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New Role for a New Healthcare Environment



Paul Katz, M.D., founder of the SNFist movement.


In October 2012, penalties for certain readmissions started for hospitals. With that came a new reliance by hospitals on their long-term care partners. Quality post-acute providers who can help curb readmissions and smooth transitions of care are now sought for hospital accountable care organizations. A new breed of primary care providers called SNFists or SNFologists are full-time physicians in skilled nursing facilities, who are more readily available to patients, particularly older ones, with multiple comorbidities at risk for readmission.

“There are probably just a couple thousand nursing-home specialist MDs,” said Paul Katz, MD to Curaspan. He is the creator of the SNFist concept and chief medical officer at Baycrest, a provider of health care to the elderly and a research institution in Toronto.

The Medicare Payment Advisory Commission (MedPAC) has reported that a quarter of hospital admissions could have been avoided if seniors received better care at home or in an outpatient setting. MedPAC's report builds on previous research that found seniors are particularly vulnerable for readmissions. A 2010 study in the Journal of the American Geriatrics Society found that two-thirds of hospitalizations in Georgia were preventable and largely due to a lack of on-site primary care.

According to Curaspan, "a SNFist is a primary-care physician who practices within the four walls of one or more nursing homes, as an employee or contractor. The SNFist sees nursing home patients — whether they are permanent residents or are in intermediate convalescent care — all day, and develops a nuanced understanding of the potential and limitations of the SNF as a care setting. The SNFist is typically paid a salary or contracting fee by the nursing home, and the nursing home collects reimbursement for physician services from public and private payers."

A perfect storm has emerged for this role to take hold. Hospitals looking to reduce length of stay often leave nursing homes with sicker patients than they received in recent years. And the shortage of primary-care physicians finds doctors less able to keep full days of appointments in their private offices and also see their ill patients in the hospital and in nursing homes.

Preventable hospitalizations are expensive and the transfers to the hospital and back to the nursing home expose patients to elevated risks. By boosting the amount of time that doctors spend with nursing-home patients and reducing the time it takes to get a doctor to the bedside, a SNFist model could reduce hospitalizations.

A SNFists' physical presence in the nursing home also facilitates communication with patients, and with the family members.

Of course this comes with a significant investment and risk for the facility. In addition, payers may balk if they believe the scheme is increasing nursing-home patients' claims for physician services. Compound that with increased recovery auditors' attention on nursing homes. Recruiting may be even more difficult in an existing primary care physician shortage.

In addition to curtailing readmissions, the SNFist model has other advantages, including improved communication with families and increased patient attention and satisfaction.

Michael Radzienda, MD, SFHM, a regional chief medical officer at Sound Physicians, a hospitalist services organization that partners with client hospitals and post-acute providers to help improve acute-care delivery, told Curaspan that hospitalists are key to achieving optimal clinical outcomes.

"It’s become clear there are often poor connections between inpatient and outpatient staff, and the importance of that connectivity is not necessarily recognized on either side. You can't just send a patient on his way and hope for the best. Ultimately, we want to ensure hospitalists have a good relationship with the primary-care physician or whichever provider assumes primary responsibility for the patient after an acute-inpatient episode. Oftentimes, this relationship doesn’t exist."

He contends that the first step is to acknowledge that there is a problem.

By way of review, a Hospitalist is the term used for doctors who are specialized in the care of patients in the hospital. This movement was initiated about a decade ago and has evolved due to many factors. These factors include: convenience, efficiency, financial strains on primary care doctors, patient safety, cost-effectiveness for hospitals, and the need for more specialized and coordinated care for hospitalized patients.

Most hospitalists are board-certified internists (internal medicine physicians) who have undergone the same training as other internal medicine doctors including medical school, residency training, and board certification examination. The only difference is that hospitalists have chosen not to practice traditional internal medicine due to personal preferences. Some hospitalist physicians are family practice doctors or medical subspecialists who have opted to do hospitalist work such as, intensive care doctors, lung doctors (pulmonologists), or kidney doctors (nephrologists).

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  6. SNFist New Position in Nursing Homes Helps Reduce Readmissions,Ease Transitions of Care

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