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

2. 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?

3. 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

4. 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

5. 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

6. 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.

7. 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

8. 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.

9. 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

10. 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

11. 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.

12. 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

13. 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.

14. 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

15. 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

16. 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.

17. 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.)

18. 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)

19. Billing and Documentation in SNFs
Different billing codes:
IV Detailed (25 min)
IV Comprehensive (35 min)
IV Complex (45 min)
F/U Problem focused (10 min)
F/U Extended problem (15 min)
F/U Detailed (25 min)
F/U Comprehensive (35 min)
Based upon:
History PE
Medical decision making
Problem severity
Coordination of care/counseling

20. 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

21. 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…)

22. 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

23. ‘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.

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

25. 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

26. 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

27. 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

28. 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.

29. 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

30. 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

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