SNF ?

[GoBeers]

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anyone here ever do SNF?
how did you start the process?
strictly med mgmt ?
was it monthly visits? bi weekly or weekly?
did you find those that d/c'd from SNF end up in your clinic eventually?
any red flag issues or logistical issues?

I'm thinking about cold calling local SNFs but have no idea what to expect

 

[PainDoc2025]

Following

 

[cowboydoc]

anyone here ever do SNF?
how did you start the process?
strictly med mgmt ?
was it monthly visits? bi weekly or weekly?
did you find those that d/c'd from SNF end up in your clinic eventually?
any red flag issues or logistical issues?

I'm thinking about cold calling local SNFs but have no idea what to expect

are you PM&R?

I was previously a med director (1/2 day/week) at a NH/SNF. It became a real hassle and not worth the "easy" income, because it interfered with regular flow of patients. You can't get paid for procedures in house, as it's DRG payments. Dispo and d/c pain meds would by yours by default by the sounds of it. Staffing is horrible (even worse now, I'm sure) I resigned before COVID.

 

[PainDoc2025]

are you PM&R?

I was previously a med director (1/2 day/week) at a NH/SNF. It became a real hassle and not worth the "easy" income, because it interfered with regular flow of patients. You can't get paid for procedures in house, as it's DRG payments. Dispo and d/c pain meds would by yours by default by the sounds of it. Staffing is horrible (even worse now, I'm sure) I resigned before COVID.

Are there possibilities for a pain physician (presumably working M-F) to do maybe like one weekend each month at a SNF? PM&R trained of course.

 

[GoBeers]

are you PM&R?

I was previously a med director (1/2 day/week) at a NH/SNF. It became a real hassle and not worth the "easy" income, because it interfered with regular flow of patients. You can't get paid for procedures in house, as it's DRG payments. Dispo and d/c pain meds would by yours by default by the sounds of it. Staffing is horrible (even worse now, I'm sure) I resigned before COVID.

i'm anesthesia trained.
i was just thinking i'd show up once a month and evaluate patient and write for any as needed simple oral medications.
in the clinic I'm at, I don't see any patients from SNFs. also this clinic is expanded into new territory so my volume is only modest.
I do think there is a simple need for these SNF patients as I'm sure the overseeing primary physicians don't want to deal with pain mgmt.
I figure I could lend a hand by managing patients specifically for their chronic pain conditions and hopefully manage any polypharmacy with more oversight. I didn't intend to go more than once a month. just to stay busy and potentially get my name out into the community.

 

[bedrock]

anyone here ever do SNF?
how did you start the process?
strictly med mgmt ?
was it monthly visits? bi weekly or weekly?
did you find those that d/c'd from SNF end up in your clinic eventually?
any red flag issues or logistical issues?

I'm thinking about cold calling local SNFs but have no idea what to expect

I’d suggest you post this question in the PMR forum. You’d get more answers.

 

[cowboydoc]

i'm anesthesia trained.
i was just thinking i'd show up once a month and evaluate patient and write for any as needed simple oral medications.
in the clinic I'm at, I don't see any patients from SNFs. also this clinic is expanded into new territory so my volume is only modest.
I do think there is a simple need for these SNF patients as I'm sure the overseeing primary physicians don't want to deal with pain mgmt.
I figure I could lend a hand by managing patients specifically for their chronic pain conditions and hopefully manage any polypharmacy with more oversight. I didn't intend to go more than once a month. just to stay busy and potentially get my name out into the community.

Reasonable plan, just have an exit strategy. Advice from the PM&R forum should net some good feedback (and maybe a Westside Story type turf battle).

At least 2x/month probably makes a lot more sense from a care standpoint. SNF has a pretty high turnover, so a 4 week f/u will mean a one and done for many visits. I'm not sure how that serves you or the patients well.

 

[RoloTomassi]

I hated this during residency. Felt like I was accomplishing nothing, just volume billing low value E&M codes. Very unsatisfying when a GT bursa injection is the highlight of your day. Plus nursing homes are depressing AF.

 

[lobelsteve]

I’d suggest you post this question in the PMR forum. You’d get more answers.

Already an active thread on this topic. Look for PMR2008.

 

[oneforfighting]

I hated this during residency. Felt like I was accomplishing nothing, just volume billing low value E&M codes. Very unsatisfying when a GT bursa injection is the highlight of your day. Plus nursing homes are depressing AF.

Completely agree. I know that subacute rehab is marketed as this thing that can make rehab docs lots of money while providing lifestyle flexibility but I found it super depressing. Don’t really feel like you’re doing much if anything for these folks. Couldn’t pay me enough to do this.

 

[SSdoc33]

Eff no

 

[GoBeers]

Completely agree. I know that subacute rehab is marketed as this thing that can make rehab docs lots of money while providing lifestyle flexibility but I found it super depressing. Don’t really feel like you’re doing much if anything for these folks. Couldn’t pay me enough to do this.

hmm... so just boring busy work?
I mean I really just need to keep myself busy while also marketing to grow the volume in clinic.
if it's pretty straightforward and easy.... can't be that bad can it?
i just have no sense of it and people around me make it seem like it's nothing.

 

[ChiSox]

From my experience, I did SNF work for about 3 months, it was a bridge before I started my fellowship and I'm PM&R trained. Great lifestyle - I worked for a national staffing company that finds opens in facilities across the country. 3-4 days a week at 3 facilities, anywhere from 35-50 patients a day - the primary team managed all the medical issues and my role was as a consultant. I managed anything from SCI to spasticity, getting patients set up for wheelchair fitting, orthotics recommendations, a bit of TBI management, bowel/bladder recommendations, non-opiate pain management, a handful of peripheral joint injections but overall bread and butter general rehab and assessing barriers to rehab/meeting functional goals.

It would be good to get in favor with the rehab team as well, developing relationships with the the therapists, attending occasional care team meetings, discussing specific patients and as they get closer to discharge, they'll be reminded to follow-up with Dr. GoBeers for their knee/back etc pain

I found that many of the patients are managed by the NP/PA from a medical standpoint and I was the only physician they'd see regularly. I agree, there were a lot of patients where it didn't seem like I was doing much but they were very appreciative of someone discussing goals with them on a bi-weekly basis as the geriatric population, particularly in these settings, are often just left behind.

 

[oneforfighting]

hmm... so just boring busy work?
I mean I really just need to keep myself busy while also marketing to grow the volume in clinic.
if it's pretty straightforward and easy.... can't be that bad can it?
i just have no sense of it and people around me make it seem like it's nothing.

Not always boring. This is the nursing home after all so people are sick. And are seen by a doc or more often an np once monthly. If you see someone who is complaining of UTI symptoms, chest pain, sob, unilateral leg swelling…you catch my drift. Suddenly you aren’t just managing their rehab or pain needs. If you want to be a good doctor these are not things that you can turn a blind eye towards and just feel comfortable turfing to an np to manage whenever they get to them. Everywhere I looked, I saw problems. And then so many have dementia.

 

[cowboydoc]

In my experience, I saw another MD in the facility once in 4 years and only spoke with docs about a patient on the phone occasionally. It was not a good networking move. If you want that, you could do acute hospital consults. You’ll definitely get your name out that way, but most here would not recommend it. There’s no way I’d do it.

I’d just market directly to referral sources, shake some hands, take good care of patients you have, maybe pick up some gas work locally if available.

 

[PMR2008]

Definity not for networking. Can bring patients to the clinic for injections. 25% of my clinic patients are patients I saw in nursing homes.
Not a lot of acute or uncontrolled pain in the SNF setting and most can be managed by primary team. PM&R can get away with seeing the whole "census" because we will do more than just manage pain as @chiCox mentioned. If Anesthesia Pain wants to make this a thing you need a high volume of facilities and have a process in place to be consulted. There will be a ton of driving around and consults will eb and flow. "You can't get paid for procedures in house, as it's DRG payments." is not true. I have done thousands of injections in the SNF setting since 2012.

@oneforfighting It is unfortunate you had that experience. Probably more based on facility, training and mindset. I work in heavy rehab facilities that pretty much work like acute rehab facilities. 30-40% ortho 25% Neuro and the rest are cardiopulmonary. Lots for us to do as PM&R. The old school SNFs can definitely be depressing. I only work at ones that have a Starbucks in the lobby. McHenry, IL | Ignite Medical Resort
Just an example I don't work at this location.

 

[Agast]

i'm anesthesia trained.
i was just thinking i'd show up once a month and evaluate patient and write for any as needed simple oral medications.
in the clinic I'm at, I don't see any patients from SNFs. also this clinic is expanded into new territory so my volume is only modest.
I do think there is a simple need for these SNF patients as I'm sure the overseeing primary physicians don't want to deal with pain mgmt.
I figure I could lend a hand by managing patients specifically for their chronic pain conditions and hopefully manage any polypharmacy with more oversight. I didn't intend to go more than once a month. just to stay busy and potentially get my name out into the community.

I started randomly getting referrals from a SNF director. I think one of my elderly patients ended up there and said enough nice things that it happened organically. They come to my office for appointments, they usually have a family member or transportation services take them. You don’t have to go over there, and it might affect your ability to bill if you’re seeing them off-site anyway. Just introduce yourself and drop off some cards and cookies for the nurses.

 

[PMR2008]

"it might affect your ability to bill if you’re seeing them off-site anyway" explain that please.

 

[GoBeers]

From my experience, I did SNF work for about 3 months, it was a bridge before I started my fellowship and I'm PM&R trained. Great lifestyle - I worked for a national staffing company that finds opens in facilities across the country. 3-4 days a week at 3 facilities, anywhere from 35-50 patients a day - the primary team managed all the medical issues and my role was as a consultant. I managed anything from SCI to spasticity, getting patients set up for wheelchair fitting, orthotics recommendations, a bit of TBI management, bowel/bladder recommendations, non-opiate pain management, a handful of peripheral joint injections but overall bread and butter general rehab and assessing barriers to rehab/meeting functional goals.

It would be good to get in favor with the rehab team as well, developing relationships with the the therapists, attending occasional care team meetings, discussing specific patients and as they get closer to discharge, they'll be reminded to follow-up with Dr. GoBeers for their knee/back etc pain

I found that many of the patients are managed by the NP/PA from a medical standpoint and I was the only physician they'd see regularly. I agree, there were a lot of patients where it didn't seem like I was doing much but they were very appreciative of someone discussing goals with them on a bi-weekly basis as the geriatric population, particularly in these settings, are often just left behind.

I've always been impressed with the true scope and abilities of a PM&R doc. 🙂

No way I plan to do any of that though.

I guess in my area (for better or for worse) it just seems that all these PCPs are sooooo paranoid about opioids and pain medications that even in the SNF I hear medical staff rarely prescribe pain medications in a thoughtful and strategic fashion. I am probably being extremely naive, but I figured I would solely assist with basic PT recommendations, analgesic med management, and as needed diagnostic workups.

Ok thanks everyone for sharing your experiences.

 

[Magnus Acus]

Definity not for networking. Can bring patients to the clinic for injections. 25% of my clinic patients are patients I saw in nursing homes.
Not a lot of acute or uncontrolled pain in the SNF setting and most can be managed by primary team. PM&R can get away with seeing the whole "census" because we will do more than just manage pain as @chiCox mentioned. If Anesthesia Pain wants to make this a thing you need a high volume of facilities and have a process in place to be consulted. There will be a ton of driving around and consults will eb and flow. "You can't get paid for procedures in house, as it's DRG payments." is not true. I have done thousands of injections in the SNF setting since 2012.

@oneforfighting It is unfortunate you had that experience. Probably more based on facility, training and mindset. I work in heavy rehab facilities that pretty much work like acute rehab facilities. 30-40% ortho 25% Neuro and the rest are cardiopulmonary. Lots for us to do as PM&R. The old school SNFs can definitely be depressing. I only work at ones that have a Starbucks in the lobby. McHenry, IL | Ignite Medical Resort
Just an example I don't work at this location.

I’m a PM&R resident.

Sounds like at least a small part of your practice has been in nicer SNFs. Do you think it’s been a decent way to add variety to your practice?

I don’t think I’ll live and die in a SNF, but like you said, doesn’t sound terrible to chat with granny and inject her knee. -especially as a way to change it up. Thanks!

 

[PMR2008]

I work with palliative providers in my facilities. They could be med director if they are open to taking call, doing admits, attending meetings. Better model is palliative consult service.

 

[PainDoc2025]

From my experience, I did SNF work for about 3 months, it was a bridge before I started my fellowship and I'm PM&R trained. Great lifestyle - I worked for a national staffing company that finds opens in facilities across the country. 3-4 days a week at 3 facilities, anywhere from 35-50 patients a day - the primary team managed all the medical issues and my role was as a consultant. I managed anything from SCI to spasticity, getting patients set up for wheelchair fitting, orthotics recommendations, a bit of TBI management, bowel/bladder recommendations, non-opiate pain management, a handful of peripheral joint injections but overall bread and butter general rehab and assessing barriers to rehab/meeting functional goals.

It would be good to get in favor with the rehab team as well, developing relationships with the the therapists, attending occasional care team meetings, discussing specific patients and as they get closer to discharge, they'll be reminded to follow-up with Dr. GoBeers for their knee/back etc pain

I found that many of the patients are managed by the NP/PA from a medical standpoint and I was the only physician they'd see regularly. I agree, there were a lot of patients where it didn't seem like I was doing much but they were very appreciative of someone discussing goals with them on a bi-weekly basis as the geriatric population, particularly in these settings, are often just left behind.

What was the pay like?

 

[sloh]

From only SNF work I make 500k+

 

[Frazier]

Are SNF facilities suitable for palliative physicians? Seems like it would be a natural fit as medical directors as they are well-trained in pain management and QOL issues. Furthermore, if im not mistaken palliative physicians don't generate much revenue and depend on being subsidized by hospital salary, so working or being medical director of SNFs wouldn't be as much of a loss of ROI compared to PM&R or Pain physicians who work more on production/procedures.

@Frazier

Great thoughts. I agree, sure they could. Depending on their primary specialty they will have more or less comfort with being director of a SNF. For example, HPM doc did their primary training in IM is going to feel more at home than HPM doc that did their primary training in radiology.

Many HPM docs avoid that sort of job -- or else they prob would have done Geriatrics fellowship instead of HPM. That said, the skillset of HPM would obviously dovetail with the SNF practice.

 

[psychemdoc]

From only SNF work I make 500k+

How? And how many hours a week are you working? Is this only doable at certain SNFs or across the board with enough SNFs under coverage?

 

[sloh]

How? And how many hours a week are you working? Is this only doable at certain SNFs or across the board with enough SNFs under coverage?

For just SNF work, about 28 hrs which includes documentation. I have a unique setup with SNF's that have a very high volume of medicare patients getting therapies. One facility I round at has 60-70. I obviously don't see all 60-70 in one visit, but you get the drift. I also round at facilities that are close in proximity to each other. If you have to round at multiple SNF's just to accumulate enough volume and they are far apart, not a good setup.

 

[Iamnew2]

i'm anesthesia trained.
i was just thinking i'd show up once a month and evaluate patient and write for any as needed simple oral medications.
in the clinic I'm at, I don't see any patients from SNFs. also this clinic is expanded into new territory so my volume is only modest.
I do think there is a simple need for these SNF patients as I'm sure the overseeing primary physicians don't want to deal with pain mgmt.
I figure I could lend a hand by managing patients specifically for their chronic pain conditions and hopefully manage any polypharmacy with more oversight. I didn't intend to go more than once a month. just to stay busy and potentially get my name out into the community.

I think the problem with this is that there are many PM&R trained docs that do SNF work - has been a good niche for PM&R. Not only are multiple PM&R docs well trained in pain management in general as generalists but also many PMR/Pain docs like myself. So if there are SNFs with PM&R docs already working, then I don't think additional pain services might necessarily be beneficial as the PM&R doc already probably will take care of that.
If you can find a SNF with no PM&R docs then that might be an option, but you'd likely have to be there more than once or twice a month.

 

[sloh]

I think the problem with this is that there are many PM&R trained docs that do SNF work - has been a good niche for PM&R. Not only are multiple PM&R docs well trained in pain management in general as generalists but also many PMR/Pain docs like myself. So if there are SNFs with PM&R docs already working, then I don't think additional pain services might necessarily be beneficial as the PM&R doc already probably will take care of that.
If you can find a SNF with no PM&R docs then that might be an option, but you'd likely have to be there more than once or twice a month.

Yep, if you only round at the SNF once per month, I'd anticipate another physiatrist will come in and basically steal that job from you.

 

[Magnus Acus]

For just SNF work, about 28 hrs which includes documentation. I have a unique setup with SNF's that have a very high volume of medicare patients getting therapies. One facility I round at has 60-70. I obviously don't see all 60-70 in one visit, but you get the drift. I also round at facilities that are close in proximity to each other. If you have to round at multiple SNF's just to accumulate enough volume and they are far apart, not a good setup.

When you say "getting therapies" do you mean interventions, injections, ect? or like med management changes, follow ups ect. Sounds busy but 500k for 28h a week is like the best gig in medicine $/h wise

 

[Iamnew2]

For just SNF work, about 28 hrs which includes documentation. I have a unique setup with SNF's that have a very high volume of medicare patients getting therapies. One facility I round at has 60-70. I obviously don't see all 60-70 in one visit, but you get the drift. I also round at facilities that are close in proximity to each other. If you have to round at multiple SNF's just to accumulate enough volume and they are far apart, not a good setup.

Out of curiosity, how many days/week do you work and how many patients/day do you see? Do you do this on your own or through a company?

 

[sloh]

How many patients do you see per hour?

I can typically see ~25-30 per hour. I have a great relationship with the therapists, nurses, and DOR. I usually stop by and check in with them first to see if there are any more pressing issues.

 

[sloh]

Out of curiosity, how many days/week do you work and how many patients/day do you see? Do you do this on your own or through a company?

Typically ~40-45 patients 6 days per week. ~5 hr workdays. I work through a company and love the relationship I have with the company. They make my life much easier and I think the 30% cut they take is fair.

 

[sloh]

When you say "getting therapies" do you mean interventions, injections, ect? or like med management changes, follow ups ect. Sounds busy but 500k for 28h a week is like the best gig in medicine $/h wise

Sorry, "getting therapies" means they are getting PT/OT/Speech. It is a very good gig if you have a good setup. It's not the most glamorous work but it has its perks. To each their own. Before this job, I worked for Kaiser doing outpatient MSK and wanted to slit my wrists. I'll take SNF patients any day compared to sitting in a room all day listening to chronic pain-lite—not to mention tending to inbox messages of chronic pain-lite 😭

 

[PMR2008]

That volume of patient her hour is hard to do. A more reasonable number is 8-10 an hour. I usually see 25-30 a day. Rounds/meetings and notes all take about 5-6 hours. It is mostly MSK and Neuro. Lots of rehab management.
Almost all the rehab heavy facilities around the country already have PM&R present. The company I contract with is in 1200 locations and 600+ Physicians + some APPs. My 11th year doing it but the secret is out now.
It is nearly impossible for Anesthesia pain to replace PM&R in the SNF setting.

 

[DMBandFan86]

How can you see 30 patients in an hour? Thats 2 min per patient if you teleport to the next room. How do you even know why you are seeing the patient. I mean are they all asleep or something or just cookie cutter type stuff?

These post acute care patients like to talk, especially when they haven’t seen a doc in a while. Don’t mention if a family member is there.

 

[sloh]

Many often aren't in their rooms when I come in the morning. Many can be in the patio, in the gym getting therapies, or in the activity room. I know why I am seeing them because most are follow-ups and I've already reviewed the records and done an initial consult (these take way longer). Family is actually rarely ever there. Some like to talk, but many actually don't. And you can tactfully redirect the conversation if it's getting long winded and not really relevant. Haven't seen a doc in a while? They see me twice per week.

 

[wendalltwolf]

When you say "getting therapies" do you mean interventions, injections, ect? or like med management changes, follow ups ect. Sounds busy but 500k for 28h a week is like the best gig in medicine $/h wise

It sounds like an even better gig when you factor in low malpractice liability.

But I spoke with someone who does SNF consults and 2 of his facilities have gotten investigated by the state and both have stopped getting new admissions for almost a month. I guess you need to make sure of their quality before starting. They said it's usually a revolving door of admins, nurses, and support staff.

 

[sloh]

It sounds like an even better gig when you factor in low malpractice liability.

But I spoke with someone who does SNF consults and 2 of his facilities have gotten investigated by the state and both have stopped getting new admissions for almost a month. I guess you need to make sure of their quality before starting. They said it's usually a revolving door of admins, nurses, and support staff.

Very much so. SNF quality can vary tremendously. And every time admins and/or medical directors change, you need to re-establish relationships and rub elbows. Always need to watch your back. Making a killing in this line of work requires a lot of soft skills. You can’t just expect to swoop in once per month lmao. Good luck with that.

 

[ErrantWhatever]

Due to a series of unfortunate events, I’ve been required to work in SNF’s for the last 6+ months almost exclusively. Not my cup a tea but cheers to those who can do it. Moving on to a full-time Pain job now thankfully. PM me for more details if I can help.

 

[PMR2008]

Definitely not for everyone. Good luck with the new job. pain clinic is not my cup of tea.

 

[GoBeers]

does anyone know if separate malpractice coverage or an add-on clause to pre-existing coverage is needed for SNF consultation services?
My insurance carrier is taking a few days to clarify and respond...