being able to predict the future, to prognosticate.

We want to be able to tell that patient and that family yes, you’ve had this thing that is bad that’s happened to you, but this is what we see you are going to be able to do down the road. That’s an important aspect of medical care. It’s an important aspect of being a human that you can say to someone, “Look, you’re going to get better. This is not the end of your life. This is something where you are going to be able to participate in life events again. You’re going to be able to do things again. We’re going to try to get you home. If we can’t, the circumstances are to that extent.” I think that those types of outcomes, your physiatrist will know where the case is going. Your physiatrist will be able to guide that patient and their family. To be able to obtain the best outcome for them that’s possible under the circumstances.

SNN: Let’s talk a little bit about the Patient Driven Payment Model [PDPM]. The role of the physiatrist is to help flesh out characteristics. Tell us a little bit more about that process and the impact on PDPM.

Gnatz: PDPM was a big change for skilled nursing facility payment as everybody in this room knows. Going from MDS RUGs counting therapy minutes, putting people into higher RUG levels based on that. When PDPM came around; it’s called the patient-driven payment model for a reason.

That’s because it’s all driven by those patient characteristics. One of the major patient characteristics that you’re dealing with is medical diagnoses. Every skilled nursing facility starts with the discharge diagnosis from the hospital but that’s really just the start. If you’re in a skilled nursing facility environment, you need to know what that patient is coming to you for, what they came from the hospital with, their diagnoses, but you also need to know what they’re there for.

If they’ve had a stroke and maybe that stroke was cared for in the hospital, they’re going to come to your skilled nursing facility with the diagnosis of a stroke, but if your physiatrist comes in and says, “Oh, by the way, this person also has swallowing difficulty,” we identify that, we put that down as an ICD 10 code in our notes and then if you have coders who are then trying to accumulate all those appropriate ICD 10 codes so that you can properly characterize that patient for PDPM, we actually specialize in providing those extra ICD 10 codes that help flesh out that case for you so that you get the appropriate resources that you need to be able to get paid for what you do.

SNN: Talk to us a little bit about how you look at your role as a partner with some of these organizations that you are working with. What stands out in terms of differentiating your role as a physiatrist to others that are out there?

Gnatz: Physiatrists, as I said, by nature are multidisciplinary. We work with your team. I think it always struck me when I first started working in the skilled nursing facility that there were facilities that were not really even familiar with this model where you would have a rehab doctor who was working with the team, coordinating things, making prognostic predictions about patients participating in multidisciplinary meetings like your Medicare meeting or whatever you have.

I think that the role for your physiatrist should be the same as what they do in an acute inpatient rehab.

Our company has 700 skilled nursing facilities across the country, but that’s still only one-fifteenth of those that are out there. The model is not universally adopted yet. I think part of that is because we don’t have a mandate from CMS that you have to have a rehab doctor in your facility, but we tried to just make our presence known, provide value, and come into your facility. We work under Medicare B as you probably know so from the standpoint there’s no cost to the facility for you to have a medical specialist in physiatry. I think that it does naturally add value. Now, we have some studies that show that value. One thing that, of course, we’ve been very interested in is proving our value. Now, we feel that we have value in terms of how patients do, they get better, they go home. Their functional outcomes are better because we’re there. If you’re a skilled nursing facility administrator at least in my experience you’re not always interested in “How did that patient do? Did they really get better?”

You want to know “What did you do for me today, doc?” We’ve shown things like decreased returns to acute care, decreased ED visits. Now, you could say, well, having a nurse practitioner in the facility also does that. That’s probably true that sometimes just an extra pair of eyes but an extra pair of very well medically trained eyes looking at that patient on a regular basis helps reduce some of those complications that might be missed if they didn’t have that extra resource. Here you have an extra resource that basically is coming into your facility providing you with a value that is at no cost to you. I just go, “Why wouldn’t everybody want to do that?”

SNN: Talking a little bit about that research, tell us a little bit about at a high level some of the findings amongst the facilities that you’re working with.

Gnatz: We have found decreased returns to acute care and decreased ED visits. One of the factors that we try to do is to right-size the rehabilitation stay. Your physiatrist is going to understand the course of the rehabilitation. They’re going to understand when a person needs to be in a facility. I heard somebody else say earlier, “Nobody wants to be in a facility.” You’re right, they don’t want to be there any longer than they have to. I’ve always said there are two types of rehab patients. One that comes in and wants to be out immediately and the second that comes in and wants to stay forever.

That’s really just a joke. The fact of the matter is we try to right-size the rehabilitation so that we’ll work with the facilities. We have shown that in general, we reduce lengths of stay. Now, that’s probably not a good thing to say in this room but I think when you’re working with post-acute networks, when you’re working with ACOs, when you’re working with managed care companies that are really interested in right-sizing that length of stay in your skilled nurse facility, it’s helpful to have a psychiatrist that knows how long that person needs to be in this level of care. That knows when they can go home, when they can go into say day rehab, when they can go into an outpatient level of care.

I think that there are aspects of this that even though we might be saying your length of stay might come down, you say, well, yes but then you open up a bed where you can put somebody else in who’s appropriate maybe higher level acuity. As you mentioned under PDPM, we have shown through our research that we provide additional income. It’s not additional income. It’s rightsizing the income. I’d like to stress that having a physiatrist in your facility will get you the reimbursement that you deserve for that particular patient.

The Future of PDPM

SNN: You talked a little bit about efficiency focusing on quality of care and obviously the reimbursement side. What does the future of PDPM look like from your point of view?

Gnatz: I think PDPM is a step on the road to a prospective payment system. Now, everybody goes, “Ah, prospective payment.” No, no, I think having lived through prospective payment, hitting acute inpatient rehab which I did at the time, it’s not something to be afraid of. [With] PDPM if you can imagine that now you’re getting paid on patient characteristics but pretty soon you’re going to get paid a case rate based on the entire package. It’s already happened in acute inpatient rehab. It happened in hospitals. It’s happened in other levels of care. If you’re prepared for it, if you know the ropes, if you know what’s going on, if you have the appropriate professional guidance in these settings, you’ll do well under a prospective payment system.

Integrated Rehab Consultants physiatrists partner with skilled nursing facilities (SNFs) and inpatient rehab facilities (IRFs) to optimize therapy treatment plans; focusing on managing pain, functional rehabilitation and recovery for patients with physical and cognitive impairments or disabilities, they can help patients discharge quicker and safer. To learn more, contact us!